Peer Review Offers Opportunities to Improve Nursing Care

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By Debra Wood, RN, contributor

Physicians have long critiqued each other's care, and now nurses have begun to support peer review as a way to improve outcomes, shape their units and grow as professionals.
"Peer review is a method of looking at nursing practice using structure, process and outcome," said Peggy Tallier, MPA, Ed.D., RN, associate professor at Mercy College's department of nursing in Dobbs Ferry, New York.
American Nurses Credentialing Center (ANCC) Magnet standards require nursing peer review. It is a Magnet component of "exemplary practice" under the accountability, competence and autonomy section. This component commonly includes involving nurses in hiring decisions and assessing each other's performance during annual evaluations.
Sacred Heart Hospital in Eau Claire, Wisconsin, began using peer review years ago when hiring new nurses and when considering nurses for leadership positions. The hospital also employs it for annual evaluations, critiquing each other's clinical skills and ability to work well with peers.

Judy Pielhop, RN, CCRN
Judy Pielhop, RN, CCRN, has found peer review effective when hiring and doing annual evaluations of nurses.

"With the interviewing process, it gives ownership to the individuals who are part of the process—ownership in making sure that person is successful if given the opportunity to join our team," said Judy Pielhop, RN, CCRN, critical care director at Sacred Heart. "For the annual evaluations, it gives good feedback for growth and development, and they take it to heart."
But peer review can be more. At some facilities it takes place on a regular basis and focuses on quality and safety.

Barb Haag-Heitman, Ph.D., RN, PHCNS, BC
Barb Haag-Heitman, Ph.D., RN, PHCNS, BC, describes peer review as a dynamic, ongoing process that helps nurses hold each other accountable.

Peer review is a dynamic process and a way to hold each other accountable for following evidence-based standards and guidelines, said Barb Haag-Heitman, Ph.D., RN, PHCNS, BC, a nurse consultant.
"It needs to be owned by the people doing the work," said Haag-Heitman, who recommends that the manager stay out of the process to avoid having it become punitive. "People will identify their own authority and accountability for the outcomes."
Peer review may take place as a formal process, with a nurse presenting a case to a panel of nurses at a nurse practice council meeting, similar to what physicians do at morbidity and mortality conferences. Nurses review the case and assess the nursing care, based on whether quality standards were met or not.  If not, they complete an analysis, change processes if necessary and then educate their peers about ways to improve.
"The purpose of nurse peer review is not to be punitive or judgmental, but to evaluate if a standard has not been met, how we come up with a solution and how do we disseminate the correct information so that situation doesn't happen again," Tallier said. "Instead of medicine looking at what nursing does right and wrong, we are reviewing our own practice." 
Peer review also may take place more informally during handoffs, added Haag-Heitman, with the oncoming nurse asking the nurse who has cared for the patient if the standards have been met for that patient. For instance when trying to prevent ventilator-associated pneumonia, the nurse would ask if the head of the bed was elevated and oral care done.
"It's for the betterment of the unit and an opportunity for the staff nurses to look at themselves, and to positively look at their colleagues," said Pat Daley, RN, MA, CAN, BC, executive director of the Organization of Nurse Executives of New Jersey. "This is not a punitive process, but how to better the nursing care on the unit and improve ourselves as a team."
Daley added that facilities must educate nurses about the peer review process and how to use it to for personal and professional growth.
"It can be a very positive experience for all," Daley said. "Once people take ownership of a project, they have a sense of pride and want this to succeed and maintain it, and that results in better patient care."

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