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HCPro

Nurse leaders should champion peer review


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Physicians have been doing it for decades, but nursing has been slow to adopt peer review as a quality of care imperative. To avoid being left behind, it's time nurse leaders added peer review to their strategic plans.

Nursing peer review operates similarly to physician peer review. Following a quality of care issue, the incident is reviewed by a committee of nursing peers to determine the reasons behind the incident and whether anything can be learned from it. This is different to root cause analysis, which is multidisciplinary, much more involved, and usually occurs after an untoward patient outcome. Nursing peer review is nurses' version of ongoing individual performance evaluation and the process often identifies system failures.

Nursing peer review can identify other issues that relate to organizational performance improvement in two important ways. First, when looking at cases, you may uncover system issues that need to be addressed by the hospital's performance improvement program. Second, in evaluating individual nurse performance, you may find issues that relate to how care is provided by a specialty or by the entire staff. In these situations, nursing should use the hospital's performance improvement structure to best decide how the issue should be addressed.

I spoke with Laura Harrington, senior nurse consultant at the Greeley Company, a division of HCPro, Inc. in Marblehead, MA, about how nursing peer review benefits organizations and why it's worth adopting.

Harrington told of a case that had come before a hospital's nursing peer review committee. The admitting orders had been written for a patient, but a bed wasn't free, so the patient waited in the ED for hours. The admitting order had included a medication that was urgent for the patient to receive, but the patient did not receive the medication until hours later when he was finally on the unit.

The case was reviewed by the nursing peer review council, and it was discovered that there was no policy for ED nurses to initiate admitting orders, which were done on the unit. In this case, the organization identified the lack of policy and changed it so that ED nurses could start admitting orders for urgent medications or procedures.

Harrington says peer review provides nursing with a structure to look at issues when there is a quality of care question and examine the reasons behind it. But successful adoption needs nurse leader backing and support. There are untold competing priorities for nurse leaders' time, but Harrington says it is worth making nursing peer review a priority. "What it really comes down to is this will benefit everyone. It's a win-win for nursing, for the hospital, and for the patient," she says.

Nursing peer review provides an opportunity to learn from mistakes and to improve patient care. It provides a real-time evaluation of care, so changes can be made almost immediately. And by evaluating processes, it decreases the possibility of future process failures.

"It's been published that if you standardize the care that you are giving and don't deviate from standardized approach, then the outcomes will be better," says Harrington. "That means we standardize the nursing care and we do it the same way over and over again, based off the identified best practice."

Nurse leaders may be concerned with how nursing staff will react to the prospect of peer review. Without education to the contrary, many nurses mistakenly believe it punishes nurses' mistakes. Harrington says it's important that nurses understand that peer review is about improving care and fixing system failures, and that the end result is educational.

"I think nurse leadership has to be the one who drives the process," says Harrington. "They have to have the buy in to say that this is the right thing to do for our patients. So we can identify trends and challenges, barriers to delivering nursing care, and make changes accordingly."

Harrington says physicians have done peer review for decades and that nursing should too. "If we don't do it now, someone else will do it to us. I think in the future it will be a mandated requirement," she says.

That's already the case in some places. Organizations pursuing ANCC Magnet Recognition Program® designation are required to have some form of nursing peer review in place, the Texas Board of Nurses requires peer review, and it's likely that other designating bodies will become interested in the process.

"I think the question should be, why wouldn't you do it?," Harrington says. "If you haven't done it, you should. It's the right thing to do."