Implementing Nursing Peer Review

In 2010, Sentara Virginia Beach General Hospital (SVBGH) established a Nursing Peer Review forum, modeled after the facility’s Physician Peer Review Committee.

SVBGH Chief Nursing Officer, Peggy Braun, MHA, BSN, RN, CENP, championed this initiative by garnering participation from staff, providing guidance, and ultimately supporting the nurses to develop autonomy as committee members.

“The initial vision, to create a true nursing practice peer review council in which staff nurses utilize critical thinking through open and transparent case reviews, aligns with the Professional Practice Model at SVBGH,” Braun said. “The vision also encompasses a drive to increase professional practice and to inspire others by raising awareness of the impact nursing creates in patient care and to the organization.”

Creating an Opportunity

SVBGH is the first facility within its 12-hospital system to establish this nursing peer review opportunity.

The purpose, to improve the quality of patient care and nursing practice, also provides an environment for nurses to identify educational and performance improvement opportunities.

The members of the peer review team committee selected through nominations made by nursing leadership based on numerous criteria, such as being a role model, articulate, someone who strives for excellence, serves as mentor/preceptor, and someone with greater than two years experience on the job.

The nominees received personal letters from the CNO and, if interested, agreed to commit their time and expertise for minimum of one year.

Model Program

During 2011, the group worked on defining the parameters under which it would operate in real-time.

Referrals can be submitted by direct care nurses, nurse managers, directors, nurse executive, physicians, and departmental leaders. The committee uses a prescribed process to present, review, discuss and recommend actions based on consensus.

In 2012, the team presented at the Sentara Nursing Grand Rounds sharing their experiences and recommendations for best practice in elevating nurse review to the next level.

Two sister facilities are replicating the nursing peer review model at their respective sites.

Nursing Philosophy

The nursing peer review forum often recommends practice concerns or trends in nursing practice to be discussed at the hospital Nursing Practice Council.

For example, at the end of 2012, the committee lifted up a process concern to the ED physicians and the inpatient nursing forums regarding our electronic medical record and the use of “Signed and Held orders”. Process changes were implemented in 2013 to improve the communication and implementation of all orders under the context of improving patient care.

“The three main components of our nursing philosophy – Relationship, Team and Coordination, are evidenced in the peer review structure by direct care nurses forming a council to provide an objective review of cases and ultimately improving care. They provide input and recommendations for changes in process, policy and in systems such as our electronic medical record,” Braun stated.

“Nursing Peer Review also complements the hospital vision to support an environment of health and healing,” she concluded. “In the end, our nurses are making a difference.”

Below are excerpts from current members of the Sentara Nursing Peer Review Council who are unnamed to support a culture of openness in which nurses at all levels are encouraged to express their concerns and champion causes.

Nurse No. 1- Operating Room Nurse, BSN, Five years experience

Peer Review is demanding because every case is unique resulting in each of us facing personal challenges but one thing remains the same; it is important to discuss these issues openly and objectively.

It is especially grueling to maintain a non-judgmental atmosphere while offering constructive criticism when we work alongside the nurse in review. Interviewing those involved is demanding because each nurse reacts differently. Recalling the information can be upsetting for the nurse. We desire to include the nurse’s perspective so that we better understand the dynamics – the workload, resources or resistance.

After the details are presented, we discuss if the nursing care was appropriate .We do not always agree but are cognizant to not condescend when we consider if the practice aligns with the ANA standards and Sentara’s expectations. Never failing, the thoughts o “It could have been me or a close colleague in that scenario”, crosses my mind.

We support our decisions with evidence and openly discuss any difference of opinions, striving for consensus. If the case is controversial or inappropriate, we decide what nursing issue needs attention. Individually, no one has the correct answer, but together we can identify the issues.

We also provide recommendations to prevent the issue from recurring. For example, one case involved PEG tube care to which the committee members referenced various ways to provide “standard” care. No one recalled the last time the procedure was reviewed. We recommended house-wide review of the PEG tube policy and related education.

Peer Review has changed my nursing practice. Not only do I include more detail in documentation, but now I also record actions I take as a charge nurse. I better understand other units in the hospital. I am influencing positive outcomes for our patients and co-workers through system policy changes, topic specific education and affirmation of appropriate care.

Reviewing cases has increased awareness of nursing practice, documentation, and processes to improve care. We embrace the experience of thinking outside our comfort zones.”

Nurse No. 2: Emergency Department, BSN, 10 years experience

I am fortunate to be a part of nursing peer review at SVBGH. In the beginning it was quite a learning curve. We developed our mission statement and confidentiality agreement. We reviewed current literature to better understand the purpose.

The real eye-opener came when we began to review actual cases. Peer Review has added to my journey as a professional nurse, personally and as a team.

Nurses strive to be recognized as professionals as evidenced by becoming involved in legislation, research, and continuing education. Nurses are seeking ways to expand their knowledge and continually review and evaluate their practice for areas of improvement. Peer Review has done that for me. I view each case as a way to review myself, my beliefs and my practice to improve for my patients and their families.

In the beginning, reviewing a fellow nurse, a peer was uncomfortable and a struggle. Each member had to accept that we were not a punitive council but a means to enact change in practice. It is a double- edged sword at times; we must take the uneasy feelings of reviewing one of our own and couple that with the comfort that with each case we can make a difference.

We take our recommendations to provide education and influence policy change within our facility. This closure allows us to fulfill our duties as professionals, in that we are proactive members of the healthcare team and we help to improve the care delivered to our patients and their families.”

Nurse 3: Cardiac Surgical ICU, Diploma Nurse, 30 years experience

Peer Review has given me a renewed sense of responsibility – to show my peers that I am not being judgmental but demonstrating understanding and compassion. As a front line nurse, I experience daily difficulties with time management and documentation. This difficulty will always remain and try as I might I cannot change it.

Peer review has allowed me to help change processes within our facility, to help relay new protocols or increase awareness to patient caregivers to improve patient safety and show better outcomes – my ultimate goal!”

In conclusion, Nursing Peer Review is a dynamic committee at SVBGH through which we learn about process, communication, interviewing and nursing expectations, to ultimately improve health every day at Sentara Virginia Beach General Hospital.

Sonia Cooper is Director, Patient Care Services at Sentara Norfolk General Hospital, Norfolk, Va., Alex Morecock is a staff nurse in Surgical Services, Katie Arnold is a staff nurse in the Emergency Department, Sandra Buckner is a staff nurse in Cardiac Surgical Intensive Care, and Peggy Braun is Vice President/Nurse Executive, all at Sentara Virginia Beach General Hospital.

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