Peer review: the evaluation of the professional performance of individual RNs by nurses with experience in the appropriate subject matter to provide a legitimate evaluation. It sounds simple, but the concept of nursing peer review has its own set of unique challenges. Despite these challenges, it remains a powerful way to educate and bring about quality improvement.
But who is a peer? A nurse peer is an RN who practices in the same role as the RN being reviewed. This means:
Bedside to bedside
Nurse manager to nurse manager
Nurse educator to nurse educator
CNS to CNS
Only nurses who are in the same (or comparable) role can provide the kind of evaluation of patient care and nursing practice required for proper peer review.
“In the clinical or any healthcare setting, I always like to ask, ‘What motivates change?’ ” Meryl Montgomery, RN, MSN, ANCC Magnet Recognition Program® (MRP) coordinator for the Medical Center of Central Georgia in Macon, told a live audience during the webcast “Nursing Peer Review: Improving Clinical Performance, Professionalism, and Accountability.” “How do we ensure quality of care? Improve conditions? What is the best way to address a near miss and be constructive?”
Montgomery has found over the years that peer review has the power to drive system improvement.
“It can be very creative and innovative in where you can go—you can engage your nurses across the board,” she said.
Peer review is a situation where “apples to apples” is a necessity. OR nurses really need to be the ones evaluating OR nurses; likewise with OB nurses to OB nurses and critical care to critical care.
“The distinctions between those roles can be important and need to be looked at,” said Montgomery.
Why is peer review necessary?
Many organizations hospitals work with have incorporated peer review components into their standards or requirements:
The Joint Commission (human resources and leadership requirements)
The American Nurses Association under the Code for Nurses
ANCC’s MRP program (Component 3: Exemplary Professional Practice (EP), EP 20)
Montgomery noted the nursing industry’s reputation for “eating its own young,” as the old saying goes. But those days are fading, she said.
“We have had a preponderance of the shark-and-guppy culture,” said Montgomery. “That environment is changing. Changing slowly in some cases, quickly in others.”
Peer review can help change this fact. In fact, the uses for peer review reach beyond individual performance improvement. The following are some other purposes of peer review:
Spotting barriers and weakness
Identifying opportunities
Collecting data for trending/evaluation
Improving patient outcomes
Strengthening accountability
Enhancing professionalism
Improving performance
Peer review comes in many types, depending on the needs of the organization and the outside agencies the organization subscribes to.
Some types of nursing peer reviews are:
Nursing state boards
Peer review organizations
External: ANCC’s MRP program
Informally structured
Incident-based
There are three key components to implementing informal peer review processes. First, determine what regulatory requirements are involved. Next, define and describe what the peer review process will entail.
“Number of things we want to consider here,” said Montgomery. “For example, we determined we wanted to be MRP designated and increased the depth and breadth of our peer review processes. CMS, The Joint Commission all have PR requirements. We had to ask, ‘Who is going to be responsible for peer review?’ ”
They put the focus on human resources but also included the professional development council, operations council, and education council to help educate and utilize tools.
Finally, peer review must be built into the culture of the organization. This process can be even more complex and challenging than the first two components.
What factors go into enculturating peer review?
Job descriptions
HR processes
Daily operations
Quality assurance/performance improvement
Education
Implementation
Evaluation
Montgomery’s organization also spent a lot of time enculturating—or hardwiring—its peer review process.
“Every job title has responsibility to be a preceptor for peer review,” said Montgomery. “Our education around peer review is included not just when we talk about peer review, but is also clearly articulated in the job description that nurses are expected to review and be reviewed.”
Factors of quality peer review
Peer review needs to be ongoing—not just once a year during performance appraisal.
“It goes on throughout the employment process, through the nurse’s stay with the organization,” said Montgomery.
Reviews can happen in a variety of intervals, whether it’s when your facility has developed new policies, procedures, or practices; implemented the use of new equipment; or when nurses act as preceptors for new hires. In all cases, however, the role of the preceptor must always be comparable to the individual being reviewed; the reviews must happen at all levels of the organization; and the reviews must be focused and narrow in scope.
“They also need to be timely,” said Montgomery. “When you put a child in timeout, it needs to be right after the event. Similarly, when we review medical records or practices, the feedback we give must be current, topical, and at an appropriate time. The peer review needs to be clearly articulated and the education for it needs to be thorough.” And, most importantly, nonpunitive.
“It’s not necessarily part of our culture to give constructive feedback,” said Montgomery. “Sometimes nurses simply don’t know how to have a real face-to-face conversation about another nurse’s practice. This requires feedback, facilitation, mentoring.”
Peer review can help spur a nurse’s career advancement, providing a collegial and systematic process. It fosters refinement of skills and decision-making processes.
“If you’re on your [MRP] journey, under components for exemplary practice, nurses at all levels should use self-appraisal, peer review, and more for performance development,” said Montgomery.
Additional benefits
The individual under review is not the only beneficiary of the peer review process. By looking at outcomes of peer review data, it is possible to spot barriers and weaknesses across the board and find opportunities for improvement.
For example, are the holes in knowledge that show up in multiple peer review sessions a matter of educational deficiencies? Are the staff unaware of the resources available to them?
“At intervals across time, we can assess where the organization’s nurses score,” said Montgomery. “Is it a low score or high? Do they not understand something across the continuum of care? Is our electronic medical record not allowing for ease of documentation? All of this can be used to trend data.”
For example, Montgomery’s organization uses specially trained RNs who focus on skin breakdown.
“We look at the data, and if we notice a lot of breakdown, there is an opportunity to make sure we have the right supplies, make sure we’re following up” appropriately, she said. “It’s an opportunity to improve patient outcome.”
Evaluating the evaluators
Montgomery’s organization also allows the preceptees the chance to evaluate the preceptors in an organized manner. “There aren’t many opportunities for that to happen naturally,” she said. “We’ve been able to improve the performance of the ‘sharks’ out there who have a hard time with the mentoring relationship. We know not everyone is cut out to be a preceptor. Not everyone can break things down to a level the novice can understand.”
The characteristics of peer review
To be valuable and fair, peer review must comply with the following characteristics:
Same skill level
Focused
Nonpunitive
Ongoing
Timely
________________________________________________________________________ This article was adapted from one that originally appeared in the August 2010 issue of HCPro's Advisor to the ANCC Magnet Recognition Program®, [http://www.hcmarketplace.com/prod-7406/HCPros-Resource-Center-for-the-ANCC-Magnet-Recognition-Program.html], an HCPro publication.
Three Twin Cities nurses who crossed their union's picket line during a mass walkout June 10 say they were harassed by the union after the fact through letters calling them to a disciplinary hearing. The nurses, all from Children's Hospitals and Clinics of Minnesota, say they resigned from the union before the 24-hour walkout in order to work behind the picket lines. Nonetheless, they received letters from the Minnesota Nurses Association saying they may be subject to reprimand, censure or expulsion. The nurses filed a complaint against the MNA late Wednesday with the National Labor Relations Board. In the past, it's been the MNA that's filed a flurry of federal complaints against the nurses' employers.
Without sufficient skills, first-line managers do not benefit an organization. The first step to increase the number and education of managers is to provide effective training designed to specifically improve organizational performance.
Currently, healthcare costs are high. When all elements of healthcare reform are implemented, higher costs may ensue. There will be a demand for more change and greater resilience from our management teams. Unless we have managers who are resourceful in their management skills, we will not achieve new and improved ways to succeed in the goals of safe, high-quality care at a reasonable cost.
Promoting a technical worker to a manager role requires training. The new manager needs an educational program with inspired faculty, dedicated mentors, and an innovative curriculum designed to deliver the new skills needed to a diverse group of adult learners.
How do you train up employees to be effective, ethical, strategic, and skilled managers? It is a tall order that requires a constant battle to balance the benefits of training with the requirements of daily operations.
Succession planning for managers is often short sighted. Many organizations spend time and money on planning for successors for their executives, but the vast majority of organizations do not have a plan in place for their middle managers. This leaves organizations with unexpected gaps in the frontline and encourages recruitment of unskilled and frequently poorly prepared staff-level employees to assume these critical positions.
We have a choke point in our educational system because most learning curriculums do not provide the tactical skills required of managers in their daily lives on the job. Most organizations choose only one technique from the myriad options available to them, such as:
Expect that seasoned practitioners will inherently have skills and be selected on the basis of informal leadership traits
Believe all that is needed is an orientation program to how your organization “does things”
Silo each discipline into their own management leadership educational program believing that each has such an abundance of special needs that it justifies a unique program
Hold a boot camp that will provide skill training in short time (and expected it to stick)
Think one-day programs are sufficient
Use faculty who are all internal members of the organization
Use online programs that allow participants to study in private at their own pace
Send one person at a time to single, off-site programs
Pair a novice with an experienced member of the team who will transfer skills on a 1:1 basis
Pick a focus and invest in a process excellence model such as Six Sigma, Lean, or other frameworks and expect this will develop leadership skills
Leave the provision of education to the academics in an executive education program
Choose an approach to curriculum development and buy the package from a consultant.
Select a leadership book and take each chapter as a trigger for discussion
Unfortunately, I usually see these options attempted in isolation to any other option. With so many options, which path should be followed?
We need to mobilize our common sense, mutual talents, mutual experiences, and not expect to come up with a single best method. We should understand that there are some universal attributes of management education.
Let’s stick to what makes sense to the people in operations who know what matters and what skills they, as employers, expect of their management team.
Then we need to chart the best course that will lead to the best impact on the business we are in. We are in the business of providing safe, effective healthcare to our community with skilful engaged employees at a price the community can afford.
Implementing a needed management education program requires skill, experience, courage, and collaboration among all stakeholders.
I suggest we begin this discussion with some validation of two common beliefs or assumptions:
The ripple effect of new managers’ lack of knowledge and self-confidence can be seen in poor statistics for manager retention, staff retention, patient safety, patient satisfaction, physician satisfaction, community engagement, interdepartmental collaboration, and financial survival of the organization.
Management requires a skills and a knowledge base. Not all informal leaders are good managers and not all managers are good leaders. You want frontline managers to perform in both areas of management tactical skills and creative leadership in an effective manner. Most healthcare management candidates do not have a knowledge base of the necessary tactical and leadership skills necessary to adequately contribute to highly functional and performing teams within a dynamic and complex healthcare system.
We need to turn to evidence-based theory of adult education to apply those tenets. Knowles (1998) developed principles that stipulate:
Adults need to know why they should learn something
Most adults were educated in school systems that fostered dependent vs. self-directed learning
Draw upon the experience of the learner
Adults want to be motivated to better their real-life tasks
Adults want to know how new learning will impact their lives
Adults are motivated by issues such as job satisfaction, self esteem, and quality of life
The management education question becomes: what content should be covered, how much content, and which delivery option do you use? But what will matter most in the long run is that learners participate in the program with the encouragement of peers, superiors, and subordinates.
My talking points for your discussion are:
Resolve that management education is necessary.
Executive buy-in and visible support by leaders is essential.
Knowing what business goals you want to achieve from any educational program will ensure better outcomes.
Be clear about what skills managers need to achieve the goals.
Management education programs should have an evaluation method with predetermined outcome metrics to evaluate the effectiveness of your organization’s program. The individual performance and engagement in the participant’s career and positive interactions with colleagues should also be measured.
Select the right faculty: Consider the values of internal and external faculty. Faculty must be credible, but not a person who signs the participant’s annual evaluation. Supervisors could be seen as in a position of authority to jeopardize the participant’s job if they have difficulty in the program. You want faculty who can bring both new ideas into the organization and yet provide support to the culture you wish to enhance.
Select diverse delivery methods that provide prolonged engagement with the learning process. Skills are not embedded into behavior overnight.
Train practically: what is taught in the classroom or online needs to be immediately applicable in the workplace.
Include a work project that will have a meaningful impact on the metrics you have selected to evaluate the program. Offer the participants an opportunity to share and present their project to senior staff and other peers.
Train everyone together. One person or one professional group in isolation does not build a community of managers. Isolation does not teach or reinforce communication skills or build the networks that are required in the collaborative practice of healthcare.
Have a mix of internal and external faculty. Honor and acknowledge organization wisdom and challenge participants to reach out to new voices and new approaches.
Know your first efforts will not be your last efforts.
Reference: Knowles, M. (1998). The Adult Learner: The Definitive Classic in Adult Education and Human Resource Development. Houston, TX: Gulf Publishing.
Betty Noyes, RN, MA, is president of Noyes & Associates, Ltd., a nationwide healthcare consulting service. For more information, visit www.noyesconsult.com.
There were 183 patients at Rock Hill's Piedmont Medical Center on Tuesday. Nurse Betty saw them all. Not most. All. Now in her 55th year at PMC, Betty Jenkins, who has been at the hospital longer than most employees there have been alive, has a new role - patient ambassador. Just a fancy title for what Nurse Betty has always done during decades in obstetrics, where the babies are born and miracles happen - bring a smile to everyone she sees. Only now, it's her full-time job.
There are significant gaps in regulatory efforts nationwide to keep nurses from avoiding the consequences of misconduct by hopping across state lines, even with a 24-state compact created to help get good nurses to areas where they are needed most. Under the decade-old partnership, a license obtained in a nurse's home state allows access to work in the other compact states. But an investigation by the non-profit news organization ProPublica found that the pact also has allowed nurses with records of misconduct to put patients in jeopardy. In some cases, nurses have retained clean multistate licenses after at least one compact state had banned them. They have ignored their patients' needs, stolen their pain medication, forgotten crucial tests or missed changes in their condition, records show.
Even as a national nursing shortage looms, many newly graduated registered nurses can't find jobs because the economic downturn has delayed retirement of experienced nurses, regulators and health care associations say. Those who find work often can't get the better-paying hospital positions they had hoped for and instead are turning to nursing homes, home health care or other settings, says Carylin Holsey, president of the National Student Nurses' Association. An advisory for new grads published by the association warns that the market is "flooded" with experienced RNs who have come out of retirement, delayed retirement or gone from part-time to full-time employment because of the recession.