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Nursing Peer Review: A Means to Improvement

By HCPro's Advisor to the ANCC Magnet Recognition Program®  
   August 01, 2010

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®, [], an HCPro publication.


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