Presented To NMH Nursing Quality Peer Review Committee Members October 27, 2009 By Nursing Quality Peer Review Steering

1. Nursing Quality Peer Review Education Presented To NMH Nursing Quality Peer Review Committee Members October 27, 2009 By Nursing Quality Peer Review Steering Committee

2. Agenda • Introductions • Overview of Nursing peer review • Define process of Nursing Quality Peer Review at NMH • Some tools for giving feedback and avoiding biases. • Practice case review.

3. Northwestern Memorial Framework for Nursing Practice

4. Nursing as a Profession • Requirements to be a profession: • Has a unique body of knowledge • Has controlled entry into the group • Demonstrates autonomy • Respect of the community • Self regulation (Hood & Leddy, 2006)

5. What is Clinical Peer Review? The evaluation of the delivery of nursing care in an objective and nonjudgmental manner when analyzing causative factors involved in medical errors with potential untoward events (Diaz, 2008). An organizational effort whereby practicing professionals review the quality and appropriateness of services ordered or performed by their professional peers (American Nurses Association (ANA), 1988). Relates to the identification of appropriate and willing peers for obtaining feedback on performance on a particular activity (Gopee, 2001). A process for evaluating performance and strengthening group communication, which also helps to maintain the integrity and self-governance of the nursing unit (Brooks, Olsen, Rieger-Kligys, and Mooney, 1995).

6. Defining Attributes of Peer Review • A peer is someone of equal standing in terms of education level, professional experience and/or employment status. • Evaluation of nursing care is measured against professional standards of practice • Non-biased feedback is provided in a manner that promotes professional development through positive communication • The goal of peer review is to develop individuals and systems (Morby, Concept Analysis 2009)

7. Why is Peer Review Important? • To reinforce the self-regulating nature of the nursing profession • Has potential to create a culture of safety (Diaz, 2008) • Can be a mechanism through which the profession acts to assure quality nursing care (ANA, 1988) • Can increase teamwork, creativity and a sense of ownership amongst nurses (Brooks, et al, 1995) • Meets the ANA’s Peer Review Guidelines • “Each nurse must participate with other nurses in the decision-making process for evaluating nursing care.”(ANA, 1988) • Facilitates identification of system or practice issues or knowledge deficits. • Promotes transparency in nursing.

8. Our Objectives for Peer Review at NMH • Reinforce the professional status of nursing by demonstrating self-regulation and transparency • Empower staff nurses who exhibit best practices to identify and address gaps in quality care. • Develop mechanisms for advancing the quality of nursing care and documentation at NMH. • Identify system or communication issues in order to advance a culture of safety. • Professional development for all parties involved in review process.

9. Nursing Quality Peer Review Committee • Scope for committee will be organization-wide. • Broadens the knowledge of the group when it includes people from all departments. • Creates a model for future departmental or unit specific peer review committees.

10. Guiding Principles • Nursing Quality Peer Review fosters a culture of continuous learning, patient safety and best practice by having a process which is: Safe and fair Timely in providing feedback Objective Confidential Continuous and routine Educational

11. Committee Structure

12. Committee Member Profile • Clinical knowledge and skills • Serves as a resource to other nurses • Honesty • Integrity • Team Work • Respected by all members of the team • Trustworthy • Exhibits interdisciplinary collaboration • Advocate for co-workers • Conducts himself/herself with professionalism • Has an excellent reputation • Is a role model • Willing to initiate constructive feedback • Shows a commitment to continual learning and growth

13. Committee Member Commitment • Attend monthly meetings • Educate peers on purpose and process of peer review. • Prepare case summary for committee review as assigned. • Maintain confidentiality per NMH policy.

14. Confidentiality • “I understand that in the course of my involvement with Northwestern Memorial Hospital (NMH), I share the responsibility of maintaining the confidentiality of any patient, hospital or employee information that I may have available to me. I understand that it is my responsibility to follow policies and procedures and all laws and regulations as they relate to the assurance of patient rights and the confidentiality of information whether verbal, written or electronic.”

15. Types of Cases • Referrals from: • Quality • Risk Management • Safety Briefings • Nurses (self or peer) • Members of the interdisciplinary team

16. Types of Cases • These cases could include: • “Near misses” • Unanticipated codes • Falls (resulting in significant patient harm) • Stage II-IV hospital acquired pressure ulcers • Medication errors • Unexpected transfer to ICU • Unexpected codes outside of ICU • Returns to surgery • Patient/family complaints • Cases that do not meet core measure expectation • Lawsuits

17. Process Flow of Case Review • Cases can be referred to NQPR committee by downloading form off Nursing Website • Cases referred to Peer Review are screened by Oversight Core Members.

18. Process Flow of Case Review • Committee Facilitators and one member of department with clinical experience that aligns with nursing practice where the event occurred: • Prepare case summary • Score the case using tools (preliminary)

19. Process Flow of Case Review • Request for additional information will be sent to nurse involved. • Review 1-2 cases per meeting • Immediate f/u: communication to nurse and manager, issues referred to other departments as appropriate • Track all cases reviewed in Case Log including date, case findings, and follow-up • Summary findings will be reviewed with Nursing Quality and Patient Safety and Oversight Core Committee.

20. Committee Tools • Request for additional information letter • Follow up communication • Scoring tool – ranking and mapping • Database/Case log

21. Understanding Root Causes Source: R Cook MD

22. Delivering the message • Emotional Intelligence (Goleman, 1998) • Self- awareness • Self-regulation • Motivation • Empathy • Social skill

23. Emotional Competence • Mindfulness • Openness • Impulse control • Personal humility • Appreciation of ambiguity • Appreciation of willpower • Compassion • Resilience • (Porter –O’Grady, Malloch, 2007)

24. Constructive feedback(Rudolph et al., 2008)

25. Nursing Feedback • Need specificity on why behavior did or did not meet standards. • Any system or communication issues should be addressed/referred and this should be communicated to the peer-reviewed nurse and nursing leadership. • Suggestions and action plan for improvement given to nurse if indicated.

26. References American Nurses Association (1988). Peer Review Guidelines. American Nurses Association. (2001) Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Publishing. Brooks, S., Olsen, P., Rieger-Kligys, S., & Mooney, L. (1995). Peer review: An approach to performance evaluation in a professional practice model. Critical Care Nursing Quarterly, 18(3), 36-47. Diaz, L. Nursing peer review: Developing a Framework for Patient Safety. (2008). The Journal of Nursing Administration, 38(11), 475-479. Gopee, N. (2001). The role of peer assessment and peer review in nursing. British Journal of Nursing, 10(2), 115-121. Hood, L. J. & Leddy, S. K. (2006) Leddy and Pepper’s Conceptual Basis of Professional Nursing (6th Ed). Philadelphia: Lippincott Williams and Wilkins. Institute of Medicine . (2001). Crossing the Quality Chasm: A New Health System for the 21st century. National Academies Press. Kohn, LT, Corrigan, JM, Donaldson, MS. (Eds). (2000). To Err is Human: Building a Safer Health System. Institute of Medicine, National Academy Press. Mantesso, J. Petrucka, P. & Bassendowski, S. (2008). Continuing professional competence: Peer feedback success from determination of nurse locus of control. The Journal of Continuing Education in Nursing, 39(5), 200-205. Masso, M. (2004). Peer review of adverse events – a perspective on Macarthur. Australian Health Review, 28(1), 26-32.

27. Committee Members • Steering Committee • Ann Schramm Leslie Klemp • Katie Doyle Robert Fortney • Susan Eller Carol Burns • Laura Lingl Cindy Barnard