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Nursing Peer Review

A Practical, Nonpunitive Approach to Case Review

Laura Cook Harrington, rn, bsn, mha, cphq, cpcqm Marla Smith, mhsa

Nursing Peer Review, Second Edition is published by HCPro, a division of BLR

Copyright ? 2015 HCPro, a division of BLR

All rights reserved. Printed in the United States of America. 5 4 3 2 1

ISBN: 978-1-55645-198-0

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Laura Cook Harrington, RN, BSN, MHA, CPHQ, CPCQM, Author Marla Smith, MHSA, Author Claudette Moore, Acquisitions Editor Rebecca Hendren, Product Manager Erin Callahan, Senior Director, Product Elizabeth Petersen, Vice President Matt Sharpe, Production Supervisor Vincent Skyers, Design Manager Vicki McMahan, Sr. Graphic Designer/Layout Jason Gregory, Cover Designer

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Contents

Nursing Continuing Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Chapter 1: Defining Incident-Based Peer Review. . . . . . . . . . . . . . . . . . . . . . . . 1

The Rise of Peer Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The ANCC Magnet? Recognition Program: A focus on standards . . . . . . . . . . . . . . . . . . . . . . 2 Other external sources may impose high standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

How Facilities Use Peer Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Reviewing complaints about nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Categories of performance review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Peer review process and identifying peers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Understanding the meaning of peer review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Other formal review processes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Chapter 2: Benefits, Rationale, and Setting Clear Expectations . . . . . . . 9

The Roots of Peer Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 The Nursing Performance Pyramid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Appoint excellent nurses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Set and communicate expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

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? Nursing Peer Review, Second Edition iii

Contents

Contributions to hospital and community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Measure performance against expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Provide periodic feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Manage poor performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Take corrective action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Applying the Pyramid to Nursing Culture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Chapter 3: Immunity, Confidentiality, and Protecting Information From Discovery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Peer Review Protection Laws. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

The Health Care Quality and Improvement Act of 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 State immunity laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Privilege: Protection from Discovery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Privilege guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Confidentiality: Security of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Chapter 4: Designing a Formal Structure to Support the Peer Review Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Functions of Peer Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Identify a Formal Structure that Works for You . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Shared governance structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Other nursing structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Defining Committee Roles and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Committee members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Impartiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Set and Communicate Nursing Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Protecting Confidential Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Peer Review Confidentiality Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Restrictions on disclosure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

?iv Nursing Peer Review, Second Edition

? 2015 HCPro

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