1. Nursing Peer Review: Improving Nursing Practice and Patient Outcomes Naval Health Clinic Cherry Point Sandra Ludwick and CAPT Denise Smith AAACN Tri-Service Pre-Conference Chicago, Il 16 April 2008

2. INTRODUCTION Naval Health Clinic Cherry Point (NHCCP) Location Organizational Scope Standard Practice

4. BACKGROUND NHCCP recognized need NHCCP recognized need Exists for Medical Staff Exists for Medical Staff Models available for Nursing Peer Review Models available for Nursing Peer Review Most subjectively based Most subjectively based Severity and Criticality (SAC) scoring component Severity and Criticality (SAC) scoring component Trigger for investigative review Trigger for investigative review

5. BACKGROUND Monitoring Tool Monitoring Tool 12 core indicators 12 core indicators 3 to 6 departmental indicators 3 to 6 departmental indicators Universally applicable (military/civilian) Universally applicable (military/civilian) PDCA (Plan, Do, Check, Act) Methodology PDCA (Plan, Do, Check, Act) Methodology

6. CRITERIA Non-punitiveEducationalSystematic

7. COMPONENTS Policy (ECONS By-Laws/Nursing Policy) Policy (ECONS By-Laws/Nursing Policy) Model Model Flow diagram Flow diagram Indicators Indicators Consistent yet flexible process Consistent yet flexible process Scoring Scoring

8. POLICY “The Nursing Peer Review program is a planned, organized and comprehensive program to continuously monitor and evaluate the nursing care provided to patients at NHCCP. The program is designed to promote professional growth among nurses and improve patient care.”

9. MODEL MODEL

10. FLOW DIAGRAM NURSE PEER REVIEW FLOW DIAGRAM

11. INDICATORS Nursing Process (1 – 5 part question) Nursing Process (1 – 5 part question) Policies and Procedures (1 – 3 part question) Policies and Procedures (1 – 3 part question) Patient Safety (7 questions) Patient Safety (7 questions) Pain Assessment (1 question) Pain Assessment (1 question) Professional Performance (1 question) Professional Performance (1 question) Department Specific (3-6 questions) Department Specific (3-6 questions)

12. SCORING Frequency Like the severity categories, the frequency rating applies to actual events and close calls. High – Likely to occur immediately or within a short period of time Medium – Likely to occur several times in 1 to 2 years. Low –May happen greater than two years. How the SAC Matrix Looks Severity & Catastrophic Major Moderate Minor Frequency High33 2 1 High33 2 1 Medium32 1 1 Medium32 1 1 Low32 1 1 Low32 1 1 How the SAC Matrix Works When you pair a severity category with a frequency category for either an actual event or close call, you will get a ranked matrix score (3 = highest risk, 2 = intermediate risk, 1 = lowest risk). These ranks, or Safety Assessment Codes (SACs) can then be used for doing comparative analysis, and, for deciding who needs to be notified about the event.

13. CHART AUDITS Random Random Peer Reviewers Peer Reviewers

14. DATA INPUT TOOL

15. Nursing Peer Review Form Month: Year: Year: Department: Department: Patient Identifier: Nurse (s): 1) 2) 3) 4) 5) NURSING PROCESS NURSING PROCESS a) Age specific care demonstrates collection of patient data through assessment; implementation; evaluation; adjustment, if appropriate; and patient education. Yes o No o N/A o Yes o No o N/A o SAC POLICIES AND PROCEDURES POLICIES AND PROCEDURES a) Adherence to departmental policies/procedures; Command instructions; BUMED and DOD instructions (note specifics in comment section) Yes o No o N/A o SAC PATIENT SAFETY a) Demonstration of patient identification Yes o No o N/A o SAC

18. DATA FINDINGS Aggregate and report findings Aggregate and report findings Review process Review process

19. IMMEDIATE RESULTS Examples of immediate “flags” during process implementation included: Examples of immediate “flags” during process implementation included: IPCU - Pain assessments / re-assessments IPCU - Pain assessments / re-assessments L&D - Breastfeeding during first hour of life L&D - Breastfeeding during first hour of life UCC - Medications UCC - Medications

20. PROCESS CHANGES NPR = Constant work in process NPR = Constant work in process Item #1 (Nursing Process) wording reflects change from hospital to ambulatory status – no inpatient discharges Item #1 (Nursing Process) wording reflects change from hospital to ambulatory status – no inpatient discharges Item #2 (Policies and Procedures) wording should be changed to NHCCP Nursing policies – encompasses DOD, BUMED Item #2 (Policies and Procedures) wording should be changed to NHCCP Nursing policies – encompasses DOD, BUMED Item 3c (Patient Safety) wording should remove “and reconciliation” as it is a provider function Item 3c (Patient Safety) wording should remove “and reconciliation” as it is a provider function

21. CURRENT RESULTS

22. COMPARING RESULTS Naval Hospital Camp Lejeune Naval Hospital Camp Lejeune Fort Knox Army Fort Knox Army

23. WHERE DO WE GO FROM HERE? Continue to “tweak” the monitoring tool Continue to “tweak” the monitoring tool Continue staff education Continue staff education Gain more staff involvement in process Gain more staff involvement in process Drill down staff results to identify goal opportunities Drill down staff results to identify goal opportunities Continue to share program with interested facilities Continue to share program with interested facilities