1. Nursing Peer Review Process Overview Linkage to BPE/BP/Finance: A nursing peer review process supports NMH’s strategic objectives to provide the Best Patient Experience and employ the Best People because it creates a professional environment that assures quality care, creates a culture of safety, continuous learning and increased teamwork. In addition, a nursing peer review process links to the Henderson Framework for Practice. Problem Statement: Peer review, as a form of self-regulation, is a recommended professional requirement in nursing. Currently, nursing does not have a formal structure for peers to review each other’s practice. There are processes for the review of general nursing practice issues through the Nursing Professional Practice Committee and for the review of system errors via the review of sentinel events, but the addition of clinical peer review would provide nursing with a vehicle to review the practice of individuals and groups and make recommendations for enhanced outcomes. Goal/Benefit: A Nursing Peer Review Committee would advance nursing’s ability to advance a culture of patient safety, analyze nursing errors, minimize the reoccurrence of errors, and increase adherence to accepted standards of practice. Our overall goal is to establish a Nursing Peer Review Process and Committee to review nursing practice issues at NMH, track issues identified, and determine the outcomes of action taken as a result of peer review Scope: The scope of this project includes peer review of staff nurse practice issues for nurses across NMH. All specialty areas will be included. The intent is to implement the peer review process by August, 2009. Peer review of APN practice is outside the scope of this committee. System Capabilities/Deliverables: Deliverables will include: (1) A set of guiding principles; (2) A structure and process for peer review; (3) Education materials; and (4) A peer review committee charter. Resources Required: Human resources for the development of clinical peer review, the support of the resultant structure, and the education and implementation of the committee. Key Metric(s) : Numbers of cases reviewed by the Nursing Peer Review Committees will be tracked as well as the common issues identified and how they were addressed. We will also track recurrence of errors. Milestones: DescriptionDate (mo/yr) D Charter development/Review of Lit2/09—4/09 D Form team/Hold 1 st meeting/Review data4/09 MA Develop peer review process using 6 steps in4/09—6/09 Diaz article I Educate members of peer review & nursing 7/09 quality committees I Implement peer review process8/09 C Review cases after six months 2/10 Milestones: DescriptionDate (mo/yr) D Charter development/Review of Lit2/09—4/09 D Form team/Hold 1 st meeting/Review data4/09 MA Develop peer review process using 6 steps in4/09—6/09 Diaz article I Educate members of peer review & nursing 7/09 quality committees I Implement peer review process8/09 C Review cases after six months 2/10 Executive Sponsor: Michelle Janney RN, PhD, NEA-BC Sponsor: Deb Livingston, RN, MSN, NE-BC Process Owner: Ann Schramm, RN, MSN, NEA-BC, Facilitator/Katie Doyle, RN, MSN, Chair of Nursing Quality & Patient Safety Committee Improvement Leader: Sue Morby, RN, BSN (Loyola Graduate Nursing Student)