Nursing peer review: Raising the bar on quality

Providing safe, high-quality care to all patients is imperative. For direct-care nurses and nurse leaders alike, reducing and eliminating preventable harm is a top priority.

Transforming individual nursing practice is the only way to achieve and sustain quality improvement. No longer is aggregating outcomes data at the organizational level sufficient. Today the focus must be on improving the quality of care provided by individual nurses and affecting system process issues. To drive exemplary outcomes, nursing professionals need to accept the challenge of adopting a nursing peer-review process.

As an organization on the Magnet® journey—and one constantly striving for excellence in patient care—our facility viewed the development of a true nursing peer-review process as the logical next step in promoting a more professional environment. Our Magnet Program Director, in concert with staff nurses and external peer-review experts, designed and disseminated a nursing peer-review program.
Going into the design phase, the team that had formed to implement the program (which included the Magnet Program Director, chief nursing officer, nursing performance improvement coordinator, and selected staff nurses) knew this part would be the easiest. The bigger challenge would be to explain what peer review was and was not, and to move staff nurses and nurse leaders to the point of understanding, acceptance, and ownership of peer review.

Getting started

The design process began by defining what nursing peer review would look like in our organization. The foundation rested on defining peer review as the nonpunitive evaluation of an individual nurse’s performance for the purpose of identifying opportunities to improve care. “Peer” was defined as an individual practicing in the same profession and having expertise in the appropriate subject matter.

The scope of the design process included:

  • developing nursing policy and procedure
  • flowcharting the nursing peer-review process
  • developing clear boundaries for what should be considered in peer review versus manager-staff performance feedback
  • developing indicators to be tracked and trended through the peer-review process.

Setting the stage

Through close collaboration with human resources colleagues, we clarified the boundaries of nursing peer review. This led to a policy and procedure that encompassed such key elements as following state and federal laws pertaining to confidentiality and nondiscoverability.


A Nursing Professional Excellence Council (NPEC) was formed, chartered, and officially added to the shared governance bylaws as the council that would perform peer review. Staff nurses from each of our five major nursing divisions were identified to serve on the council, along with the nursing performance improvement coordinator and one nursing director serving as administrative liaison. As with all shared governance councils, a staff nurse would serve as council chair.

NPEC became part of our facility’s quality structure to allow protection under state statutes of quality. We clearly delineated that the peer-review process wouldn’t replace annual appraisals, manager feedback on practice, or other human resource policies. Managers would use nurse-specific peer-review results as one component of the annual performance review process. Also, as with any confidential process, all documents pertaining to peer review would be maintained in a secure, locked file kept separate from the employee file. Only staff members with a legitimate need to know this information would have access to it, and no copies of peer-review documents would be created or distributed. With these important foundational elements defined, it was time to move on to flowcharting the peer-review process.

Standardizing the process

Realizing we needed a highly structured, easily understood process to ensure fairness and reliability, we decided to use a detailed algorithm as a guidance document. The nursing performance improvement coordinator—the first person to receive referrals—is central to the peer-review process. This individual prescreens all referrals based on set criteria, and determines if the case is appropriate for peer review. If criteria are met, the case is referred to an NPEC member for review. Review findings are presented to NPEC by the member who completes the review.

Unless additional information is needed, the council makes a recommendation within its scope. Recommendations for the referred nurse may include:

  • completing a continuing education module
  • conducting research on evidence related to a specific practice and presenting the information to staff nurses
  • reviewing a technical skill with an advanced practice nurse or preceptor.

A letter is sent to the staff nurse in question, outlining the review and recommendations. A copy of all correspondence goes to the nurse manager for follow-up and implementation. Although NPEC recommends actions, it doesn’t enforce them or oversee that they’re followed; these duties fall within the scope and realm of the nurse manager and the staff nurse.

Focusing the review criteria

The design team and NPEC members were highly engaged in the opportunity to improve patient care by influencing individual practice. Our outside expert guided us in narrowing our focus. A thorough review of each case would be time consuming, especially at the beginning when the learning curve was steep. Given that reviews would be completed by busy direct-care staff nurses, identifying sensitive indicators was important. (See Rate, rule, and review indicators by clicking on the PDF icon above.)

Lessons learned

Since the launch of nursing peer review in 2008, the program has had outstanding success—partly because the entire process was clearly communicated to staff nurses and leaders at the outset. Before implementation, multiple information sessions were held so the staff could learn about peer review and understand their role in strengthening professional practice. Written information was made available and questions were answered. NPEC members completed mock case reviews and discussed their findings, questions, and concerns with peers and leaders. Staff nurses received ongoing feedback through council meetings, staff meetings, and other nursing forums.

The peer review program has led us to address systemic process issues in the areas of patient handoffs, patient flow, documentation, and interdepartmental communication barriers. Individual case review and feedback, commendations for exceptional practice, and acceptance of professional ownership have led to nurse-sensitive and other quality outcomes reaching top performance levels. RN engagement scores at the 95th percentile indicate a healthy work environment for our nurses to provide excellent patient care. Most importantly, dedicated nursing professionals have transformed their individual practice and influenced care within our hospital.

Selected references

Hitchings KS, Hathen-Davies N, Capuano TA, Morgan G. Peer case review sharpens event analysis. J Nurs Care Qual. 2007;23(4):296-304.

Pagano L, Lookinland S. Nursing morbidity and mortality conferences: promoting clinical excellence. Am J Crit Care. 2006;15(1):78-85.

Francine Barr is Vice President and Chief Nursing Officer at Bon Secours St. Mary’s Hospital in Richmond, Virginia.

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