Transcript NHCP Nursing Peer Review - American Academy of Ambulatory

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
INTRODUCTION
Naval Health Clinic Cherry Point
(NHCCP) Location
Organizational Scope
Standard Practice
BACKGROUND



NHCCP recognized need
Exists for Medical Staff
Models available for Nursing Peer Review


Most subjectively based
Severity and Criticality (SAC) scoring component

Trigger for investigative review
BACKGROUND

Monitoring Tool
12 core indicators
 3 to 6 departmental indicators


Universally applicable (military/civilian)

PDCA (Plan, Do, Check, Act) Methodology
CRITERIA
Non-punitive
Educational
Systematic
COMPONENTS
Policy (ECONS By-Laws/Nursing Policy)
 Model
 Flow diagram
 Indicators



Consistent yet flexible process
Scoring
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.”
MODEL
Individual skills
and abilities
= process
= outcome
Provide
Feedback
Nursing
Process
Sll/Patient Safety
2/27/2008
Nursing
Peer
Review
Model
Improvement in
Patient Care
Promote
Professional
Growth
Professional
Performance
FLOW DIAGRAM
Begin
Nurse
PeerREVIEW
ReviewFLOW
FlowDIAGRAM
Diagram
NURSE PEER
End
Gain approval
of ECONS
Plan
Do the
Process
Process
Identify
participants
Identify
benchmark
data
Define purpose
Determine
appropriate
number of
charts to review
Gather /
research
information
Report results to
Staffing
Effectiveness,
ECONS, ECOMS,
BOD, and
incorporate into
PARS
Check
Act on
the
Process
Process
Results
Identify data
trends and take
action on them
Determine if
process has
areas that
break down
Take action and
redefine areas
of breakdown
Monitor
corrections
Begin to
monitor
Select general
and department
specific criteria
Develop
competencies
and monitoring
tool
Develop expanded
monitors for
examining / tracking
adverse events
sll / Patient Safety
2/28/2008
INDICATORS
Nursing Process (1 – 5 part question)
 Policies and Procedures (1 – 3 part
question)
 Patient Safety (7 questions)
 Pain Assessment (1 question)
 Professional Performance (1 question)


Department Specific (3-6 questions)
SCORING
Safety Assessment Code Matrix
Severity Categories
Frequency
Like the severity categories, the frequency rating applies to actual events and
close calls.
For actual close calls/actual events, assign severity based on the patient's actual condition.
Some incidents that occur may have an overwhelming potential for a catastrophic event, but that
determination will be left to the discretion of the ECONS.
Catastrophic
Major
Patients with Actual:
Death or major permanent loss of function
(sensory, motor,
Physiologic, or intellectual) not related to the
natural course
of the patient's illness or underlying condition (i.e.,
acts of
commission or omission).
Patients with Actual:
Permanent lessening of bodily functioning
(sensory, motor, physiologic, or intellectual)
not related to the natural course of the
patient's illness or underlying conditions (i.e.,
acts of commission or omission).
Suicide (inpatient or outpatient)
Surgical intervention required
Rape
Increased length of stay or level of care of 3
days or more
Disfigurement
Hemolytic transfusion reaction
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 &
Frequency
High
Medium
Low
Catastrophic
3
3
3
Major
3
2
2
Moderate
2
1
1
Minor
1
1
1
Surgery/Procedure on the wrong patient or wrong
body part
Infant abduction or infant discharge to the wrong
family
Death or major permanent loss of function that is a
Direct result of injuries sustained in a fall; or
associated
With an unauthorized departure from an aroundthe-clock treatment setting; or the result of an
assault or other crime
Moderate
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.
Minor
Patients with Actual:
Patients with Actual:
Increased length of stay or higher level of care for
No increased length of stay or increased level
Adapted (in part) from the VA National Center for Patient Safety
10/2002
1
CHART AUDITS
Random
 Peer Reviewers

DATA INPUT TOOL
Patient Identifier
Month
Department
Nurse(s)
Category
Nursing Process
Ple
Yes
No
N/A
a) Age specific plan of care demonstrates collection of patient data through
assessment; implementation; evaluation; adjustment, if appropriate;
and discharge instructions
Policies and
Procedures
Patient Safety
a) Adherence to departmental policies/procedures; Command instructions;
BUMED and DOD instructions (note specifics in comment section)
a) Demonstration of patient identification
b) Effective communication through verbal/telephone orders, standardized
abbreviations, critical lab reporting and handoffs
c) Medication safety and reconciliation addressed and documented
d) Contact or respiratory infection identified and documented, if appropriate
e) Prevention of patient falls through assessment, if appropriate
f) Encouragement of patient involvement in care
g) Identification of patient risk such as suicide, if appropriate
Pain Assessment
Professional
Performance
a) Patient is assessed and monitored for pain reduction using 1:10 scale
a) Assistance is obtained when situation goes beyond nurse's
scope of practice (note specifics in comment section)
b) Evidence of critical thinking skills
Department Specific
Reviewer
SAC Score
() ECONS review required
COMMENTS:
DATA INPUT TOOL
Nursing Peer Review Form
Month:
Year:
Department:
Patient Identifier:
Nurse (s):
1)
2)
3)
4)
5)
a)
NURSING PROCESS
Age specific care demonstrates collection of patient data through assessment; implementation;
evaluation; adjustment, if appropriate; and patient education.
No o
N/A
o
SAC
POLICIES AND PROCEDURES
Adherence to departmental policies/procedures; Command instructions; BUMED and DOD instructions
(note specifics in comment section)
Yes
a)
a)
o
Yes
o
No o
N/A
SAC
PATIENT SAFETY
Demonstration of patient identification
Yes
o
No
SAC
o
N/A
o
o
DATA FINDINGS

Aggregate and
report findings
Review process
120.0
ED
IPCU
L&D
100.0
OR Avg =
99.8%
80.0
Percent Compliant

Departmental Nursing Peer Review Over Time
OR
L&D Avg =
86.4%
Limited ED staffing began in May
due to BRAC conversion,
prohibiting data collection. IPCU
and L&D began conversion in
June, thus July data is based
60.0
IPCU Avg =
88.2%
40.0
ED Avg =
87.5%
20.0
Staffing
change
Overall avg = 92.2%
0.0
Aug '06
Sept
Oct
Nov
Dec '06
Jan '07
Feb
Mar
Apr
May
June
Month
Nursing Peer Review
Percent Compliance Improvement
Nsg Proc
Pol & Proc
Pt Safety
Pain Assess
Prof Per
4.5%
Dept Spec*
4.0%
1.4%
15.1%
36.0%
2.5%
July
IMMEDIATE RESULTS

Examples of immediate “flags” during
process implementation included:
IPCU - Pain assessments / re-assessments
 L&D - Breastfeeding during first hour of life
 UCC - Medications

PROCESS CHANGES

NPR = Constant work in process
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 3c (Patient Safety) wording should
remove “and reconciliation” as it is a provider
function

CURRENT RESULTS
NPR Compliance Rate by Department
NPR Department Volume Over Time
N = 1596
100
102
OR/ASU
ED/ICC
90
100
FHP
80
WH
98
96.6
Compliance Rate
70
60
50
40
96
94.8
93.6
94
92
90.7
30
90
20
88
10
86
0
Aug
'06
Sept
Oct
Nov
Dec
'06
Jan
'07
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
'07
ASU
Jan
'08
FCC
FHP
Departm ent
Month
Aggregated Nursing Compliance Rate Over Time
Average Rate = 93.2%
120.0
BRAC
100.0
80.0
Percent Compliant
Number Charts Reviewed
100
FCC
60.0
40.0
20.0
0.0
Aug
'06
Sept
Oct
Nov
Dec
'06
Jan
'07
Feb
Mar
Apr
May
Month
June
July
Aug
Sept
Oct
Nov
Dec
'07
Jan
'08
ICC
WH
COMPARING RESULTS
Naval Hospital Camp Lejeune
 Fort Knox Army

WHERE DO WE GO FROM HERE?
Continue to “tweak” the monitoring tool
 Continue staff education
 Gain more staff involvement in process
 Drill down staff results to identify goal
opportunities
 Continue to share program with interested
facilities
