Open Forum

Our organization has a Nurse Peer Review Program. I have attached the documents we use.

Thank you,

Sharon J-J Peacock, MSN-Ed., RN, AMB-BC

Nursing Professional Development Generalist

Sentara Ambulatory Services Division

Office: 434-654-4529

Email: SJPEACOC@sentara.com | SASDClinEduTeam@sentara.com

590 Peter Jefferson Parkway, Suite 323, Charlottesville, VA 22911

RQI: RQI_SASD@sentara.com | Resuscitation Quality Improvement (RQI) (sharepoint.com)

Hello,

I designed a one-way blind peer feedback process for our primary care (PC) nursing staff. I call it peer feedback because in the Veterans Administration, there is a separate peer review process that is mandated (could result in loss of job) and that is not we're doing for PC nursing; it's feedback. I will say that I have not found sources that state it must be a one-way blind process. I've seen it actually encouraged that it should not be, however, there is a lot of anxiety about being reviewed and personal relationship dynamics that do not lend itself to staff buy-in.

Here's the general outline:

• All staff are assigned a code that is only known to myself.
• Our process is for only 1 peer feedback assignment per year due to the other reviews that are being completed and due to the volume of staff (over 100 LPNS and RNs).
• Staff are assigned a peer in another clinic on a rotational basis. We have 10 PC clinics, so this is not a challenge. This is done primarily so that staff are not reviewing their co-worker and indirectly encourages buy-in.
• Notes are randomly selected for note type and timeframe. Our PC RNs have many types of encounters but for the purposes of quality monitoring, we are only looking at care management activities, such as chronic disease management and telephone triage.
• Assignments are sent to staff via encrypted email with info on the form that includes the employee being reviewed, the patient being reviewed, the date of the encounter, and the reviewer code. The indicators depend on the type of note. For example, telephone triage has more indicators than chronic disease management.
• Staff are given approx. 4 wks. to complete. They review/complete the form and send back to me via encrypted email.
• Reminder is sent to staff who have not completed after 2 wks.
• Status is sent to respective clinic managers 1 wk. prior to due date to help facilitate completion by their employees.
• Once completed forms are received, I perform a technical review to ensure it is correct and if it is not, then I provide the feedback to the peer performing the review. I have found not performing technical reviews is problematic because staff receive a review that is not correct and then they are upset and/or confused. It could be that there was an indicator that was not marked. It could be that an indicator was marked as unmet, however, upon review of the record, the nurse did meet the indicator. Conversely, it could be that the indicator was marked as met, however, upon review of the record, the nurse did not meet the indicator. I also provide screenshots to validate my findings if needed. Sometimes it's just a matter that someone overlooked something that was documented.
• Forms allow for comments on individual indicators as well as overall comments.
• When I perform the technical review, I may also leave some overall comments. At times there is something that I observe that may not be included in the indicators but deserves attention like an incorrect encounter.
• Validated review is sent via encrypted email to the nurse and their respective manager.
• Cumulative review findings are shared with staff and leadership. Sometimes a change to an indicator is needed, sometimes the data supports a change to the documentation template.

cam

Courtney A. Monterusso BSN, RN, AMB-BC, FNS

Performance Improvement Facilitator –Primary Care Nursing 

ONS Detail Electronic Enterprise Standardization Consultant

VA St. Louis Health Care System | 915 N. Grand Ave, St. Louis, MO 63106 

314.652.4100 ext. 54396 or 289-7676  11F/JC  courtney.monterusso@va.gov

                                           "There is no limit to the amount of

                                            good you can do if you don't care

                                            who gets the credit."

                                                                 ~Ronald Reagan~

Hello,

I designed a one-way blind peer feedback process for our primary care (PC) nursing staff. I call it peer feedback because in the Veterans Administration, there is a separate peer review process that is mandated (could result in loss of job) and that is not we're doing for PC nursing; it's feedback. I will say that I have not found sources that state it must be a one-way blind process. I've seen it actually encouraged that it should not be, however, there is a lot of anxiety about being reviewed and personal relationship dynamics that do not lend itself to staff buy-in.

Here's the general outline:

• All staff are assigned a code that is only known to myself.
• Our process is for only 1 peer feedback assignment per year due to the other reviews that are being completed and due to the volume of staff (over 100 LPNS and RNs).
• Staff are assigned a peer in another clinic on a rotational basis. We have 10 PC clinics, so this is not a challenge. This is done primarily so that staff are not reviewing their co-worker and indirectly encourages buy-in.
• Notes are randomly selected for note type and timeframe. Our PC RNs have many types of encounters but for the purposes of quality monitoring, we are only looking at care management activities, such as chronic disease management and telephone triage.
• Assignments are sent to staff via encrypted email with info on the form that includes the employee being reviewed, the patient being reviewed, the date of the encounter, and the reviewer code. The indicators depend on the type of note. For example, telephone triage has more indicators than chronic disease management.
• Staff are given approx. 4 wks. to complete. They review/complete the form and send back to me via encrypted email.
• Reminder is sent to staff who have not completed after 2 wks.
• Status is sent to respective clinic managers 1 wk. prior to due date to help facilitate completion by their employees.
• Once completed forms are received, I perform a technical review to ensure it is correct and if it is not, then I provide the feedback to the peer performing the review. I have found not performing technical reviews is problematic because staff receive a review that is not correct and then they are upset and/or confused. It could be that there was an indicator that was not marked. It could be that an indicator was marked as unmet, however, upon review of the record, the nurse did meet the indicator. Conversely, it could be that the indicator was marked as met, however, upon review of the record, the nurse did not meet the indicator. I also provide screenshots to validate my findings if needed. Sometimes it's just a matter that someone overlooked something that was documented.
• Forms allow for comments on individual indicators as well as overall comments.
• When I perform the technical review, I may also leave some overall comments. At times there is something that I observe that may not be included in the indicators but deserves attention like an incorrect encounter.
• Validated review is sent via encrypted email to the nurse and their respective manager.
• Cumulative review findings are shared with staff and leadership. Sometimes a change to an indicator is needed, sometimes the data supports a change to the documentation template.

cam

Courtney A. Monterusso BSN, RN, AMB-BC, FNS

Performance Improvement Facilitator –Primary Care Nursing 

ONS Detail Electronic Enterprise Standardization Consultant

VA St. Louis Health Care System | 915 N. Grand Ave, St. Louis, MO 63106 

314.652.4100 ext. 54396 or 289-7676  11F/JC  courtney.monterusso@va.gov

                                           "There is no limit to the amount of

                                            good you can do if you don't care

                                            who gets the credit."

                                                                 ~Ronald Reagan~

Hello,

I designed a one-way blind peer feedback process for our primary care (PC) nursing staff. I call it peer feedback because in the Veterans Administration, there is a separate peer review process that is mandated (could result in loss of job) and that is not we're doing for PC nursing; it's feedback. I will say that I have not found sources that state it must be a one-way blind process. I've seen it actually encouraged that it should not be, however, there is a lot of anxiety about being reviewed and personal relationship dynamics that do not lend itself to staff buy-in.

Here's the general outline:

• All staff are assigned a code that is only known to myself.
• Our process is for only 1 peer feedback assignment per year due to the other reviews that are being completed and due to the volume of staff (over 100 LPNS and RNs).
• Staff are assigned a peer in another clinic on a rotational basis. We have 10 PC clinics, so this is not a challenge. This is done primarily so that staff are not reviewing their co-worker and indirectly encourages buy-in.
• Notes are randomly selected for note type and timeframe. Our PC RNs have many types of encounters but for the purposes of quality monitoring, we are only looking at care management activities, such as chronic disease management and telephone triage.
• Assignments are sent to staff via encrypted email with info on the form that includes the employee being reviewed, the patient being reviewed, the date of the encounter, and the reviewer code. The indicators depend on the type of note. For example, telephone triage has more indicators than chronic disease management.
• Staff are given approx. 4 wks. to complete. They review/complete the form and send back to me via encrypted email.
• Reminder is sent to staff who have not completed after 2 wks.
• Status is sent to respective clinic managers 1 wk. prior to due date to help facilitate completion by their employees.
• Once completed forms are received, I perform a technical review to ensure it is correct and if it is not, then I provide the feedback to the peer performing the review. I have found not performing technical reviews is problematic because staff receive a review that is not correct and then they are upset and/or confused. It could be that there was an indicator that was not marked. It could be that an indicator was marked as unmet, however, upon review of the record, the nurse did meet the indicator. Conversely, it could be that the indicator was marked as met, however, upon review of the record, the nurse did not meet the indicator. I also provide screenshots to validate my findings if needed. Sometimes it's just a matter that someone overlooked something that was documented.
• Forms allow for comments on individual indicators as well as overall comments.
• When I perform the technical review, I may also leave some overall comments. At times there is something that I observe that may not be included in the indicators but deserves attention like an incorrect encounter.
• Validated review is sent via encrypted email to the nurse and their respective manager.
• Cumulative review findings are shared with staff and leadership. Sometimes a change to an indicator is needed, sometimes the data supports a change to the documentation template.

cam

Courtney A. Monterusso BSN, RN, AMB-BC, FNS

Performance Improvement Facilitator –Primary Care Nursing 

ONS Detail Electronic Enterprise Standardization Consultant

VA St. Louis Health Care System | 915 N. Grand Ave, St. Louis, MO 63106 

314.652.4100 ext. 54396 or 289-7676  11F/JC  courtney.monterusso@va.gov

                                           "There is no limit to the amount of

                                            good you can do if you don't care

                                            who gets the credit."

                                                                 ~Ronald Reagan~

Hello,

I designed a one-way blind peer feedback process for our primary care (PC) nursing staff. I call it peer feedback because in the Veterans Administration, there is a separate peer review process that is mandated (could result in loss of job) and that is not we're doing for PC nursing; it's feedback. I will say that I have not found sources that state it must be a one-way blind process. I've seen it actually encouraged that it should not be, however, there is a lot of anxiety about being reviewed and personal relationship dynamics that do not lend itself to staff buy-in.

Here's the general outline:

• All staff are assigned a code that is only known to myself.
• Our process is for only 1 peer feedback assignment per year due to the other reviews that are being completed and due to the volume of staff (over 100 LPNS and RNs).
• Staff are assigned a peer in another clinic on a rotational basis. We have 10 PC clinics, so this is not a challenge. This is done primarily so that staff are not reviewing their co-worker and indirectly encourages buy-in.
• Notes are randomly selected for note type and timeframe. Our PC RNs have many types of encounters but for the purposes of quality monitoring, we are only looking at care management activities, such as chronic disease management and telephone triage.
• Assignments are sent to staff via encrypted email with info on the form that includes the employee being reviewed, the patient being reviewed, the date of the encounter, and the reviewer code. The indicators depend on the type of note. For example, telephone triage has more indicators than chronic disease management.
• Staff are given approx. 4 wks. to complete. They review/complete the form and send back to me via encrypted email.
• Reminder is sent to staff who have not completed after 2 wks.
• Status is sent to respective clinic managers 1 wk. prior to due date to help facilitate completion by their employees.
• Once completed forms are received, I perform a technical review to ensure it is correct and if it is not, then I provide the feedback to the peer performing the review. I have found not performing technical reviews is problematic because staff receive a review that is not correct and then they are upset and/or confused. It could be that there was an indicator that was not marked. It could be that an indicator was marked as unmet, however, upon review of the record, the nurse did meet the indicator. Conversely, it could be that the indicator was marked as met, however, upon review of the record, the nurse did not meet the indicator. I also provide screenshots to validate my findings if needed. Sometimes it's just a matter that someone overlooked something that was documented.
• Forms allow for comments on individual indicators as well as overall comments.
• When I perform the technical review, I may also leave some overall comments. At times there is something that I observe that may not be included in the indicators but deserves attention like an incorrect encounter.
• Validated review is sent via encrypted email to the nurse and their respective manager.
• Cumulative review findings are shared with staff and leadership. Sometimes a change to an indicator is needed, sometimes the data supports a change to the documentation template.

cam

Courtney A. Monterusso BSN, RN, AMB-BC, FNS

Performance Improvement Facilitator –Primary Care Nursing 

ONS Detail Electronic Enterprise Standardization Consultant

VA St. Louis Health Care System | 915 N. Grand Ave, St. Louis, MO 63106 

314.652.4100 ext. 54396 or 289-7676  11F/JC  courtney.monterusso@va.gov

                                           "There is no limit to the amount of

                                            good you can do if you don't care

                                            who gets the credit."

                                                                 ~Ronald Reagan~