A system engineering approach is used to reduce frontline nursing care variability by integrating peer review to enhance quality of care efforts on the frontline.

1. Nursing Peer Review:
How to improve care and reduce costs
Abstract
This proposal advocates a systems engineering approach to reducing frontline nursing care variability by integrating a comprehensive Professional Peer Review model to enhance quality and safety efforts in the clinical setting. This model offers continuous daily improvement (CDI), professional collaboration, improved safety and quality, and practice accountability as a framework to build an organizational learning culture.

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Copyright © 2014 iCareQuality Inc.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the copyright owners.
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Document No. 08201403
Published by iCareQuality Incorporated® 2014
Any comments relating to the material contained in this document may be submitted to:
 761 West Sproul Road, Suite #301 Springfield, PA 19064
 Phone: 610 732 8500
 PR@iCareQuality.org

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Table of Contents
Abstract ................................................................................................................ 1
Context and Opportunity Statement ................................................................. 3
Professional Peer Review Supports QI ............................................................... 4
Systems Engineering Approach .......................................................................... 5
Patient Safety Focus with CloseCareGap ........................................................... 6
Summary and Call to Action ............................................................................... 8
References ............................................................................................................ 8
About iCareQuality Organization .................................................................... 10
About Our Team ................................................................................................ 11
Context and Opportunity Statement
The Healthcare system is undergoing unprecedented change. Patients, providers and policy leaders are coming together to

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re-design care delivery, expand services, improve patient safety, reduce errors, and decrease total cost of care.3 At the same time, professional associations and regulatory agencies are striving to close gaps in care by adopting new technologies, building creative care models, and developing collaborative learning programs. 2,3,4,6
According to recent IOM reports, The Future of Nursing,7,8 nurses can play a key role in the healthcare transformation process. Organizations such as the American Nurses Credentialing Center,9,10 the American Nurses Association11 and Magnet programs have supported and strengthened the mission to improve the nursing profession through education, advanced degrees and certifications. Central to the transformation process is self-regulation and accountability for clinical practice (Code of Ethics, ANA 12). The Peer Review process affirms the nurse's duty to being accountable for professional practice, competence in skills and knowledge in evidence-based care delivery.13
Professional Peer Review Supports QI
In this proposal, we embrace “Peer Assessment” methodology since it creates a non-punitive culture and supports experimental and shared learning. A Peer review provides a healthy means for obtaining critical feedback and compliance measures for clinical performance in care delivery.13 A robust Peer Review Process (PRP) is achieved through direct, real-

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time clinical observations or through retrospective chart review. Peer-to-Peer observations measure the current practice against industry standards and reduce care variability. Continuous performance improvement fosters the refinement of knowledge, skills, and clinical decision-making processes to enhance individual competencies and enterprise capabilities.14 Thus, peer feedback promotes patient safety, reduces the likelihood of errors, and addresses the human factor element in patient care delivery.13 PRP brings additional benefits by meeting professional requirements to various organizations such as Magnet designation, ANCC for evaluating learning effectiveness, the employer for improved patient outcomes, and society by making care affordable.
Systems Engineering Approach
Our mission is to identify and measure unexplained gaps in clinical care. These critical gaps lead to unnecessary care variability and medical errors15. To close the gaps and incorporate evidence into action, we advocate a clinical improvement learning platform by leveraging lessons from proven industry leaders4,16. Toyota and the airline industries have revolutionized the consumer experience by systematically simplifying, standardizing, combining and automating processes and raising the bar to zero error defects. Healthcare is now realizing the benefits of such EBP models16 and incorporating checklists, bundles, Lean, Six Sigma and Crew Resource Management to improve care delivery.17, 18

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Our solution advocates a Lean approach (effective tool to tame wicked problems – see insert on left) with Six Sigma tools building a Clinical Learning Improvement Platform (CLIP). This process improvement learning model includes two key components - peer review and real-time process observations. The professional clinical learning platform collects data from peers and then measures care delivery against best practice standards. Clinical Improvement Learning Platform (CILP) includes:
 Self-paced online learning for common nursing processes
 Instructor-led education delivered to geographically diverse audiences
 Ability to engage in the Peer Review process through real time clinical process observation
 A guide to continuous improvement initiatives through the project management life cycle
 An industry repository data bank to measure variations in clinical care delivery
 Adoption of an agile real-time health information system that is integrated with current EHR and delivers pertinent patient health information at the point of care
Patient Safety Focus with CloseCareGap
Our team developed an integrated HIT capability to help reduce variations in the clinical practice at the bedside. CloseCareGap, PSO is a federally approved Patient Safety Organization that designed a Patient Safety Evaluation

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System (PSES). The PSES is a globally scalable cloud based safety solution for reducing hospital acquired infections and adverse events. Our capability employs a sustainable quality engagement framework to effectively measure best practice and close gaps in knowledge to improve care delivery on the frontline.
Our quality improvement platform can be implemented incrementally, one patient unit at a time, with minimum disruption to the hospital’s current operations. Our Patient Safety Organization adapted the CMS "Partnership for Patients” program to make hospital care safer, more reliable, and less costly. The Partnership for Patients identified core patient safety areas listed below. These aims and priorities have the potential to rapidly improve health outcomes and increase the effectiveness of care for our patient populations.20
 Catheter-associated urinary tract infections (CAUTI)
 Central line-associated blood stream infections (CLABSI)
 Injuries from falls and immobility
 Pressure ulcers
 Surgical site infections
 Venous thromboembolism (VTE)
 Ventilator-associated pneumonia (VAP)
Our bedside clinical smart tools can help to identify and measure gaps in care delivery and adverse events using a

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Continuous Learning Improvement Platform. Our goal is to work with providers and clinical leaders to ensure safe, cost effective care by focusing on targeted opportunities for improvement, such as: high risk events, high volume events, patient outcomes, problem prone events, and hospital acquired conditions
Summary and Call to Action
At iCareQuality, our mission is simple – to close knowledge gaps in care delivery and engage frontline providers using a real-time, collaborative learning platform. Our professional practice model embraces transparency and accountability to identify and measure unexplained gaps in clinical care. These critical gaps in care delivery lead to escalating healthcare costs, increased rates of infection, poor patient satisfaction, delays in care and medical error. By identifying gaps in clinical practice, clinical leaders can develop specific action plans to improve patient outcomes, support quality improvement, foster transparency, and build a culture of safety.
References
1. Berwick, D. Hackbarth, A. Waste in Healthcare. JAMA. 2012;307(14):1513-1516. Website: http://www.hta.hca.wa.gov/documents/Waste_in_Healthcare_JAMA_2012.pdf
Accessed April 20, 2013.
2. Report of the Lucian Leape Institute Roundtable. Order from Chaos: Accelerating Care Coordination (2012) Website: http://www.npsf.org/wp-content/uploads/2012/10/Order_from_Chaos_final_web.pdf Accessed April 20, 2013.
3. Department of Health and Human Services. Report to Congress (2012) National Strategy for Quality Improvement in Healthcare. Website: http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf Accessed April 20, 2013.

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4. IOM Consensus Report (2012). Better Healthcare at Lower Cost: The Path to Continuously Learning in Healthcare in America. Website: http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The- Path-to-Continuously-Learning-Health-Care-in-America.aspx Accessed April 20, 2013.
5. Stiegel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. http://www.ihi.org/knowledge/Pages/IHIWhitePapers/AGuidetoMeasuringTripleAim.aspx Accessed April 20, 2013.
6. IOM Core Metric for Better Care, Lower Cost and Better Health (2012). Website http://www.iom.edu/Activities/Quality/VSRT/2012-DEC-05.aspx Accessed April 20, 2013.
7. IOM Report Brief. The Future of Nursing, Leading Change Advancing Health (2010).
http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of- Nursing/Future%20of%20Nursing%202010%20Report%20Brief.pdf
Accessed April 20, 2013.
8. IOM Consensus Report. The Future of Nursing, Leading Change Advancing Health (2011).
http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
Accessed April 20, 2013.
9. American Nurses Credentialing Center’s Commission on Accreditation (2012). The Value of Accreditation for Continuing Nursing Education: Quality Education Contributing to Quality Outcomes. Silver Spring, MD: American Nurses Credentialing Center.
http://www.nursecredentialing.org/Accreditation/ResourcesServices/Accreditation- WhitePaper2012.pdf Accessed April 20, 2013.
10. American Nurses Credentialing Center’s Commission on Accreditation. ANCC Primary Accreditation Application Manual (2013) http://www.nursecredentialing.org/Accreditation/2013- PrimaryAccreditationManual.html Accessed April 20, 2013.
11. American Nurses Association. ANA Scope and Standards of Practice Nursing, 2nd edition (2010). http://library.brcn.edu/upload/docs/BRCN/Library/ANA/eBk_SL%20Nursing%20Scope%20%20Standards%202e%202010.pdf Accessed April 20, 2013.
12. Nursing World. ANA, Code of Ethics with Interpretive Statements (2010).
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of- Ethics.pdf Accessed April 20, 2013.
13. Diaz, L. Nursing Peer Review: Developing a framework for patient safety. Journal of Nursing Administration (2008) Nov. 38(11) 475-9.
14. IOM Workshop Summary . Digital Data Improvement Priorities for Continuous Learning in Healthcare (2012). http://www.iom.edu/Reports/2012/Digital-Data-Improvement-Priorities-for- Continuous-Learning-in-Health-and-Health-Care.aspx Accessed April 20, 2013
15. Hospital Survey on Patient Safety: 2012 User Database Comparative Report by AHRQ.
http://www.ahrq.gov/legacy/qual/hospsurvey12/hospsurv1223.pdf Accessed April 20, 2013.
16. Closing the Gap: From Evidence into Action (2012). The International Council of Nurses.
http://www.icn.ch/images/stories/documents/publications/ind/indkit2012.pdf
Accessed April 20, 2013.

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17. Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. http://www.ihi.org/knowledge/Pages/IHIWhitePapers/UsingCareBundles.aspx
Accessed April 20, 2013.
18. Gawande, Atul, MD. The Checklist Manifesto: How to Get Things Right. Picador Publishing (2011) (ISBN 10: 0312430000 / ISBN 13: 9780312430009)
19. Conklin, J. Wickedness and Social Complexity. http://cognexusgroup.com/wp- content/uploads/2013/03/wickedproblems.pdf Accessed April 20, 2013.
20. Agency for Healthcare Quality Research (2013). Annual Progress Report to Congress: National Quality Strategy for Quality Improvement in Healthcare. Retrieved 8-15-13 http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm
About iCareQuality Organization
iCareQuality, Inc. is a benefit corporation registered in state of Delaware United States with head office in Springfield Pennsylvania. We believe systematic engagement of care providers is key to building a sustainable healthcare system globally. To support our mission we build provider engagement tools, enable care providers develop new knowledge and freely disseminate this knowledge to care

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providers globally. As a benefit corporation, we pledge 40% of our profits to our providers, 50% for reinvestment and 10% for our investors.
About Our Team
Chief Architect
 Jason Uppal, P.Eng.
 Jason.Uppal@iCareQuality.org
Clinical Support
 Kate ONeill, MSN, RN
 Kate.Oneill@iCareQuality.org
Sales and Business Development
 Bryan Weston
 Bryan.Weston@iCareQuality.org