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The Many Faces of Peer Review – Part 2 
The Manager’s Role 
Barb Haag-Heitman, PhD, RN, 
PHCNS-BC 
Vicki George, PhD, RN, FAAN 
Yvon Martel, VP of Sales, Healthcare, 
Halogen Software 
http://www.nursingconsultingpartners.com/ 
© 2014 Halogen Software. All rights reserved. All contents are confidential.
Objectives 
© 2014 Halogen Software. All rights reserved. All contents are confidential. 
• Describe: 
• The roles of the Nurse Manager in 
supporting a peer review program to 
achieve sustainable outcomes 
• Define: 
• The manager’s peer review process 
• Provide: 
• Three best practice examples
Safety Crisis in the US 
No Real Progress 
• Significant patient harm continues 
• Medical errors, unsafe practices and poor 
quality care continue to kill 98,000 
patients and waste billions of dollars every 
year 
• The average hospitalized patient 
experiences at least one medication error 
each day 
• 1-in 25 hospital patients has at least one 
healthcare-associated infection. 
© 2014 Halogen Software. All rights reserved. All contents are confidential.
© 2014 Halogen Software. All rights reserved. All contents are confidential.
ANA Definition Peer Review 
“an organized effort whereby practicing professionals 
review the quality and appropriateness of services 
ordered or performed by their professional peers” 
“the process by which practicing registered nurses 
systematically assess, monitor, and make judgments 
about the quality of nursing care provided by peers as 
measured against professional standards of practice” 
ANA Peer Review Guidelines, 1988, p.3 
© 2014 Halogen Software. All rights reserved. All contents are confidential.
Evidence Based Peer Review 
Principles 
• A Peer is Someone of the Same Rank 
• Peer Review is Practice Focused 
• Feedback is Timely, Routine and a 
Continuous Expectation 
• Peer Review Fosters a Continuous 
Learning Culture of Patient Safety and 
Best Practice 
• Feedback is Not Anonymous 
• Feedback Incorporates the 
Developmental Stage of the Nurse 
© 2014 Halogen Software. All rights reserved. All contents are confidential. 
© George/Haag-Heitman 2009
Peer Review 
© 2014 Halogen Software. All rights reserved. All contents are confidential. 
• Clarity in Definition 
• Focus on Outcomes 
• Cost and quantity of 
care, not just quality 
• Use the 6 EBP Principles of Peer Review 
• Assure Peer Review - all levels and all roles
Conceptual Model for Successful 
Implementation of Peer Review 
© 2014 Halogen Software. All rights reserved. All contents are confidential. 
Manager 
©George,1999
In the Responsive Environment, Managers 
Structurally Empower: 
• Involving all staff in quality and safety initiatives 
• Supporting the structures for clinical ladders, novice to 
expert, credentialing and privileging 
• Resources for staffing,& shared governance 
• Just culture 
© 2014 Halogen Software. All rights reserved. All contents are confidential.
Peer Review Vs. Performance Review 
• Understanding the peer 
review is different that 
performance evaluation 
• Peer review data can be 
used in the yearly 
performance evaluation 
• Peer review is about practice 
and not “good citizen” 
behaviors 
© 2014 Halogen Software. All rights reserved. All contents are confidential.
Colleague Evaluation vs Peer Review 
• 360 evaluation is not peer review. 
• Colleague evaluation is a form of 360 evaluation. 
• The 360 evaluation should be with all members of team 
contributing, not just peers. 
• 360 evaluation is optional for the organization, peer 
review is NOT optional for a professional. 
• Peer evaluation should not be done with performance 
© 2014 Halogen Software. All rights reserved. All contents are confidential. 
review.
Get the full story on the many faces! 
Watch the full webinar to learn about peer review 
evidence-based practice principles and processes that 
help build professional practice environments and 
accountability for nurses in all roles and in all settings. 
Watch now! 
Visit our website to learn more: 
www.halogensoftware.com 
© 2014 Halogen Software. All rights reserved. All contents are confidential.

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The Many Faces of Peer Review – Part 2 The Manager’s Role

  • 1. The Many Faces of Peer Review – Part 2 The Manager’s Role Barb Haag-Heitman, PhD, RN, PHCNS-BC Vicki George, PhD, RN, FAAN Yvon Martel, VP of Sales, Healthcare, Halogen Software http://www.nursingconsultingpartners.com/ © 2014 Halogen Software. All rights reserved. All contents are confidential.
  • 2. Objectives © 2014 Halogen Software. All rights reserved. All contents are confidential. • Describe: • The roles of the Nurse Manager in supporting a peer review program to achieve sustainable outcomes • Define: • The manager’s peer review process • Provide: • Three best practice examples
  • 3. Safety Crisis in the US No Real Progress • Significant patient harm continues • Medical errors, unsafe practices and poor quality care continue to kill 98,000 patients and waste billions of dollars every year • The average hospitalized patient experiences at least one medication error each day • 1-in 25 hospital patients has at least one healthcare-associated infection. © 2014 Halogen Software. All rights reserved. All contents are confidential.
  • 4. © 2014 Halogen Software. All rights reserved. All contents are confidential.
  • 5. ANA Definition Peer Review “an organized effort whereby practicing professionals review the quality and appropriateness of services ordered or performed by their professional peers” “the process by which practicing registered nurses systematically assess, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice” ANA Peer Review Guidelines, 1988, p.3 © 2014 Halogen Software. All rights reserved. All contents are confidential.
  • 6. Evidence Based Peer Review Principles • A Peer is Someone of the Same Rank • Peer Review is Practice Focused • Feedback is Timely, Routine and a Continuous Expectation • Peer Review Fosters a Continuous Learning Culture of Patient Safety and Best Practice • Feedback is Not Anonymous • Feedback Incorporates the Developmental Stage of the Nurse © 2014 Halogen Software. All rights reserved. All contents are confidential. © George/Haag-Heitman 2009
  • 7. Peer Review © 2014 Halogen Software. All rights reserved. All contents are confidential. • Clarity in Definition • Focus on Outcomes • Cost and quantity of care, not just quality • Use the 6 EBP Principles of Peer Review • Assure Peer Review - all levels and all roles
  • 8. Conceptual Model for Successful Implementation of Peer Review © 2014 Halogen Software. All rights reserved. All contents are confidential. Manager ©George,1999
  • 9. In the Responsive Environment, Managers Structurally Empower: • Involving all staff in quality and safety initiatives • Supporting the structures for clinical ladders, novice to expert, credentialing and privileging • Resources for staffing,& shared governance • Just culture © 2014 Halogen Software. All rights reserved. All contents are confidential.
  • 10. Peer Review Vs. Performance Review • Understanding the peer review is different that performance evaluation • Peer review data can be used in the yearly performance evaluation • Peer review is about practice and not “good citizen” behaviors © 2014 Halogen Software. All rights reserved. All contents are confidential.
  • 11. Colleague Evaluation vs Peer Review • 360 evaluation is not peer review. • Colleague evaluation is a form of 360 evaluation. • The 360 evaluation should be with all members of team contributing, not just peers. • 360 evaluation is optional for the organization, peer review is NOT optional for a professional. • Peer evaluation should not be done with performance © 2014 Halogen Software. All rights reserved. All contents are confidential. review.
  • 12. Get the full story on the many faces! Watch the full webinar to learn about peer review evidence-based practice principles and processes that help build professional practice environments and accountability for nurses in all roles and in all settings. Watch now! Visit our website to learn more: www.halogensoftware.com © 2014 Halogen Software. All rights reserved. All contents are confidential.