Hospitals in Pursuit of Excellence, a key component of the AHA's health reform strategies, encourages and promotes hospital-led improvements in care that are based on best practices and can be replicated across the field. On a recurring basis, AHA News spotlights hospitals and leaders that use HPOE principles to deliver more efficient, effective and safer care. For more information, visit
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By Jennifer Towne
In 2006, 25-bed Sunnyside (WA) Community Hospital was looking for ways to establish a strong safety culture throughout the organization. As part of that effort, it wanted to get its nursing staff more engaged in the patient experience and patient safety.
At the time, there was no forum for staff to come together and discuss patient care. Nurses felt uneasy giving constructive suggestions to other nurses.
Quality management coordinator Sheila Robinson looked to the physician peer review process as a model for providing constructive, but non-punitive, criticism and for helping caregivers sharpen skills and improve patient care.
To be successful, peer reviews need to be done by an actual peer with similar expertise, Robinson says. For instance, emergency department (ED) nurses need to review ED cases. It's a minor point, but a serious one. Robinson says nurses need instruction from other nurses in their department. Otherwise, they tend to disregard the advice because the reviewer doesn't have "real-life" experience on how processes actually work in the department.
Hospitals also need to emphasize that peer reviews are not a punitive tool. "We made sure we were very consistent in our messaging," says Robinson. "We said what we meant and meant what we said - reviews would not be used for any disciplinary action."
At first, staff was leery of the entire process and acceptance was slow. But hospital leadership stressed that the reviews would only be used as a tool to improve patient care and encourage professional development. Yet, even with consistent messaging from hospital leadership, it took nearly two years for staff nurses to put down their guard and accept the reviews.
Besides the consistent messaging, part of the acceptance was due to the fairness shown in the actions of this committee. "It shows that the hospital cares about patient care," says Linda Monroe, a surgery charge nurse. "The hospital cares about nurses; they take the time to help us."
Putting information to good use. Each completed peer review is brought to a nurse-practice committee for further discussion. This committee features staff nurses and nurse managers representing every hospital department, a union representative, a quality manager and the chief executive officer and chief nursing officer. The review process by itself will go a long way to foster collaborative relationships among nurses, but Sunnyside leaders wanted to be sure the hospital acted on the nurses' suggestions for improvement.
A nursing team took a storage room and transformed it into an education room. Each month, different learning opportunities are identified from the review process. Staff nurses research the problem, define solutions and provide training or education opportunities to the rest of the nursing staff. For instance, after a couple peer reviews, staff nurses noted that documentation could be improved. Senior leaders asked them how to do it and what kind of resources and education they needed to get the job done. Then they stepped back to allow the nurses to make the change.
"They [frontline staff] usually have the solution," Robinson says. "And if they come up with it, they'll accept it, especially if it takes time out of their day." Part of the success is that Sunnyside follows up with an action plan, adds Jean Clark, Sunnyside's chief nursing officer. "We are going to be very supportive of our frontline staff."
Quality Impact. Peer reviews have long been used in all types of industries to improve quality, including health care. "As professionals, we have an obligation to raise the professional standard," Clark says. "Continuing education is important and this is a form of continuing education."
It is especially useful for new nurses. A form of mentoring has grown out of Sunnyside's peer review process. "If you have new nurses, they may not know what they don't know," says Clark. This mentoring has brought a huge change to the culture. While traditional hospital culture may tend to pit new nurses against experienced nurses, the two groups work together at Sunnyside. Says Sunnyside medical-surgical nurse Doug Coley: "I enjoy being here and learning from [Clark], and anything new that I have to offer, she wants to hear."
Measuring Success. Sunnyside has implemented many changes to processes in every department of the hospital based on the feedback from the reviews. It also has offered several classes to its nursing staff based on lessons learned from the peer review process. For instance, it was discovered that the description of a pressure ulcer with patients who present on admission was inconsistent. A consistent description of the wound helps all clinicians identify any changes in progression. As a result, a wound care specialist gave classes to identify a consistent method of identifying pressure ulcers.
In another project, the nursing staff reviewed and tweaked the process of documenting pain assessment in patients with a fractured hip. Additionally, more than 20 different classes have been offered, ranging from code drills for pediatric and adult patients to management of sexual assault victims.
Jennifer Towne is the AHA Quality Center's director of content and knowledge management.
