UTAH STATE
Guidelines for Peer Review for
Advanced Practice Registered Nurses

Purpose of the Guidelines for Peer Review:
Peer review is a process by which Advanced Practice Registered Nurses (APRN), engaged in the practice of providing health care, systematically assess, monitor and evaluate the quality of care provided to patients or clients by their peers as measured against established components of standard practice.

Goals to be achieved in the Guidelines for Peer Review:

  1. To identify providers of Utah APRN peer review.
  2. To design a systematic peer review process for Utah State APRNs.
  3. To identify the process of reporting and correcting deficiencies found in APRN practice during the peer review process.

Established Standards of Practice:
The proposed peer review process is based on components of standard practice which include obtaining patient history, performing appropriate assessment, diagnosing problems, ordering, performing and interpreting diagnostic tests, and developing, implementing and evaluating treatment plans. In addition, each APRN will ensure that the tasks performed in their practice is appropriate to the APRNs level of competence, education and experience as well as the clinical setting.

Establishment of Reviewer Status:
Any APRN or physician in the State of Utah may be a reviewer. An APRN need only choose another APRN or a physician who is willing to perform the peer review. However, APRNs being reviewed must identify the provider group under which they are being reviewed.

Establishment of Providers:
A provider of Utah APRN peer review may be any licensed health care facility, or organized nursing organization (i.e., UNA, Nurse Practitioner Conference Group (NPCG), Utah Council of Psychiatric/Mental Health Nurses, state nurse anesthetists group, or special interest group such as the Intermountain Chapter of the Oncology Nursing Society (ICONS) who are able to establish to the Utah Board of Nursing concurrence with the following criteria:

  1. Establish that the members of their group are competent to perform satisfactory peer review.
  2. Establish a committee to approve guidelines for APRN peer review submitted by clinical facilities, such as licensed health care facilities or established nursing organizations, such as the NPCG, NAPNAP, whose membership includes advanced practice registered nurses using formats other than those provided in this document.
  3. Designate members of the provider group who will establish a process to correct deficiencies demonstrated by peer review as well as an appeals process for APRNs found to have deficiencies.
  4. Develop a system of reporting to the Utah Board of Nursing, APRNs who are found deficient in peer review and who have been unable to correct the deficiency.

Organizations or licensee health care facilities who desire to function as providers shall submit to the Utah Board of Nursing a summary, as suggested in Form A, Establishment of Provider Status. This summary will demonstrate how the group or organization will satisfy the above criteria, including fees, if any, to be charged for the review, remediation counseling and documentation. This information will be resubmitted yearly in order to maintain current information on providers at the Utah Board of Nursing.

Peer Review Process:
In order to evaluate the practice of an APRN, the peer review process will consist of a systematic chart review or oral case presentation. Each APRN utilizing the APRN Peer Review Audit, Form B (attached), will have a minimum of six (6) charted patient visits or oral presentations of patient visits (or a combination thereof) reviewed by another APRN or physician every year. No more than two visits for a single patient per year may be reviewed. (It is proposed that for the six month period from 1 July 1999 to 31 December 1999 only three visits should be reviewed.) All charted patient visits or oral presentations must pass review with every component of the review at a yes level. Charted patient visits or oral presentations must be reviewed in a fashion that will guarantee the confidentiality of the patients involved. Documents of review, deficiencies, and corrective counseling are to be kept by the reviewer and the APRN being reviewed.

The peer review process will begin on 1 July 1999. A trial period to accustom APRNs to the review process will be carried out from 1 May to 1 July 1999. On 1 July 1999, the peer review process will formally begin and APRNs will have to pass the peer review process at an 80% success rate from that time forward. Patient visits prior to 1 July 1999 will not be reviewed.

Current clinical practice requirements by the Utah Board of Nursing, Utah Department of Professional Licensure (DOPL) or national nursing groups, such as American Academy of Nurse Practitioners or the AACN, will not be reviewed in this peer review process.

Correction and reporting of deficiencies:
APRNs who demonstrate deficiencies in the audit of their charted patient visits or oral presentations shall receive documented assistance from their reviewer to correct the problem. A second review of three charted patient visits or oral presentations occurring during the two months following the deficiency finding shall be conducted by the same reviewer. If a second review demonstrates deficiencies, the APRN will receive counseling from a member of their provider group. A third review of three charted patient visits or oral presentations will be carried out by a member of the provider group within two months of the second deficiency review. The review by the provider group may include the appeal process outlined by the provider group, if desired by the APRN being reviewed. A third deficient review will require reporting to the Utah Board of Nursing for consideration of corrective actions.Another appeal process may be considered by the Utah Board of Nursing at this time. The process of review of such deficiencies by the Utah Board of Nursing will be defined by that board. Findings during the first or second review that are considered by the reviewer or provider to be indicative of gross incompetence or gross negligence or a pattern of gross incompetence or negligence must be reported to the Utah Board of Nursing within five working days of the review. Corrective action by the reviewer or provider should not be taken in the case of gross deficiencies.

Maintaining Records of Peer Review:
Each APRN will maintain individual records of annual reviews of charted patient visits or oral presentations for (7) seven years. These records will be considered confidential.

Persons or organizations performing peer review shall maintain the following records:
  1. Name of APRN being reviewed
  2. Name and address of the practice of the APRN being reviewed.
  3. Status of review (pass or deficiencies)
  4. Records as described in next paragraph if deficiencies are demonstrated.

If deficiencies occur, the person or organization performing the review will keep a confidential record of the patient visit reviewed, deficiencies demonstrated and documentation of corrective counseling. When the deficiencies are corrected, the reviewer will return a copy of the corrections and counseling to the APRN who has been reviewed. If the APRN being reviewed fails to correct deficiencies by the second review, copies of all documentation will be forwarded to the Utah State Board of Nursing for appropriate action.

Records of review of charted patient visits or oral presentations may also be requested by the Utah Board of Nursing during periodic audit for license renewal.



FORM B

APRN PEER REVIEW AUDIT

Name of provider:
(examples: hospital, office, clinic, NPCG, ICONS, NAPNAP, Nurse Anesthetists Group, Utah Council of Psychiatric/Mental Health Council)

APRN name:

Reviewer name:

APRN Utah license #:

Reviewer Utah license # and type of licensee:

APRN telephone:

Reviewer telephone:

APRN address:

Reviewer address:

Date of Audit:

1. Is the entry dated, legible and signed by the provider? Y/N
2. Is chief complaint adequately addressed? Y/N
3. Relevant medical history is in the record, including: Y/N
A. medications, either prescribed or OTC.
B. allergies or adverse reactions, including medication allergies or adverse reactions.
C. Illness, injuries, and surgeries pertinent to the chief complaint are identified.
4. Subjective and objective findings are pertinent and consistent with diagnosis and management. Y/N
5. Plans of action/treatment are consistent with the diagnosis. Y/N
A. Plan includes relevant teaching
B. Plan for follow-up is documented.
C. Referrals made when appropriate.
6. Chart complies with accepted medico-legal requirements: Y/N
A. if prescribed, controlled substances are prescribed appropriately
B. informed consent is documented for all invasive procedures
C. agreement for treatment documented where appropriate

All items shall be scored on a yes/no model. Items which are appropriately not included in the review, because they are not part of the APRN's practice or because they were not appropriate to a particular visit, shall be graded as yes.

The above items were chosen to review compliance with scope of practice and competency of the APRN.

CONFIDENTIAL REPORT FOR IMPROVEMENT OF HOSPITAL FACILITY AND PATIENT CARE - Not part of medical record and not to be used in litigation - pursuant to Utah code annotated, 26-25-1 et seq. And Utah Code annotate 58-12-43 (7-9).





FORM A

ESTABLISHMENT OF PROVIDER STATUS

1. Name of organization or facility
Address of organization or facility
Name and phone # of contact person

2. Description of how deficiencies in peer review audit will be documented

3. Description of process that will be used to correct deficiencies

4. Description of appeals process to be used by APRN being reviewed

5. Description of process that will be used to report deficiencies to the Utah Board of Nursing

6. Discussion of how patient confidentiality will be maintained

7. Discussion of how peer review processes other than those described in this document will be reviewed and approved.

8. Fee, if any, to be charged by organization or facility to perform review, remediation counciling, and maintenance of documentation. Provide validation for such a fee.

Above information will be submitted to the Utah Board of Nursing for approval of provider status.





QUESTIONS WHICH HAVE BEEN ASKED ABOUT THE PEER REVIEW PROCESS

Please note that the comments on these questions are not part of the guidelines, but are written by Pat Rushton only for clarification.

1. What authority does the current committee, headed by Patricia Rushton and including Millene Murphy, Judy Bendowski and Vicki Anderson, have to write these peer review guidelines?

According to Laura Poe of the Utah Board of Nursing and Becky Wallace, past president of the Nurse Practitioner Conference Group (NPCG), the NPCG is seen as the voice organization for advance practice registered nurses in the State of Utah. As such, the organization was asked by the Utah Board of Nursing to form a committee to write the guidelines required by the Nurse Practice Act of 1999 for peer review. Pat Rushton volunteered to take on this task and organized the above committee. Once the guidelines are completed and forwarded to the Utah Board of Nursing, the writing committee, as listed above, will be dissolved and only reassembled by request of the Utah Board of Nursing. However, Pat Rushton will take input from APR Ns during the trial period of 1 May to 1 July 1999 and forward that input to the Utah Board of Nursing.

2. Is the whole chart to be audited, one visit to be audited, or only the APRN's documentation in the chart to be audited?

The purpose of this process is to audit the Practice of APRNs. Though skill in charting is required to demonstrate that the APRN has fulfilled the requirement of this audit, the goal of the audit is not to audit the completeness of the chart, insurance issues, physician practice or other such issues. Charted patient visits or oral presentations of such visits seemed to be the best way of currently evaluating APRN practice. The goal of the review is to find some minimum, logistically possible method of determining that APRNs in the State of Utah are practicing in a safe competent fashion. It is understood that it does not guarantee safe competent practice, but it is not logistically possible to have a reviewer follow every APRN around in their practice for a period of time to provide a better evaluation.

3. Provide clarification on what documentation must be provided to demonstrate that the patient agrees to treatment, as required under section 6B and 6C of Form B.

As has been pointed our by several contributors to the peer review guidelines, many facilities have a patient sign an agreement for treatment during their first visit to the facility. This agreement should cover permission to do physical examinations, injections, IV starts and IV administration of medication, etc. If the patient requires an invasive procedure such as a surgical procedure, bone marrow biopsy, culposcopy, or procedures of this invasive nature, it would seem that a separate permit should be signed. This question will be submitted to the State Board of Nursing for further clarification.

4. When does the peer review process begin? Does documentation prior to that date need to be reviewed or does documentation beginning with that date only need to be reviewed?

This question is answered in the section titled Peer Review Process in the guidelines. Only patient visits beginning 1 July 1999 should be reviewed.

5. How are the items on Form B weighted to produce the final percentage?

Each of the six items on Form B should be graded on a scale of 0-100%. If the item is required and completely fulfilled, the item would be given a 100% grade. If the item is required and only partially completed, it would be given a percentage of something less than 100%.
For instance, item 1 states Is each entry dated, legible and signed by the provider?. All of this item is required. Therefore, the charted patient visit or the oral presentation should include a date, a signature (or name of the practitioner, if it is an oral presentation,) and if the entry is written, it must be legible. If all of these factors are present, the item would be graded at 100%. If one of the items is missing, the grade for this item might be 80%. At this time the grade is decided by the reviewer. Incidentally, knowing how difficult it is to identify initials, either because more than one person may have the same ones or they are illegible or they can. To be identified, it would seem that the best practice would be to sign each note, even if the name has been types by the transcriber.

If an item is not required during a particular visit, for instance no referral is necessary, no controlled substance has been prescribed or no invasive procedure has been performed, then the reviewer would grade these items at 100%, since the APRN is in compliance with the guideline. However, if these items are important to that patient visit, the required items would be included as part of the evaluation. Incidentally, it is understood that some APRNs do not have prescriptive practice. However, if the APRN is seeing and documenting on a patient for whom a medication is prescribed or a controlled substance is provided, the APRN should document what physician signed the scripts for those medications, unless the physician is going to write a separate note documenting his participation in the patient's treatment. If such documentation is not included, the APRN would be graded at less than 100% for that item.

6. How will deficiencies found during the review of charted patient visits or oral presentations be handled?

Deficiencies will be handled as described in the section titled, Correction and Reporting of Deficiencies in the guidelines. The first review will be handled by the reviewer. Deficiencies not corrected with the first review will be handled by the provider group, as outlined by that group on Form A. Deficiencies not corrected with the provider review will be reported to the Utah Board of Nursing for correction. Deficiencies at every level should be handled with confidentiality and information distributed on a need-to-know basis only.

7. How will it be determined who will review whom and how the charted patient visits or oral presentations to be reviewed will be chosen?

As described in the section titled Establishment of Reviewer Status, any APRN or MD in the State of Utah may be a reviewer. Each APRN will have the freedom to determine who should perform their review. Some suggestions may be helpful.

1. Though a review can be carried out by an MD, it would seem prudent to use another APRN if at all possible. Another APRN will probably have a better understanding of APRN practice and requirements. Another APRN is less likely to be in a supervisory position over the APRN being reviewed than a physician may be. An APRN in an independent practice situation may not have access to another APRN. In which case, the assistance of an MD who is appropriately appraised of the goals and requirements of the review and who is willing to perform the review will be greatly appreciated.

2. If a group of APRNs is working closely together, they may be able to design a method of designating reviewers that will decrease bias and perhaps even decrease the workload. The term . working together. need not imply that they are physically in the same facility, but perhaps implies that the group enjoys a collegial relationship, though they may be physically separated.

3. Remember that whoever is chosen to do the review will be in a position to provide constructive criticism, so the person being reviewed should be sure they are able to accept constructive criticism from the reviewer chosen.

The patient visits chosen to be reviewed or presented orally can also be chosen in any creative fashion the APRN prefers. The reviewer can make a site visit or arrange to have the documents sent to be reviewed. Of course, it is preferable to use as little bias as possible. So, the APRNs being reviewed may wish to find a way to have a non-APRN or an APRN not associated with the practice being reviewed choose the patient visits. However, this is not mandatory and may not even be possible in some practices. The goal is have a wide variety of patient visits reviewed in order to evaluate the safety and competency of the APRN being reviewed.

8. Why are oral presentations given as an option for review?
The psychiatric nurse group felt that oral presentations may facilitate confidentiality for their patients. It seemed a reasonable option in terms of confidentiality and facility of review for many APRNs in the state. There are some practices in the state that already carry out a sort of M&M conference as a method of peer review, so such an option could continue to be used by these practices. It is also clear that oral case reviews provide a more satisfactory learning experience for everyone involved than a review of the charted patient visit, but it also takes more time and so many be logistically feasible in all situations.

9. Please clarify the phrase gross incompetence or gross negligence used in the section titled Correcting and Reporting Deficiencies.

This phrase was a contribution made by Laura Poe of the Board of Nursing. There is no specific definition. However, the Board is probably concerned that such behaviors as unsafe practice, unethical or illegal behaviors, controlled substance abuse not go unreported for a prolonged period of time. Therefore, if the reviewer felt that the practitioner being reviewed demonstrated such behaviors, they should be reported and deficiencies be managed by the Utah Board of Nursing rather than a single review or a provider group.

10. How was the scale of 0-100% determined?

This scale was arbitrarily chosen. Any number of scales or tools could have been used. However, this one seemed to be easily applied and effective.

11. Why is a chart audit or oral presentation being used as the measure of peer review or quality care review required by the Nurse Practice Act of 1999?

There has been concern that a chart audit type peer review does not guarantee safe, competent practice. There is no guarantee that the limited number of charts being reviewed will demonstrate deficiencies or problems in a single APRNs practice. Perhaps a better way would be to have the APRN followed for period of time by a reviewer or member of the provider group to actually observe the practice. However, with 600-700 APRNs in the State of Utah, it is probably not logistically feasible to perform that kind of review. Due to lack of another logically possible method of performing a practice review, it seemed that a chart audit of some sort was the best means of reviewing APRN practice.

12. Why is the question of a fee charged by the provider group presented on Form B?

There is no intent on the part of this committee or the Utah Board of Nursing to make APRN peer review a business. It is hoped by the members of the peer review guidelines committee that most of the review will go on among peers on a free professional colleagial basis. However, there is a good probability that there will be nurses, being the creative people they are, who will see peer review as a nursing need to be filled and as a possible business venture created to fill that need. There may also be a necessity for provider groups to recover the cost of review, counseling, and documentation, since many of these groups have no regular funding to assist with that process. The third possible need for a fee might be that a group of APRNs just feels it is easier to pay another group to do the review, rather than them having to take the time to review themselves. It is hoped that if there is a fee, that it will be a reasonable one.

13. Why does there need to be a provider level of review?

In the rules attached to the Nurse Practice act, in rule R156-31b-304, with reference to section 58-31b-305 3 b in the Act itself, it states that there shall be a provider group supervising APRN review. These guidelines have attempted to define what a provider group is and their role in the review process. Though rules can be changed much easier than the laws which are part of the act itself, this committee does not have the power to repeal them, and therefore, will ask the Utah Board to review the need for a provider group with their legal counsel.

Questions to be reviewed by the state legal counsel and/or the Utah Board of Nurses

1. Can initialing, rather than signing, the written documentation of a patient visit be considered a legal signature?

2. Can the rules be changed to delete the need for a provider level of review?

3. Are these records confidential and exempt from subpeona .

4. Is there any reason that there is a limit to the number of possible provider groups? Can there be 6 or 600 if that many apply?

5. How will the State of Utah pay for a group to approve the provider groups?