Enhancing Peer Review to Support APN Practice

Marianne Davies,

RN, MSN, ACNP, AOCN

Yale-New Haven Hospital (YNHH) currently credentials more than 400 advanced practice nurses (APNs) who practice in a wide range of roles and geographic locations. The number of practitioners more than doubled in the past 3 years, and now more than 50 APNs are practicing in oncology in Smilow Cancer Hospital at YNHH and at community care centers.

Credentialing is required for all providers to practice at YNHH, and the Chief Nursing Officer (CNO), a member of the Medical Staff Credentialing Committee, is responsible to authorize re-credentialing applications for all APNs.¹ The credentialing process incorporates both initial and ongoing peer review—the evaluation of professionals by a peer who practices in a similar role and scope of practice.

The CNO recognized the need to provide structure to this rapidly expanding group of providers. As a result, the YNHH APN council was developed in 2010 to provide a supportive, inclusive environment for the APN community. The APN council represents advanced practice registered nurses, certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists from the 12 nursing divisions, the community, and Yale School of Nursing.

Initially, the APN council conducted a survey to identify the needs and practice models of the APNs credentialed. Oncology advanced practice providers responded to a second survey with specialty specific questions.² The results of both indicated that APNs had various employment and collaborative practice models, had minimal involvement in the peer review process, and the peer review lacked incorporation of APN metrics. The APNs expressed the need for peer advocacy and networking.

The Institute of Medicine and Robert Wood Johnson Foundation recommended in The Future of Nursing, that nurses be full partners in healthcare. This includes taking responsibility for professional practice, identifying problems, devising and implementing plans for improvement, and tracking improvements over time, as well as making necessary adjustments to realize goals.³ In order to achieve this, APNs must be involved in developing useful tools for collecting data about competencies and patient outcomes. Much of this goal can be achieved through an enhanced peer-review process.

The APN council’s first goal was to develop a peer review process that:

• Standardized the peer review process for all credentialed APNs in the organization
• Incorporated the feedback of APN peers
• Fostered a sense of community of practice for APNs
• Integrated metrics to reflect APN contributions to patient care
• Incorporated metrics to reflect APN competencies
• Incorporated specialty specific APN competencies
• Promoted professional self-regulation
• Promoted evaluation and improvement in quality of healthcare

The APN council reviewed the existing policies and procedures of the institution, federal and state requirements, The Joint Commission’s Standards, American Nurse Credentialing Center Magnet designation requirements, and APN specialty certification competencies. All underscored that peer review is deemed an essential component of credentialing for licensed providers.⁴ Ongoing professional practice evaluation (OPPE) is the mechanism used by the medical staff office to conduct peer review, following a traditional medical model. The initial step in the credentialing process includes a Focused Professional Practice Evaluation (FPPE). OPPE is needed more than annually as a mechanism to obtain peer review.

Yale-New Haven Hospital APN Council Competencies Framework

• Patient care skills
• Medical knowledge
• Interpersonal & communication skills
• Professionalism
• Practiced-based learning
• Systems-based practice

The Council developed an OPPE tool utilizing the Joint Commission’s six domains as a framework with integration of specialty specific competencies within each domain (Box).

Each indicator within the domain was measured on a Likert-like scale. The Council recommended that the OPPE tools be completed by two peers and a self-review evaluation.⁵ The review would be conducted by observation of clinical practice and chart review. Peer review would also include a feedback summary of the six core competencies, strengths, and opportunities for improvement. OPPE would be completed twice yearly, consistent with the current process. Peer review coordinators from each division would be identified to collect the documents, summarize with the APN, and submit to the medical staff office for credentialing documentation.

The new peer review process was piloted with the Oncology Advanced Practice Provider Division during the final quarter of 2013. The process was presented at several staff and faculty meetings to obtain their buy-in and support. Peer review documents were distributed to each APN for review and completion. APNs provided feedback on the use of the tools, process, and scheduling of the reviews.

The oncology APNs recommended that one of the peer reviews be aligned with the yearly performance review and that chart reviews be aligned with the new electronic medical record format, EPIC. The peer review process is currently being implemented by each of the other divisions within YNHH.

Peer review is an essential component of the credentialing process, and it is important that all APNs actively participate. The benefits of participation in peer review include promotion of self-regulation of practice and quality patient care, as well as review of common patient care themes. This process also provides an opportunity to highlight the contributions of APNs to patient care within the institution and stimulate collaborative education and research initiatives.

References

• Yale-New Haven Hospital. Medical Staff Policy—Ongoing Professional Practice Evaluations. www.ynhh.org/medstaff/POPPE. Accessed September 12, 2014.
• McCorkle R, Lazenby M, Engelking C, Davies MJ, Ercolano E, Lyons, C.A. (2012). Perceptions of roles, practice patterns, and professional growth opportunities: the first step in broadening the scope of advanced practice in oncology. Clin J Oncol Nurs. 2012;16(4):382-387.
• Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx. Washington, DC: The National Academies Press; 2010.
• American Nurses Credentialing Center. Magnet Hospital Recognition Program Overview. http://nursecredentialing.org/Magnet/ProgramOverview. Accessed August 30, 2014.
• The Joint Commission. Standards BoosterPak™ for Focused Professional Practice Evaluation/Ongoing Professional Practice Evaluation (FPPE/OPPE). Oak Brook, IL: Joint Commission Resources; 2011.