Peer Review: Measuring the Quality of Nursing Care
RAND Health has developed a way to use structured implicit review of the medical record to measure the quality of nursing care practically and reliably.
Peer review relies on quality judgments by expert professionals to evaluate quality of care based on review of the medical record. A structured implicit review is more reliable because the key aspects of care and data sources to be reviewed are specified in advance.
We developed structured implicit reviews of the quality of inpatient nursing care for congestive heart failure and cerebrovascular accident patients.
We used the nursing care literature and the clinical judgment of nurses and physicians to conceptualize the "nursing process" and to identify standards against which the process of care could be evaluated.
We asked a national expert panel of nurses to review both our model and the standards.
We rigorously tested the review forms in large studies, and found them to be reliable and valid.
In the review process, quality of nursing care is judged in terms of whether the nurse fulfilled the independent responsibilities called for by nursing practice as well as those initiated by physicians' orders. The form also asks the reviewer to rate overall quality of care.
The implicit review forms for congestive heart failure and cerebrovascular accident and the instruction manuals for using them are available directly from RAND. The relevant documents are listed below.
Chang BL, Lee JL, Pearson ML, Kahn KL, Elliot MN, Rubenstein LL. Evaluating Quality of Nursing Care: The Gap Between Theory and Practice, Journal of Nursing Administration, Vol. 32, No. 7, July 2002, pp. 405-418.
Chang BL, Rubenstein LV, Keeler EB, Kahn KL. The Validity of a Nursing Assessment and Monitoring of Signs and Symptoms Scale in ICU and non-ICU Patients, American Journal of Critical Care, Vol. 5, 1996, pp. 298-303.
Lee JL, Chang BL, Pearson ML, Kahn KL, Rubenstein LV. Does What Nurses Do Affect Clinical Outcomes for Hospitalized Patients? Health Services Research, Vol. 34, No. 5, 1999, pp. 1011-1032 [accompanying editorial].
Pearson ML, Lee JL, Chang BL, Elliott M, Kahn KL, Rubenstein LV. Structured Implicit Review: A New Method for Monitoring Nursing Care Quality, Medical Care, Vol. 38, No. 11, 2001, pp. 1074-1091.
Rubenstein LV, Chang B, Keeler EB, Kahn KL. Measuring the Quality of Nursing Surveillance Activities for Five Diseases Before and After Implementation of the DRG-Based Prospective Payment System, Public Health Service National Institutes of Health, NIH Publication No. 93,3411, October 1992, pp. 39-53.