¶ … quality of care and ensuring patient safety. In the home health care organization, peer review also measures staff competence and provides valuable feedback for performance reviews and making necessary changes to improve quality of service or efficiency of operations. One of the cornerstones of an effective peer review process is its ability to enhance accountability by promoting "self-regulation," (Kent, 2014, p. 1). Another important emblem of an effective peer review process in the home health care venue specifically is shared governance, a model of peer review that has been shown to be particularly easy to implement and also maintain (Furrer, 1996). In the home health care organization that I belong to, a formal peer review process does exist and it also reflects the core missions and values of the organization. Moreover, the formal peer review process that exists in my home health organization is modeled after those espoused by both the American Academy of Nurse Practitioners (AANP) and the American Nurses Credentialing Center (ANCC). Our peer review process and its procedures bear special resemblance to and inspiration from the AANP. The ANCC program has been effective because it entails voluntary membership, which does empower organizations like ours to practice the ideals of "self-regulation," as Kent (2014) points out. Our organization has achieved credentials and places a great degree of value in maintaining a high standard of care through the peer review process.

The main features of our organization's peer review process include implementing peer review during the initial training for incoming employees. By introducing new employees to the process of peer review early, they are better prepared to meet the goals of the organization. The organizational culture should ideally reflect the goals and missions of the home health agency, which include the provision of proper care for patients and the elimination of preventable medical errors. Through the training process, new home health care nurses and staff members learn how to review their peers in a non-threatening way and also how to ensure that their performance will be positively evaluated. They are taught the inherent value of the peer review process for creating a system of self-governance and mutual support and empowerment. The end results of a strong peer review process are also shared with new employees, so that they enjoy the fruits of a transparent corporate governance policy espoused by the leaders of our home health organization. As Kent (2014) points out, well-designed, developed, and implemented peer review processes result in measurable performance outcomes including "increased professionalism, accountability, autonomy, retention and improved communication skills and quality outcomes," (p. 1). The administrators of our home health care organization understand the importance of peer review processes in exceeding industry standards in core performance areas and measurable outcomes.

The ongoing peer review process is systematic and organized, in accordance with AANP recommendations. We have quarterly reports that invite employees to share their concerns and thoughts and offer suggestions. Additionally, we have established a formal system whereby nurses and staff members can voice their concerns or questions anonymously through a digital system that ensures privacy and confidentiality. By doing so, nurses feel less intimidated, more encouraged, and more supported in their desire to make the home health care industry more responsible and more accountable to patients. As an aspiring industry leader, our organization wants nurses to feel empowered and confident enough to voice concerns and not fear reprisal from their supervisors or peers. The peer review process is about creating an organizational culture built on support and trust.

Without a peer review process already present, an organization would need "a significant change in its culture, requiring a paradigm shift on the part of both the nursing staff and administration," (Kent, 2014, p. 1). Luckily for our nursing staff and administrators, we already had a peer review process present because of progressive leadership in the organization that recognized the benefits of peer review over a decade ago. Now, peer review has become entrenched in the way we work. As nurses, we are regularly encouraged to review our performance standards so that we know what to look for and what to look out for while we are self-reflecting and reflecting on the work of our peers. To ensure that nurses remember the core elements of the organization's mission, vision, and ethics, we have mandatory nurse education every three months. This way, our nurses are up-to-date with the rules, regulations, ethical guidelines, and notes for best practice. The nurse leaders in our organization, as well as guest speakers, deliver lectures...

We have learned about best practices in the types of procedures most commonly used by our home health care staff, and we also learn about advancements in the research that might impact our performance and our peer review process. After all, it is impossible to perform a solid peer review without knowing what guidelines and standards we are expected to meet.
An important part of the peer review process is how to identify problems before they arise or immediately after they present themselves in nurse behavior. Early intervention begins during employee screening, when the human resources department evaluates the candidates' past performance reviews and assessments. Any concerns about a nurse's ethical standards or ability to work within established guidelines for safety are noted, and the training program helps those nurses improve their performance. If the nurses show little improvement, an intervention is held. The supervisor leads an intervention whereby the issue is addressed frankly and a set of standards and consequences are laid out. For example, a nurse who does not wash hands regularly enough or at critical times might be informed that she will be under review for this behavior and if she does not improve the frequency of her hand-washing, she may lose her job.

Disciplinary procedures are integral to the peer review process, because the point of peer review is to improve quality of care in our organization and throughout all the properties we manage. Therefore, we have a formal process of discipline that is non-punitive in nature and which encourages nurses to be responsible for their actions and those of their peers. Supervisors are particularly responsible for the nurses under them, placing the greatest degree of accountability on leaders. The early intervention standards are upheld by the ANCC, which has no tolerance for unethical behavior from member organizations like ours. Using early intervention, supervisors monitor their staff conscientiously and notice when nurse behaviors might signal problems related to patient care. Any potential issue, such as a nurse who suddenly exhibits greater absenteeism, is addressed rather than allowed to fester. This way, a potential problem does not turn into an actual problem. For more serious cases of nurses violating standards of safety or ethics, peers are required to make a report immediately to the supervisor.

Nurses under review are always offered the opportunity to improve their behavior, ask questions, or defend their position. Part of the peer review process is self-governance and empowerment, rather than the creation of an authoritarian organization. Through the democratization of the peer review process, the ANCC and the AANP can trust that home health agencies like ours are directly accountable to our patients and for our actions, thereby improving the overall image of the industry in general.

Peer reviews are, by definition, made by people of the "same rank," meaning that supervisors do not actually review the nurses who work under them but other supervisors (Haag-Heitman, 2011). This ensures the ideal of self-governance and creates a standard of fairness. Other critical components of peer review processes in our organization include the routine nature of the reviews, their being based on practice rather than on personality, and their encouragement of openness and transparency. With the exception of the anonymous system offered to nurses, the formal peer review process does not allow for anonymity but rather, encourages nurses and staff to be open with sharing their views on their peers. An "open exchange of views" is used to "preserve practice integrity and safety," (Haag-Heitman, 2011, p. 49). The nurse under review can trust the information is honest and has an opportunity to respond, rather than feeling like an external entity is targeting him or her for no reason.

Accreditation and review boards like the AANP and ANCC stress peer review in all nursing organizations because these processes have the potential to change organizational culture in ways that improve patient outcomes as well as efficiency of the organizations. Peer review processes have become instrumental to our organization's success. After more than ten years of using the same peer review model, our organization has shown consistent improvement in main home health care safety areas and quantitative outcomes including reducing numbers of bedsores, infections, and other preventable problems. Overall patient satisfaction has improved, and we remain accredited by national organizations. We have earned the right to be proud of our peer review process, and our nurses enjoy a rate of job satisfaction arguably higher than their counterparts in organizations with less robust peer review processes.