Peer Review in Home Health Care: Process and Best Practices

Peer review is a foundational mechanism for maintaining quality of care and ensuring patient safety. In the home health care setting, peer review also measures staff competence and provides valuable feedback for performance reviews, as well as a basis for making necessary changes to improve quality of service or operational efficiency. 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 feature of an effective peer review process in the home health care setting specifically is shared governance — a model of peer review that has been shown to be particularly easy to implement and maintain (Furrer, 1996). In the home health care organization described here, a formal peer review process exists that reflects the core missions and values of the organization.

The formal peer review process in this home health organization is modeled after those espoused by both the American Academy of Nurse Practitioners (AANP) and the American Nurses Credentialing Center (ANCC). The peer review process and its procedures bear particular resemblance to and inspiration from the AANP. The ANCC program has been effective because it entails voluntary membership, which empowers organizations to practice the ideals of "self-regulation," as Kent (2014) points out. This 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 the 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 how to ensure that their own 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 can appreciate the benefits of a transparent governance policy. 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 this home health care organization understand the importance of peer review processes in exceeding industry standards across core performance areas and measurable outcomes.

The ongoing peer review process is systematic and organized, in accordance with AANP recommendations. Quarterly reports invite employees to share their concerns, thoughts, and suggestions. Additionally, a formal system has been established whereby nurses and staff members can voice their concerns or questions anonymously through a digital system that ensures privacy and confidentiality. This arrangement helps nurses feel less intimidated, more encouraged, and more supported in their desire to make the home health care industry more responsible and accountable to patients. As an aspiring industry leader, the organization wants nurses to feel empowered and confident enough to voice concerns without fearing reprisal from supervisors or peers. The peer review process is ultimately 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). This organization, however, already had a peer review process in place because of progressive leadership that recognized the benefits of peer review over a decade ago. Now, peer review has become entrenched in the way the organization works. Nurses are regularly encouraged to review their performance standards so that they know what to look for — and what to be mindful of — while self-reflecting and evaluating the work of their peers.

To ensure that nurses remain grounded in the core elements of the organization's mission, vision, and ethics, mandatory nurse education sessions are held every three months. This keeps nurses up-to-date with rules, regulations, ethical guidelines, and notes on best practice. Nurse leaders and guest speakers deliver lectures and hold workshops on accountability practices. Staff learn about best practices in the procedures most commonly used by home health care staff and also about advancements in research that might impact performance and the peer review process itself. After all, it is impossible to conduct a meaningful peer review without knowing the guidelines and standards that are expected to be met.

An important part of the peer review process is identifying problems before they arise, or immediately after they appear in nurse behavior. Early intervention begins during employee screening, when the human resources department evaluates candidates' past performance reviews and assessments. Any concerns about a nurse's ethical standards or ability to work within established safety guidelines are noted, and the training program helps those nurses improve their performance. If a nurse shows little improvement, an intervention is held in which the supervisor addresses the issue directly and lays out a clear set of standards and consequences. For example, a nurse who does not wash hands regularly enough or at critical moments might be informed that she will be under review for this behavior and that failure to improve may result in termination.