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UWHC,

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Annual Peer Review and Colleague Review for Professional Nurses (4.60)

Annual Peer Review and Colleague Review for Professional Nurses (4.60) - Policies, Administrative, UWHC, Department Specific, Nursing Administrative, Personnel

4.60

POLICY & PROCEDURE





Effective Date:
January 1, 2016

Administrative Manual
Nursing Manual
 Other _______________

Policy #:
4.60
Original
 Revision

Page 1
Of 3

Title:
Annual Peer Review and Colleague
Review for Professional Nurses



I. PURPOSE:
A. The purpose is to provide a standardized process for delivering peer and colleague
feedback in order to ensure competency, compliance with professional standards, and
professional development.
II. DEFINITIONS:
A. Peer Review:
Peer review in nursing is the process by which practicing registered nurses systematically
assess, monitor, and make judgments about the quality of nursing care provided by peers
as measured against professional standards of practice (ANA, 1975) American Nurses’
Association.
B. Professional Peers:
Professional peers are defined as registered nurses with similar roles and education,
clinical expertise, and level of licensure against predetermined standards. (2008 Magnet
Application Manual)
C. Colleague Feedback:
Colleague feedback is feedback provided by interdisciplinary colleagues (Examples: MD,
PT, OT, HUC, PCT, NA).
III. POLICY STATEMENT:
A. A minimum of a self-assessment, and one (1) peer review will be included in the annual
performance evaluation of professional nurses at all levels. Colleague feedback is
encouraged.
B. Peer feedback will be solicited and documented utilizing the electronic process provided
by Human Resources.
IV. FORMS USED, IF APPLICABLE:
A. Utilize the nursing specific drop down menu provided in the electronic annual evaluation
process.
V. PROCEDURE:
A. The professional nurse will follow their respective manager’s process for soliciting the
names of peers and other non-nursing colleagues.
B. The respective manager will select at least one peer from the list provided by the
professional nurse being evaluated.
C. In addition to the above, the manager is encouraged to solicit feedback from other peers
and colleagues.

POLICY & PROCEDURE





Effective Date:
January 1, 2016

Administrative Manual
Nursing Manual
 Other _______________

Policy #:
4.60
Original
 Revision

Page 2
Of 3

Title:
Annual Peer Review and Colleague
Review for Professional Nurses



D. The manager will request peer feedback and self-appraisal through the electronic process
provided by Human Resources.
E. The professional peer preparing the feedback will access the nursing specific drop down
menu to access specific nursing standards that speak to the organizational criteria.
1. The use of direct quotes, consistencies or inconsistencies in performance
examples are encouraged
2. Patient confidentiality must be maintained
3. If unable to provide fair, complete and accurate review, discuss appropriateness
with manager
F. Record work hours for preparing peer feedback in the scheduling / time and attendance
system..
G. The manager will incorporate all requested feedback into the electronic performance
appraisal form. Feedback will be clearly labeled as:
1. Manager
2. Self
3. Peer/Colleague
H. Manager will conduct a verbal review and discussion regarding all feedback
and goals for the upcoming year. Every professional nurse will have a minimum of three
(3) documented goals. It is encouraged that goals be written using “SMART” verbiage:
(S = Specific M = Measurable A = Attainable R = Results-oriented T = Time-
framed)
1. Personal
2. Professional
3. Strategic

VI. REFERENCES:
A. UWHC Administrative Policy 9.24 Competency Assessment
B. UWHC Administrative Policy 9.26 Probationary and Annual Performance Appraisals
C. UWHC Administrative Policy 9.64 Maintenance of Employee Personnel Records
D. Application Manual - Magnet Recognition Program 2008.
E. American Nurses’ Association Peer Review Guidelines – 1988.
F. American Nurses’ Association. A plan for implementation of the standards of nursing
practice. Kansas City, MO. The Association, 1975.

POLICY & PROCEDURE





Effective Date:
January 1, 2016

Administrative Manual
Nursing Manual
 Other _______________

Policy #:
4.60
Original
 Revision

Page 3
Of 3

Title:
Annual Peer Review and Colleague
Review for Professional Nurses



G. Haag-Heitman, B., George, V., Peer Review in Nursing – Principles for Successful
Practice. Jones and Bartlett Publishers. 2011.
VII. REVIEWED BY:
A. Nursing Advancement Council, January 2016
B. Nursing Administrative Policy & Procedure Committee, January 2016

SIGNED BY:

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services,
Chief Nursing Officer