Structured implicit review - A new method for monitoring nursing care quality

BACKGROUND. Nurses' independent decisions about assessment, treatment, and nursing interventions for hospitalized patients are important determinants of quality of care. Physician peer implicit review of medical records has b een central to Medicare quality management and is considered the gold stand ard far reviewing physician care, but peer implicit review of nursing proce sses of care has not received similar attention. OBJECTIVE. The objective of this study was to develop and evaluate nurse st ructured implicit review (SIR) methods. RESEARCH DESIGN. We developed SIR instruments for rating the quality of inp atient nursing care for congestive heart failure (CHF) and cerebrovascular accident (CVA). Nurse reviewers used the SIR form to rate a nationally repr esentative sample of randomly selected medical records for each disease fro m 297 acute care hospitals in 5 states (collected by the RAND-HCFA Prospect ive Payment System study). SUBJECTS. The study subjects were elderly Medicare inpatients with CHF (n = 291) or CVA (n = 283). MEASURES. We developed and tested scales reflecting domains of nursing proc ess, evaluated interrater and interitem reliability, and assessed the exten t to which items and scales predicted overall ratings of the quality of nur sing care. RESULTS. Interrater reliability for 14 of 16 scales (CHF) or 10 of 16 scale s (CVA) was greater than or equal to0.40. Interitem reliability was >0.80 f or all but 1 scale (both diseases). Functional Assessment, Physical Assessm ent, and Medication Tracking ratings were the strongest predictors of overa ll nursing quality ratings (P < 0.001 for each). CONCLUSIONS. Nurse peer review with SIR has adequate interrater and excelle nt scale reliabilities and can be a valuable tool for assessing nurse perfo rmance.