Source: http://bon.state.tx.us/faq_peer_review.asp
Timestamp: 2019-04-25 02:16:42+00:00

Document:
the resolution of workplace and practice questions relating to nursing and patient care.
A nursing peer review committee may review the nursing practice of an LVN, RN, or APRN (Advanced Practice Registered Nurse).
Safe harbor nursing peer review (SHNPR), a process that protects a nurse from employerretaliation, suspension, termination, discipline, discrimination, and licensure sanction when anurse makes a good faith request for nursing peer review of an assignment or conduct the nurseis requested to perform and that the nurse believes could result in a violation of the NursingPractice Act (NPA) or Board rules. Safe harbor must be invoked prior to engaging in the conductor assignment for which nursing peer review is requested, and may be invoked at any timeduring the work period when the initial assignment changes.
It is a committee established under the authority of the governing body of a national, state, or local nursing association; a school of nursing; the nursing staff of a hospital, health science center, nursing home, home health agency, temporary nursing service, or other health care facility; or state agency or political subdivision for the purpose of conducting nursing peer review. The committee includes an employee or agent of the committee, including an assistant, an investigator, an intervener, an attorney, and any other person who serves the committee in any capacity. The nursing peer review process is one of fact-finding, analysis, and study of events by nurses in a climate of collegial problem solving focused on obtaining all relevant information about an event. Nursing peer review conducted by any entity must comply with NPR Law and with applicable Board rules related to incident-based or safe harbor nursing peer review.
for professional nurses: if the person regularly employs, hires, or contracts for the services of eight (8) or more nurses, at least four (4) of whom are registered nurses.
A person required to establish a nursing peer review committee under this section may contract with another entity to conduct the nursing peer review for the person.
A NPRC must have nurses (LVNs, RNs, and/or APRNs) as ¾ of its members.
A NPRC conducting nursing peer review of a LVN’s practice must, to the extent feasible, includeLVNs as members of the NPRC and only RNs and LVNs may vote (other non-nurse members ofthe committee may NOT vote).
A NPRC conducting nursing peer review of a RN’s practice must have RNs as 2/3 of its membersand only RNs may vote (LVNs and other non-nurse members of the committee may NOT vote).
A NPRC must include, to the extent feasible, at least one nurse who has working familiarity withthe same area of nursing practice as the nurse being reviewed.
For incident-based nursing peer review (IBNPR): the NPRC may not include any person(s) with administrative authority for personnel decisions directly relating to the nurse. Any person(s) with administrative authority for personnel decisions directly relating to the nurse may not attend the IBNPR hearing (the only exception is a person who is administratively responsible over the nurse being reviewed may appear before the NPRC to speak as a fact witness to the conduct being reviewed).
For safe harbor nursing peer review (SHNPR): the NPRC may not include any person(s) with administrative authority for personnel decisions directly affecting the nurse. A CNO, nurse administrator, or other individual with administrative authority over the nurse, including the individual who requested the conduct or made the assignment for which the nurse under review invoked SHNPR, may only appear before the committee to speak as a fact witness.
All proceedings of the nursing peer review committee are confidential and all communications made to the committee are privileged. A member, agent, or employee of a nursing peer review committee or a participant in a proceeding before the committee may not disclose or be required to disclose a communication made to the committee or a record or proceeding of the committee. A person who attends a nursing peer review committee proceeding may not disclose or be required to discloseinformation acquired in connection with the proceeding or an opinion, recommendation, or evaluation of the committee or a committee member. A nursing peer review committee member and a person who provides information to the committee may not be questioned about testimony before the committee or an opinion formed as a result of the committee proceedings. All information made confidential is not subject to subpoena or discovery in any civil matter, is not admissible as evidence in any judicial or administrative proceeding, and may not be introduced into evidence in a nursing liability suit arising out of the provision of, or failure to provide, nursing services. Tex. Occ. Code §303.0075 addresses protection of information shared between a nursing peer review committee and a patient safety committee established by the same entity.
A facility conducting incident-based nursing peer review must have written policies and procedures that, among other requirements, found in Tex. Admin. Code §217.19(d)(2), must address confidentiality and safeguards to prevent impermissible disclosures, including written agreement by all parties to abide with NPR Law and Tex. Admin. Code §217.19(h). The CNO/Nurse Administrator must ensure that policies are in place relating to sharing of information and documents between an incident-based NPRC and a patient safety committee [See Tex. Admin. Code §217.19(h)(3)].
To whom may a nursing peer review committee disclose privileged information (Tex. Occ. Code §303.007)?
a law enforcement agency investigating a criminal matter.
a person engaged in bona fide research, if all information that identifies a specific individual isdeleted.
A nursing peer review committee that discloses information permitted by law and each person receiving the disclosed information must protect, to the extent possible, the identity of each patient.
Yes, an entity conducting nursing peer review may choose to use an informal review process utilizing a workgroup of the nursing peer review committee for either incident-based or safe-harbor nursing peerreview. A nurse involved as the primary party in nursing peer review does not waive due process rights by agreeing to work with an informal workgroup, including the right to reject the decision of theinformal workgroup and have a review by the entire nursing peer review committee. See Tex. Admin.Code §§217.19(e) and 217.20(k) for specific requirements when using an informal workgroup of the nursing peer review committee. Specific policies must be in place for using informal work groups. The timelines applicable to the NPRC remain the same with the informal workgroup.
Can the Nursing Peer Review Law and Board rules serve as an organization’s policies and procedures?
How many nurses (LVN and RN) will be members of the facility’s nursing peer reviewcommittee?
How long does a nurse serve on the nursing peer review committee?
How will nurses be informed of their minimum due process rights?
Level of participation by the nurse (or his/her representative at an incident-based nursing peerreview hearing?
How are incidents involving an impaired nurse (or a nurse suspected of being impaired)reviewed by a NPRC?
Reporting of nurses to the Board by incident-based NPRC in compliance with Tex. Occ. Code §301.403?
How is the facility’s legal counsel involved in nursing peer review, and how does the facilityassure "parity of counsel?"
How will documents of the nursing peer review committee and the patient safety committee bemarked so that the origin of any shared documents can be determined in order to comply withTec. Occ. Code §303.0075(c).
How will the facility meet the requirements specified in both Tex. Admin. Code §§217.19(e) and217.20(k) when using an informal workgroup of the nursing peer review committee?
All policies should include effective dates, and any changes to policies cannot be applied to proceedings initiated before the change is adopted unless the nurse being reviewed agrees in writing. All policies and procedures concerning NPR should be provided to the nurse being reviewed, including a copy of the facility’s incident-based nursing peer review plan and a copy of Tex. Admin. Code §217.19.
Entities desiring to establish or substantially revise their nursing peer review policies and procedures may find it helpful to contact professional organizations that represent nurses or other similar healthcare settings. Such organizations may have developed generic policies, forms, etc. on nursing peer review for the benefit of their membership, and may have such information available for sale to the public.
What records should a nursing peer review committee chairperson maintain, and for how long? What records should the nursing peer review committee chairperson send to the Board when subpoenaed by the Board to send all nursing peer review records related to the nurse under investigation?
The NPR statute does not specify requirements related to records retention of nursing peer review proceedings, nor has the Board established any time frame by rule. The Board encourages facilities and employers to consider a permanent method of archiving nursing peer review documents. There is no statute of limitations on when nursing violations can be reported to the Board, including alleged violations of the nurse’s due process rights in relation to a nursing peer review proceeding. Therefore, if permanent archiving is not possible, then the longest retention period possible is encouraged.
Documents showing the nursing peer review committee’s evaluation anddetermination/recommendation, corrective actions taken, if any, and evidence ofcompleted remediation, if any.
The above listed sections of the NPA and Board rules address protections a nurse has when reporting unsafe practices of practitioners other than nurses (such as physicians, dentists, etc.) or entities (such as hospitals, nursing homes, home health agencies, etc.) to the appropriate licensing entities/agencies of such practitioners and/or healthcare settings. The Board does not regulate practitioners who are not nurses, or facilities, agencies, or other entities that utilize the services of nurses. Thus, reports regarding other practitioners or entities should be reported to the appropriate licensing or regulatory agency not to the Board. Should a nurse experience or be threatened with retaliatory measures for reporting unsafe conditions or practitioners, the nurse may seek his/her own legal counsel for guidance.
Incident-based nursing peer review focuses on determining if a nurse’s actions, be it a single event or multiple events (such as in reviewing up to five (5) minor incidents by the same nurse within a year’s period of time), should be reported to the Board or if the nurse’s conduct does not require reporting because the conduct constitutes a minor incident that can be remediated. The review includes whether external factors beyond the nurse’s control may have contributed to any deficiency in care by the nurse, and to report such findings to a patient safety committee as applicable.
Review of Chapter 303 of the Texas Occupations Code (NPR Law) in its entirety is recommended in order to ensure compliance with due process and good faith nursing peer review requirements. Tex. Admin. Code §217.19(d) delineates specific requirements for minimum due process during IBNPR. Committee membership and voting requirements are described in Tex. Occ. Code §303.003; Tex. Admin. Code §217.19(d).
A copy of the facility’s incident-based nursing peer review plan, policies and proceduresand Tex. Admin. Code §217.19.
Additionally, the incident-based nursing peer review committee must provide the nurse theopportunity to review, in person or by attorney, documents concerning the event under review,at least 15 calendar days prior to appearing before the committee.
make a closing statement to the committee after all evidence is presented.
permit the nurse to file a written rebuttal statement within 10 calendar days of thenotice of the committee’s findings and make the statement a permanent part of theincident-based nursing peer review record to be included whenever the committee’sfindings are disclosed.
Employment and licensure issues are separate. An employer may take disciplinary action before the nursing peer review committee is convened, as nursing peer review does not have to be utilized to determine issues related to employment. The role of the nursing peer review committee is to determine if licensure violations have occurred and, if so, if the violations require reporting to the Board. If a report to the BON is required under Tex. Occ. Code §301.405(b), then the role of the nursing peer review committee is to investigate whether external factors impacted the error or situation and to report their findings to a patient safety committee (or CNO if no patient safety committee) if they determine the nurse’s deficiency in care was the result of external factors [Tex. Occ. Code §301.405(c)].
If an employer terminates a nurse for non-practice-related reasons (such as too many absences, or non-patient-related misconduct), this is an employment-related issue, not a licensure issue, and is not Board-reportable.
any additional information the Board requires.
Tex. Occ. Code §301.405(c) requires that if a mandatory report by the employer has been made to the BON under Tex. Occ. Code §301.405(b), a copy of the report must be submitted to the nursing peer review committee and the nursing peer review committee must still meet to determine if external factors beyond the nurse’s control impacted the nurse’s deficiency in care. If the nursing peer review committee believes external factors were involved in the incident (whether or not the nurse is being reported to the BON), the committee is required to also report the issue to the patient safety committee at the facility where the reported conduct occurred or to the CNO/nurse administrator if there is no patient safety committee.
Because the nursing peer review committee is reviewing the incident solely to determine the existence of external factors, the due process rights of incident-based nursing peer review do not apply. In addition, a nursing peer review committee cannot make a determination that would negate the duty of the employer to report the nurse under Tex. Occ. Code §301.405(b) or of the CNO/nurse administrator to report the nurse under Tex. Occ. Code §301.402(b).
Must the recommendations made by the incident-based nursing peer review (IBNPR) committee be followed by the employer?
The nursing peer review committee does not have the authority to make employment or disciplinary decisions. The employer must make their own decisions about appropriate disciplinary actions; however, the employer may choose to utilize the decisions of the incident-based nursing peer review committee in determining what actions they wish to take with regard to the nurse’s employment. In addition, an employer may not prohibit a nursing peer review committee from filing a report to the BON if the nursing peer review committee has determined in good faith that a nurse’s practice must be reported to the Board in compliance with Tex. Occ. Code §301.403 and Tex. Admin. Code §§217.11(1)(K) and 217.19.
A "minor incident" is conduct by a nurse that may be a violation of the Texas Nursing Practice Act or a Board rule but does not indicate that the nurse’s continued practice poses a risk of harm to a patient or another person.
actions that indicate the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior.
What are the factors for determining if minor incidents are reportable to the Board or the nursing peer review committee?
Tex. Admin. Code §217.16(d)&(e) describe how to evaluate whether conduct is a minor incident. A combination of factors must be reviewed, including the nurse’s conduct, those factors viewed to be beyond the nurse’s control, and the relationship between the two that influenced or impacted the nursing practice breakdown.
In determining whether multiple minor incidents constitute grounds for reporting the nurse to the nursing peer review committee or the Board if the practice setting does not have nursing peer review, an evaluation must be conducted to determine if the minor incidents indicate a pattern of practice that demonstrates the nurse's continued practice poses a risk of harm.
If a nurse commits five minor incidents within a 12-month period, the nurse must be reported to the nursing peer review in practice settings with nursing peer review. In practice settings with no nursing peer review, the nurse who commits five minor incidents within a 12-month period must be reported to the Board.
A nursing peer review committee is required to make a report to the Board if they believe in good faith that a nurse has engaged in conduct subject to reporting as defined under the Tex. Occ. Code §301.401(1). This typically involves one or more suspected violations of Tex. Admin. Code §§217.11,Standards of Nursing Practice, or 217.12, Unprofessional Conduct, or may fail to meet the criteria for consideration as a minor incident [Tex. Admin. Code §217.16(h) discussed above].
Note that failure to classify an event appropriately in order to avoid reporting the nurse to the BON may result in action against the nurse or nurses on the nursing peer review committee responsible for reporting, and/or the CNO who failed to report to the Board under his/her duty as a nurse in compliance with Tex. Occ. Code §301.402.
Any person or entity with a mandatory reporting requirement (outlined in NPA Subchapter I, Reporting Violations and Patient Care Concerns) to report a nurse for impairment or suspected impairment may report the nurse to a peer assistance program approved by the Board, instead of reporting the nurse to the Board or the nursing peer review committee, so long as there is not a practice violation.
Any person or entity with a mandatory reporting requirement (outlined in NPA Subchapter I) to report a nurse for impairment or suspected impairment MUST report the nurse to the Board if the person/entity believes the impaired nurse committed a practice violation.
If a nurse is being reviewed by the incident-based nursing peer review committee (IBNPRC) and during the course of the incident-based nursing peer review process there is evidence of impairment or suspected impairment due to chemical dependency, drug or alcohol abuse, substance abuse/misuse, “intemperate use”, mental illness or diminished mental capacity, nursing peer review of that nurse must be suspended. If there is no reasonable factual basis for determining that a practice violation is involved, the IBNPRC can either report the nurse to the Board or to a Board-approved peer assistance program. If there is a reasonable factual basis for determining that a practice violation is involved, the IBNPRCmust report the nurse to the Board.
The incident-based nursing peer review (IBNPRC) committee must reconvene following suspension ofnursing peer review of the nurse who was impaired or suspected of being impaired for the sole purpose of determining whether any factors beyond the nurse’s control contributed to a practice violation and any deficiency in external factors enabled the nurse to engage in unprofessional or illegal conduct. If the committee determines that external factors do exist, the committee must report its findings to the patient safety committee or the CNO if there is no patient safety committee. Remember that because the nurse’s practice is not being reviewed (only the surrounding factors), due process rights for the nurse do not apply.
The nurse who works through a temporary agency or contractor may be subject to nursing peer review by the facility where services are provided, the compensating agency, or both. For the purposes of exchange of information, the nursing peer review committee reviewing the conduct is considered as established under the authority of both so that the confidentiality requirements of nursing peer review are enforceable against any nurse involved in the investigation or the nursing peer review proceeding. The two entities may choose to have a contract with respect to which entity will conduct incident-based nursing peer review of the nurse.
Safe harbor is a nursing peer review process that a nurse may initiate when asked to engage in an assignment or conduct that the nurse believes, in good faith, would potentially result in a violation of the Nursing Practice Act (NPA) or Board rules. When invoked in good faith, safe harbor protects a nurse from employer retaliation, suspension, termination, discipline, discrimination, and from licensure sanction by the Board of Nursing (“BON” or “Board”). Safe harbor must be invoked prior to engaging in the conduct or assignment for which nursing peer review is requested, and may be invoked at any time during the work period when the initial assignment changes.
Examples of safe harbor situations include clinical assignments related to staffing and/or acuity of patients when the nurse believes patient harm may result [Tex. Admin. Code §217.11(1)(B) and (T)], and can involve a request to engage in unprofessional or illegal conduct, such as falsifying medical record documents.
Safe harbor also allows for a nurse to request that a determination be made on the medical reasonableness of a physician’s order [Tex. Occ. Code §303.005(e)]. There is a separate form for requesting a determination regarding the Medical Reasonableness of a Physician’s Order.
may not be disciplined by the Board for engaging in that conduct while the nursing peer reviewcommittee’s determination is pending.
Where do I send my safe harbor request? Do I fax it to the Board of Nursing?
Please DO NOT mail or fax your request for safe harbor nursing peer review to the Board of Nursing. The BON does not conduct nursing peer review. Safe harbor nursing peer review must be done through the nursing peer review committee at the facility or agency where the conduct was requested/assignment was made. You should submit your request to the supervisor who requested the conduct/made the assignment. Please review the instructions on the Comprehensive Written Request for Safe Harbor Nursing Peer Review form. Remember, you are not required to use the forms provided by the BON; however, your request must be written and include the minimum information outlined in Tex. Admin. Code §217.20(d). The forms provided by the BON are meant to be a helpful resource to ensure you include all of the necessary information in your request.
A brief explanation of why safe harbor is being requested.
the nurse’s name, title, and relationship to the supervisor making the assignment or request.
Remember, you are not required to use the forms provided by the BON; however, your request must be written and include the minimum information outlined in Tex. Admin. Code §217.20(d). The forms provided by the BON are meant to be a helpful resource to ensure you include all of the necessary information in your request. Please do not submit any safe harbor request forms to the Board. Please submit your request forms to your nursing supervisor requesting the conduct/making the assignment.
If a nurse invokes safe harbor and the supervisor subsequently is able to remedy the situation that caused the nurse to invoke safe harbor (such as obtaining more staff), is the nurse’s request for safe harbor invalid? Does the nurse have to withdraw his/her request for a nursing peer review committee to evaluate the nurse's request?
The nurse's request for safe harbor nursing peer review does not become invalid and the nurse does not have to withdraw his/her request for safe harbor when a supervisor is able to respond with adequate staff, equipment or other resources. It is the nurse's decision whether or not he/she wishes to have a nursing peer review of the situation.
Tex. Occ. Code §301.352, permits a nurse to refuse an assignment/refuse to engage in an act or omission relating to patient care when the nurse believes in good faith that the requested conduct or assignment could constitute grounds for reporting the nurse to the Board under Tex. Occ. Code §301, Subchapter I, could constitute a minor incident, or could constitute a violation of the NPA or Board rules if the nurse notifies the person at the time of the refusal that the reason he/she is refusing the act or omission constitutes grounds for reporting the nurse to the Board OR is a violation of the NPA or a Board rule. Situations involving potential risk of harm to patients or the public are referred to as “violating the nurse’s duty to the patient” because all nurses have a duty under Tex. Admin. Code §217.11(1)(B) to maintain a safe environment for patients/clients and others for whom the nurse isresponsible.
the nurse lacks the basic knowledge, skills, and abilities that would be necessary to render thecare or engage in the conduct requested or assigned at a minimally competent level such thatengaging the requested conduct or assignment would expose one or more patients to anunjustifiable risk of harm.
A request to falsify a patient record is an example of conduct that a nurse should refuse to engage in while awaiting a nursing peer review committee determination, since there is no legal or factual basis that would support a nurse falsifying a patient record. A request to accept an assignment when a nurse believes the nurse staffing levels are unsafe would be conduct a nurse normally would engage in pending nursing peer review’s determination since the supervisor normally would have some reasonable legal or factual basis to support her/his belief that the requested assignment does not violate a nurse’s duty to a patient, even if nursing peer review ultimately determines otherwise. While Tex. Admin. Code §217.11(1)(B) establishes the nurse’s duty to maintain patient safety, Tex.Admin. Code §217.11(1)(T) requires each nurse to “accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability.” The BON urges each nurse to consider their duty to the patient(s) as the highest priority when making any determination to accept or refuse an assignment or requested conduct. The ability to invoke safe harbor protections and to have a safe harbor nursing peer review committee evaluate the requested assignment are the same whether the nurse accepts or refuses the assignment in good faith.
Tex. Admin. Code §217.20(g)(2) requires the nurse and supervisor to collaborate in an effort to identify an acceptable assignment that “is within the nurse’s scope and enhances the delivery of safe patient care” if the nurse refuses to engage in the conduct or assignment because it is beyond the nurse’s scope of practice. A collaborative effort with patient safety as the focus will require the nurse and supervisor to explore additional options that are safer for both the patient(s) and the nurse(s).
Invoking safe harbor has no effect on a nurse’s civil or criminal liability for their nursing practice. The BON does not have authority over civil or criminal liability issues. Safe harbor does protect a nurse invoking safe harbor in good faith from retaliation by an employer or contracted entity for which the nurse performs nursing services. There is no expiration of the protection against retaliatory actions such as demotion, forced change of shifts, pay cut, or other retaliatory actions against the nurse.
When can an informal workgroup of the nursing peer review committee be utilized?
An informal workgroup of the nursing peer review committee may be used in either safe harbor or incident-based nursing peer review. The nurse involved in either type of nursing peer review must agree to the use of the informal workgroup. The nurse does not give up his/her right to review by the full nursing peer review committee because they initially agree to the informal review process utilizing a workgroup of the nursing peer review committee. As stated in Tex. Admin. Code §§217.19(e) and 217.20(k), the workgroup must be made up of members of the nursing peer review committee, and must follow the same time lines, due process steps, and other procedures that apply to the full nursing peer review committee. Additionally, there must be written policies for the workgroup that specifically address requirements set out in Tex. Admin. Code §§217.19(e) and 217.20(k).
The nursing peer review rules do not address use of an informal workgroup when a nurse is terminated for practice related reasons. When a report to the BON is mandated under Tex. Occ. Code §301.405(b), nursing peer review is conducted solely to look for the existence of external factors that may have impacted the nurse’s actions. Since neither the statute nor Board rules specifically allow or prohibit the use of the informal workgroup for this purpose, facility policy and procedure on nursing peer review would need to address this as an option for nursing peer review under Tex. Occ. Code §301.405(c).
Tex. Occ. Code §303.005(d) requires the employer/nurse manager to consider the decision of the safe harbor nursing peer review committee ‘in any decision to discipline the nurse’ if the nurse refused to engage in the requested conduct/refused the assignment pending the nursing peer review. However, the “non-binding” provision in this statute means that if the CNO/Nurse Administrator believes the safe harbor nursing peer review was conducted in “bad faith,” or the committee otherwise made an incorrect determination of the nurse’s duty, the committee’s decision is non-binding. The CNO/Administrator must document his/her rationale for disagreeing with the committee’s determination, and this must be retained with the nursing peer review records. In addition, if the CNO/Nurse Administrator believes the nursing peer review was conducted in bad faith, he/she has a duty to report the nurses who participated on the nursing peer review committee to the BON [see Tex. Admin. Code §217.20(j)(4)(C)].
The BON encourages CNOs/Nurse Administrators to remember that each nurse has a duty to advocate for patient/client safety. This is expressed in Tex. Admin. Code §217.11(1)(B) and explained in Position Statement 15.14 Duty of a Nurse in Any Practice Setting.
If you have additional questions regarding Peer Review, see Nursing Peer Review (TOC) Chapter 303 and BON Rules 217.19 and 217.20.

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