Source: http://bon.texas.gov/practice_peer_review.asp
Timestamp: 2018-04-21 15:25:37
Document Index: 67257880

Matched Legal Cases: ['§303', '§303', '§217', '§301', '§301', '§301', '§301', '§301', '§301', '§301', '§301', '§301', '§303', '§303', '§301', '§301', '§301', '§303', '§301', '§217', '§217', '§303', '§303', '§303', '§217', '§217', '§217']

Texas Board of Nursing - Practice - Nursing Practice Peer Review
Practice - Peer Review: Incident-Based or Safe Harbor
A Peer Review Committee may review the nursing practice of a LVN, RN, or APRN (RN with advanced practice authorization). 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 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.
Safe Harbor (SHPR), which may be initiated by a LVN, RN or APRN prior to accepting an assignment or engaging in requested conduct that the nurse believes would place patients at risk of harm, thus potentially causing the nurse to violate his/her duty to the patient(s). Invoking safe harbor in accordance with Rule 217.20 protects the nurse from licensure action by the BON as well as from retaliatory action by the employer.
Due Process rights for Incident-Based Peer Review (IBPR) [ Rule 217.19(d)]
Review of NPR Chapter 303 in its entirety is recommended, as compliance with various sections of this chapter is necessary to assure compliance with “due process” and “good faith” peer review requirements. Rule 217.19(d) delineates specific requirements for minimum due process during IBPR. Committee membership and voting requirements are described in NPR §303.003(a)-(d); §303.0015, and §217.19(c) and (d)(3)(B).
that his/her practice is being evaluated by the nursing peer review committee,
that the peer review committee will meet on a specified date not less than 21, but not more than 45 calendar days from the date of notice,
a copy of the peer review plan, policies and procedures.
be provided copies of the witness list and written testimony or evidence at least 48 hours in advance of the proceeding;
make an opening statement to the committee;
ask questions of the committee and respond to questions of the committee; and
make a closing statement to the committee after all evidence is presented.
the committee must complete it’s evaluation within 14 calendar days from the date of the peer review hearing.
Disciplinary action prior to conducting Incident-Based Peer Review [ NPA 301.405(e)]
Duty to report by employer [Section 301.405 (b)]
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, not licensure, issue and is not board-reportable.
any additional information the board requires.
Due process rights under peer review for nurses who voluntarily resign or is involuntarily terminated [NPA §301.405(c) and Rule 217.19(f)(1)]
SB993 (80th Legis. Session, 2007) amended NPA ( TOC) §301.405(c) requiring that even if a mandatory report by the employer has been, or will be, made to the BON under §301.405(b), the 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 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 now required to also report the issue to the entity’s patient safety committee, 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 existence of external factors, due process rights of incident-based peer review do not apply. In addition, a peer review committee cannot make a determination that would negate the duty of the employer to report the nurse under §301.405(b) or of the CNO/nurse administrator to report the nurse under §301.402(b).
Recommendations by IBPR Committee be followed by the employer
The nursing peer review committee does not have authority to make employment or disciplinary decisions. The employer must make their own decision about appropriate disciplinary actions; however, the employer may choose to utilize the decisions of the peer review committee in determining what action they wish to take with regard to the nurse’s employment. In addition, an employer may not prohibit a peer review committee from filing a report to the BON if the PRC has determined in good faith that a nurse’s practice must be reported to the Board in compliance with §301.403, Rule 217.11(1)(K), and Rule 217.19.
Definition of Minor Incident. [NPA 301.401(2)]
“Minor incident” means conduct by a nurse that does not indicate that the nurse’s continued practice poses a risk of harm to a patient or another person. This term is synonymous with “minor error” or“ minor violation of this chapter or board rule.”
Exclusions of Minor Incident.	[Rule 217.16]
Rule 217.16(c) defines 3 types of circumstances in which the conduct cannot be considered a minor incident:
Criteria for determining if Minor Incidents are Board reportable.
Requirements to report to Peer Review committee [NPA §301.401, 301.403, & Rule 217.11, Rule 217.12, Rule 217.16]
A 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 Nursing Practice Act (NPA), §301.401(1). This nearly always involves one or more suspected violations of Rules 217.11, Standards of Nursing Practice, or 217.12, Unprofessional Conduct, or may fail to meet the criteria for consideration as a minor incident [217.16(c) Exclusions, or 217.16(d) discussed above].
a recommendation whether the Board should take formal disciplinary action against the nurse and the basis for the recommendation;
a description of the conduct subject to reporting [defined under 301.401(1)];
the extent to which any deficiency in care provided by the nurse was the result of a factor beyond the nurse’s control; and
Peer review conduction for nurses suspected of secondary impairment (chemical dependency, drug or alcohol abuse, substance abuse/misuse, “intemperate use,”mental illness, or diminished mental capacity). [NPA §301.410 & Rule 217.19(g)]
Peer Review for a temporary or contract employees (NPR §303.004)
Definition of Safe Harbor - [NPR §303.005(b) and (e); Rule 217.19(a)(15), Rule 217.20(a)(15)]
Examples of Safe Harbor situations include clinical assignments related to staffing and/or acuity of patients where the nurse believes patient harm may result [217.11(1)(B) and (T)], and can involve a request to engage in unprofessional or illegal conduct, such as falsifying medical record documents. The latter is an example of a situation where a prudent nurse would refuse to engage in the conduct requested.[NPA §301.352(a-1), Rule 217.20(g)(1)(B)]
Safe Harbor also allows for a nurse to request that a determination be made on the medical reasonableness of a physician’s order [NPR 303.005(e)]. [Note: There is now a separate form on the BON web page that can be used for this process.]
Applicable protections of nurse's license under Safe Harbor - [NPA §301.352, §301.413; NPR §303.005(c), (d), and (h),]
Invocation of Safe Harbor protections [Rule 217.20(d)]
Activation of Safe Harbor protections:
(A)	The nurses(s) name(s) making the safe harbor request and his/her signature(s);
(B)	The date and time of the request;
(C)	The location of where the conduct or assignment is to be completed;
(D)	The name of the person requesting the conduct or making the assignment; and
(E)	A brief explanation of why safe harbor is being requested.
Withdrawal Request of Safe Harbor Peer Review
The nurse's request for Safe Harbor Peer Review does not become invalid and the nurse does not have to withdraw his/her request for Safe Harbor just because a supervisor is able to respond with adequate staff, equipment, or whatever else was at issue with the original requested assignment. It is the nurse's choice whether or not he/she wishes to still have a nursing peer review of the situation. [See the Quick Request and Comprehensive Request for Safe Harbor forms and the Peer Review Page.
When to Invoke Safe Harbor and Refuse Nursing Assignment [NPA (TOC) §301.352, Rule 217.20(g)]
The NPA, section 301.352 permits a nurse to refuse an assignment when the nurse believes in good faith that the requested conduct or assignment could constitute grounds for reporting the nurse to the board under NPA 301.401(1), could constitute a minor incident, or could constitute another violation of the board statutes or rules. 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 Rule 217.11(1)(B) to maintain a safe environment for patients/clients and others for whom the nurse is responsible. Safe Harbor enables a nurse in most circumstances to accept the assignment, thus allowing the nurse to protect his/her nursing license from board sanctions while at the same time delivering the best care possible to a patient(s).
Patients are better off with the nurse than without the nurse in the vast majority of cases; however, Rule 217.20(g) clarifies that a nurse may engage in an assignment or requested conduct pending peer review determination unless the requested assignment or conduct is one that:
A request to falsify a patient record is an example of conduct that a nurse should refuse to engage in while awaiting a 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 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 peer review ultimately determines otherwise.
While §217.11(1)(B) establishes the nurse’s duty to maintain patient safety, standard §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.” It is also impossible in the rule-writing process to anticipate every possible situation a nurse might face in every practice setting, and where a nurse may believe in good faith that his/her duty to one or more patients is in greater jeopardy to accept the assignment than to refuse it. The BON urges each nurse to consider the duty to the patient(s) as the highest priority in make any determination to accept or refuse an assignment or requested conduct. The ability to invoke Safe Harbor protections and to have a nursing peer review committee evaluate the requested assignment are the same whether the nurse accepts or refuses the assignment.
Note that Rule 217.20(g)(2) now requires the nurse and supervisor to collaborate in an effort to identify an assignment that “is within the nurse’s scope and enhances the delivery of safe patient care.” This is based on the premise that in any staffing crisis, the patients are almost always better off with the nurse, than without the nurse. A collaborative effort with patient safety as the focus will require the nurse and supervisor to set aside any personal animosity and to explore additional options that are safer for both the patient(s) and the nurse(s).
Protection of Civil or Criminal Liability under Safe Harbor [NPR §303.005(h), 217.20(e)(2) & (3)]
Safe Harbor has no effect on a nurse’s civil or criminal liability for his/her nursing practice. The BON does not have any authority over civil or criminal liability issues. Safe Harbor does protect the nurse from retaliation by an employer or contracted entity for whom 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 action against the nurse.
Use of small workgroups for Nursing Peer Review Committee
A smaller 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 peer review must agree to the use of the smaller workgroup. The nurse does not give up his/her right to review by the full peer review committee just because they initially agree to the smaller workgroup. As stated in the rule, the workgroup must be made up of members of the 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.
The peer review rules do not address use of a smaller workgroup of peer review in the event a nurse was terminated for practice related reasons. When a report to the BON is mandated under NPA 301.405(b), 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 or board rules specifically allow or prohibit the use of the smaller workgroup for this purpose, facility policy and procedure on nursing peer review would need to address if this is an option for peer review under NPA 301.405(c).
Recommendations made by the SHPR Committee to CNO/Nurse Administrators [NPR §303.005(d); Rule 217.20(j)(4)(A)]
NPR law §303.005(d) requires the employer/nurse manager to consider the decision of the SHPR Committee “in any decision to discipline the nurse.” The “non-binding” provision in this statute means that if the CNO/Nurse Administrator believes the SHPR was conducted in “bad faith,” or otherwise made an incorrect determination, the CNO/Administrator must document his/her rationale for disagreeing with the SHPR Committee determination, and this must be retained with the SHPR records. In addition, if the CNO/Nurse Administrator believes the SHPR was done in bad faith, he/she has a duty to report the nurses who participated on the PRC to the BON [see Rule 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 Rule 217.11(1)(B) and explained in Position Statement 15.14 Duty of a Nurse in Any Setting. Another document is the BON’s Six-Step Decision-Making Model for Determining Nursing Scope of Practice and LVN Six-Step Decision-Making Model for Determining Nursing Scope of Practice. Step 3 asks if there is nursing literature, research, or guidance documents from national specialty nursing organizations related to the nursing issue in question. National patient safety organizations, such as the Institute for Safe Medication Practices, would also be applicable with regard to “best practices” in a given area of nursing and patient safety. Safe Harbor peer review can be an opportunity to take stock of how nursing and support departments surrounding nursing are organized, and how safe patient care is helped or hindered by those systems.
Where to send Safe Harbor requests
Texas Secretary of State -TITLE 22 EXAMINING BOARDS
Texas Administrative Code, Rule §217.16, Reporting of Minor Incidents
Rule 217.19, Incident-Based Nursing Peer Review and Whistleblower Protections
Rule 217.20, Safe Harbor Peer Review and Whistleblower Protections
Safe Harbor Nursing Peer Review Forms
BON §217.19 Incident-Based Peer Review (IBPR) & §217.20
Nursing Peer Review Statutes and Rules References
Safe Harbor Statutes and Rule References pdf