PEER REVIEW CINDY L FARLEY CNM PHD FACNM

PEER REVIEW CINDY L. FARLEY, CNM, PHD, FACNM KATE WASHBURN, BSN, SNM ERIN LISTERMANN, BSN, SNM OLIVIA DIXON, BSN, SNM

OBJECTIVES • Define peer review and describe its contribution to continuous quality improvement measures in midwifery • Identify at least 3 modalities of peer review and discuss the strengths and limitations of each peer review method • Participate in peer review of 3 selected recent clinical midwifery cases through dialogue and interactive computer technology

CONNECTION FOR INTERACTION VIA COMPUTER • https: //georgetown 1. adobecon nect. com/r 5 fcpfvrhn 6/

DISCLOSURES • No conflicts of interest • 15 years leading peer review efforts in Southern Ohio Chapter • 1983 -1998

PEER REVIEW DEFINED • The assessment and evaluation of midwifery practice by other midwives to measure compliance with ACNM standards • Professional self-regulation • Professional knowledge and skills • Peer review is non-discoverable in Ohio.

PEER REVIEW: 1 OF 3 COMPONENTS OF QUALITY MANAGEMENT • Quality assurance • Monitors structural, procedural, and outcome indicators as they relate to accepted standards • Quality improvement • Modifies the process for providing care in order to improve outcomes • Look at ACNM Benchmarking data • Available on the ACNM web site

PEER REVIEW MODELS: SITE VISIT EVALUATION • Piloted in 1983 by Southern Ohio Chapter • Adopted by all chapters later • Successful when chapter was small • Difficulties with participation now

PEER REVIEW MODELS: INTERNAL PRACTICE REVIEWS • Various methods • Example • Quarterly review by all midwives of the practice • Chart review checklist • Individual midwife statistics • Narrative summary

PEER REVIEW MODELS: GROUP CASE PRESENTATION & DISCUSSION • Launched last year at the Ohio Forward • Kudos to Kim Randle Hertzfeld • Used by a number of ACNM and MANA chapters

EXAMPLES FROM OHIO PEER REVIEW: SITE VISIT MODEL • Universally positive but time consuming • What if we find poor care? • What if we find something illegal?

EXAMPLES OF CONCERNING FINDINGS • Midwife had woman with • Midwife using ultrasound footling breech up in practice without walking training

WHAT WOULD YOU DO AS PEER REVIEWER? • In each case, summary • Limited authority report made mention of • Other options these as deficiencies • Reporting to and referred to ACNM • OBN • OBM and other resources for • ACMB corrective actions • Follow up done • several months after

EXAMPLES OF REVIEW BY OTHERS • The circumcision question and the Medical Board • The episiotomy question and the Nursing Board

OHIO STATE LAW GOVERNING MIDWIFERY PRACTICE • No certified nurse-midwife may perform version, deliver breech or face presentation, use forceps, do any obstetric operation, or treat any other abnormal condition, except in emergencies. Division (A) of this section does not prohibit a certified nurse-midwife from performing episiotomies or normal vaginal deliveries, or repairing vaginal tears. A certified nurse-midwife who holds a certificate to prescribe issued under section 4723. 48 of the Revised Code may, in collaboration with one or more physicians, prescribe drugs and therapeutic devices in accordance with section 4723. 481 of the Revised Code.

CAUTIONARY TALES IN OHIO • A nurse-midwife called the Medical Board to see if midwives were allowed to do circumcisions. • A hospital asked the Nursing Board if nurse-midwives were permitted to do episiotomies.

CIRCUMCISION TALE, CONTINUED • The Medical Board said “No” and told the Nursing Board to have nurse-midwives cease and desist circumcision. • The Nursing Board interpreted the scope of practice prohibition on surgery as a prohibition on circumcision. • Some midwives had to stop practicing this skill and others had to devote energies to fight this ruling. • Where should that nurse-midwife have gone with her question? What would you do?

EPISIOTOMY TALE, CONTINUED • The Nursing Board sent a non-peer nurse to evaluate this nurse-midwife. • The nurse interpreted the scope of practice prohibition on surgery as a prohibition on episiotomy. • The nurse-midwife was reprimanded by the Board and required to have continuing education and on-site monitoring by Board Approved practitioners. • Enter myself and Gretchen Mettler • A peer would not have made this judgment • Too late for this midwife

THE MORAL OF THE STORY • The current Boards are • Not peers and do not understand midwifery practice • Are charged with protecting the public, not the practitioner • Can be hostile • Take away message: if ever contacted by either Board • Get a lawyer immediately AND • Insist on peer evaluation • Long term vision: a Board of Midwifery

ON TO OUR REVIEWS, BUT FIRST…

CHOOSING A PEER REVIEW CASE • Of interest to a local peer group (e. g. , premature labor) • Universally recognized as a problem in midwifery management (e. g. , shoulder dystocia) • Requires ongoing or periodic reevaluation (e. g. , low Apgar score or postpartum hemorrhage) • Recognized institutional problem that needs to be solved (e. g. , a recent increase in number of cases of postpartum endometritis)

A SAFE PLACE FOR DISCUSSION OF CLINICAL CARE • Interactive discussion and examination of evidence to support or question practice decisions is rigorously undertaken; • The presenter takes responsibility to put forward evidence to expand, support, or question the management of a specific case; • Discussion is framed constructively with the goal being learning and enhanced practice for all; • Confidentiality is assiduously maintained; and • Multiple viewpoints are welcome and explored

OLIVIA DIXON’S CASE • Case information will be provided at the forward

KATE WASHBURN’S CASE • Case information will be provided at the forward

ERIN LISTERMANN’S CASE • Case information will be provided at the forward

THANK YOU FOR PARTICIPATING IN PEER REVIEW

REFERENCES • American College of Nurse-Midwives. (2005). Quality management in midwifery care. Author. • American College of Nurse-Midwives. (2006). Creating a culture of safety in midwifery care. Author. • American College of Nurse-Midwives. (2011). Standards for the practice of midwifery. Author. • Engels, Y. , Verheijen, N. , Fleuren, M. , Mokkink, H. , & Grol, R. (2003). The effect of small peer group continuous quality improvement on the clinical practice of midwives in The Netherlands. Midwifery, 19(4), 250 -258.

REFERENCES, CONTD. • Martinez, A. W. , & Mariella, A. M. (1986). Nurse-midwifery peer review at Phoenix memorial hospital. Journal of Midwifery and Women's Health, 31(1), 20 -25. • Nijm, L. M. (2003). Pitfalls of Peer Review The Limited Protections of State and Federal Peer Review Law for Physicians. The Journal of legal medicine, 24(4), 541 -556. • Rout, A. , & Roberts, P. (2008). Peer review in nursing and midwifery: a literature review. Journal of clinical nursing, 17(4), 427 -442. • Sorg, B. A. (2015). Is Meaningful Peer Review Headed Back to Florida? . Akron Law Review, 46(3), 6.