UT-Harris County Psychiatric Center
Nursing Procedures


Peer Review


Harris County Psychiatric Center: Office Administration

Peer review is one method of ensuring high quality healthcare by investigating reportable conduct of registered nurses

nursing peer review, reportable conduct, peer review committee

The University of Texas Health Science Center at Houston






Patient Advocacy Protection for Nurses:

Date of Last Review: 6-20-2012
SME: Chief Nurse Officer

Individual competence and ethical conduct are essential components of quality healthcare. Peer review is one method of ensuring high quality healthcare by investigating reportable conduct of both registered nurses and licensed vocational nurses (LVN).

The UTHCPC Department of Nursing Services complies with Senate Bi11 192, which enforces prohibition of retaliatory actions for requesting a Safe Harbor peer review determination and for refusing to engage in a certain act of omission relating to patient care.

What is peer review?

According to Nurse Practice Act (NPA) peer review is defined as:

“…the evaluation of nursing services, the qualifications of nurses, the quality of patient care rendered by nurses, the merits of complaints concerning nurses and nursing care, and determinations or recommendations regarding complaints including: (http://www.bne.state.tx.us)

  • Evaluation of nursing services
  • Qualifications of nurses
  • Quality of patient care rendered by nurses
  • Merits of complaints concerning nurses and nursing care
  • Determinations or recommendations concerning complaints including:

(A) the evaluation of the accuracy of a nursing assessment and observation and the appropriateness and quality of the care rendered by a nurse;

(B) a report made to a nursing peer review committee concerning an activity under the committee’s review authority;

(C) a report made by a nursing peer review committee to another committee or to the Board as permitted or required by law; and

(D) implementation of a duty of a nursing peer review committee by a member, an agent, or an employee of the committee.


“[Section 303.001 (5)]

Peer review process is one of involving 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. Once a decision is made that a nurse is subject to peer review, Texas Occupations Code 303.002(e) provides that the nurse is entitled to minimum due process .

The intent is that Peer Review will be a collegial, non-adversarial review of a nurse or an event. It is not intended to be a form of punishment.

Reportable conduct

Reportable conduct is any conduct by a registered nurse (RN) or licensed vocational nurse (LVN) that unnecessarily exposes or is likely to expose a patient or other person to a risk of harm because of any of the following:

  • Unprofessional conduct (BNE, Rule 217.12)
  • Failure to care adequately for a patient
  • Failure to conform to the minimum standards of acceptable professional nursing practice (BNE, Rule 217.11)
  • Impaired status


Who reports conduct?

Reportable conduct is communicated as follows:

  • Any registered nurse employed by UTHCPC who observes a registered nurse engaging in reportable conduct or is aware of evidence that such conduct has occurred must make a written variance/incident report of that conduct to the Nurse Manager.

Any reportable conduct by a registered nurse that results in termination, suspension, or probation is reported to the Peer Review Committee and to the BNE/NPDB, as required.

Nurse manager duties

The nurse manager has the following responsibilities for recording reportable conduct:





Maintains a record of each minor incident involving the RNs under her supervision


Assures that the incident/variance report contains:

·   A complete description of the incident

·   Patient record number

·   Witnesses

·   Nurse involved

·   Action taken to remedy the problem


Reports nurse to the Peer Review Committee for any significant/major infraction and/or three minor incidents involving the nurse are documented within one-year’s time.

Result:  The Peer Review Committee reviews the three minor incidents and makes a determination as to whether a report to the Board of Nurse Examiners is warranted.


Peer review committee function

The Peer Review Committee functions as follows:

  • Advisory in nature
  • Makes recommendations as permitted by law, but cannot take action against a nurse being reviewed
  • Cannot supersede administrative actions which may result in termination, suspension, or placement of a registered nurse on probationary status
  • Keeps all proceedings confidential, except as otherwise provided in Texas Occupation Code 303.006 and 303.007
  • Recommends programs to educate nursing staff regarding Texas Statutes regulating professional nurses with emphasis on:

–  Accountability and responsibility of the registered nurse

–  Utilization and purpose of the Peer Review process

–  Quality assurance of patient care delivery

Committee composition

The Peer Review Committee is composed as follows:

·   Assistant Administrator/Director of Nursing appoints chairperson

·   Committee appointment(s) are for one year

·   Consists of eleven (11) registered nurses

·   Seven (7) must be present to conduct business

·   Meets on an on-call basis

Peer review committee process

The table below shows the steps involved when the Peer Review Committee investigates reportable conduct:





The committee chairperson:

  • Receives the Initial Investigation Report
  • Convenes the peer review committee will meet on a specified date not sooner than 21 calendar days and not more than 45 calendar days from date of notice, unless otherwise agreed upon by the nurse and peer review committee.
  • Has committee members sign Confidentiality Guidelines for Participants in Nursing Peer Review Process ( See Texas Occupations Code 303.006 & 303.007 )
  • Notifies, in writing, the affected nurse using the Notice of Receipt of Report as below:
    • Notify the nurse by certified mail if employee is not available at work
    • Describe the events to be evaluated in sufficient detail as to inform the nurse of the incident
    • Include circumstances and conduct with date(s), time(s), location(s), and individual(s) involved. (Patient is identified by MR#)
    • Provide the nurse with the name, address, and telephone number of a contact person to receive the nurse’s response


The nurse acknowledges receipt of the notification with a signature.


The committee chairperson provides the nurse with the opportunity to:

  • Submit a written statement regarding the event
  • Call witnesses, question witnesses and be present when testimony or evidence is being presented
  • Be provided copies of the witness list and written testimony or evidence at least 48 hours in advance
  • Make an opening statement
  • Ask questions and respond to questions of the committee
  • Make closing statement after all evidence is presented


The committee:

  • Evaluates the allegations no more than fourteen (14) calendar days from the initial committee meeting
  • Reviews all evidence to determine the extent to which any deficiency in care by the nurse was the result of deficiencies in the Nurse’s judgment, knowledge, training, or skill rather than other factors beyond the nurse’s control. A determination that a deficiency in care is attributable to a nurse must be based on the extent to which the nurse’s conduct was the result of a nurse’s judgment knowledge, training or skill.
  • Provides a Detailed Summary of Peer Review Committee Findings to the nurse in person, or by certified mail (to the last known address on file ) within ten (10) calendar days of when the committee review has been completed.
  • Gives the nurse ten (10) calendar days to submit a Written Rebuttal Statement.
  • Permits the nurse to make the rebuttal statement a permanent part of the Peer Review record to be included whenever the committee’s findings are disclosed.
  • Submits Peer Review Committee’s Final Report to Administration within five (5) calendar days of the committee’s recommendation (Report will include corrective action recommended – See Final Report form for additional content)


Nurses Right to Representation:

A nurse has a right of representation as set out in Section 217.19 of the BNE Standards . The peer review process is not a legal proceeding; therefore, rules governing legal proceedings and admissibility of evidence do not apply and the presence of attorneys is not required. The nurse has the right to be accompanied to the hearing by a nurse peer or an attorney. Representatives attending the peer review hearing must comply with the facility’s peer review policies and procedures regarding participation beyond conferring with the nurse. If either the facility or nurse will have an attorney or representative present at the peer review hearing in any capacity, the facility or nurse must notify the other at least seven (7) calendar days before the hearing that they will have an attorney or representative attending the hearing and in what capacity. Notwithstanding any other provisions of these rules, if an attorney representing the facility or peer review committee is present at the peer review hearing in any capacity, including serving as a member of the peer review committee, the nurse is entitled to “parity of participation of counsel.” “Parity of participation of counsel” means that the nurse’s attorney is able to participate to the same extent and level as the facility’s attorney; e.g., if the facility’s attorney can question witnesses, the nurse’s attorney must have the same right



Confidentiality of information presented to and/or considered by the peer review committee shall be maintained and not disclosed except as provided by Texas Occupations Code §§ 303.006 and 303.007. (Disclosure/discussion by a nurse with the nurse’s attorney is proper because the attorney is bound to the same confidentiality requirements as the nurse.)

7 The Assistant Administrator/Director of Nursing considers committee recommendations, makes final decision, and submits required reports to Board of Nurse Examiners.


UTHCPC abides by all peer review requirements as defined on BNE website at ( http://www.bne.state.tx.us )


Related standard:

JCAHO NR 2/Texas Occupation Code 303.006, 303.007