NQSC Confidentiality NPR and Quality Review Committee Members

Confidentiality Guidelines for Nursing Peer Review and NQSC Quality Reviews


The Nursing Quality and Safety Review committees function in accordance with the requirements of the Nursing Peer Review Law, (Chapter 303 of the Occupations Code) and BON Rule 217.19 and 217.20 governing incident-based and safe harbor nursing peer review. They require that confidentiality be maintained for all information presented or considered in the peer review process. Confidentiality is necessary to protect not only the nurse being reviewed, but also to facilitate the open discussion of opinions by members and other participants in the process. The Nursing Peer Review Law provides significant protections from civil liability for persons participating in good faith in nursing peer review. Violating confidentiality could result in loss of these protections and expose both the person breaching confidentiality and the committee itself to civil liability. The following guidelines are designed to assist participants in avoiding any inadvertent breaches of confidentiality.

Restrictions on Disclosure

  1. A member, agent or employee of the committee, the nurse being reviewed, witnesses or any other participant in any peer review proceedings may not voluntarily disclose any communication to the committee or any record or proceeding of the committee. Nor may they be required to disclose such information.
  2. Any person who attends any proceeding of the committee may not voluntarily disclose any information acquired or disclose any opinion, recommendation, or evaluation of the committee or any member of the committee. Nor may they be required to disclose this information.
  3. Members of the committee and participants may not be questioned about their testimony or about opinions formed as a result of the committee proceedings.
  4. Peer review committees are required to protect to the extent possible the identity of patients.
  5. Reviewers should maintain the confidentiality of medical information utilized in the review process and protect the non-authorized disclosure of protected health information (PHI) addressed under the Health Information Portability and Accountability Act (HIPAA), 45 CFR Part 142. Any participant who discloses PHI will be subject to penalties as described in this federal regulation.
  6. In the event the nurse elects to consult with an attorney, confidentiality will not be breached.
  7. Members of the committee may not report the nurse being reviewed to the BON independently of the committee if the member’s sole source of information about the nurse’s conduct results from serving on the committee.

Guidelines for Participants

I understand it is my legal and ethical responsibility to abide by the following:

  1. I will not discuss any case except as part of my official responsibilities on the committee. Casual or “cocktail” conversation about a case is one of the easiest ways to breach confidentiality. Discussing a case with a third party to get their opinion or feeling can also result in inadvertently disclosing confidential information. Seemingly unimportant information can sometimes permit a third party to identify the person that is being discussed.
  2. If I am questioned about a case or my participation in a proceeding, I will explain that the Nursing Peer Review Law does not permit me to respond to any questions. I will refer the person to the committee chair and immediately notify the chair of the incident.
  3. I understand that procedures have been developed to permit a case to be discussed without identifying patients by name. I will refer to individual patients using the ARCHI Medical Record Number only.
  4. If I have any questions about confidentiality, I will consult the committee chair.
  5. I understand as a committee member, documents for the review will be made available to me through the Accellion program. I will use the Accellion program to review the documents and will not print, download, or copy any of the files associated with the review.
  6. I understand that documents for the review (original and blinded) will be made available to the nurse and/or representative through the Chief Nursing Officer at the reporting organization.
  7. I recognize that unauthorized release of confidential information may make me subject to legal action and/or dismissal from the committee.
  8. I realize that access to electronic systems can be audited and that any inappropriate access to information may make me subject to legal action and/or dismissal from the committee.
  9. I will not share my login or password with anyone.
  10. I accept the responsibility for the destruction of any hardcopy materials used with this proceeding. I agree that the material will be shredded immediately after use.
  11. I understand that violation of any portion of the policies and procedures related to confidentiality of medical records or any violation of federal regulations governing the patient’s right to privacy or violating the integrity of the peer review protections will result in a report to hospital and/or the Board of Nursing.