NARM Community Peer Review

Community Peer Review Process

Community Peer Review brings midwives in an area together on a regular basis to discuss their cases and learn from each other. It is an opportunity for cohesiveness within a community and can serve as a foundation when difficult situations arise. Sooner or later in every community there will be an issue that must be faced. Having ongoing Community Peer Review provides a stable environment for solving problems and lending support to one another.

Beyond community support lie the professional ethical concerns. Peer Review adds validity to the certification process and is required in many medical settings.

Citizens can know that their practitioner participates in Peer Review, and that, if a concern is raised, there is a platform for discussion and follow-up. Other health care practitioners can also know and recognize the professionalism involved in maintaining Community Peer Review.

If a formal complaint is filed against a Certified Professional Midwife (CPM, the first place the complaint will be addressed officially will be in local Peer Review. A formal complaint against an apprentice/CPM applicant may be addressed by a review committee of NARM Board members.

Establishing Community Peer Review is worthwhile preparation for future problem solving.

The suggested format for Community Peer Review is as follows. Decision making by consensus is strongly encouraged and supported by NARM.

Peer Review is as follows. Decision making by consensus is strongly encouraged and supported by NARM.

I. Community Peer Review is to be held quarterly. In cases of unusual hardship in meeting, it is suggested that meetings happen at least every six months, and that, in between meetings, the midwives involved make phone contact to discuss any difficult cases.

II. Students and assistants are included in Community Peer Review.

III. A midwife who also facilitates the meeting hosts Community Peer Review. This job rotates among those participating.

IV. Upon arrival, each midwife writes down for the facilitator the number of cases they have to bring to review and how much time they estimate they will need to present them.

V. At the opening of the meeting, the midwife facilitating is to review the basic guidelines for Community Peer Review as listed below.

a. The information presented at Community Peer Review is confidential.

b. The intention of peer review is not punitive or critical but supportive, educational, and community based. Positive feedback is encouraged, concerns should be raised respectfully and with the assumption that feedback is welcome.

c. While a midwife presents a case, everyone remains quiet. Questions are asked after the midwife has finished.

d. Recommendations for follow-up are made individually and/or by consensus, and the group offers support.

VI. Each midwife states the following to the best of her ability:

a. Total number of clients currently in the midwife’s care;

b. The number of upcoming due dates;

c. How many women in the practice are postpartum;

d. The number of births done since the last Community Peer Review;

e. The number of cases the midwife has to present. The midwife must present all cases involving consultation, transfer of care, transport to the hospital, instances where the midwife is outside of practice guidelines (including in these the process of Informed Choice used), and cases where the midwife wishes more input from the community of midwives. It is helpful to the community if the midwife also discusses interesting cases or situations.

f. The midwife then presents each case. After each case, questions may be asked and suggestions given.

VII. When presenting a case, the following information should be available:

a. Gravidity and parity of client along with any significant medical or OB history or psychosocial concerns;

b. Relevant lab work and test results;

c. Significant information regarding pregnancy, birth and postpartum;

d. Consultations with other providers (midwives, MDs, DCs, NDs, DOs, etc.); and include the present care plan and how that may change with the ongoing situation.

VIII. After everyone has presented their cases and discussion has ended, the Community Peer Review group is encouraged to discuss professional educational objectives for the current recertification period.

IX. If a conflict arises between a client and a midwife, a local Community Peer Review may discuss the details with the midwife. NARM urges the use of NARM Complaint Review. Mediation may be utilized to reach an acceptable outcome. This is to be done on the most local level possible. If this cannot be achieved to the client’s satisfaction and the client wishes to take action against the CPM’s certificate, a written complaint may be filed with the NARM Board. A written complaint to the NARM Board initiates the Grievance Mechanism, which begins with peer review at the most local level possible. Peer review in response to such a written complaint utilizes the NARM Complaint Review process. If prior to the written complaint to NARM, this complaint was addressed by a local peer review process and resolution was not reached, the written complaint to NARM initiates the Grievance Mechanism.

X. Some Community Peer Review groups have decided to include an agreement regarding consensus and binding recommendations. The Community Peer Review group may decide that the recommendation made for follow-up in instances of extreme concern need to be binding. If so, the recommendations must be reached by consensus and each participating midwife must agree to such binding decisions in the future. No recommendations are made that the other midwives would not themselves carry out.

NARM Accountability Processes for Addressing a Complaint Against a CPM

The North American Registry of Midwives (NARM) recognizes that each Certified Professional Midwife will practice according to her/his own conscience, practice guidelines and skills levels. Certified Professional Midwives shall not be prevented from providing individualized care.

When a midwife acts beyond Guidelines for Practice, the midwife must be prepared to give evidence of informed choice. The midwife must also be able to document the process that led the midwife to be able to show that the client was fully informed of the potential negative consequences, as well as the benefits of proceeding outside of practice guidelines.

NARM recognizes its responsibility to protect the integrity and the value of the certification process. This is accomplished through the availability of a grievance mechanism. Each Certified Professional Midwife or CPM applicant will have the opportunity to speak to any written complaints against them before any action is taken against their certificate (or application).

All NARM Certified Professional Midwives (CPMs) and CPM applicants are encouraged to attend peer review on the local level.
If a conflict arises between a client and a midwife, a community peer review may discuss the details with the midwife. Mediation may be utilized to reach an acceptable outcome. This is to be done on the most local level possible. If this cannot be achieved to the client’s satisfaction and the client wishes to take action against the midwife’s certificate, a written complaint must be filed. A CPM or CPM applicant who has been named in a written complaint to NARM is required to participate in NARM Complaint Review and/or Grievance Mechanism. Failure to participate in the accountability processes will result in revocation of the credential.

A CPM with inactive or expired status is bound by all policies regarding NARM Community Peer Review, Complaint Review, and Grievance Mechanism. Failure to respond to a complaint will result in revocation of the credential.

NARM accountability processes work to address concerns regarding competent midwifery practice. The NARM Board reserves the right to evaluate, in its sole discretion, the appropriate application of NARM’s Complaint Review and Grievance Mechanism. Complaints received by the NARM Board that do not involve issues relating to competent midwifery practice will not be addressed through the Complaint Review or Grievance Mechanism that NARM has established.

A complaint against a CPM or CPM applicant may only be made by a client or a party with first hand knowledge of the cause for concern. A complaint will be addressed in Complaint Review only if the client whose course of care has prompted the complaint is willing to sign a records release. With a records release, her chart will be confidentially reviewed and discussed by the midwives participating in Complaint Review. Without permission to review a client’s chart the complaint is closed.

When a complaint is made to local peer review against a CPM, NARM urges the use of the NARM Complaint Review. When a written complaint against a CPM or CPM applicant is received by NARM, the first step is Complaint Review. The outcome and recommendations which result from the NARM Complaint Review are sent to the NARM Accountability Director and a formal letter stating the outcome is issued to the midwife, complainant, and peer review chairperson. The NARM Accountability Committee may make additional recommendations to the midwife. A formal complaint against a CPM applicant may impact the progress of the application. NARM maintains record of the Complaint Review.

Peer review groups are as local as possible. If an issue becomes contentious within a local group, the peer review group may consist of midwives from a larger vicinity. A complaint against a CPM applicant may be heard by a review committee consisting of NARM Board members.

Recommendations resulting from NARM Complaint Review are not binding. However, the midwife named in the complaint may reach resolution with the complainant by addressing the concerns expressed in Complaint Review.

A second complaint against a CPM or applicant initiates the NARM Grievance Mechanism. A second complaint may result from another complainant regarding a different course of care, or from a complainant who does not agree that resolution was reached with the outcome of Complaint Review. The outcome of the NARM Grievance Mechanism is binding and failing to meet the stated requirements results in the revocation of a CPM’s credential, conditional suspension or denial of an application.

NARM will not begin the processes of Complaint Review or Grievance Mechanism with a CPM or applicant who is also facing regulatory investigation, or civil or criminal litigation. NARM will proceed with these processes only after such proceedings are concluded. With a complaint against a CPM, it is the responsibility of the complainant to notify NARM within 90 days of the conclusion of proceeding. With a complaint against a CPM applicant, it is the applicant’s responsibility to notify NARM within 90 days after such proceedings are concluded.

A complaint may be made against a midwife whose CPM certification has been revoked. NARM cannot require a midwife who is not a CPM to participate in Peer Review or Grievance Review, but participation would be a requirement of re-application should the midwife attempt to re-activate her certification.

Complaints must be received within 18 months of the conclusion of care. The status of the CPM or CPM applicant at the time of occurrence is irrelevant. A complaint against a CPM applicant will usually include her preceptor. Notice of complaints received regarding a midwife whose CPM credential has been revoked will be placed in this person’s file in Applications; the original complaint will be kept in Accountability. Should this person reapply for a CPM credential in the future, all fees must be paid prior to NARM continuing the process appropriate to the complaint. Applications will notify Accountability. The complainant will be notified and given the opportunity to pursue the original complaint. If the complainant cannot be located at that time with the information on file, the applicant may proceed with the application. The complaint may be reactivated by the complainant within one year of the CPM’s new certification period.

NARM Complaint Review

When a written complaint against a CPM (or CPM applicant) is received by NARM, it is referred to NARM’s Accountability Committee. The first step in reviewing the complaint is Complaint Review. If resolution is not reached through Complaint Review and the complainant wishes to take action against the CPM’s credential, this must be initiated by a formal letter of complaint with NARM. Formal complaints are referred to NARM’s Accountability Committee for due process within the Grievance Mechanism.

Complaints against a CPM applicant which are reviewed by a committee of NARM Board members may result in binding recommendations or additional application requirements. A complaint resulting in binding recommendations or additional application requirements may be appealed by the applicant but will not continue to the Grievance Mechanism, as there has already been an opportunity for binding recommendations to be issued. A second complaint against an applicant may not involve the same incident. However, a second complaint is addressed by a committee of NARM Board members through NARM’s Grievance Mechanism.

The suggested format for Peer Review to address a complaint is as follows:

The Accountability Committee provides to the Complaint Review group copies of this process, the NARM Complaint Review Conclusion and Summary forms, the written complaint letter, and the midwife’s chart and practice guidelines (which were supplied upon request by the midwife named in the complaint).
The members of the Complaint Review group read these documents, contacting NARM’s Accountability Committee Chairperson with questions. Each member makes a list of questions and points of concern that they intend to address to the midwife during the Complaint Review session. A group discussion of these questions and areas of concern is held prior to the opening of the Complaint Review session. (During the Complaint Review session, the testimony and presentation of events may answer these questions and concerns, or they may be asked directly.)
The midwife and complainant are notified to schedule the Complaint Review session. If necessary, additional written or oral testimony is arranged for the scheduled session by the midwife and complainant.
The Complaint Review session is begun with the midwife, complainant, and review members present.
All parties agree to uphold confidentiality.
The agenda for the session is read.
The complaint is read aloud.
The complainant gives testimony, and any additional testimony on the complainant’s behalf is given or read.
Reviewers may ask questions of the complainant and supporting testifiers.
The complainant and supporting testifiers are excused.
The midwife presents the case. Supporting testimony is given or read.
Reviewers may ask questions of the midwife and supporting testifiers.
The midwife is excused from proceedings.
Reviewers discuss the case. Recommendations and findings are made.
The outcome of the proceedings is given in writing to the midwife and complainant.

The Complaint Review group provides NARM with their findings and recommendations. In extreme circumstances, NARM may make additional recommendations or requirements to the midwife. Complaint Review Conclusion Forms are available in the Professional Accountability section on the NARM web page.

Grievance Mechanism

Complaints must be filed within eighteen months of occurrence or conclusion of care.
All complaints shall be kept confidential.
A written complaint to the NARM Board initiates the Grievance Mechanism, which begins with peer review at the most local level possible. Peer review in response to such a written complaint utilizes the NARM Complaint Review process. If prior to the written complaint to NARM, this complaint was addressed by a local peer review process and resolution was not reached, the written complaint to NARM initiates the Grievance Mechanism. The NARM Board then refers the complaint to the Accountability Committee.
The Accountability Committee shall identify a local review committee made up of the midwife’s peers (at least two (2) CPMs, one of whom will chair, and may include one consumer) at the appropriate local level. The NARM Grievance Mechanism may be a face to face meeting or conducted by teleconference, to be determined at the discretion of the NARM Accountability Committee. A complaint is against a CPM applicant may be reviewed by a committee of NARM Board members.
Upon receipt of a complaint, the Accountability Committee Chair will respond to the complainant with a letter stating that the complaint has been received and will ideally be heard in review committee within 90 days.
The CPM or applicant is notified of this pending action, and, within one week of notification, the CPM (or applicant and preceptor) must submit to the Accountability Committee a complete copy of the client chart and the CPM’s own practice guidelines. The chart is then passed on to the local review committee chairperson.
The opposing sides are each invited to supply written or verbal testimony for the review. Written testimony must be sent from witnesses directly to the local committee chair. Copies of all written material are supplied to the local level chairperson for dissemination to 1) the CPM (or applicant and preceptor), and 2) review committee members, at least two weeks before the review. The local review committee chair is also responsible for coordinating the details of the review committee meeting time and location and will notify the involved parties at least 30 days in advance.
Complainant must respond within two weeks of being notified by the NARM Grievance Mechanism Chairperson with attempts to establish a date for the Grievance Mechanism session. If the complainant does not continue participation in the process, the complaint will be dropped and will not reflect on the CPM or applicant in question.

The Proceedings

I. All participants are required to sign a statement of confidentiality. If the session is via teleconference, this will be established prior to the call and reaffirmed verbally at the opening of the session.

II. The complaint shall be read aloud along with the agenda. The agenda will be drawn from a list of proceedings and the material to be presented.

III. Written testimony will be read and verbal testimony given by the complainant. The midwife may be present during this time.

IV. Complainant is excused form the proceedings.

V. The midwife in question will present the case. Then the CPM (or applicant) is excused.

VI. The review committee discusses the case, writes a synopsis, and makes recommendations to the Accountability Committee.

VII. The Accountability Committee derives appropriate action after the synopsis and recommendations are considered. NARM’s intention in the Grievance Mechanism is to provide educational guidelines and support where appropriate. Punitive action is only taken when educational avenues have failed and further action is deemed necessary. Actions are limited to the following possibilities:

a. Midwife is found to have acted appropriately and no action is taken against the CPM. If the review process has not resolved the dispute, concerned parties are urged to seek professional mediation.

b. Midwife is required to study areas outlined by the Accountability Committee. The committee will involve the midwife in identifying areas needing further study. Upon completion of the assigned study, the midwife will submit a statement of completion to the Accountability Committee.

c. Midwife is placed on probation and given didactic and/or skills development work to address the areas of concern. The midwife must find a mentor, approved by NARM, to follow the assigned studies and lend support in improving the areas of weakness. The mentor will report to the Accountability Committee regarding the progress and fulfillment of the probation requirements. While on probation, the midwife may be required to attend births with a more experienced midwife assisting.

d. Midwife’s certification is suspended, and the CPM is prohibited from practicing as a primary midwife for a period of time during which the CPM is mentored by another midwife and focuses on specified areas of study. The mentor midwife will report progress to the Accountability Committee. Upon completion of required study and/or experience, the CPM is reinstated. If a midwife on suspension is found to be in deliberate violation of suspension guidelines, this CPM risks certificate revocation.

e. In the case of dishonesty, refusal to inform, negligent or fraudulent action of self-interest in which the certified midwife or applicant compromised the well being of a client or client’s baby, or non- compliance with the Grievance Mechanism, this CPM’s certificate must be revoked, or the CPM application must be denied. Midwives with revoked certificates may reapply for certification after two years. This application must include the full fee. Prior to recertification all outstanding complaints must be resolved, including the completion of previous Grievance Mechanism requirements. A midwife with a denied application may reapply after meeting all requirements resulting from the review process.

f. If the case involves the abuse of a controlled substance, the certified midwife (or applicant) in question will be required to participate in a rehabilitation program in addition to the above possible outcomes. Proof of participation and release will be necessary for full certification reinstatement, or for an applicant to continue in the CPM application process.

VIII. The midwife in question is notified of findings and appropriate action taken.

IX. The complainant is notified of action taken regarding the midwife. If no action is taken, a compassionate approach is taken to honor the complainant’s perspective.

Appeals Process

Appeals are handled directly by the Accountability Committee, all decisions are final.

Revocation of Certification

The NARM Certified Professional Midwife credential may be revoked for the following reasons:

Falsification of Application information.
ailure to participate in the Grievance Mechanism or to abide by the conditions set as a result of the Grievance Mechanism.
nfractions of the Non-Disclosure policy, which threaten the security of the NARM Examinations.
f the Grievance Mechanism determines that the CPM acted with dishonesty, did not use appropriate informed consent with the client, or that negligent or fraudulent actions compromised the well being of a client or client’s baby, the CPM credential must be revoked. Midwives with revoked certificates may reapply for certification after two years. Prior to recertification all outstanding complaints must be resolved, including completion of previous Grievance Mechanism requirements. Grievance Mechanism Forms are available in the Professional Accountability section on the NARM web page.

Confidentiality

Confidentiality is an integral part of Peer Review and the Grievance Mechanism.

In the case of NARM’s Peer Review for Handling a Complaint and the Grievance Mechanism, participants sign confidentiality agreements at the onset of these proceedings.

If a CPM breaks the confidentiality of the NARM Accountability process, a formal review will consist of the following:

Written statements from at least 2 individuals who have first hand knowledge of the break of confidentiality. Statements must include the details which were revealed, the setting and date of the conversation.
NARM Director of Accountability will contact the peer review chairperson (or if the accusation is about that person, another participant in the session) and discuss the details that were revealed in the break of confidentiality. If the details are confirmed as part of the confidential proceedings, this will confirm the accusation.
NARM Director of Accountability will contact the person accused and inform her/him that this has been documented and that if another documentation is made in the future, the CPM in question will be put on probation for period of one year during which time she/he must meet requirements assigned by the Accountability Committee.

Grievance Chart

The preceding pages are taken from the Candidate Information Bulletin (CIB). Click here for a pdf file of the entire CIB.

When conducting a peer review that is addressing a complaint, the following forms might be of benefit to you.

NARM Peer Review For Addressing a Complaint: Complaint Review

When a written complaint against a CPM is received by NARM it is referred to NARM's Accountability Committee. The first step in reviewing the complaint is Compliant Review.

If resolution is not reached through Complaint Review and the complainant wishes to take action against the CPM's credential, this must be initiated by a formal letter of complaint with NARM. Formal complaints are referred to NARM's Accountability Committee for due process within the Grievance Mechanism.

The suggested format for Peer Review to address a complaint is as follows:

1. The Accountability Committee provides to the Complaint Review group copies of this process, the NARM Complaint Review Conclusion and Summary forms, the written complaint letter, and the midwife's chart and practice guidelines (which were supplied upon request by the midwife named in the complaint).

2. The members of the Complaint Review group read these documents, contacting NARM's Accountability Committee Chairperson with questions. Each member makes a list of questions and points of concern that they intend to address to the midwife during the Complaint Review session. A group discussion of these questions and areas of concern is held prior to the opening of the Complaint Review session. (During the Complaint Review session, the testimony and presentation of events may answer these questions and concerns, or they may be asked directly.)

3. The midwife and complainant are notified to schedule the Complaint Review session. If necessary, additional written or oral testimony is arranged for the scheduled session by the midwife and complainant.

4. The Complaint Review session is begun with the midwife, complainant, and review members present.

5. All parties agree to uphold confidentiality.

6. The agenda for the session is read.

7. The complaint is read aloud.

8. The complainant gives testimony, and any additional testimony on the complainant's behalf is given or read.

9. Reviewers may ask questions of the complainant and supporting testifiers.

10. The complainant and supporting testifiers are excused.

11. The midwife presents the case. Supporting testimony is given or read.

12. Reviewers may ask questions of the midwife and supporting testifiers.

13. The midwife is excused from proceedings.

14. Reviewers discuss the case. Recommendations and findings are made.

15. The outcome of the proceedings is given in writing to the midwife and complainant.

The Complaint Review group provides NARM with their findings and recommendations. In extreme circumstances, NARM may make additional recommendations or requirements to the midwife.

NARM Complaint Review Conclusion

After careful consideration of the information presented, reviewers are asked to complete this form. Score each item 1-4, as follows:

4 = excellent
3 = good
2 = fair
1 = poor; please note why you are scoring a 1.
0 = critically insufficient; please note why you are scoring a 0.
n/a = not applicable

Midwifery Care

___ Midwife's screening criteria/assessment of client as a home birth candidate was appropriate.

___ Midwife provided appropriate prenatal care.

___ Midwife's attendance during labor and birth was adequate.

___ Midwife perceived problem accurately.

___ Midwife perceived problem in timely manner.

___ Midwife provided prompt, appropriate action to resolve problem.

___ Midwife demonstrated knowledge of appropriate action / intervention.

___ Midwife provided adequate skills required in action taken.

___ Midwife had adequate equipment available.

___ Midwife interacted appropriately with woman during labor and birth.

___ Midwife consulted when advisable.

___ Midwife transferred/transported appropriately.

___ Midwife provided adequate client follow-up, including post partum care.

___ Midwife adhered to personal practice guidelines.

___ Midwife demonstrated creative problem solving in providing adequate care.

___ Midwife offered client adequate informed consent.

NARM Complaint Review Conclusion

Issues of Charting and Presentation:

___ Midwife communicated clearly during review session.

___ Midwife was self-confident during review session.

___ Midwife maintained adequate records in client chart.

___ Midwife was able to supply information from client chart records.

___ Midwife responded in a timely manner to review requirements.

Issues of Professional Communication:

___ Midwife interacted appropriately with family and others present.

___ Midwife interacted appropriately with other attendants present.

___ Midwife interacted appropriately with medical/ambulance personnel.

NARM Complaint Review Summary Statements

Midwife under review __________________________Date __________________

Reviewers are asked to check the following statements as they apply to this review. For each item checked, state why or how the statement applies.

o Midwife is found to have acted appropriately,

o Midwife is found to have shown insufficient knowledge, specifically: __________

o Midwife is found to have shown insufficient skill level, specifically: __________

o Midwife is found to have failed to consult appropriately, specifically: __________

o Midwife is found to have used poor judgment, specifically: __________

o Midwife is found to have been materially unprepared for appropriate response (lack of functioning equipment, lack of appropriate equipment or supplies), specifically: __________

o Midwife is found to have been dishonest, specifically: __________

o Midwife is found to have failed to appropriately inform client of risks, using informed consent, specifically: __________

o Midwife is found to have acted fraudulently, specifically: __________

o Midwife is found to have been under the influence of alcohol and / or drugs, specifically: __________

o Midwife is found to have acted in her own self interest, with blatant disregard for client well being, specifically: __________

I affirm that this document has been completed honestly, with the sincere intention of providing fair and impartial consideration of the information presented.

Signature _________________________________ Date __________________

Name _____________________________________________________________

Based on this review, the Complaint Review group may make constructive recommendations to the midwife regarding areas of study, instances when consultation or assistance is advised, change of practice guidelines, etc. Compliance with these recommendations is voluntary. If resolution is not reached, a formal complaint with NARM initiates the Grievance Mechanism.

The Complaint Review group provides NARM with their findings on these forms. The group must also include all recommendations made to the midwife. In extreme circumstances, NARM may make additional recommendations or requirements to the midwife.

updated 9-1-06