QSEN (Quality and Safety Education in Nursing) Partnership in Education and Practice

1. QSEN(Quality and Safety Education in Nursing) Partnership in Education and Practice Jane H. Barnsteiner, PhD, RN, FAAN Professor, University of Pennsylvania Supported by a grant from the Robert Wood Johnson Foundation

2. Supported by a grant from the Robert Wood Johnson Foundation

3. In 2010…2011 • NYT – some hospital infection rates rise • NYT – look- alike tubes kill patients • USA Today - lax safety practices in 5000 ambulatory surgical centers • USA Today – only 20% of USA hospitals using WHO surgery checklist • Wall Street Journal – Near misses creeping up Supported by a grant from the Robert Wood Johnson Foundation

4. Health Care Is Not As Safe As It Could Be • Deaths Per Year • Medical Errors - 98,000 • Post-operative infections and other preventable complications – 32,000/year • 8% of hospitalized patients experience preventable outcomes from adverse events. • Motor Vehicle Accidents - 43,458 • Breast Cancer - 42,297 • AIDS – 16,000 Supported by a grant from the Robert Wood Johnson Foundation

5. Errors • Medications – prescribing, dispensing, administering • Surgery – wrong site • Diagnostic inaccuracy – wrong treatment • Equipment failure – IV pump • Transfusion error – blood type, wrong patient • Laboratory – incorrect labeling • System failure – no independent double check • Environment – clean up spills • Security – child abduction Supported by a grant from the Robert Wood Johnson Foundation

6. Nurses at the “Sharp End” Health Systems Patients Health Care Organizations Nurses Quality Improvement Working Conditions Organizational Culture Organizational Climate Complex Needs External Drivers Physicians Human Factors Perceptions Critical Thinking Teamwork Communication Cost Containment Benchmarks Supported by a grant from the Robert Wood Johnson Foundation

7. Institute Of Medicine’s (IOM) Quality Chasm Series Supported by a grant from the Robert Wood Johnson Foundation

8. External Drivers • IOM Chasm series • Effective, Efficient, Safe, Timely, Patient-Centered, Equitable • Public demand to know • Reporting healthcare (e.g., hospital) acquired infections to the state (i.e.., DE, MN, NJ, NM, OR, TX, WA, etc.) or CDC • Linking payment to quality of care • Center for Medicare and Medicaid Services (CMS) rule for healthcare (e.g., hospital) acquired infections began 10-1-07) • Patient Safety Act of 2005 • Priority: Transparency Supported by a grant from the Robert Wood Johnson Foundation

9. 35% 34% 29% 2004 2005 2010 Judgments Despite all of the quality improvement activities over the past few years, the public’s perception of the health system is in decline U.S. adults whoview hospitals as generally trustworthy and honest Supported by a grant from the Robert Wood Johnson Foundation SOURCE: Harris Interactive Poll November 2010

10. What is quality care? (Institute of Medicine, IOM) • S • T • E • E • E • P a.k.a STEEEP Supported by a grant from the Robert Wood Johnson Foundation

11. What is quality care? • S afe • T imely • E fficient • E quitable • E ffective • P atient-Centered Supported by a grant from the Robert Wood Johnson Foundation

12. Do you know? • What are the most frequently cited factors in patient safety incidents (sentinel events )? • Leadership • Communication • Orientation • Staffing • Do you know what a patient safety incident/sentinel event is? • Do you know what a serious reportable event/‘never event’ is? Supported by a grant from the Robert Wood Johnson Foundation

13. A patient safety incident/sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  • Serious injury specifically includes loss of limb or function.  • Are called "sentinel" because they signal the need for immediate investigation and response. Supported by a grant from the Robert Wood Johnson Foundation

14. Sentinel Event Experience to Date 741 wrong site surgery 698 inpatient suicides 631 operative/post op complications 492 medication errors 442 deaths related to delay in treatment 341 patient falls 218 assault/rape/homicide 212 foreign body left 189 deaths of patients in restraints 175 perinatal death/injury 132 transfusion-related events 113 infection-related events 105 medical equipment related 86 deaths following elopement Of 5632 sentinel events reviewed by the Joint Commission, January 1995 through December 2008: = 5632 Root Cause Analyses (RCA) Supported by a grant from the Robert Wood Johnson Foundation

15. What’s a Serious Reportable Event (SRE) ‘never event’? • An error so serious it should never happen: (n =29 6/13/11 www.qualityforum.org) • Examples: • Surgery performed on the wrong body part • Surgery performed on the wrong patient • Infant discharged to the wrong person • Stage 3 or 4 pressure ulcersacquired after admission to a healthcare facility • Patient death associated with a fallwhile being cared for in a healthcare facility • Patient death or serious disability associated with a medication error or blood transfusion of wrong type Supported by a grant from the Robert Wood Johnson Foundation

16. EFFECT CAUSE why? Supported by a grant from the Robert Wood Johnson Foundation

17. Supported by a grant from the Robert Wood Johnson Foundation

18. Supported by a grant from the Robert Wood Johnson Foundation

19. van der Schaaf- modified for healthcare Return to Normal Technical Close Call Dangerous Situation Adequate defenses Organi- zational ERROR (Inadequate Defenses) Human Factors Developing Errors Patient Factors Supported by a grant from the Robert Wood Johnson Foundation

20. Managing Healthcare Risk – The Three Behaviors At-Risk Behavior Reckless Behavior Normal Error Intentional Risk-Taking Unintentional Risk-Taking Product of our current system design • Manage through: • Understanding our at-risk behaviors • Removing incentives for at-risk behaviors • Creating incentives for healthy behavior • Increasing situational awareness • Manage through: • Disciplinary action • Manage through changes in: • Processes • Procedures • Training • Design • Environment Normal Error Negligence? Recklessness *David Marx – Just Culture

21. Vigilance as a Safety Defense Avoiding reliance on individual vigilance ..because of the limits of human ability to maintain a high level of vigilance over prolonged periods of time , it is important not to rely upon a single individuals vigilance ……… Keeping Patients Safe: Transforming the Work Environment of Nurses, IOM, 2004 Supported by a grant from the Robert Wood Johnson Foundation

22. System Improvements • System failure – decrease 75% of adverse medication events: • Standardize and simplify equipment and supplies • Use computer order entry • Reduce prescribing errors by 50% • Pharmacist on rounds • Wireless computer and bar coding decrease med errors 70% (VA) Supported by a grant from the Robert Wood Johnson Foundation

23. What is RCA? Root cause analysis/event analysis • . . . a class of problem solving methods aimed at identifying the root causes of problems or events. • Based on the belief that problems are best solved by attempting to correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. Supported by a grant from the Robert Wood Johnson Foundation

24. What is FMEA? • Failure Mode and Effects Analysis • … a procedure for analysis of potential failure modes within a system for classification by severity or determination of the effect of failures on the system. • Failure causes are any errors or defects in process, design, or item, especially those that affect the customer, and can be potential or actual. • Effects analysis refers to studying the consequences of those failures. Supported by a grant from the Robert Wood Johnson Foundation

25. Most Frequently Identified Event Analysis/Roots Causes of Patient Safety Incidents/Sentinel Events Reviewed by The Joint Commission by YearThe majority of events have multiple root causes

26. Root Cause Information for Fall-related EventsReviewed by The Joint Commission(Resulting in death or permanent loss of function)

27. Root Cause Information for Infection-related Events Reviewed by The Joint Commission

28. Root Cause Information for Medical Equipment-related Events Reviewed by The Joint Commission(Resulting in death or permanent loss of function)

29. Root Cause Information for Medication Error Events Reviewed by The Joint Commission(Resulting in death or permanent loss of function)

30. Reporting Adverse Events and Near Misses • What happens after an adverse event or near miss? • Reporting systems in place, event analysis processes? • How are patients and families informed of an unanticipated outcome? • Who is accountable for patient safety? • What is the process in your school of nursing? Supported by a grant from the Robert Wood Johnson Foundation

31. Making Care Safer Supported by a grant from the Robert Wood Johnson Foundation

32. Improve Communication Skills • Differences between therapeutic and professional communication • Skills to accurately describe situation, clearly articulate positions and recommendations (SBAR = Situation, Background, Assessment, Recommendation) • Skills in negotiation and conflict resolution • Increased emphasis on ensuring that correct message was heard • Respect and valuing of each member of the team drives communication Supported by a grant from the Robert Wood Johnson Foundation

33. Benefits of Interprofessional Collaboration • Improved mortality outcomes after adjustment for patient severity • Increased patient and family satisfaction with care • Improved team perception of micro-system conflict management, collaboration, job satisfaction and quality of care Supported by a grant from the Robert Wood Johnson Foundation

34. Raising the Bar All health professionals should be educated to deliver patient-centered careas members of aninterdisciplinary team,emphasizingevidence-based practice, quality improvementapproaches, andinformatics. Committee on Health Professions Education Institute of Medicine (2003) Supported by a grant from the Robert Wood Johnson Foundation

35. “We can’t hope to make lasting changes in the ability of health care systems to improve without changes in the ways we develop future health professionals. Those changes require faculty and schools to change.” Paul Batalden Dartmouth College QSEN Advisory Board Supported by a grant from the Robert Wood Johnson Foundation

36. Quality & Safety Education in Nursing (QSEN) • Purpose: to prepare nurses with the competencies necessary to continuously improve the quality and safety of the health care systems in which they work • Funded by RWJ Foundation • PI: Linda Cronenwett, PhD, RN, FAAN • Investigators for Phase 1: Jane Barnsteiner, Joanne Disch, Jean Johnson, Pam Mitchell, Dory Sullivan, Judith Warren Supported by a grant from the Robert Wood Johnson Foundation

37. The Response from Medicine: Accreditation Council for Graduate Medical Education (ACGME) • ACGME identifies competencies all residents must demonstrate • Residency program directors meet annually prior to the Institute for Healthcare Improvement (IHI) National Forum to work on methods of assessing competencies Supported by a grant from the Robert Wood Johnson Foundation

38. Competencies • Patient/Family Centered Care • Teamwork and Collaboration • Safety • Evidence-based Practice • Quality Improvement • Informatics Supported by a grant from the Robert Wood Johnson Foundation

39. Old – Listen to patient and demonstrate compassion and respect. New - Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values and needs Patient/Family Centered Care

40. Old – Work side by side with other HC professionals while performing nursing skills. New - Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care Collaboration and Teamwork

41. Old – Adhere to internal policies and procedures. New - Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. Evidence-Based Practice

42. Old – Update nursing policies and procedures, chart audits of documentation. New - Use data to monitor outcomes of care processes and improvement methods to design and test changes to continuously improve quality and safety of health care systems Quality Improvement

43. Old – focus on individual performance, vigilance to keep patients safe. New - Minimize risk of harm to patients and providers through both system effectiveness and individual performance Safety

44. Old – timely and accurate documentation New - Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making Informatics

45. QSEN Long-Range Goal • Reshape professional identity formation in nursing so that it includes commitment to the implementation of the IOM competencies • Make it easy for faculty to envision roles in supporting quality & safety education • Transform education to transform practice Supported by a grant from the Robert Wood Johnson Foundation

46. Any Improvement Requires… • Will • Ideas • Execution - Don Berwick Supported by a grant from the Robert Wood Johnson Foundation

47. 1. Build the will - • Describe the gap between what is and what could be • Stimulate realization of why we need to change • Attract innovators • Define the territory (desired competencies) Supported by a grant from the Robert Wood Johnson Foundation

48. 10/05-3/07 Phase 1 • Proposed 6 competencies definitions and learning objectives (KSAs) for pre-licensure education • Faculty could identify gaps between current curricular content and desired future • Assessed state of q & s education in schools of nursing nationwide • Implemented website www.qsen.org to share teaching strategies, annotated bibs & q & s research • Presentations, publications, accrediting & licensing Supported by a grant from the Robert Wood Johnson Foundation

49. 4/07-10/08 Phase 2 • Developed graduate KSA competencies • 11 specialty organizations • Licensing and accrediting agencies for pre-licensure and graduate programs • AACN and NLN, NCSBN • Pilot pre-licensure comps in 15 schools Supported by a grant from the Robert Wood Johnson Foundation

50. Building Will - Graduate Education • Graduate KSAs (Dec 2009, Nursing Outlook) • NONPF Task Force led by Joanne Pohl cross-mapped NONPF core NP competencies and QSEN graduate KSAs (Dec 2009, Nursing Outlook) • AACN DNP Essentials mandated inclusion of quality and safety competency development • NONPF implemented special session on QSEN competencies at annual meetings – May, 2010 Supported by a grant from the Robert Wood Johnson Foundation