Qsen quality and safety education in nursing partnership in education and practice
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QSEN (Quality and Safety Education in Nursing) Partnership in Education and Practice. Jane H. Barnsteiner, PhD, RN, FAAN Professor, University of Pennsylvania. In 2010…2011. NYT – some hospital infection rates rise NYT – look- alike tubes kill patients

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Qsen quality and safety education in nursing partnership in education and practice

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


Qsen quality and safety education in nursing partnership in education and practice

Supported by a grant from the Robert Wood Johnson Foundation


In 2010 2011

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


Health care is not as safe as it could be

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


Errors

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


Qsen quality and safety education in nursing partnership in education and practice

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


Qsen quality and safety education in nursing partnership in education and practice

Institute Of Medicine’s (IOM) Quality Chasm Series

Supported by a grant from the Robert Wood Johnson Foundation


External drivers

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


Qsen quality and safety education in nursing partnership in education and practice

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


What is quality care institute of medicine iom

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


What is quality care

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


Do you know

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


Qsen quality and safety education in nursing partnership in education and practice

  • 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


Sentinel event experience to date

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


What s a serious reportable event sre never event

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


Qsen quality and safety education in nursing partnership in education and practice

EFFECT CAUSE

why?

Supported by a grant from the Robert Wood Johnson Foundation


Qsen quality and safety education in nursing partnership in education and practice

Supported by a grant from the Robert Wood Johnson Foundation


Qsen quality and safety education in nursing partnership in education and practice

Supported by a grant from the Robert Wood Johnson Foundation


Van der schaaf modified for healthcare

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


Managing healthcare risk the three behaviors

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


Vigilance as a safety defense

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


System improvements

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


What is rca

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


What is fmea

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


Qsen quality and safety education in nursing partnership in education and practice

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


Qsen quality and safety education in nursing partnership in education and practice

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


Root cause information for infection related events reviewed by the joint commission

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


Qsen quality and safety education in nursing partnership in education and practice

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


Qsen quality and safety education in nursing partnership in education and practice

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


Reporting adverse events and near misses

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


Making care safer

Making Care Safer

Supported by a grant from the Robert Wood Johnson Foundation


Improve communication skills

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


Benefits of interprofessional collaboration

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


Raising the bar

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


Qsen quality and safety education in nursing partnership in education and practice

“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


Quality safety education in nursing qsen

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


The response from medicine accreditation council for graduate medical education acgme

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


Competencies

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


Patient family centered care

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


Collaboration and teamwork

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


Evidence based practice

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


Quality improvement

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


Safety

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


Informatics

Old – timely and accurate documentation

New - Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making

Informatics


Qsen long range goal

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


Any improvement requires

Any Improvement Requires…

  • Will

  • Ideas

  • Execution

    - Don Berwick

Supported by a grant from the Robert Wood Johnson Foundation


1 build the will

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


10 05 3 07 phase 1

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


4 07 10 08 phase 2

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


Building will graduate education

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


4 07 10 08 phase 21

4/07-10/08 Phase 2

  • Delphi Study – placement of KSAs

    • Beginning, intermediate, advanced content

  • Published – Nursing Outlook 12/07, 5/09, J of Urologic Nursing, J of Nursing Education

  • Website – continued development

  • Academic/Service Partnerships

Supported by a grant from the Robert Wood Johnson Foundation


Building will publications

Building Will - Publications

  • Use of Collaborative model to build will and motivate change (Dec 2009, Nursing Outlook)

  • Report of survey of student perceptions of extent to which they are learning the knowledge, skills & attitudes related to QSEN competencies (Dec 2009, Nursing Outlook)

  • Kovner CT, Brewer CS, Yingrengreung S, Fairchild S. New nurses' views of quality improvement education. Joint Commission Journal on Quality and Patient Safety, 2010: 36(1):29-5AP(-23)

    • 39% of new nurses thought they were “poorly” or “very poorly” prepared or “had never heard of” QI

Supported by a grant from the Robert Wood Johnson Foundation


2 generate and share ideas

2. Generate and share ideas

  • Outline the knowledge, skills, and attitudes (KSAs) that would be logical learning objectives for pre-licensure and advanced practice curricula

  • Stimulate and spread the ideas of early adopters

  • Share teaching strategies for classroom, group work, simulation, clinical site teaching, and inter-professional learning

Supported by a grant from the Robert Wood Johnson Foundation


Sharing ideas special issues

Sharing Ideas– Special Issues

  • 2007 May/June issue of Nursing Outlook (Ed. Cronenwett)

  • 2008 issue of Journal of Urologic Nursing (Ed: Sherwood)

  • 2009 Nov/Dec issue of Nursing Outlook – (Ed:Cronenwett)

  • 2009 Nov/Dec issue of Journal of Nursing Education (Ed:Ironside)

Supported by a grant from the Robert Wood Johnson Foundation


11 08 2 12 phase 3

11/08-2/12 Phase 3

  • QSEN/AACN Faculty Institutes

    • 9 2 ½ day train-the-trainer sessions

    • 1200 faculty

  • National Forums

  • VA Quality Scholars

  • Consultation Service

  • Interprofessional Education - IPEC

Supported by a grant from the Robert Wood Johnson Foundation


Sharing ideas

Sharing Ideas

  • QSEN National Forums – showcase innovation, promote dissemination and dialogue

  • QSEN Regional Institutes - ‘train the trainers’

  • VA Quality Scholars – inter-professional learning and development of future scholars

  • QSEN Consultants

  • QSEN website www.qsen.org

Supported by a grant from the Robert Wood Johnson Foundation


Video based learning modules

Video-based Learning Modules

Supported by a grant from the Robert Wood Johnson Foundation


Faculty self development modules editor pam ironside iupui

Faculty Self-Development ModulesEditor: Pam Ironside, IUPUI

  • Getting Started with QSEN: Why is QSEN Important to Nursing Clinical Education?

  • Managing the Complexity of Nursing Work: Cognitive Stacking

  • Introduction to Teaching Informatics in Clinical Courses

  • Inter-professional education

  • Evaluation of QSEN competencies

  • Changing a curriculum

  • Integrating QSEN in intermediate level courses

  • Integrating QSEN in advanced courses

Supported by a grant from the Robert Wood Johnson Foundation


Sharing ideas qsen regional institutes

Sharing Ideas – QSEN Regional Institutes

  • San Antonio, TX January 13-15, 2010

  • Washington, DC April 14-16, 2010

  • Palo Alto, CA June 9-11, 2010

  • Minneapolis, MN September 22-24, 2010

  • Phoenix, AZ January 12-14, 2011

  • Chicago, IL March 16-19, 2011

  • Boston, MA June 8-10, 2011

  • Seattle, WA September 14-16, 2011

  • Charleston, SC November 2-4, 2011

Supported by a grant from the Robert Wood Johnson Foundation


Qsen quality and safety education in nursing partnership in education and practice

QSEN Forum – Tucson, AZ

May 30-31, June 1, 2012

Supported by a grant from the Robert Wood Johnson Foundation


Support execution 11 08 2 12 phase 3

Support Execution 11/08-2/12 Phase 3

  • Text – Quality & Safety in Nursing: A Competency Approach to Improving Outcomes.

  • Content in NCLEX and certification exams

  • Days of Dialogue – Academic/Service Partners

Supported by a grant from the Robert Wood Johnson Foundation


Support execution phase 4 2012 2013

Support execution Phase 4 2012-2013

  • Create website resources for faculty and students

  • Train early adopters to train others

  • Share products with professional organizations involved in licensure, certification and accreditation of education and transition to practice residency programs

  • Seek support from publishers and authors to integrate quality and safety concepts in textbooks

Supported by a grant from the Robert Wood Johnson Foundation


Supporting execution

Supporting Execution

  • Accreditation standards

    • AACN – BSN and DNP Essentials

    • NLN – Competency Development Task Force

    • NONPF – Core Competency work

  • Licensure

    • NCSBN Transition to Practice Residency Program Proposal

    • State level QI requirements for re-licensure

  • Certification - the next frontier

Supported by a grant from the Robert Wood Johnson Foundation


Qsen quality and safety education in nursing partnership in education and practice

  • Michigan Task Force on Nursing Education (April, 2010)

Nursing Education Position Papers (NEPPs):

  • National accreditation for all nursing programs in Michigan

  • All nursing education programs in Michigan must make quality and safety a priority

  • Nurse residency programs required in Michigan for newly licensed graduates of all nursing education programs

  • Increase the capacity of nursing education to graduate more advanced practice registered nurses

  • Financing of nursing education in Michigan

  • Improve nursing education through the Michigan Nursing Education Council

Supported by a grant from the Robert Wood Johnson Foundation


Qsen quality and safety education in nursing partnership in education and practice

  • West Virginia Center for Nursing

  • Duane Napier, Executive Director

Statewide Implementation of Quality and Safety Education for Pre-licensure Nursing Programs in West Virginia Schools of Nursing

Approved by the WV Association of Deans and Directors of Nursing Education

  • Phase 1 – 3 pre-licensure programs

  • Phase 2 – 4 additional RN and 1 LPN program to join

Supported by a grant from the Robert Wood Johnson Foundation


Support execution 2012 2013 phase 4

Support Execution 2012 – 2013 Phase 4

  • Annual National Forum

  • Graduate Education Institutes

  • NCSBN funded study on Just Culture

    • Data repository of nursing student errors and near misses

Supported by a grant from the Robert Wood Johnson Foundation


Qsen quality and safety education in nursing partnership in education and practice

Supported by a grant from the Robert Wood Johnson Foundation


Closing the gaps what can you do

Closing the Gaps – What Can You Do?

  • What do you need to learn?

  • How can you add content (KSAs) across your curricula and in your courses?

  • How can you role model curiosity about the QSEN work and its potential?

  • What can you do in the next week/month/ semester to advance this effort?

  • How can you foster Academic Service Partnerships?

  • Who can you work with?

Supported by a grant from the Robert Wood Johnson Foundation


Attendees

Attendees

  • Why are you here?

    • To create a sea change

  • Why is it important?

    • We need to prepare our graduates for today’s health care arena

  • Why does it matter?

    • Patients lives are at stake

  • Supported by a grant from the Robert Wood Johnson Foundation


    Change the world of health care

    CHANGE THE WORLD OF HEALTH CARE

    • Start where you are

    • Use what you have

    • Do what you can

      • A. Ashe

    Supported by a grant from the Robert Wood Johnson Foundation


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