Helping Students Understand Nurse- Sensitive Quality Indicators

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1 Helping Students Understand Nurse- Sensitive Quality Indicators Terry L. Jones RN, PhD Assistant Professor, Clinical Nursing University of Texas at Austin 2007 NIH Clinical Scholar University of Texas Medical Center at Dallas

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3 Disclosure This presentation was supported by Grant Number UL1RR024982, titled North and Central Texas Clinical and Translational Science Initiative (Milton Packer, MD, PI) from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research, and its contents are solely the responsibility of the author and do not necessarily represent the official view of the NCRR or NIH. Information on NCRR is available at Information on Re-engineering the Clinical Research Enterprise can be obtained from ew-ttranslational.asp.

4 Background & Key Documents 2000 IOM: To Err is Human 2001: Crossing the Quality Chasm 2003: Health Professions Education A Bridge to Quality 2004: Transforming the Nursing Workforce 2007: RWJ QSEN Project: Knowledge, Skills, & Attitudes 2008: AACN: Essentials of Baccalaureate Education Nurse-Sensitive Quality Indicators (NSQIs) ANA AHRQ NQF

5 IOM Competencies for All Health Care Providers Patient-centered care Working in interdisciplinary teams Employing evidence-based practice Applying quality improvement principles Using informatics

6 Patient Centered Care 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

7 Teamwork & Collaboration Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care

8 Evidence-Based Practice Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care

9 Quality Improvement Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems

10 Safety Minimize risk of harm to patients and providers through both system effectiveness and individual performance

11 Informatics Use information and technology to communicate, manage knowledge, mitigate error, and support decisionmaking

12 BSN Essentials Liberal Education Basic Organizational and Systems Leadership for Quality Care & Patient safety Scholarship for EVP Information Management & Application of Patient Care Technology Healthcare Policy, Finance, & Regulatory Environments Inter-professional Communication & Collaboration for Improving Patient Health Outcomes Clinical Prevention & Population Health Professionalism & Professional Values Baccalaureate Generalist Nursing Practice

13 Endorsed NSQIs Nursing Structures HPPD & Skill Mix RN LVN UAP % Temporary Staff RN Education RN Certification Nursing Unit Processes Practice Environment (PES Scales) Restraint Utilization Pediatric Pain AIR Cycle Smoking Cessation Counseling

14 Endorsed NSQIs (cont) Nursing Outcomes Nursing Turnover Job Satisfaction Scales Patient Outcomes Nosocomial Infections Failure to rescue Falls Pressure Ulcers Pediatric PIV Infiltration Psychiatric Physical/Sexual Assault Patient satisfaction

15 Up-and-Coming NSQIs Medication errors Burnout Compassion fatigue Moral Distress Perceived rationed/missed care Direct care time

16 It s All Good!

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19 KSAs for Quality Improvement - 1 Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice Seek information about outcomes of care for populations served in care setting Seek information about quality improvement projects in the care setting Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals

20 KSAs for Quality Improvement - 2 Recognize that nursing and other health professions students are parts of systems of care and care processes that effect outcomes for patients and families Give examples of the tension between professional autonomy and system functioning Use tools (such as flow charts, cause-effect diagrams) to make processes of care explicit Participate in a root cause analysis of a sentinel event Value own and others contributions to outcomes of care in local settings

21 KSAs for Quality Improvement - 3 Explain the importance of variation and measurement in assessing quality of care Use quality measures to understand performance Use tools (such as control charts and run charts) that are helpful for understanding variation Identify gaps between local and best practice Appreciate how unwanted variation affects care Value measurement and its role in good patient care

22 KSAs for Quality Improvement - 4 Describe approaches for changing processes of care Design a small test of change in daily work (using an experiential learning method such as PDCA) Practice aligning the aims, measures and changes involved in improving care Use measures to evaluate the effect of change Value local change (in individual practice or team practice on a unit) and its role in creating joy in work Appreciate the value of what individuals and teams can do to improve care

23 BSN Essential II As a member of a healthcare team, baccalaureate graduates will understand and use quality improvement concepts, processes, and outcome measures. In addition, graduates will be able to assist or initiate basic quality and safety investigations; assist in the development of quality improvement action plans; and assist in monitoring the results of these action plans within the clinical micro-system, which is embedded within a larger system of care

24 BSN Essential II Baccalaureate nursing graduates are distinguished by their abilities to identify, assess, and evaluate practice in care delivery models that are based in contemporary nursing science and are feasible within current cultural, economic, organizational, and political perspectives.

25 The BSN program prepares the graduate to 5. Participate in quality and safety initiatives, recognizing that these are complex system issues, which involve individuals, families, groups, communities, populations, and other members of the healthcare team

26 The BSN program prepares the graduate to 6. Apply concepts of quality and safety using structure, process, and outcome measures to identify clinical questions and describe the process of changing current practice

27 The BSN program prepares the graduate to 9. Apply quality improvement processes to effectively implement patient safety initiatives and monitor performance measures, including nurse-sensitive indicators in the micro-system of care

28 The BSN program prepares the graduate to 11. Employ principles of quality improvement, healthcare policy, and cost effectiveness to assist in the development and initiation of effective plans for the micro-system and/or system-wide practice improvements that will improve the quality of healthcare delivery

29 Staff Nurse Manager Performance Improvement Director Care Management Director Clinical Researcher Chief Nursing Officer Patient Family Nursing Faculty Student BSN Essentials Quality KSAs Nurse-Sensitive QIs

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34 How do you eat an elephant?

35 One bite at a time!

36 Factors to Consider Teacher/Role Model Content/Behavior Student/Learner Environment

37 Content/Behaviors NSQIs Performance improvement Outcomes measurement Indicator development Data management Data interpretation Public Reporting Healthcare System Regulatory Pay for Performance Reimbursement System Change management

38 Implications Complex topics Many pre-requisite topics Many overlapping topics Unique body of knowledge Need Didactic foundation Need Application opportunities Requires high level analytical thinking Requires Context!!!!

39 Student/Learner 22 years old Senior I Minimal experience Clinical Work Focused on clinical competencies Task oriented Its all about the grade! Not generally reflective Don t know what they don t know Poor judge of personal skill set School schedules Work schedules Readiness to learn?? Perceived low functional value?? Have no context!!! Pedagogy??? Androgogy??

40 Pedagogy Characteristics Learner dependent Learner needs external rewards and punishment Learner s s experiences are unimportant or limited Subject centered Teacher directed Climate is authoritative Competition is encouraged Teacher sets goals Teacher makes decisions Teacher evaluates

41 Androgogy Characteristics Learner is self-directed Learner is internally motivated Learner s experiences are valued and varied Task or problem centered Self-directed Climate is relaxed and informal Collaboration is encouraged Teacher and class set goals Decisions are made by teacher and students Teacher, self, and peers evaluate

42 Period of Transition Androgogy Nursing Students Pedagogy

43 Environment - Resources How thin do you have to slice the pie? What kind of partnerships do you have? What is the local context??

44 N377 Course Description: Examination of selected concepts and theories of management and leadership in the context of the delivery of dynamic nursing care. The use of management concepts in working with a health care team to provide high quality patient care is discussed. The course concentrates on historical development of the health care system, current issues and contemporary trends, standards of professional practice, management and leadership roles, and political and cultural influences on health care and professional career development.

45 N377 Examine the historical development of the health care delivery system. Analyze contemporary health care trends and issues relative to delivery of nursing care, including the importance of the National Patient Safety Goals. Demonstrate knowledge of concepts and strategies related to professional career development, work related stress and the management of self. Explore the implications of concepts and theories of organization design and management relative to the delivery of nursing care. Explore the implications of standards of care, performance improvement concepts, tools, and strategies, and the role of regulatory bodies in the management and delivery of health care services. Analyze the Texas Nurse Practice Act, the Board of Nursing Rules, and contemporary professional issues and their implications for nursing practice. Examine the impact of socio-political and cultural and cost influences on management and delivery of health care.

46 Role Model/Teacher Content expertise Assess current learner knowledge Assess student learning styles Try to match teaching style to learning styles Generate high functional value Give them context Create opportunities for application

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48 Q&S Performance Improvement Problem Solving & Decision Making Leadership & Management Career Development Nursing Work Environment Jurisprudence

49 The Dual Role of Nurses Professional Provider Employee Nurse-Patient Relationship Individualized Care Legal obligation to protect patients BON Goal is quality health care Work Assignment Efficiency & Standardization Employee obligations Managers Goal is profit margin

50 Your nursing practice is embedded in the business of health care delivery No margin no mission!

51 Societal & Cultural Pressures Legal & Regulatory Rules Organizational Behavior Team Behavior Individual Behavior Physical Ergonomics Physical Devices

52 Historical Approaches to Quality Assessment/Improvement QA Quality Assessment QM Quality Management CQI Continuous Quality Improvement TQM Total Quality Management PI Performance Improvement

53 Donabedian Model (S-P-O) Structures of Care Processes of Care Outcomes of Care

54 Donabedian Model (S-P-O) Structures of Care Processes of Care Outcomes of Care Hospital Characteristics Equipment Teaching Status FTEs Staffing Policies & Procedures EVP Standards of Care Interventions Mortality Morbidity Functional Status Satisfaction Quality of Life

55 FOCUS-PDCA Approach Plan Find a process that needs improvement Organize a team Clarify the process Understand variation Select an improvement Do - implement Check evaluate results Act incorporate/standardize

56 Safety & Quality Topics Regulatory Quality and Safety Initiatives/Accreditation Programs (JCAHO/CMS/TMF) Non-Regulatory National Quality Initiatives (IQI/NQF/Leap Frog) National Patient Safety Goals AHRQ Indicators (QIs( & PSIs) JCAHO Core Measures

57 Safety & Quality Topics Nurse Sensitive Quality Indicators Pay for Performance (P4P) Miscellaneous CMS Quality Indicators (LOS/readmissions) Magnet Certification Public Reporting of Hospital Quality Data (Hospital Report Cards)

58 Quality & Safety Group Presentation Criteria Point Value Earned Points Concise but comprehensive summary of topic 50 Points Concise but comprehensive summary of group discussion regarding personal values and beliefs about the topic 30 Points Concise but comprehensive of the implications for health care delivery and/or professional nursing practice 30 Points Professional appearance of the audiovisuals utilized 20 Points Professional oral presentation style including appearance of speakers 20 Points Total 150 Points

59 Sample Essay Question The patient safety nurse of your hospital has informed your unit manager that your unit experiences a higher error rate than other units and that many of the errors seem to be occurring between 1200 and She has requested that a performance improvement team be established to work on this issue. The unit manager has asked that you chair this team. Discuss how you would approach this assignment and include the performance improvement plan. Utilize what you have learned about the work environment, human factors/systems approach to medical error, leadership, teamwork, and performance improvement.

60 Hurdles Yet to Cross Integration Application Evaluation Cultivate Partnerships Clinical faculty Clinical sites

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62 Resources NQF website ANA website IOM Reports AACN BSN Essentials AACN Clinical Leader MacPhee et al Savitz, Jones, & Bernard Nursing Outlook (2007) Volume 55 Day & Smith Cronenwett et al Smith et al Salmon Bargagliotti & Lancaster Sherwood & Drenkard

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