Objectives. Integrating Quality and Safety Throughout a Masters Entry to Nursing Practice Curriculum. The Institute of Medicine.

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1 Objectives Identify emerging views of safety and quality in health care Integrating Quality and Safety Throughout a Masters Entry to Nursing Practice Curriculum Kim Amer, PhD, RN Associate Professor in School of Nursing DePaul University Author of Quality and Safety for Transformational Nursing Core Competencies Describe the current safety crisis and key elements from the IOM report. Strategies to integrate Quality and Safety in Nursing Curriculum Discuss QSEN, AACN & NCLEX Safety Goals Identify the types of errors and provide examples. Discuss the impact of the blame culture and how to avoid it. Examine leadership strategies for managing change in a culture focused on quality My interest in safety and quality Transforming Care at the Bedside (TCAB) funded by Robert Wood Johnson Foundation and Institute for Healthcare Improvement (IHI) www. RWJF.org Ten hospitals nationally Staff nurses identified problems and proposed solutions to help improve safety The Institute of Medicine To Err Is Human (1999) Safety In Healthcare Delivery Institute of Medicine. (1999). To Err Is Human. Washington, DC: National Academies Press. A Safety Crisis The IOM report on safety opened the door to acknowledge there is a healthcare safety crisis, for example data indicated in 1999: Approximately 44,000 to nearly 100,000 patients die annually in U.S. hospitals due to error. What is your reaction to this? Concepts of Safety and Quality Chapters 1 & 2 Define safety, quality and the models used to measure quality in health care settings Nurses are the key to improving both safety and quality Case studies: 1) nursing student incorrectly reports newborn weight loss of 1 lb (instead of 100 grams) 2) TPN double the glucose for 12 hours in ICU

2 Perspectives on quality Safe Care=Quality Care? What is your definition of safety and quality? What are economic consequences? What are ethical considerations? Just because care is considered safe does not mean that it is of a higher quality. BUT There is a greater chance that the care is of higher quality. Types of Errors Other Types of Errors 1. Diagnostic 2. Treatment 3. Preventive 4. Other Many errors go undocumented or are not reported due to staff fear of reprisal, lack of adequate systems to report, limited staff education about safety and report process, and lack of computerized surveillance systems. 1. Active error 2. Adverse error 3. Error of commission 4. Error of execution 5. Error of planning 6. Iatrogenic injury 7. Latent error 8. Near-miss 9. Sentinel event Quality and Safety Errors Models of safety and quality are based on non-blame and continual change to improve care Creating a culture of safety is part of building a system of continuous quality improvement

3 Patient Role in Errors More Common Care-Management Problems Patients make errors in their own care or during self-management. Patient noncompliance may lead to errors (accidental or unintentional non-adherence to a therapeutic regimen) Failure to carry out preoperative checks Deviation from an agreed protocol without clinical justification Failure to seek help when necessary Use of incorrect protocol Treatment given to wrong body site Wrong treatment plan Institute of Medicine Transition to practice model (chapter 3 in book) To Err is Human 1999 revealed serious mistakes and deaths of 50,000 to 100,000 per year in the US! Some Progress has been made, however there is a lot to do. Power in nursing chapter 4 in book Power Analysis in Nursing How do you have power in your life, your workplace and how can you influence others and develop and implement policy Measuring outcomes (chapter 6) Metrics and Stakeholders Evidence based practice is essential We need to look at consistent measures based on Affordable Care Act Reliable and Valid measure Make sure the tools work well for your quality initiative

4 Quality and Safety Education for Nurses (QSEN: chapter 5 in Amer book Quality carries a moral and ethical imperative Principal Investigator: Linda Cronenwett, PhD, RN, FAAN Co-Investigator: Gwen Sherwood, PhD, RN, FAAN Project Manager: Denise Hirst, MSN, RN Librarian: Jean Blackwell National expert panel and pedagogical experts Funded by the Robert Wood Johnson Foundation for the University of North Carolina at Chapel Hill Phase I Pre-licensure Education Phase II Graduate Education and Pilot School Collaborative Phase III Partnered with American Academy of Colleges of Nursing to disseminate information to faculty and educators Nurses are the most trusted profession People become nurses in order to relieve suffering and contribute to the overall health of communities and individuals Quality care is an essential value Reported in special issue: Nursing Outlook, May 2007 Quality: Factors to consider Raising the Bar: the Framework What is the role of technology and informatics (chapter 9) ROBOTS How do nurses acquire Interdisciplinary team skills to achieve goals of care How do we include patients and families as partners in care What are strategies for improving the way health professionals must work together to achieve quality outcomes All health professionals should be educated to deliver patientcentered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics. Committee on Health Professions Education Institute of Medicine (2003) New challenges 6 competencies to transform systems are not linear but are broad and overlapping To achieve the goals of care, health professionals must examine new views of quality and safety science for redesigning how care is delivered, monitored, and improved. Nurses must be a the table for input. Informatics Patient centered care Teamwork And collaboration Quality improvement Evidence Based practice Safety

5 Quality Improvement Knowledge Describe strategies for learning about the outcomes of care in the setting in which one is engaged in practice Skills Seek information about outcomes of care for populations served in care setting Seek information about quality improvement projects in the care setting Attitudes Appreciate that continuous improvement is an essential part of the daily work of all health professionals Teaching Quality and Safety in Nursing Programs Fundamentals Siarkowski Amer (SA) Chapters 1&2 Safety in Health Care (50,000 lives lost due to error) Quality Improvement Defining safety and quality QSEN KSA Three P s Physical Assessment, Pharmacology, Physiology One minute safety check Ethics, Policy, Culture SA Chapters 4, 10 & 11 Power in Nursing and effecting Change Research, Theory, Informatics SA Chapters 6,7,8,9 Evidence based practice Bar Coding for safe Current status of Measuring outcomes med administration legislation related to safety Rapid response teams Person centered care Technology and safety and quality SBAR and Running a Vulnerable Theories of quality Code populations and improvement access to care Medication interactions Professional Development SA Chapters 3, 5, & 12 Transition to Practice QSEN and teaching nurses Future focused nursing SA=Siarkowski Amer s Quality and Safety for Transformational Nursing: Core Competencies (2013) Pearson Implications for nursing Developing Quality Improvement Skills Focus on quality and safety requires new knowledge, skills and attitudes about how care is delivered, monitored, and improved. Preparing nurses to work to work in quality focused settings. Staff development in quality improvement processes, safety and error prevention techniques, and informatics. Knowing the specific steps to interpret integrative literature reviews to identify the evidence to support data based care protocols. Learning new quality improvement terminology such as variance reports, benchmarks, dashboards, report cards, statistical control charts, and satisfaction measures. The Blame Culture What is the Blame Culture? Why is this important in the IOM report and its recommendations for change? How might this be applied to nursing? Teaching QSEN in Clinical Settings and Simulation Scenarios Mandatory reporting of errors or near miss incidents The IOM recommends a mandatory reporting system. What do you think about this?

6 Major Sources of Adverse Event Data 1. Voluntary and mandatory reporting 2. Document review 3. Automated surveillance 4. Monitoring patient progress to identify circumstances when adverse events might occur Root Cause Analysis Definition of Root causes: Specific underlying causes. Causes that can reasonably be identified Causes management or practitioners have control to fix. Causes for which effective recommendations for preventing recurrences can be made. Should include: failed and successful defenses and recoveries for the patient; outcomes for the patient; and lessons learned and ways to improve patient safety (IOM, 2004, p. 160). Near-Misses Common Care-Management Problems Errors of commission or omission that could harm a patient but do not Think about the times that you almost made an error. We all have these experiences. What do you do to learn from these experiences? Failure to monitor, observe, or act Delay in diagnosis Incorrect assessment of risk Loss of information during transfer to other healthcare staff Failure to note faulty equipment The call to leadership Raising Awareness About Safety and Quality Health Care To change practice calls for transformational leadership to achieve the collective purpose Ordinary methods will not create behavior change What is in your tool kit to teach new nurses to be safe and to create new work environments where quality is valued? Organizations with a quality focus are where Improving outcomes is recognized Teamwork is valued A just culture is embraced Questions are part of everyday practice Evidence supports clinical decisions and pathways No one tries to do it all alone

7 EBP and Safety Issues The AHRQ report, Making Healthcare Safer: A Critical Analysis of Patient Safety Practices Thanks So Much for your attention Questions?? Don t chicken out. Ask! kamer@depaul.edu