1. Jane H. Barnsteiner, PhD, RN, FAAN
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
Jane H. Barnsteiner, PhD, RN, FAAN 1 1

2. Supported by a grant from the Robert Wood Johnson Foundation
Jane H. Barnsteiner, PhD, RN, FAAN 2 2

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
Cost of preventable errors is estimated at 17 – 29 billion.
Supported by a grant from the Robert Wood Johnson Foundation
Jane H. Barnsteiner, PhD, RN, FAAN 4 4

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
In any part of the system
Supported by a grant from the Robert Wood Johnson Foundation
Jane H. Barnsteiner, PhD, RN, FAAN 5 5

6. Nurses at the “Sharp End”
External Drivers
Health Systems
Working Conditions
Organizational Culture
Organizational Climate
Health Care Organizations
Nurses
Human Factors
Perceptions
Critical Thinking
Cost Containment
Benchmarks
Physicians
Nurses at the “Sharp End”
Complex Needs
Teamwork
Communication
Quality Improvement
Patients
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 )
Patient Safety Act of 2005
Priority: Transparency
Supported by a grant from the Robert Wood Johnson Foundation

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

10. What is quality care? (Institute of Medicine, IOM)P
a.k.a STEEEP
Supported by a grant from the Robert Wood Johnson Foundation
Jane H. Barnsteiner, PhD, RN, FAAN 10 10

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? Leadership Communication Orientation Staffing
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
Of 5632 sentinel events reviewed by the Joint Commission, January 1995 through December 2008:
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
= 5632 Root Cause Analyses (RCA)
Supported by a grant from the Robert Wood Johnson Foundation
Jane H. Barnsteiner, PhD, RN, FAAN 14 14

15. What’s a Serious Reportable Event (SRE) ‘never event’?
An error so serious it should never happen: (n =29 6/13/11
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 ulcers acquired after admission to a healthcare facility
Patient death associated with a fall while 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
Jane H. Barnsteiner, PhD, RN, FAAN 16 16

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

18. Supported by a grant from the Robert Wood Johnson Foundation
Jane H. Barnsteiner, PhD, RN, FAAN 18 18

19. van der Schaaf- modified for healthcare
Return to
Normal
van der Schaaf- modified for healthcare
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
Jane H. Barnsteiner, PhD, RN, FAAN 19 19

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
Jane H. Barnsteiner, PhD, RN, FAAN 20 20

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
Jane H. Barnsteiner, PhD, RN, FAAN 21 21

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
Jane H. Barnsteiner, PhD, RN, FAAN 22 22

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 Year The majority of events have multiple root causes
2008
(N=927)
2009
(N=936)
2010
(N=802)
Assessment
528
580
Communication
1971
Care Planning 93
131
Leadership
1862
584
590
1797
Continuum of Care
111 94
Human factors
1288
Human Factors
519
599
Physical Environment
824
Information Management
241
243
606
636
Operative Care
514
Medication Use 84
477
130
Operative care
268
213
234
226

26. Root Cause Information for Fall-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)
2004 through Fourth Quarter 2010 (N=366)
The majority of events have multiple root causes
Assessment
280
Communication
207
Leadership
201
Human Factors
189
Physical Environment
142
Care Planning 79
Information Management 57
Continuum of Care 32
Patient Education 27
Medication Use 20

27. Root Cause Information for Infection-related Events Reviewed by The Joint Commission
2004 through Fourth Quarter 2010 (N=122)
The majority of events have multiple root causes
Leadership 61
Communication 60
Surveillance, Prevent. & Cotrl of Infect. 59
Human Factors 55
Assessment 44
Information Management 31
Care Planning 22
Physical Environment 20
Continuum of Care 14
Medication Use 10

28. Root Cause Information for Medical Equipment-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)
2004 through Fourth Quarter 2010 (N=137)
The majority of events have multiple root causes
Human Factors 98
Leadership 87
Physical Environment 85
Communication 84
Assessment 77
Information Management 20
Care Planning 18
Operative Care 6
Medication Use 5
Continuum of Care 4

29. Root Cause Information for Medication Error Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)
2004 through Fourth Quarter 2010 (N=291)
The majority of events have multiple root causes
Medication Use
251
Leadership
211
Communication
206
Human Factors
201
Assessment
116
Information Management
110
Physical Environment 51
Continuum of Care 32
Care Planning 29
Patient Education 7

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
Jane H. Barnsteiner, PhD, RN, FAAN 30 30

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
Jane H. Barnsteiner, PhD, RN, FAAN 32 32

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
Jane H. Barnsteiner, PhD, RN, FAAN 33 33

34. Raising the Bar
All health professionals should be educated to deliver patient-centered 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)
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. 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
Jane H. Barnsteiner, PhD, RN, FAAN 39 39

40. 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
Jane H. Barnsteiner, PhD, RN, FAAN 40 40

41. 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.
Jane H. Barnsteiner, PhD, RN, FAAN 41 41

42. 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
Jane H. Barnsteiner, PhD, RN, FAAN 42 42

43. 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
Jane H. Barnsteiner, PhD, RN, FAAN 43 43

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

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 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

51. 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

52. 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

53. 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

54. 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

55. 11/08-2/12 Phase 3 QSEN/AACN Faculty Institutes National Forums
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

56. 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
Supported by a grant from the Robert Wood Johnson Foundation

57. Video-based Learning Modules
Supported by a grant from the Robert Wood Johnson Foundation

58. Faculty Self-Development Modules Editor: 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

59. 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

60. QSEN Forum – Tucson, AZ May 30-31, June 1, 2012
Supported by a grant from the Robert Wood Johnson Foundation

61. 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

62. 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

63. 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

64. 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 64 64

65. 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 65 65

66. 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

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

68. 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

69. 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

70. 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