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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.

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Presentation on theme: "QSEN (Quality and Safety Education in Nursing) Partnership in Education and Practice Jane H. Barnsteiner, PhD, RN, FAAN Professor, University of Pennsylvania."— Presentation transcript:

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

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

10 What is quality care? (Institute of Medicine, IOM) S T 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 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

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19 van der Schaaf- modified for healthcare Technical Organi- zational Human Factors Adequate defenses Return to Normal Developing Errors Close Call Dangerous Situation Dangerous Situation ERROR (Inadequate Defenses)ERROR (Inadequate Defenses) 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 Unintentional Risk-Taking Intentional Risk-Taking Manage through: Disciplinary action Manage through: Understanding our at-risk behaviors Removing incentives for at-risk behaviors Creating incentives for healthy behavior Increasing situational awareness Product of our current system design Manage through changes in: Processes Procedures Training Design Environment Negligence?Recklessness * David Marx – Just Culture Normal Error

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.problem solvingroot causes 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.procedure 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) Assessment528Assessment580Communication1971 Care Planning93Care Planning131Leadership1862 Communication584Communication590Assessment1797 Continuum of Care111Continuum of Care94Human factors1288 Human Factors519Human Factors599Physical Environment824 Information Management241Information Management243Information Management606 Leadership584Leadership636Operative Care514 Medication Use93Medication Use84Care Planning477 Operative Care130Operative care131Medication Use268 Physical Environment213Physical Environment234Continuum of Care226

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 Assessment280 Communication207 Leadership201 Human Factors189 Physical Environment142 Care Planning79 Information Management57 Continuum of Care32 Patient Education27 Medication Use20

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 Leadership61 Communication60 Surveillance, Prevent. & Cotrl of Infect.59 Human Factors55 Assessment44 Information Management31 Care Planning22 Physical Environment20 Continuum of Care14 Medication Use10

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 Factors98 Leadership87 Physical Environment85 Communication84 Assessment77 Information Management20 Care Planning18 Operative Care6 Medication Use5 Continuum of Care4

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 Use251 Leadership211 Communication206 Human Factors201 Assessment116 Information Management110 Physical Environment51 Continuum of Care32 Care Planning29 Patient Education7

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 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 American Association of Colleges of Nursing. © All Rights Reserved. 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

40 American Association of Colleges of Nursing. © All Rights Reserved. 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

41 American Association of Colleges of Nursing. © All Rights Reserved. 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.

42 American Association of Colleges of Nursing. © All Rights Reserved. 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

43 American Association of Colleges of Nursing. © All Rights Reserved. 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

44 American Association of Colleges of Nursing. © All Rights Reserved. Informatics Old – timely and accurate documentation New - Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making

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 researchwww.qsen.org 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 – 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 – 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 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 Michigan Task Force on Nursing Education (April, 2010) Supported by a grant from the Robert Wood Johnson Foundation

65 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 West Virginia Center for Nursing Duane Napier, Executive Director Supported by a grant from the Robert Wood Johnson Foundation

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

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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


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