Building on Strength: Blending TCAB and QSEN

Our Team Deborah Struth, MSN, RN Cheryl Carr, MSN, RN, CNE Wendeline Grbach, MSN, RN, CCRN, CNLC Alex Saladino, PhD Linda Kmetz, PhD, RN

A Wonderful Opportunity….. Doesn’t mean there won’t be Challenges

TCAB Academic Partners – The Faculty Team Facilitator: Patricia Chiverton, EdD, RN, FANP Dean, University of Rochester School of Nursing Deborah Struth, MSN, RN UPMC Shadyside School of Nursing Berni Jordan, PhD, CRNP, FHCE University of Pittsburgh School of Nursing Kim Amer, PhD, RN DePaul University Linda Leach, PhD, RN UCLA School of Nursing Lorie Judson, PhD, RN California State – LA Deborah Cantero, MSN, ARNP University of South Florida Connie Overman BSN, RN Sacramento State University Geri L Wood, PhD, RN, FAAN University of Texas, Houston Bernadette Curry, PhD, RN, Dean Molloy College Denise Cundy South Dakota State University Linda Carpenter University of Texas, Austin Shelley Mitchell, MS, RN Austin Community College Carrie Thompson Fox Valley Community College Jen Basler University of Wisconsin

UPMC Shadyside’s Faculty Transformational Journey TCAB Team Faculty Retreat Test of Change Methodology in Curriculum Deep Dive Faculty Vitality Survey UPMC Shadyside School of Nursing

Patient Safety Objectives Addressed through the ACGME Prism The resident will be able to : Recognize and understand team behaviors that strengthen/weaken patient safety. Incorporate effective team behaviors into their practices. Identify errors in their practices, analyze them and learn from them. Develop system-based strategies to prevent recurrence of errors. Recognize and understand communication behaviors that strengthen/weaken patient safety. Incorporate effective communication behaviors into their practices. Provide appropriate disclosure to patients when errors occur.

QSEN Assumptions Each competency is broad and contains elements of the others Patient-centered care Safety Teamwork/collaboration Informatics Quality improvement Evidence-based practice UPMC Shadyside School of Nursing

Example: Teamwork and Collaboration Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect and shared decision-making to achieve quality patient care. Knowledge Skills Attitudes Describe examples of the impact of team functioning on safety and quality of care Explain how authority gradients influence teamwork and patient safety Identify system barriers and facilitators of effective team functioning Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care Assert own perspective (using SBAR or other team communication models) Participate in designing systems that support effective teamwork Appreciate the risks associated with handoffs among providers and across transitions in care Value the influence of system solutions in achieving effective team functioning UPMC Shadyside School of Nursing

Example: Safety Minimizes risk of harm to patients and providers through both system effectiveness and individual performance. Knowledge Skills Attitudes Discuss effective strategies for reducing reliance on memory Describe processes used in understanding causes of error and allocation of responsibility (such as, root cause analysis) Use appropriate strategies for reducing reliance on memory (such as, forcing functions and checklists) Use organizational error reporting systems for near miss and error reporting Engage in root cause analysis rather than blaming when errors or near misses occur Appreciate the cognitive and physical limits of human performance Value own role in preventing errors Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team UPMC Shadyside School of Nursing

Blending: Transforming Care at the Bedside (TCAB) Patient Centered Care Value Adding Vitality and Teamwork Safety and Reliability Transformational Leadership Quality and Safety Education for Nurses (QSEN) Safety Patient-centered care Teamwork/collaboration Informatics Quality improvement Evidence-based practice

TCAB: “While there were a wide range of changes being tested, sustained, and spread in participating hospitals, participants repeatedly emphasized in our interviews that the change in unit culture and engagement of front line staff in improvement activities were central to their TCAB experience…no single innovation made a difference. Rather it was the process of TCAB, that made a difference.” Jack Needleman, PhD, FAAN

Initial Areas of Program Development Incorporation of Crew Resource Management principles Investigation of clinical education utilizing Work Sampling Methodology of faculty and students Curricular additions of Human Patient Simulation Incorporation of teamwork and safety utilizing TeamSTEPPS curriculum UPMC Shadyside School of Nursing

N101: Introduction to Professional Nursing Teaching Activities Relationship-Based Care introduced and integrated throughout course Lab: Hospital of the Future: emphasizes need for effective communication, teamwork, rapid response, a caring and healing environment, and TCAB initiatives Citation for this model and I wonder if Sue M has a clearer picture…still fuzzy when blown up. (WJG) Koloroutis, Mary, (2004). Relationship-Based Care: A Model for Transforming Practice Creative Health Care Management Relationship-Based Care: A Model for Transforming Practice Creative Health Care Management. Koloroutis, Mary, (2004). UPMC Shadyside School of Nursing

N102: Introduction to Nursing Practice Strategies Teaching Activities SBAR-R 60 Second “Situational Assessment” High-fidelity Patient Simulation Focused standardized communication strategies to minimize risk and error. SA--- not only patient but environmental and team based observations to assure safety UPMC Shadyside School of Nursing

Situational Assessment Tool “60 Second” Situational Assessment Tool UPMC Shadyside School of Nursing

SBAR-R UPMC Shadyside School of Nursing

N300: Nursing Practice Strategies Pediatrics/Obstetrics/Mental Health/Critical Care Eight-hour day high-fidelity high risk simulation experiences every 8 weeks Student and faculty members utilize SBAR-R for communication pathways throughout the scenarios Pre- and post-test evaluations related to problem-based scenario with improvements noted UPMC Shadyside School of Nursing

N400: Professional Role Transitions Teaching Activities Student driven test of change projects designed to identify practice system vulnerabilities which impact patient safety and develop action plans for best practice solutions Students utilize SBAR-R when collaborating with healthcare team members Students perform open chart audits to identify patient risk using Global Triggers tool UPMC Shadyside School of Nursing

N200 Level Courses: PDA Time Study Goal: Redesign of Clinical Education into Structured Standardized Clinical Education Curricula PI Methodology Collect data regarding current process – TCAB Validate assumptions – TCAB Observation Process Involve workers in redesign Prototype: Rapid Cycle Tests of Change Adopt, Adapt or Abandon

Definitions TCAB: All care processes are free of waste and promote continuous flow – Muda Value added nursing care Necessary but not necessarily value added Non-value added nursing care

Using the latest technology, adapted for the education environment. What the study is… A form of work/self sampling designed to give minutes back to the clinical instructor and the student Using the latest technology, adapted for the education environment. What the study is A form of work/self sampling designed to give minutes back to the clinical instructor and the student We will be using the latest technology, adapted for the educational environment. No other school is doing this, so we have the privilege of being at the forefront of this technology.

What is getting in the way? Barriers Work around Broken processes Time eaters What are the barriers, the broken processes, the workarounds, in other words… the time eaters? Are their factors that get in the way of best opportunities to expose students to the best possible clinical experience.

Faculty Engagement Presented study idea at Nursing 200 (Medical Surgical Nursing) Faculty Retreat

Easy to use interface redesigned for education Time Study Features Easy to use interface redesigned for education Study is conducted with minimal distraction Detailed category list developed by instructors Over 80 hospitals currently using for RN studies Statistical software automatically provides analysis-in the form of pie charts, stack charts, pareto charts and tabular output Original program designed for IHI TCAB initiatives Time Study Features Easy to use interface redesigned for education Study is conducted with minimal distraction Detailed category list developed by instructors Over 80 hospitals currently using for RN studies Statistical software automatically provides analysis-in the form of pie charts, stack charts, pareto charts and tabular output Original program designed for IHI TCAB initiatives

Randomly Selected Clinical Instructors and Students

Methodology Each week, 2 random faculty and 2 random students carry a PDA to their clinical site. 8 hour day on Wednesday and Thursday The PDAs are returned to the school for downloading of data and subsequent “turnaround” to the next 4 people carrying them. System analyst assists in organizing the data into graphs and pareto charts. Not necessarily the same site

Data Points Approximately 10-14 data points are captured in an 8 hour clinical day Goal – 300 data points/semester

How Student Nurses Spend their time on Medical-Surgical Units: Work Sampling through 060608

The Redesign: Improvement Specialists to observe and clarify PDA data. Situational Assessment adapted to meet clinical judgment expectations of the student nurse in the medical-surgical environment. Dissemination Redistributing clinical unit based hours to simulation center N200 level team to design idealized medical-surgical clinical curricula, incorporating QSEN competencies