Quality and Safety Improvement Discussion

Quality and Safety Improvement Discussion

Quality and Safety Improvement Discussion

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QSEN Discussion Board #1 Rubric

As a nurse leader, you are charged with improving quality and safety in health care systems. Describe a nursing or patient care concern or issue from your clinical practice that needs improvement. If your clinical practice is limited, you may draw from experiences encountered during your clinical rotations in nursing school. Analyze the significance of the concern for nursing practice in relation to the Quality and Safety Education for Nurses (QSEN) competences described in the Cronenwatt article (Cronenwatt website – http://qsen.org/competencies/pre-licensure-ksas/).

This assignment is limited to the Evidence-based Practice (EBP) or Quality Improvement (QI) competencies.  Why is it important to explore this concern or issue? What would be the best or preferred practice for this concern? As a nurse manager or leader, how will you improve practices in your work environment related to this concern?

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Quality and Safety Improvement Discussion

Textbook:

Sullivan, E. J. (2012). Effective leadership and management in nursing. Boston: Pearson. ISBN-13: 978-0132814546

Quality and Safety Improvement Discussion

Quality and safety education for nurses Linda Cronenwett, PhD, RN, FAAN Gwen Sherwood, PhD, RN, FAAN Jane Barnsteiner, PhD, RN, FAAN Joanne Disch, PhD, RN, FAAN Jean Johnson, PhD, RN-C, FAAN Pamela Mitchell, PhD, CNRN, FAAN Dori Taylor Sullivan, PhD, RN, CNA, CPHQ Judith Warren, PhD, RN, BC, FAAN, FACMI on whether the KSAs for pre-licensure education are appropriate goals for students preparing for basic practice as a registered nurse. Quality and Safety Education for Nurses (QSEN) addresses the challenge of preparing nurses with the competencies necessary to continuously improve the quality and safety of the health care systems in which they work. The QSEN faculty members adapted the Institute of Medicine1 competencies for nursing (patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics), proposing definitions that could describe essential features of what it means to be a competent and respected nurse. Using the competency definitions, the authors propose statements of the knowledge, skills, and attitudes (KSAs) for each competency that should be developed during pre-licensure nursing education. Quality and Safety Education for Nurses (QSEN) faculty and advisory board members invite the profession to comment on the competencies and their definitions and A series of national commissions have documented significant problems related to safety and quality in the US health care system.1–5 In light of these problems, reports from multiple national committees concluded that if health care is to improve, providers need to be prepared with a different set of competencies than are developed in educational programs today.1,6 Health professionals, using scientific evidence, need to be able to describe what constitutes good care, identify gaps between good care and the local care provided in their practices, and know what activities they could initiate, if necessary, to close any gaps.7 Faculties of medicine, nursing, and other health professions are challenged by the 2003 Institute of Medicine (IOM) Health Professions Education report1 to mindfully alter learning experiences that form the basis for professional identity formation so that graduates are educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.1 Will, ideas, and execution are required to incorporate the development of the above competencies in nursing education. Unlike medicine, where commitment to an adapted version of the IOM competencies is now in place for the continuum from medical school to residency program to certification,8,9 nursing has no consensus on the competencies that could apply to all nurses—that would define what it means to be a respected and qualified nurse. At the core of nursing, however, lies incredible historical will to ensure quality and safety for patients. Evidence of valuing quality and safety competencies in nursing is evident in nursing publications,10 –12 standards of practice,13 and accreditation guidelines.14,15 The American Association of Colleges of Nursing Task Force on the Essential Patient Safety Competencies for Professional Nurs- Linda Cronenwett is a Professor and Dean at the School of Nursing, University of North Carolina at Chapel Hill. Gwen Sherwood is a Professor and Associate Dean for Academic Affairs at the School of Nursing, University of North Carolina at Chapel Hill. Jane Barnsteiner is a Professor and Director of Translational Research at the School of Nursing and Hospital of the University of Pennysylvania, Philadelphia, PA. Joanne Disch is Kathyrn R. and C. Walton Lillehei Professor and Director of the Densford International Center for Nursing Leadership at the School of Nursing, University of Minnesota, Minneapolis, MN. Jean Johnson is a Professor and Senior Associate Dean for Health Sciences at The George Washington University, Washington, DC. Pamela Mitchell is Elizabeth S. Soule Professor and Associate Dean for Research at the School of Nursing, University of Washington, Seattle, WA. Dori Taylor Sullivan is an Associate Professor and Chair, Department of Nursing at Sacred Heart University, Fairfield, CT. Judith Warren is an Associate Professor at the University of Kansas School of Nursing and Director of Nursing Informatics at Kansas University Center for Healthcare Informatics, Kansas City, KS. Reprint requests: Linda Cronenwett, PhD, RN, FAAN, Dean and Professor, School of Nursing, University of North Carolina at Chapel Hill, Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460. E-mail: lcronenwett@unc.edu Nurs Outlook 2007;55:122-131. 0029-6554/07/$–see front matter Copyright © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2007.02.006 122 V O L U M E 5 5 ● N U M B E R 3 N U R S I N G O U T L O O K Quality and safety education for nurses Cronenwett et al Table 1. Patient-centered Care Definition: 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. Knowledge Integrate understanding of multiple dimensions of patient-centered care: ● patient/family/community preferences, values ● coordination and integration of care ● information, communication, and education ● physical comfort and emotional support ● involvement of family and friends ● transition and continuity Skills Attitudes Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care Communicate patient values, preferences and expressed needs to other members of health care team Provide patient-centered care with sensitivity and respect for the diversity of human experience Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values Value seeing health care situations “through patients’ eyes” Respect and encourage individual expression of patient values, preferences and expressed needs Value the patient’s expertise with own health and symptoms Seek learning opportunities with patients who represent all aspects of human diversity Recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds Willingly support patientcentered care for individuals and groups whose values differ from own Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort Assess presence and extent of pain and suffering Recognize personally held values and beliefs about the management of pain or suffering Assess levels of physical and emotional comfort Appreciate the role of the nurse in relief of all types and sources of pain or suffering Elicit expectations of patient & family for relief of pain, discomfort, or suffering Recognize that patient expectations influence outcomes in management of pain or suffering Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs Examine how the safety, quality, and cost-effectiveness of health care can be improved through the active involvement of patients and families Examine common barriers to active involvement of patients in their own health care processes Describe strategies to empower patients or families in all aspects of the health care process Remove barriers to presence of families and other designated surrogates based on patient preferences Assess level of patient’s decisional conflict and provide access to resources Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management M A Y / J U N E Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care Respect patient preferences for degree of active engagement in care process Respect patient’s right to access to personal health records N U R S I N G O U T L O O K 123 Quality and safety education for nurses Cronenwett et al Table 1. Continued Definition: 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. Knowledge Skills Explore ethical and legal implications of patient-centered care Recognize the boundaries of therapeutic relationships Describe the limits and boundaries of therapeutic patient-centered care Facilitate informed patient consent for care Attitudes Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care Appreciate shared decisionmaking with empowered patients and families, even when conflicts occur Discuss principles of effective communication Assess own level of communication skill in encounters with patients and families Describe basic principles of consensus building and conflict resolution Participate in building consensus or resolving conflict in the context of patient care Examine nursing roles in assuring coordination, integration, and continuity of care Communicate care provided and needed at each transition in care ing Care recently completed an enhancement to the Essentials of Baccalaureate Education for Professional Nursing Practice to include exemplars of quality and safety competencies.16 But the ideas for what to teach, how to teach, and how to assess learning of the competencies are sorely lacking, and there are few, if any, examples of schools claiming to execute a comprehensive quality and safety curriculum. continuing education programs. In addition, the definitions can provide a framework for regulatory bodies that set standards for licensure, certification, and accreditation of nursing education programs. PRE-LICENSURE NURSING EDUCATION . Quality and Safety Improvement Discussion. The competency definitions provided a broad framework for QSEN’s work to define pedagogical strategies for quality and safety education; however, as is evident in the accompanying article in this issue, when the competency names and definitions were used alone, the vast majority of pre-licensure program leaders stated that they already included content related to the competencies in their curricula.17 Relying on the respondent to interpret the general definitions of the QSEN competencies, levels of satisfaction with the extent to which students developed these competencies were high, and program leaders believed that faculty possessed the necessary expertise to teach these competencies. The QSEN faculty and advisory board members did not share the view that pre-licensure nursing students were graduating with these competencies. We knew that many students graduated without ever communicating a recommendation for a change in patient care to a physician. Many of us knew that students learned the “five rights” of medication administration but lacked the language of common concepts related to safety sciences or quality improvement methods. With the DEFINING THE COMPETENCIES Quality and Safety Education for Nurses (QSEN), funded by the Robert Wood Johnson Foundation, was designed to address these gaps—to build on the will, to develop the ideas, and to facilitate execution of changes in nursing education. Before teaching strategies could be developed, however, the QSEN faculty needed to identify specifically what was to be achieved. Working with an Advisory Board of thought leaders in nursing and medicine (see acknowledgments), the authors reviewed the relevant literatures and adapted the IOM1 competencies for nursing. The goal was to describe competencies that would apply to all registered nurses. In Tables 1– 6, the definitions are shared with the profession with the hope that nursing, through its professional organizations, can benefit from the work. If nursing constituencies find these competency definitions clear and compelling, over time the competencies can serve as guides to curricular development for formal academic programs, transition to practice, and 124 V O L U M E 5 5 ● N U M B E R Value continuous improvement of own communication and conflict resolution skills 3 N U R S I N G O U T L O O K Quality and safety education for nurses Cronenwett et al Table 2. Quality and Safety Improvement Discussion. Teamwork and Collaboration Definition: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care. Knowledge Describe own strengths, limitations, and values in functioning as a member of a team Skills Attitudes Demonstrate awareness of own strengths Acknowledge own potential to and limitations as a team member contribute to effective team functioning Initiate plan for self-development as a team member Appreciate importance of intra- and inter-professional Act with integrity, consistency and collaboration respect for differing views Describe scopes of practice and Function competently within own scope Value the perspectives and roles of health care team of practice as a member of the health expertise of all health team members care team members Describe strategies for identifying Assume role of team member or leader and managing overlaps in based on the situation team member roles and Initiate requests for help when accountabilities appropriate to situation Recognize contributions of other Clarify roles and accountabilities under individuals and groups in conditions of potential overlap in helping patient/family achieve team-member functioning health goals Integrate the contributions of others who play a role in helping patient/family achieve health goals Respect the centrality of the patient/family as core members of any health care team Analyze differences in communication style preferences among patients and families, nurses, and other members of the health team Value teamwork and the relationships upon which it is based Communicate with team members, adapting own style of communicating to needs of the team and situation Respect the unique attributes that members bring to a team, including variations in professional orientations and accountabilities Demonstrate commitment to team goals Value different styles of communication used by Solicit input from other team members to Describe impact of own patients, families, and health improve individual, as well as team, communication style on others care providers performance Discuss effective strategies for Contribute to resolution of communicating and resolving Initiate actions to resolve conflict conflict and disagreement conflict Describe examples of the Follow communication practices that Appreciate the risks associated impact of team functioning on minimize risks associated with handoffs with handoffs among safety and quality of care among providers and across transitions providers and across in care transitions in care Explain how authority gradients influence teamwork and Assert own position/perspective in patient safety discussions about patient care Choose communication styles that diminish the risks associated with authority gradients among team members Identify system barriers and facilitators of effective team functioning Participate in designing systems that support effective teamwork Value the influence of system solutions in achieving effective team functioning Examine strategies for improving systems to support team functioning M A Y / J U N E N U R S I N G O U T L O O K 125 Quality and safety education for nurses Cronenwett et al Table 3. Evidence-based Practice (EBP) Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. Knowledge Skills Demonstrate knowledge of basic scientific methods and processes Describe EBP to include the components of research evidence, clinical expertise and patient/family values Participate effectively in appropriate data collection and other research activities Appreciate strengths and weaknesses of scientific bases for practice Adhere to Institutional Review Board (IRB) guidelines Value the need for ethical conduct of research and quality improvement Base individualized care plan on patient values, clinical expertise and evidence Differentiate clinical opinion from research and evidence summaries Read original research and evidence reports related to area of practice Describe reliable sources for locating evidence reports and clinical practice guidelines Locate evidence reports related to clinical practice topics and guidelines Explain the role of evidence in determining best clinical practice Participate in structuring the work environment to facilitate integration of new evidence into standards of practice Describe how the strength and relevance of available evidence influences the choice of interventions in provision of patient-centered care Question rationale for routine approaches to care that result in less-than-desired outcomes or adverse events Discriminate between valid and invalid reasons for modifying evidence-based clinical practice based on clinical expertise or patient/family preferences Consult with clinical experts before deciding to deviate from evidence-based protocols goal of clarifying rather than prescribing current meanings of the competency definitions, we outlined the knowledge, skills, and attitudes (KSAs) appropriate for pre-licensure education. During 2 workshops and multiple email communications, the authors led the process of KSA development. We focused on all of pre-licensure education (associate, diploma, baccalaureate, and master’s entry), because the ultimate goal is to assure that all patients will be cared for by nurses who have developed the KSAs for each competency. Quality and Safety Improvement Discussion. We tried to answer the question, “What should nursing promise with regards to its pre-licensure graduates’ quality and safety education?” At each step, we sought feedback from nursing faculty. In contrast to the results of the survey, when nursing 126 V O L U M E 5 5 ● N U M B E R 3 Attitudes N U R S I N G Value the concept of EBP as integral to determining best clinical practice Appreciate the importance of regularly reading relevant professional journals Value the need for continuous improvement in clinical practice based on new knowledge Acknowledge own limitations in knowledge and clinical expertise before determining when to deviate from evidence-based best practices school faculty from 16 universities in the Institute for Healthcare Improvement Health Professions Education Collaborative reviewed the KSA draft, they uniformly reported that nursing students were not developing these KSAs. Additional focus groups were held with faculty who taught pre-licensure students in QSEN faculty members’ schools, and the responses were the same. Although the faculty agreed that they should be teaching these competencies and, in fact, had thought they were, focus group participants did not understand fundamental concepts related to the competencies and could not identify pedagogical strategies in use for teaching the KSAs. A chief nurse executive serving on the QSEN advisory board led a focus group of new graduates. Not only did these nurses report that they lacked learning expeO U T L O O K Quality and safety education for nurses Cronenwett et al Table 4. Quality Improvement (QI) Definition: 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. Knowledge Skills Attitudes Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clini ..Quality and Safety Improvement Discussion