Quality and Safety in Nursing E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Drawing on the universal values in health care, the second edition of Quality and Safety in Nursing continues to devote itself to the nursing community and explores their role in improving quality of care and patient safety. Edited by key members of the Quality and Safety Education for Nursing (QSEN) steering team, Quality and Safety in Nursing is divided into three sections. Itfirst looks at the national initiative for quality and safety and links it to its origins in the IOM report. The second section defines each of the six QSEN competencies as well as providing teaching and clinical application strategies, resources and current references. The final section now features redesigned chapters on implementing quality and safety across settings. New to this edition includes: * Instructional and practice approaches including narrative pedagogy and integrating the competencies in simulation * A new chapter exploring the application of clinical learning and the critical nature of inter-professional teamwork * A revised chapter on the mirror of education and practice to better understand teaching approaches This ground-breaking unique text addresses the challenges of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the health care system in which they practice.
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Table of Contents
Cover
Title Page
Contributors
Foreword
References
Preface
Section 1: Quality and Safety
1 Driving Forces for Quality and Safety
The Compelling Case for Quality and Safety
A Systems Approach to Improve Quality and Safety Outcomes: High Reliability Organizations
Summary
References
Resources
2 Policy Implications Driving National Quality and Safety Initiatives
Policy in the Context of Health Care Quality and Safety
The Landscape of Formal Stakeholders in the Ongoing Quality Dialogue
Affordable Care Act Emerged Where Efforts Converged
National Quality Strategy Is the Future
Building the Momentum for Quality
National Quality Forum: A Strategic Model
Measure Applications Partnership Driving Selection of Measures
National Database of Nursing Quality Indicators: Capturing the Data
Institute for Healthcare Improvement Focused on System Improvement
Informatics, Electronic Health Records, and Impact of Technology on Quality and Policy
National Priorities Partnership and Implementation of the National Quality Strategy
Quality Alliances Influence Policy Actions Through a Professional Lens
Federal Agencies Engage with Alliances
Standard Setting by Nonfederal Agencies
“Stand for Quality in Health Care”‐focused Health Reform Efforts
Common Strategies Run Through Formalized Initiatives
Challenges All Collective Efforts Face in Improving the Quality of Care
What Can Every Nurse Do to Influence Policy That Improves Quality?
Summary
References
Resources
3 A National Initiative
QSEN Origins: 2000–2005
Building Will: Phase I (October 2005–March 2007)
Generating and Sharing Ideas: Phase II (April 2007–October 2008)
Embedding New Competencies: Phase III
QSEN and Beyond
QSEN: 2012–2017
References
Section 2: Quality and Safety Competencies
4 Patient‐centered Care
Definitions
Key Concepts
Background: What Do Patients and Families Want?
National Standards and Regulations
Teaching the Competencies
Conclusion
References
Resources
5 Teamwork and Collaboration
Teamwork
Collaboration
Nurse‐Physician Collaboration
The Benefits of Collaboration
Communication
Mutual Support
Factors That Compromise Effective Team Performance
Conflict Resolution
Creating Expert Teams
Team Training
The Patient/Family as a Member of the Team
The QSEN Competency on Teamwork and Collaboration
Sequencing the Content
Interprofessional Education
Who Teaches IPE?
Interprofessional Education and Collaborative Practice
The Interprofessional Education Collaborative
Strategies for Learning TWC
Conclusion
References
Resources
6 Quality Improvement
Background of Quality Improvement
Measuring Nursing Care Quality
Quality Improvement Process
Teaching Quality Improvement
Conclusion
References
Resources
7 Evidence‐based Practice
Definition and Description of Evidence‐Based Practice
Evidence‐Based Practice–Models and Process
The Evidence for Evidence‐based Practice
Teaching Strategies for Students
Didactic Strategies
Simulation or Skills Lab Strategies
Clinical Strategies
Teaching Strategies for Clinical Staff
Broadening the Evidence‐based Practice Perspective
Conclusion
References
Resources
8 Safety
A National Mandate
Categories of Errors
Culture of Safety
What Students and Clinicians Need to Know About Safety
Safety Challenges in All Settings
Voluntary Versus Mandatory Error Reporting Systems
Second Victim
Integrating a Culture of Safety into the Curriculum and into the Ongoing Education of Clinicians
Summary
References
Resources
9 Informatics
Development of the QSEN Informatics Competencies
Educational Strategies for Teaching Informatics
Strategies for Building an Informatics Curriculum
Implications for Nursing Practice
Emerging Informatics Trends and Implications for Nurse Educators
Conclusion
References
Section 3: Strategies to Build a Culture of Quality and Safety
10 Transforming Education to Transform Practice
QSEN: Integrating Quality and Safety Competencies in Nursing
Situated Coaching to Promote Interactive Knowledge Use
Integrating Innovative Ideas into the Nursing Classroom
A Method for Constructing an Unfolding Case Study
Reflective Practice and Questioning Strategies for Situated Coaching
Summary
References
Resources
11 Using Narrative Pedagogy to Foster Quality and Safety
Teaching Nursing Practice
Narrative Pedagogy
Cycles of Interpretation
Narrative Pedagogy and Quality and Safety Education for Nurses
Summary
References
12 Integrating Quality and Safety Competencies in Simulation
Overview of Simulation‐based Learning
Uses of Simulation‐based Learning in Nursing Education
QSEN Competencies and Simulation
Conclusion
References
Resources
13 Quality and Safety Education in Clinical Learning Environments
Workplace Learning and Social Learning Theory
Learning the Work of Nursing
Clinical Assignments to Promote Quality and Safety
Assessing Student Learning: QSEN Competencies and Evaluation of Student Performance
Bringing Academic and Workplace Learning Together
Reflective Practice: Debriefing to Learn
Summary
References
Resources
14 Interprofessional Approaches to Quality and Safety Education
The Added Value of Interprofessional Education to the Quality and Safety Learning Process
Examples of National Interprofessional Training Programs in Quality and Safety Education
Summary
References
Resources
15 Improving Quality and Safety with Transition‐to‐Practice Programs
Transition‐to‐Practice Programs: Definition and Extent
Evidence Linking Transition‐to‐Practice Programs to Quality and Safety
Standardized TTP Programs
Major Study Findings
Implications for Educators and Practice Partners
Conclusion
References
16 Leadership to Create Change
The Evolution of Leadership
The Relationship Between Leadership and Safety
Creating a Culture of Safety
The Role of Nurses in Quality and Safety
Creating and Sustaining Change
Implementation Strategies for Education and Practice
Conclusion
References
Resources
17 Global Perspectives on Quality and Safety
Quality and Safety: A Global Perspective
Education as the Bridge to Improving Quality and Safety
Preparing a Global Work Force to Address Quality and Safety
Resources from a Global Perspective
Summary
References
Appendix A: Prelicensure Competencies
Appendix B: Quality and Safety Education for Nurses Graduate/Advanced Practice Nursing Competencies
Appendix C: Quality and Safety Education for Nurses
Glossary
Index
End User License Agreement
List of Tables
Chapter 03
Table 3.1 QSEN faculty, staff, and advisory board members.
Table 3.2 Participants in April 2007 workshop to generate graduate‐level QSEN competencies and associated knowledge, skills, and attitude learning objectives.
Chapter 04
Table 4.1 Cultural values aligned with core concepts of patient/family‐centered care.
Chapter 05
Table 5.1 Components of teamwork from a synthesis of the literature.
Table 5.2 Instructional strategies for teamwork training.
Table 5.3 Criteria for full engagement of interprofessional education (IPE).
Chapter 06
Table 6.1 HCAHPS Survey Questions Example of Benchmarking for “Patients Who Reported That Their Nurses “Always” Communicated Well.
Table 6.2 Questions related to Plan, Do, Study, Act.
Chapter 07
Table 7.1 Roles of students, faculty, and clinical staff in a student‐led clinical alarm management evidence‐based practice project.
Chapter 08
Table 8.1 Safety culture assessment tools.
Chapter 09
Table 9.1 Crosswalk for AACN BSN Essentials, TIGER Competencies, and QSEN KSAs for Informatics.
Table 9.2 Matriculation Crosswalk: AACN Essentials for Patient Technologies and Information Management.
Chapter 12
Table 12.1 INACSL Standards of Best Practice: Simulation
SM
Table 12.2 Examples of select knowledge, skills, and attitudes and simulation learning activities for prelicensure and graduate students.
Chapter 14
Table 14.1 Examples of IHQSE certificate training program teams and outcomes.
Chapter 15
Table 15.1 Evidence on competency from research reviews of TTP programs.
Table 15.2 Elements of TTP programs from research reviews of TTP studies.
Chapter 16
Table 16.1 Kotter’s model of change.
Appendix A
Table A.1 Patient‐centered care.
Table A.2 Teamwork and collaboration.
Table A.3 Evidence‐based practice (EBP).
Table A.4 Quality improvement.
Table A.5 Safety.
Table A.6 Informatics.
Appendix B
Table B.1 Patient‐centered care.
Table B.2 Teamwork and collaboration.
Table B.3 Evidence‐based practice.
Table B.4 Quality improvement.
Table B.5 Safety.
Table B.6 Informatics.
Appendix C
Table C.1 Patient‐centered care.
Table C.2 Teamwork and collaboration.
Table C.3 Evidence‐based practice (EBP).
Table C.4 Quality improvement.
Table C.5 Safety.
Table C.6 Informatics.
List of Illustrations
Chapter 03
Figure 3.1 QSEN Phases I and II: Aims and actions (IOM = Institute of Medicine).
Figure 3.2 QSEN Phase III: Embedding new competencies (UNC = University of North Carolina‐Chapel Hill; AACN = American Association of Colleges of Nursing; VAQS = Veterans Administration Quality Scholars Program).
Chapter 04
Figure 4.1 Your cultural values.
Chapter 06
Figure 6.1 Structure, process, outcome framework (Donabedian framework).
Figure 6.2 Triple aim goals.
Figure 6.3 Line graph of RN vacancy.
Figure 6.4 Histogram of medication errors.
Figure 6.5 Bar graph of CAUTI per 1000 device days.
Figure 6.6 Fishbone diagram.
Figure 6.7 Summary of the quality improvement process. PDSA = plan, do, study, act.
Chapter 07
Figure 7.1 Five components of a PICOT question.
Chapter 08
Figure 8.1 Reason’s Swiss cheese model.
Chapter 09
Figure 9.1 Mind map of the pre‐licensure informatics competencies group by conceptual categories using FreeMind, a mind mapping tool, available at http://freemind.sourceforge.net/wiki/index.php/Download
Figure 9.2 Mind map of the advanced nursing practice informatics competencies group by conceptual categories, using FreeMind.
Chapter 15
Figure 15.1 NCSBN’s TTP model.
Chapter 16
Figure 16.1 The 5 Levers for Change: A change model.
Figure 16.2 Missing elements leading to ineffective change.
Guide
Cover
Table of Contents
Begin Reading
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Quality and Safety in Nursing
A competency approach to improving outcomes
Second edition
Edited by
Gwen Sherwood, PhD, RN, FAAN, ANEF
Professor and Associate Dean for Practice and Global InitiativesSchool of NursingUniversity of North Carolina at Chapel HillChapel Hill, NC
Jane Barnsteiner, PhD, RN, FAAN
Professor EmeritaSchool of NursingUniversity of PennsylvaniaPhiladelphia, PAEditor, Translational Research and QI, American Journal of Nursing
Copyright © 2017 by John Wiley & Sons, Inc. All rights reserved
Published by John Wiley & Sons, Inc., Hoboken, New Jersey
Published simultaneously in Canada
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per‐copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750‐8400, fax (978) 750‐4470, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748‐6011, fax (201) 748‐6008, or online at http://www.wiley.com/go/permission.
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.
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Library of Congress Cataloging‐in‐Publication data applied for:
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Cover image: Ralf Hiemisch/GettyimagesCover design: Wiley
To faculty, students, and clinicians who are successfully pioneering the work of QSEN. On a daily basis their work demonstrates their commitment that the highest quality, safest care can only be achieved when all clinicians are delivering person‐and‐family‐centered care as members of an interprofessional team, emphasizing evidence‐based practice, safety, quality improvement approaches, and informatics.
Contributors
Editors
Gwen Sherwood, PhD, RN, FAAN, ANEFProfessor and Associate Dean for Practice and Global InitiativesSchool of NursingUniversity of North Carolina at Chapel HillChapel Hill, NCJane Barnsteiner, PhD, RN, FAANProfessor EmeritaSchool of NursingUniversity of PennsylvaniaPhiladelphia, PAEditor, Translational Research and QI, American Journal of Nursing
Contributors
Kathryn R. Alden, EdD, MSN, RN, IBCLCAssociate ProfessorSchool of NursingUniversity of North Carolina at Chapel HillChapel Hill, NCElizabeth Cerbie Brown, MSN, RNDirector of Nursing EducationIndiana University HealthIndianapolis, INThomas R. Clancy, MBA, PhD, RN, FAAN Clinical Professor and Associate Dean Faculty Practice, Partnerships and Professional DevelopmentSchool of NursingThe University of MinnesotaMinneapolis, MNLinda R. Cronenwett, PhD, RN, FAANDean Emerita and ProfessorUNC‐Chapel Hill, School of NursingChapel Hill, NCandCo‐Director, RWJF Executive Nurse Fellows ProgramLisa Day, PhD, RN, CNEAssociate ProfessorJosiah Macy Jr Foundation Faculty ScholarDuke University School of NursingChapel Hill, NCJoanne Disch, PhD, RN, FAANProfessor ad HonoremUniversity of Minnesota School of NursingMinneapolis, MNMary A. Dolansky, PhD, RN, FAANAssociate ProfessorDirector, QSEN InstituteFrances Payne Bolton School of NursingCase Western Reserve UniversityCleveland, OHCarol F. Durham, EdD, RN, ANEF, FAANProfessorSchool of NursingUniversity of North Carolina at Chapel HillChapel Hill, NCPamela M. Ironside, PhD, RN, FAAN, ANEFPrairie du Sac, WIJean Johnson, PhD, RN, FAANProfessor, Founding Dean (retired) and Executive CoachSchool of NursingGeorge Washington UniversityWashington, DCEllen Luebbers, MDVA Quality Scholars FellowLouis Stokes Cleveland VA Medical CenterCase Western Reserve University School of MedicineCleveland, OHShirley M. Moore, PhD, RN, FAANEdward J. and Louise Mellen Professor of NursingFrances Payne Bolton School of NursingCase Western Reserve UniversityCleveland, OHMary Jean Schumann, DNP, MBA, RN, CPNP, FAANAssociate Professor of Nursing and Senior Associate Dean for Academic AffairsGeorge Washington University School of NursingWashington, DCMamta K. Singh, MD, MSAssociate Professor of MedicineCase Western Reserve University School of MedicineLouis Stokes Cleveland Veterans Affairs Medical CenterCleveland, OHNancy Spector, PhD, RN, FAANDirector of Regulatory InnovationsNational Council of State Boards of NursingChicago, ILMary Fran Tracy, PhD, RN, APRN, CNS, FAANAssociate Professor/Nurse ScientistUniversity of Minnesota School of NursingUniversity of Minnesota Medical CenterMinneapolis, MNBeth T. Ulrich, EdD, RN, FACHE, FAANProfessor, University of Texas Health Science Center at Houston School of NursingEditor, Nephrology Nursing JournalPearland, TXMary K. Walton, MSN, MBE, RNDirector, Patient and Family Centered Care; Nurse EthicistHospital of the University of PennsylvaniaAdjunct Assistant Professor of Medical Ethics and Health PolicyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphia, PAJudith J. Warren, PhD, RN, BC, FAAN, FACMIConsultant, Warren Associates, LLCPlattsmouth, NEAmy Hagedorn Wonder, PhD, RNAssistant ProfessorIndiana University School of NursingBloomington, IN
Foreword
The Carnegie Foundation for the Advancement of Teaching’s Preparation for the Professions Program called out important changes needed in the preparation for professional work in medicine, nursing, law, engineering, and the clergy. Professor Patricia Benner led the team for nursing (Benner et al., 2010). They began by noting that profound changes were occurring in the practice of the nursing professional that were arising from science, technology, patient activism, market‐driven financing of health care service, and in the settings where these forces come together and where nurses now practice. They noted a practice‐to‐education gap characterized by the need to match learning with the realities of the work that nursing professionals face. This book begins to address that gap by opening the knowledge and skills needed to understand and improve these new practice settings of nursing.
All professions earn societal recognition as a “profession” by the ongoing improvement of their own work (Houle, 1980). But as Benner and colleagues (2010) note, improving health care service now isn’t easy or simple. Health care service for patients and populations today occurs in complex, interdependent systems (Batalden, Ogrinc, and Batalden, 2006). Designing and testing changes for improvement in those systems requires new knowledge and skill. This book is about developing those competencies essential for a sense of professional mastery.
“Doing quality improvement” is not necessarily the same as “improving the quality of what we do”–the profession‐enabling work. This is not the work of a small department of zealots who staff offices to meet regulations; it is part of the work of every person who claims designation today as a health care professional.
Improving the quality, safety, and value of health care service invites the use of multiple knowledge disciplines (Batalden et al., 2011). Diverse knowledge‐building traditions from biological, social, and physical sciences and the humanities come together to contribute to the development of the knowledge and science of improvement. This book is about those knowledge domains and invites attention to the scholarly and applied work of educators and researchers who develop and foster critical thinking about improving health care.
At the core of professional work in service of improving health for a patient is a series of interactions that can be represented by the simple logic formula:
Generalizable science X Particular patient → Measured improvement.
Each element of this logic comes together millions of times every day as clinical health professionals do their work.
We can use a similar logic representation for improving health care service:
(Individual, population goal + Generalizable science) X Particular context → Measured performance improvement.
Each phrase or symbol of this simple logic formula is informed by knowledge that is developed and tested in customized ways. Because all health care service is co‐produced by two parties, the person we know as a “patient” and the person we know as a “health care professional,” the process begins by creating a shared aim (Batalden et al. 2015). The shared aim comes from knowledge of the goal sought by the patient and identification of the contribution that the professional’s generalizable knowledge can offer. They work together. Good professional knowledge about “generalizable science” is developed by carefully controlling and minimizing “context” as a variable. In contrast, particular context knowledge comes from obsessing about context, that is, the systems, processes, traditions, patterns, and so forth, that characterize and give “particular” identity to contexts. Measuring performance improvement means measuring over time–not just at two points in time–and it means using balanced measures to understand the multidimensional aspects of quality, safety, and value of process and outcome of health care service. Even the symbols represent knowledge domains. The “+” sign signifies knowing how to match the contribution that the professional’s science can make to the realization of the patient’s goal. The “X” signifies the important role that context plays in the results of the shared work. The “→” represents the knowledge of actually executing change–making it happen. Each part and symbol of the formula invites a different way of knowing, and they must all come together to make change for the improvement of health care service. (Batalden and Davidoff, 2007).
Benner and her colleagues (2010) also note that nurses have very diverse entries, pathways, curricula, and time frames to become a nurse. This book invites attention to that diversity by focusing on the content of what must be mastered–the competencies themselves. As health professions engage in competency‐based learning, it will be important to avoid reducing all the content that is signaled by the competencies into mechanical packages that fail to invite the whole person to the learning and its application in relationship to another person in need.
What is important in health care service is reducing the burden of illness for individuals and populations. The people, and what they are struggling to do together, is what is real in health care. Together they form some relationship and engage in some activity. This relationship and activity are connected by knowledge, skill, and habit. The intervention for improving health care service quality, safety, and value is a social change that is learned experientially (Batalden et al., 2011). Improvement theories, methods, tools, and techniques are all potentially helpful, but we must never confuse them with the work of improving health care service, lest we make an error similar to the one of confusing a map for the territory it represents.
Creating work environments that sustain the generative, refreshing work of improving health care service involves the inextricable linkage of three aims and invites the work of everyone, illustrated in Figure F.1 (Batalden and Foster, 2012). Health care professionals have an opportunity to help design and weave these together.
Figure F.1 Creating work environments for improving health care service.
It is often noted by practicing nurses and other clinicians that their job is to protect the patient from the system of health care service in which the patient and clinician meet. This frames responsibility for the design of the system and its ongoing improvement as external to the working professional on the front lines of health care service. I prefer a different view of professional work, one that accepts the professional responsibility for health care service system quality, safety, and value. This book can help nurses and other clinicians who are not content to work in alien systems.
A nurse who was a member of a class I was teaching many years ago said it very succinctly: “We actually have two jobs–to do our work and to improve it.”
This book invites the work of improving health care, the work that helps make health care workers professionals. Enjoy it.
Paul Batalden, M.D.Emeritus Professor, The Dartmouth Institute forHealth Policy and Clinical PracticeDartmouth Medical SchoolLebanon, New HampshireUSA
References
Batalden, M., Batalden, P. Margolis, P., Seid, M., Armstrong, G., Opipari‐Arrigan, L., and Hartung H. (2015) Coproduction of healthcare service.
BMJ Quality & Safety,
Published Online First [15 September 2015] doi:10.1136/bmjqs‐2015‐004315.
Batalden, P., Bate, P., Webb, D., and McLoughlin, V. (2011) Planning and leading a multidisciplinary colloquium to explore the epistemology of improvement.
BMJ Quality & Safety
, 20, i1–i4.
Batalden, P., and Davidoff, F. (2007) What is quality improvement and how can it transform healthcare?
Quality & Safety in Health Care
, 16, 2–3.
Batalden, P., Davidoff, F., Marshall, M., Bibby, J., and Pink, C. (2011) So what? Now what? Exploring, understanding and using the epistemologies that inform the improvement of health care.
BMJ Quality & Safety
, 20, i99–i105.
Batalden, P. and Foster, T. (eds.) (2012) Sustainably Improving Health Care: Creatively Linking Care Outcomes, System Performance, and Professional Development. London: Radcliffe.
Batalden, P., Ogrinc, G., and Batalden, M. (2006) From one to many.
Journal of Interprofessional Care
, 20, 549–551.
Benner, P., Sutphen, M., Leonard, V., and Day L. (2010) Educating nurses: A call for radical transformation. San Francisco: Jossey‐Bass.
Houle, C.O. (1980) Continuing learning in the professions. San Francisco: Jossey‐Bass.
Preface
The synergy inspired by the Quality and Safety Education for Nursing (QSEN) project over the past decade is leading the transformation of nursing education and practice to improve quality and safety of health care (Cronenwett et al., 2007; Cronenwett et al., 2009). Through a series of grants from the Robert Wood Johnson Foundation between 2005 and 2012, the QSEN project was led by a steering team, a national expert panel, and an advisory board who identified the knowledge, skills, and attitudes (KSA) for the six competencies first identified by the Institute of Medicine (IOM) think tank (2003): patient‐centered care, teamwork and collaboration, evidence‐based practice, quality improvement, safety, and informatics. With the second edition of this seminal text, we celebrate the continuing journey to improve our health care systems launched 11 years ago by a group of pioneers who helped identify and lead early adopters through four phases of QSEN.
The original two dozen pioneers who launched QSEN expanded to 40 champions who became QSEN facilitators (www.qsen.org) and then to hundreds of educators, clinicians, and administrators who led the Pilot Schools Learning Collaborative, the American Association of Colleges of Nursing (AACN)/QSEN Faculty Development Institutes, and countless projects. Although transformation has been swift and pervasive in many settings, many gaps remain. The six quality and safety competencies from the QSEN project are firmly embedded in nursing education essential competencies in both the National League for Nurses and the AACN documents and are spreading globally across education and clinical settings. A train‐the‐trainer approach helped spread educational approaches, preparing thousands of nursing faculty to integrate the new KSAs for the six core competencies. The passion to improve health care has transformed into new education models and teaching strategies, clinical initiatives and applications, evidence‐based practices, and safety cultures.
Faculty and clinicians are embracing a new way of thinking about quality and safety; new partnerships are evolving across professions and among academic and service agencies creating a bold new vision for health professions, education, and practice. Consumers and health care professionals both recognize that health care in America remains far from ideal, but believing joint efforts among educators and clinicians across multiple professions can together make it better.
Quality and safety are universal values in health care; nurses in both education and practice settings have the will through a common value system if they are helped to develop the ideas for leading change, and are provided the tools to execute the change needed and in fact are inspired by the opportunity to work in systems focused on safe quality care.
Education is indeed the bridge to quality (IOM, 2003), and progress comes with each generation of nurses prepared with the competencies to work in and lead health care systems focused on safety: patient‐centered care, teamwork and collaboration, quality improvement, safety, evidence‐based practice, and informatics. Have we reached a tipping point? Nurse leaders have long recognized the imperative to improve patient care outcomes and have been a part of early quality improvement work within nursing. Safety and patient‐centered care have been recognized as cornerstones of effective nursing practice, but with new evidence, a science of safety and quality improvement provide a sharper focus to quality and safety initiatives.
The expanded version of this book seeks to address the needs of faculty, practicing nurses, administrators, and nursing students at all educational levels. Each chapter tells a part of the story and collectively offers a roadmap to improve quality and safety. Updated information in each chapter provides a current view of application of quality and safety; consumer efforts driving change are found in Chapter 2; and Chapter 3 presents the first person account from Dr. Cronenwett of how QSEN began as well as the continuing story of this award‐winning project to become the QSEN Institute at Case Western Reserve University School of Nursing. Section 2 includes an in‐depth current view of each of the six competencies. The chapters provide a resource for faculty, graduate students, practicing nurses, and other leaders including teaching strategies, resources, and current references. Section 3 has redesigned chapters on implementing quality and safety across settings. A revised chapter is provided on the mirror of education and practice to better understand teaching approaches for redesigning teaching approaches. Other instructional approaches include narrative pedagogy, integrating the competencies in simulation, a new chapter to explore application in clinical learning, the critical nature of interprofessional teamwork to improve quality and safety, and developing personal leadership to lead change in organizations focused on improving quality and safety. The last chapter examines global applications of quality and safety, and outlines the need for sharing strategies related to education, research, and practice changes around the world. Three appendices provide additional resources with the knowledge, skills, and attitudes tables for each of the prelicensure and graduate competencies, the results of a Delphi study to assist educators with placing the 162 KSAs for beginner, middle, and advanced placement in nursing programs and staff development, and an extensive glossary.
Each contributor is a leader in quality and safety and offers his or her work to stimulate all nurses and health care professionals to share and disseminate their work around the globe. Together, we hope to rebuild health care as a high‐reliability system focused on safety and quality. It is our hope that the shared and expanding story of QSEN provides motivation and will, that the expansive tool kit within these pages stimulates ideas, and that the continuing efforts for faculty and leader development translate to execution as we move toward new generations of nurses fully prepared to lead and work in health care systems based on cultures of quality and safety.
Gwen Sherwood, PhD, RN, FAAN, ANEFJane Barnsteiner, PhD, RN, FAANCoeditors
Section 1Quality and Safety: An Overview
1Driving Forces for Quality and Safety: Changing Mindsets to Improve Health Care
Gwen Sherwood, PhD, RN, FAAN, ANEF
Julia stashed her umbrella and looked at the overflowing waiting room of the Emergency Department (ED) where she had worked weekends for the past five years. It was summer and staffing was short even for a Sunday evening in August; several staff were on vacation and one called in sick. A storm had pounded the area, and there was a power outage. The hospital was on the emergency generators, and that meant the electronic chart was slow in response because of the overload. Staff were taking shortcuts due to time pressures. She thought about these breakdowns and remembered the workshop she recently attended on quality improvement. The focus had been on identifying problems and applying quality improvement tools to collect data on the problem, analyze results, and design solutions to close the gap between actual and desired practice. She noted that Ms. Masraf was in the waiting area; she had diabetes, and wounds were difficult to heal. Infection was a constant threat so she had been to the emergency department on several occasions. Julia turned at the sound of a crash and saw that one of the nurse aids had fallen where water had collected from wet umbrellas. Falls were common in the ED as a result of the population served. Patients may be unstable due to their disease condition or influence of alcohol or drug use. She wondered if she could initiate a quality improvement study on any of these continuing problems she saw every time she came to work. Other staff seemed to think this was just a part of how the emergency room functioned.
In 1999, the Institute of Medicine (IOM), a not‐for‐profit organization sponsored by the United States National Academy of Sciences, released To Err Is Human (2000), which estimated there were between 44,000 and 98,000 deaths each year as a result of medical harm. Makary and Daniel (2016) declare this number is both limited and out of date. Their projection released in 2016 cites the deaths due to medical error is more likely 251,454, making this the third leading cause of death in the United States. Since the IOM series of reports focused attention on the issues in health care quality and safety, responses have included regulatory changes, new roles and responsibilities for health care professionals, and calls for a new educational paradigm. Still, health care safety remains a major threat (Balik and Dopkiss, 2010; Cronenwett, 2012; Leape and Berwick, 2005; Wachter, 2004; Wachter, 2010).
The original 1999 report was the first evidence of the gap between the status of health care delivered and the quality of health care that the IOM panel believed Americans were entitled to receive. A number of reports have heralded ways to improve the system of care. The 2001 Crossing the Quality Chasm: A New Health System for the 21st Century issued recommendations for sweeping changes in our systems. This was followed by the 2003 IOM report, Health Professions Education: A Bridge to Quality, which called for a radical redesign of health professions education to achieve six core competencies described as essential to improve twenty‐first century health care: patient‐centered care, teamwork and collaboration, evidence‐based practice, quality improvement, safety, and informatics. The attention from the series of IOM reports over the past 15 years demonstrates that quality and safety are the leading contemporary issues in health care, contributing to costs and poor outcomes. Current health care reform in the United States is based on improving quality outcomes; health care mistakes cost the system between $17 billion and 29 billion each year and costs patients and families economically but also emotionally and physically. Providers who work in flawed systems and deal with inadequate resources experience dissatisfaction and low morale. For all, there is an erosion of trust from the pitfalls experienced.
Health professions education continues to undergo transformation to include preparation in the knowledge, skills, and attitudes (KSA) needed to improve our systems of care (Batalden, Leach, and Ogrinc, 2009; Cronenwett et al., 2007). In 2011, representatives of the major health professions worked together to reach consensus on four domains of interprofessional education competencies that crosswalk these competencies for improving quality and safety: roles and responsibilities, teamwork, communication, and ethics and values (Interprofessional Education Collaborative [IPEC], 2011).
The same questions from 15 years ago continue to need solutions. What are issues in redesigning our systems of care? How do we prepare health professionals with what they need to know and do? How can organizations develop cultures of quality and safety? This chapter will examine the impact of the driving forces for the changes needed, application of quality and safety science to reframe organizational cultures for quality improvement and safety, and a fresh look at how these reframe the education needs for nurses. In a safety culture, the paradigm shifts from individual performance to system initiatives and redesigns to monitor outcomes of care, and situates the patient as a full partner in care.
The Compelling Case for Quality and Safety
When the initial data revealed in the IOM Quality Chasm series of reports became public it, sent shock waves throughout the industry and grabbed the attention of consumers (Textbox 1.1). The evidence reported in this series identified the imperative for changing mindsets to include quality and safety as part of the everyday work of nurses and other health professionals. Prior to release of the first report in 1999, the issues were wrapped in silence; without a reporting system, there was not an evidence base to establish the scope or depth of system issues that contributed to poor quality and safety. There was no national tracking system and little pressure to improve quality and safety outcomes from regulators, health care purchasers, or third‐party payers. And, without just culture emphasis, there was little transparency or accountability in sharing information with patients and families who experienced harm.
Textbox 1.1 Summary: The Institute of Medicine Quality Chasm Series (www.iom.edu)
To Err Is Human: Building a Safer Health System
(2000)
This first IOM report presented the first aggregate data on the depth and breadth of quality and safety issues in US hospitals. Analysis of outcomes from hospitals in Colorado and Utah concluded that 44,000 people die each year as a result of medical errors and that in New York hospitals, the number is 98,000. Even using the lower number, more people die annually from medical error than from motor vehicle accidents, breast cancer, or AIDS. Medical errors are the leading cause of unexpected deaths in health care settings. Communication is the root cause of 65% of sentinel events. The report presents a strategy for reducing preventable medical errors with a goal of a 50% reduction over five years.
Crossing the Quality Chasm: A New Health System for the 21st Century
(2001)
The IOM issued a call for sweeping reform of the American health care system. A set of performance expectations for twenty‐first century health care seeks to assure that patient care is STEEEP. These aims provide the measures of quality to align incentives for payment and accountability based on quality improvements. The report includes causes of quality gaps and barriers to improve care. Health care organizations are analyzed as complex systems with recommendations for how system approaches can help implement change.
Health Professions Education: A Bridge to Quality
(2003)
Education is declared as the bridge to quality based on five competencies identified as essential for health professionals of the twenty‐first century: patient‐centered care, teamwork and collaboration, evidence‐based practice, quality improvement (and safety), and informatics. Recommendations include developing a common language to use across disciplines, integrating learning experiences, developing evidence‐based curricula and teaching approaches, initiating faculty development to model the core competencies, and implementing plans to monitor continued proficiency in the competencies.
Keeping Patients Safe: Transforming the Work Environment of Nurses
(2004)
The 2004 IOM report links nurses and their work environment with patient safety and quality of care. The findings of this report have helped shape the role of nurses in patient care quality and safety efforts. Key recommendations are creating a satisfying and rewarding work environment for nurses, providing adequate nurse staffing, focusing on patient safety at the level of organizational governing boards, incorporating evidence‐based management in the management of nursing services, building trust between nurses and organizational leaders, giving nurses a voice in patient care delivery through effective nursing leadership and participation in executive decision‐making, providing organizational support to promote learning for both new and experienced nurses, promoting interdisciplinary collaboration, and designing work environments and culture that promote patient safety.
Identifying and Preventing Medication Errors
(2006)
Medication errors make up the largest category of error with as many as 3–4% of patients experiencing a serious medical error while hospitalized. This report presents a national agenda for reducing medication errors and the huge costs associated with medication errors. Changes across the health care industry require collaboration from doctors, nurses, pharmacists, the Food and Drug Administration and other government agencies, hospitals and other health care organizations, and patients.
The 2001 IOM report, Bridging the Quality Chasm, identified the STEEEP model to improve health care quality and safety. STEEEP outlines performance measures to assure care is safe, timely, effective, efficient, equitable, and patient centered. These aims provide the measures of quality and accountability that continue to elude health care. Although the United States spends more than any other country on health care, the system has significant shortcomings, particularly in efficiency, quality, access, safety, and affordability (Davis, Schoen, and Stremikis, 2010). The fragmentation and decentralization of the health care system is a barrier to quality and safety; for example, patients may see multiple providers who may not be able to share critical patient information due to a lack of technology infrastructure or have a feeling of ownership that precludes sharing and consultation. Although most data are based on acute care in patient settings, errors can occur in physician offices, outpatient settings, nursing homes, patient homes, and so forth. An annotation of the reports with their recommendations is provided in Textbox 1.1.
The data are startling, particularly related to medication errors, one of the most common according to Identifying and Preventing Medication Errors (Aspen et al., 2007). Medication errors particularly impact nurses. Nurses have the primary responsibility for medication administration with patients in a complex environment. Medication errors account for over 7,000 deaths annually. On average, inpatients may experience at least one medication error per day. At least 1.5 million preventable adverse drug events occur each year. Almost 2% of admissions experience a preventable adverse drug event, which increases hospital costs by $4,700 per admission or about $2.8 million annually for a 700‐bed hospital; multiplied, this would account for $2 billion nationally.
The costs associated with quality and safety are complex; accounting includes lost income, health care costs, and other expenses. The national cost for preventable adverse events ranges between $17 billion and $29 billion; additional health care accounts for more than half of these totals because tests and treatments may have to be repeated or others added, and patients may need to extend their hospital stay. In addition to these costs, there are intangible, immeasurable costs, such as patients may suffer or be inconvenienced, have lower satisfaction with care, and lose trust in the system. Most of what is known about the financial and other burdens are hospital related. Data are just beginning to emerge on costs associated with quality and safety across the continuum of care, including ambulatory, home health care, and skilled care.
Health care workers are also affected by the quality of care in the systems in which they work. They may experience loss of morale and lower satisfaction when they are not able to provide the best care possible. Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004) is a comprehensive analysis of the factors influencing nurses’ work. Health care is value based; as professionals we pledge, first, to do no harm. Quality is an essential value. Professionals take pride in doing the right thing, but quality is more than will; it is a mindset of inquiry and the capacity to use appropriate tools to improve systems in which we work. Quality improvement intersects all areas of health care from economic issues to the moral basis undergirding quality for doing our best. It builds on the shared values and moral commitment common to all health professionals. Health professionals have the motivation and ability to improve systems if they have the necessary education and training and work in organizations where quality improvement is integrated as part of daily work.
Consumers have helped motivate changes in health care. Patients and families who experienced adverse events have called for reform in how health care systems identify, investigate, report, and share information related to errors. Patients and families who experience health care mistakes leverage their influence to prevent similar events happening to others. National organizations such as the National Patient Safety Foundation (NPSF) (www.npsf.org) serve both consumers and health professionals. Numerous nonprofit organizations created in response to adverse events focus attention on particular care delivery issues as well as broader issues, establishing patient advocacy with an increasing influence in health care. Many patients or their family members now serve on hospital boards or consumer panels, share their stories in learning situations, and bring growing pressures to have systematic participation in all areas of health care.
The health care industry is applying lessons from other industries, particularly those known as high‐reliability organizations (www.ahrq.gov). A key difference is that most other industries that have had dramatic improvements in quality and safety were supported by a designated agency that sets and communicates goals, brings visibility, and systematically collects and analyzes error reports for root cause analysis; however, health care lacks a single designated agency, as responsibilities are spread among various groups. Although numerous agencies have emerged to promote the safety and quality agenda, none have the purpose of collecting safety or quality data for systematic analysis with broad dissemination to assure that best practice and safety alerts are implemented across all settings. Schumann (2017) offers a summary of these federal, regulatory, professional, and consumer agencies and organizations.
With lack of information on which errors occur and how they occur, and systematic dissemination of the information we do have, health care has lagged behind other high‐risk industries in establishing a safety focus. Aviation has focused on safety for more than 50 years with significant reduction in fatalities. Health care has adopted and adapted principles and approaches from aviation as well as other high‐reliability organizations that have similar characteristics, such as intermittent, intense tasks that demand exacting responses. By systematically collecting data on sentinel events for review through standardized processes, these industries have been able to monitor and improve safety in their systems.
Health care delivery organizations have a significant role in safety. Systems are a set of interdependent components that interact to achieve a common goal. For example, a hospital is a system composed of service lines, nursing care units, ancillary care departments, outpatient care clinics, and so forth. The way in which these separate but united system components interact and work together is a significant factor in delivering high‐quality, safe care. Organizational leadership helps align quality and safety goals with mission and vision so that it is practiced consistently throughout all areas and levels of the system (Triolo, 2012). High‐reliability organizations focus on safety; it is pervasive in their culture to be mindful of where the next error may occur to increase vigilance, establish check lists, or implement other preventions (Barnsteiner, 2012).
Examining Familiar Terms: The Science of Quality and Safety
Quality and safety are intertwined, complex concepts with multiple dimensions. Lack of a comprehensive understanding of the full scope of these terms is but one barrier for implementing quality and safety strategies. It is difficult to reshape the mental model of these broad terms held by health care workers and change attitudes about the necessity of focusing on safety. Overcoming these historic views and overuse of the terms are part of the application of the new KSAs associated with the science of quality and safety.
Though interrelated, quality and safety comprise different concepts. Quality improvement uses data to monitor outcomes of care processes that help guide improvement methods to design and test changes in the system to continuously improve outcomes (Compas, Hopkins, and Townsley, 2008; Johnson, 2017). The goal of quality is to reach for the best practice, and the goal is determined by measuring the reality of the care delivered compared with benchmarks or the ideal outcome. Continuous quality monitoring is the mechanism by which the health care system can be transformed through the collaboration of health care professionals, patients and their families, researchers, payers, planners, and educators. All are working toward a triangle of improvements that lead to better patient outcomes (health), better system performance (care), and better professional development (education) (Bataldan and Davidoff, 2007). All health professionals must know how to assess the scientific evidence to determine what constitutes good care, identify gaps between good care and care delivered in their setting, and implement actions to close gaps (Sherwood and Jones, 2011).
Safety science embraces an organizational framework to minimize risk of harm to patients and providers through both system effectiveness and individual performance by applying human factors as discussed more fully by Barnsteiner in another chapter (2017) and Sammer and colleagues (2010). Safety science builds on Reason’s human error trajectory, which uses the model of lining up a stick through the holes of Swiss cheese; sometimes redundancies in the system fail, and all the holes line up (2000).
Error is the failure of a planned action to be completed as intended or the use of an incorrect plan to achieve an aim. Reason identified two kinds of failure that constitute error:
Error of execution in which the correct action does not proceed as intended
Error of planning in which the original intended action is not correct
An adverse event is the injury that results from care delivered or from care management, not from the underlying patient condition or the reason the patient was seeking care. Preventable adverse events are those attributed to error. There are also various types of errors. Diagnostic errors delay diagnosis, prevent use of appropriate tests, or result in failure to act. Treatment errors can occur while administering treatment, include errors in administering medication, lead to avoidable delay in treatment or response to treatment, or contribute to inappropriate care. Other examples are failure to provide prophylactic treatment, inadequate monitoring or follow‐up, failure to communicate, equipment malfunction, or other system failure.
Errors can be defined in multiple ways with varied components. It is a challenge to develop a unified reporting system that can be used across settings or nationally, in the same way that the aviation industry aggregates reports of airline events. Inconsistent nomenclature of a long list of terms adds to the difficulty of consistently reporting similar events in a central system. Organizations with a culture of safety have implemented processes through risk management to collect error reports for root cause analysis, often classifying them using a tiered system of potential for harm. Carefully detailing all steps and decisions leading to an error or near miss can formulate a system redesign of processes that lessens the chance of future occurrence. The focus is on improving the system to prevent future errors rather than merely blaming individuals. Exploring what happened acknowledges the influence of complex systems and human factors that influence safety. In a just culture, the focus is to determine what went wrong rather than identifying exactly who committed the error to establish blame and punishment. Just culture establishes an environment in which errors and near misses are acknowledged, reported, and analyzed for ways to improve the system. Accountability remains a critical aspect of a culture of safety; recognizing and acknowledging one’s actions is a trademark of professional behavior.
Nurses are in the forefront of examining the work environment to identify quality and safety issues and the influence of human factors, the interrelationship between people, technology, and the environment in which they work (Page, 2004). Human factors consider the ability or inability to perform exacting tasks while attending to multiple tasks at once. For system improvements, organizational leadership must give attention to human factors such as managing workload fluctuations, seeking strategies to minimize interruptions in work, and attending to communication and care coordination across disciplines. Nurses manage care coordination and employ checklists and other strategies to assure safe handoffs between providers and settings. Nurses are challenged by other human factors that impact quality and safety, such as multitasking, distractions, fatigue, task fixation that limits environmental scanning, and hierarchy and authority gradients. Staffing, interpersonal relationships, and the lack of education on quality and safety are among the multiple human factors that impact quality and safety.
Assuring quality and safety involves more than individual accountability; poorly designed protocols and system designs also contribute to quality and safety outcomes (Hughes, 2008). The best way to reduce health care harm is by preventing errors before they happen. Focusing on safety helps eliminate discrepancies in care that result from provider actions in delivering care. Safety huddles or safety briefings are becoming a part of daily routine in many hospitals to identify and focus on high risk situations.
Quality improvement is a critical component of safety—it requires assessing safety issues for prevalence, making comparisons across units or departments, and using benchmark data to help clinicians improve their own practice as well as that of the system. When principles and strategies from quality improvement are applied, the rate of medication errors occurring in a given setting can be measured and compared with a peer unit or industry benchmark. Root cause analysis can determine reasons for errors in medication administration to change the system to prevent or lessen the possibility of errors occurring.
National Organizations for Quality and Safety
Many of the improvements in our health care systems are the result of regulatory mandates from groups such as the Joint Commission (www.jointcommission.org), which grants institutional accreditation and opens the possibility of different aspects of federal funding (Wachter, 2004; Wachter, 2010). The Joint Commission also established the National Patient Safety Goals that are updated annually. The goals provide guidance in key areas of high vulnerability and share evidence for solutions by emphasizing a systematic process for quality improvement, patient safety, and monitoring outcomes. The Joint Commission also established regulations to eliminate disruptive behavior among health care professionals and required organizations to have a code of conduct to define acceptable and inappropriate behavior as well as a process for managing such behaviors.
The Institute for Healthcare Improvement (IHI) (www.ihi.org) is a strong advocate for quality and safety innovations, bringing collaboration among all professions. The IHI’s 100,000 and 5 Million Lives campaigns are just two examples of focused collective efforts for improving outcomes. IHI describes the goals of health care reform in the US as the Triple Aim: improve population health, reduce costs, and improve the quality of care (Berwick, Nolan, and Whittington, 2014). These goals align with the STEEEP model from the IOM (2001) and also place new demands on health care professions education programs to prepare a workforce capable of changing the system (Reeves et al., 2013). New skills for interprofessional care, quality and process improvement, and population health management‐meaning educational institutions must align with practices, health systems and the communities they serve (Brandt et al., 2014). The work of the Affordable Care Act seeks reform and redesign of the systems of care to provide better care, align cost and value, and improve outcomes. Professional nursing organizations have responded to the imperative to improve quality and safety in health care systems (Earnest and Brandt, 2014).
Schumann (2017) provides a comprehensive description of national groups and their goals of quality and safety. The American Nurses Association, following a long history of promoting quality assurance, and the International Council of Nurses (2002) developed a new framework on quality improvement distributed nationally and globally (Doran, 2010). The Magnet recognition program based standards on continuous quality improvement to recognize nursing leadership and organizational quality in nursing care delivery (Triolo, 2012). The standards reinforce conditions in the organization and practice environment that support and facilitate nursing excellence. Recognition is linked to improvement in nurse recruitment, retention, quality outcomes, and patient satisfaction scores. The American Nurses Association also established the National Database of Nursing Quality Indicators in 1998, which maintains data on sustained improvement in a designated nursing‐sensitive indicator such as staffing, hospital‐acquired pressure ulcers, falls and prevention of injury from falls, staff satisfaction, and pediatric and psychiatric mental health data (Montalvo and Dunton, 2007; Schumann, 2017).
Federal programs in Medicare and Medicaid have helped define nurses’ roles and revised the payment structure for health care. Medicare and Medicaid subsequently developed programs to reduce hospital‐acquired conditions, or those conditions that were not present at the time of a patient’s hospital admission (Bodrock and Mion, 2008; Centers for Medicare and Medicaid Services, 2008). Hospitals are no longer reimbursed for 10 preventable hospital‐acquired conditions, many of which were part of nursing care interventions (Hines and Yu, 2009). Other third‐party payers and large employers have “pay for performance” plans in which health systems receive additional economic incentives when specific quality targets are met, many of which are nurse driven.
Comparing Progress to Improve Quality and Safety
The IOM (2001) issued four recommendations to change the system:
Create a national focus through leadership, research, tool kits, and protocols to enhance knowledge about safety.
