quality and safety education for nurses

Quality and Safety Education for Nurses

2007 Jowers Lecture Linda Cronenwett, PhD, RN, FAAN

December 5, 2007

Greetings from the University of North Carolina - Chapel Hill School of Nursing

Quality and Safety Education for Nurses (QSEN)

Linda Cronenwett Principal Investigator, Professor and DeanGwen Sherwood Co-Investigator, Professor and Associate Dean for Academic Affairs

U.S. Institute of Medicine Quality Chasm Reports

To Err Is Human: Building a Safer Health System (2000)

Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

Health Professions Education: A Bridge to Quality (2003)

Patient Safety: Achieving a New Standard for Care (2004)

Identifying and Preventing Medication Errors (2007)

Development of Safety Sciences

Worldwide, scientists in other industries uncovering knowledge about the interventions that produced safe systems Lean, zero defect production systems Aviation Nuclear energy

Health care remains committed to the ideal of the individual professional as source of quality and safety

Impetus for Change

Variations in outcomes shown to be related to systems of care rather than individual patient characteristics

U.S. hospitals adopt quality improvement and safety science methods in the late 1990’s

Health care professionals in hospitals taught, one by one, about quality and safety

Yet -- No health professions education on QI/safety

Impetus for Change in Nursing People become nurses in order to relieve

suffering and contribute to the overall health of communities and individuals

Quality care is an essential value As nurses work in systems where quality is

eroded, joy in work diminishes Less joy in work leads to work force shortages Health professionals run our systems -- they

can improve our systems if they possess the competencies required to make improvement a part of daily work

Health Professions Education: A Bridge to Quality (2003)

All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.

Relative Focus of Education in the Health Professions

Professional knowledge

Individual learning Individual

consequences for error

Disciplinary focus

Systems knowledge

Team/Group learning

Learning from error

Interprofessional/ patient focus

Medicine’s Translation of General Competencies(Adopted February, 1999 by ACGME)

• Patient Care• Medical Knowledge• Practice-based Learning and

Improvement• Professionalism• Interpersonal and Communication Skills• Systems-based Practice

Goals

To alter nursing’s professional ‘identity’ so that when we think of what it means to be a respected nurse, we think not only of caring, knowledge, honesty and integrity….

But also, that it means that we value, possess, and collectively support the development of quality and safety competencies

Quality and Safety Education for Nurses (QSEN)

Long-Range Goal To reshape professional identity formation in

nursing so that it includes commitment to the development and assessment of quality and safety competencies

Phase I: October 2005 – March 2007 Phase II: April 2007 – September 2008

QSEN Personnel

QSEN Leaders based in UNC-Chapel Hill QSEN Faculty – Experts in quality and safety

from throughout the U.S. QSEN Advisory Board – Leaders of

organizations that set standards for nursing regulation, certification, and accreditation of nursing programs

QSEN Core Faculty Jane Barnsteiner U Pennsylvania Lisa Day UC San Francisco Joanne Disch U Minnesota Carol Durham UNC – Chapel Hill Pamela Ironside Indiana U Jean Johnson George Washington U Pamela Mitchell* U Washington, Seattle Shirley Moore Case Western Reserve Dori Taylor Sullivan Sacred Heart, CT Judith Warren U Kansas

* Phase II: Deborah Ward U Washington, Seattle

QSEN Advisory Board Members

Paul Batalden IHI, ACGME Geraldine Bednash AACN Karen Drenkard AONE Leslie Hall HPEC, ACT Polly Johnson NCSBN Maryjoan Ladden ACT Audrey Nelson ANA Safe Patient

Handling Joanne Pohl NONPF Elaine Tagliareni NLN

* Phase II: Jeanne Floyd ANCC

QSEN Phase I Define the territory (desired competencies) Describe the knowledge, skills, and attitudes

(KSAs) expected to be developed in prelicensure curricula

Disseminate/seek feedback and build consensus for inclusion of competencies in prelicensure curricula

Develop teaching strategies for classroom, group work, simulation, clinical site teaching, interprofessional learning

Create website resource for faculty

IOM/QSEN Competencies

Patient-centered care: 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

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

Cronenwett, Sherwood, Barnsteiner et al, 2007

IOM/QSEN Competencies

Evidence-based practice: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care

Quality improvement: 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

Cronenwett, Sherwood, Barnsteiner et al, 2007

IOM/QSEN Competencies

Safety: Minimize risk of harm to patients and providers through both system effectiveness and individual performance

Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making

Cronenwett, Sherwood, Barnsteiner et al, 2007

QSEN Assumptions

Competency definitions could serve the profession as:

Curricular threads Foci of accreditation of nursing programs Foci of licensure or certification exams Foci of transition to work (residency) program

development Foci of criteria for recertification or relicensure

Current Assessments of Quality and Safety Education

Smith, E. L., Cronenwett, L., & Sherwood, G. (2007). Current assessments of quality and safety education in nursing. Nursing Outlook, 55 (3), 132-137.

Summary

The overwhelming majority of schools reported that they include content/learning experiences are satisfied with students’ competency

achievement, and have the faculty expertise to teach

the competencies patient-centered care, teamwork and collaboration, and safety

Summary EBP, QI and Informatics are the competencies where

a significant minority (25-43%) of schools reported desire for more content/learning experiences (but it was a minority, not majority, reporting they need to do something more)

These same competencies elicited mean ratings below “satisfied” for level of satisfaction with student competency achievement

These same competencies elicited lower ratings of faculty expertise to teach the topics

Prelicensure Knowledge, Skills and Attitudes (KSAs) by Competency

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P, & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131.

Example: Patient-centered care

Knowledge Skills Attitudes

Examine common barriers to active involvement of patients in their own health care process 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

Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management

Respect patient preferences for degree of active engagement in care process

Respect patient’s right to access to personal health records

Cronenwett, Sherwood, Barnsteiner et al, 2007

Example: Safety

Knowledge Skills AttitudesDiscuss 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

Cronenwett, Sherwood, Barnsteiner et al, 2007

Examples: Focus Group Feedback

Faculty didn’t understand many KSAs (particularly related to safety, informatics and QI)

Faculty said “we’re not doing it – but we want to - tell us how”

Students/new grads said ‘Not only did we not learn this content, our faculty couldn’t have taught it”

Faculty report that nursing students can graduate never having had a meaningful patient-centered conversation with a physician

QSEN Publications

NCSBN Leader to Leader article – April 2007

Special issue of Nursing Outlook May-June 2007 - five articles plus commentaries from AACN and NLN Presidents Mailed to every nursing education program in

country (using NCSBN mailing list)

Two NO articles the most frequently downloaded articles from January-June 2007

Policy Strategies

Shared products with professional organizations involved in licensure and certification or in accreditation of prelicensure programs

What and How Do We Guide Student Learning?

www.qsen.organd

Pilot School Learning Collaborative

QSEN Assumptions

Faculty and students are committed to quality and safety in all they do

Learning experiences aimed only at knowledge acquisition will be insufficient for development of competencies

Invitations to select from and experiment with a variety of curricular strategies will yield greater long-term gains than being highly prescriptive

Teaching Resource: QSEN Website

www.qsen.org Competency definitions and KSAs Annotated references by competency Teaching strategies for classroom, clinical,

skills/simulation labs, and interprofessional learning

Opportunity for all faculty to upload ideas and evaluations of teaching strategies

Website Sessions

QSEN Assumptions

Each competency can be, indeed needs to be, taught or reinforced in multiple methods and sites

Classroom

Skills/simulation Lab Clinical Teaching Sites

Interprofessional Courses

Nursing Courses

Papers ReadingsPBLReflective practice

Case Studies

Web Modules

QSEN Phase II: Prelicensure Education

Pilot School Learning Collaborative Goal: Engage prelicensure faculty members in

developing and testing teaching strategies for the QSEN competencies

Call for proposals mailed to all nursing education programs in March, 2007

15 schools selected July 2007 from 53 applications

QSEN Learning Collaborative Augustana College (SD) Catholic University (DC) Charleston Southern Univ

(SC) Curry College (MA) Emory University (GA) Lasalle University (PA) St. John’s College of

Nursing/Southwest Baptist (MO)

University of Colorado at Denver

University of Massachusetts-Boston

University of Nebraska Medical Center

University of South Dakota, Sioux Falls

University of Tennessee Health Science Center, Memphis

University of Wisconsin-Madison

University of Pittsburgh Medical Center-Shadyside School of Nursing (PA)

Wright State University (OH)

QSEN Learning Collaborative

All have committed practice partners Associate degree, diploma, BSN programs in

schools without graduate programs, and BSN programs in universities

Our “edgerunners” Some focusing on simulation Some focusing on innovations in clinical

teaching Some focusing on curriculum as a whole

QSEN Learning Collaborative

Collaborative meetings (October, 2007 and June, 2008) Evaluate one class of graduating students’ perceptions of

competency achievement Produce a curricular map with the quality and safety KSAs

integrated into their pre-licensure curriculum Develop and evaluate teaching strategies for classroom,

clinical, and simulation/skills laboratories Share teaching strategies through submissions to the

QSEN website Document specific challenges encountered in the process

of curricular change Share successful strategies for overcoming challenges with

others in collaborative conferences and conference calls

QSEN Assumptions

Nurses in practice settings are critical partners in accomplishing competency development

Examples: Staff are role models for how these competencies

define what it means to be a respected and qualified nurse

Students and faculty know the safety and QI initiatives – always know the ‘next likely error’ in the setting

Students learn from staff what “good care” is and how “local care” compares to that standard

QSEN Assumptions

Students use information technology during clinical practice

Students see team skills in action in communications between nurses and other health professionals

Students see patients and families involved as partners in care

Health professions students in a setting interact with each other in improvement work

Transition to practice programs build on the competency development from pre-licensure programs

Quality and Safety Education for Nurses

Graduate Education

Phase I: Graduate Education

Sought feedback from major APN organizations about KSAs: Can they represent all of nursing?

Added NONPF representative to Advisory Board

QSEN Phase II: Graduate Education

April, 2007 workshop Representatives of

nurses in advanced practice responsible for:

Standards of practice

Accreditation of education programs

Certification of APNs QSEN faculty and

advisory board

NONPF (2)

NACNS (2)

ACNM (1)

ONCC (1)

CCNE (2)

APNA (1)Council on Accreditation of CRNAs (1)

ANCC (2)ANA (2)

AACN Cert Board (1) (critical care)

Ped Nurs Cert Board 2)

Graduate Education

Initial conversation: Focus on advanced practice rather than all

advanced roles Focus on advanced practice rather than the

type of program in which the graduate student is prepared

Focus on goal of assisting faculty who wish to develop quality and safety competencies already identified as essential elements

Graduate Education Workshop Topics

Are the competency definitions relevant to APNs? All of nursing?

Which of the prelicensure KSAs are also relevant objectives for APN education?

What new KSAs, if any, should be added at the graduate level?

Will KSAs vary by specialty and role or can they encompass all APNs?

Graduate Education KSAs

On the following slides: Green represents language of prelicensure

KSA Black represents that same KSA in language

proposed for APN education Blue represents an item without a correlary in

the prelicensure KSAs

Example: Patient-centered Care

Knowledge Skills Attitudes

Discuss principles of effective communication---------------------- Integrate principles of effective communication with knowledge of quality and safety competencies

Describe process of reflective practice

Participate in building consensus or resolving conflict in the context of patient care ---------------------Provide leadership in building consensus or resolving conflict in the context of patient care

Create or change organizational cultures so that patient and family preferences are assessed and supported

Respect patient preferences for degree of active engagement in care process ------------------------Valued shared decision-making with empowered patients and families, even when conflict occurs

Value cultural humility

Value the process of reflective practice

Example: Teamwork and Collaboration

Knowledge Skills Attitudes

Describe own strengths, limitations, and values in functioning as a member of a team---------------------- Analyze own strengths, limitations, and values as a member of a team

Analyze impact of own advanced practice role and its contributions to team functioning

Clarify roles and accountabilities under conditions of potential overlap in team-member functioning ---------------------Guide the team in managing areas of overlap in team member functioning

Initiate and sustain effective health care teams

Acknowledge own potential to contribute to effective team functioning ------------------------Acknowledge own contributions to effective or ineffective team functioning

Appreciate the importance of inter-professional collaboration

Example: Evidence-based PracticeKnowledge Skills Attitudes

Explain the role of evidence in determining best clinical practice -----------------------Analyze how the strength of available evidence influences the provision of care (assessment, dx, tx, and evaluation)

Determine evidence gaps within the practice specialty

Read original research and evidence reports related to area of practice -----------------------------Critically appraise original research and evidence summaries related to area of practice

Exhibit contemporary knowledge of best evidence related to practice specialty

Appreciate the importance of regularly reading relevant professional journals ----------------------------Value knowing the evidence base for practice area

Value public policies that support evidence-based practice

Recognize importance of search skills in locating best evidence

Example: Quality Improvement

Knowledge Skills AttitudesDescribe strategies for learning about the outcomes of care in the setting in which one is engaged in practice-----------------------------Describe strategies for improving outcomes of care in the setting in which one is engaged in practice

Explain common causes of variation in outcomes of care in the practice specialty

Seek information about outcomes of care for populations served in care setting------------------------------Use a variety of sources of information to review outcomes of care and identify potential areas for improvement

Assert leadership in shaping the dialogue and providing leadership for the introduction of best practices

Appreciate how unwanted variation affects care-----------------------------Appreciate the importance of data that allows one to estimate the quality of local care

Appreciate that all improvement is change but not all change is improvement

Example: Safety

Knowledge Skills AttitudesDiscuss effective strategies to reduce reliance on memory---------------------------Evaluate effective strategies to reduce reliance on memory

Describe best practices that promote patient and provider safety in the practice specialty

Participate appropriately in analyzing errors and designing system improvements -----------------------------Design and implement microsystem changes in response to identified hazards and errors

Report errors and support members of the health care team to be forthcoming about errors and near misses

Value own role in preventing errors ------------------------------Value own role in reporting and preventing errors

Appreciate the importance of being a safety mentor and role model

Value the use of organizational error reporting systems

Example: Informatics

Knowledge Skills AttitudesDescribe examples of how technology and information management are related to quality and safety of patient care---------------------------Describe and critique taxonomic and terminology systems used in national efforts to enhance interoperability of information and knowledge management systems

Navigate the electronic health record -----------------------------Model behaviors that support implementation and appropriate use of electronic health records

Participate in the design of clinical decision-making supports and alerts

Value technologies that support clinical decision-making, error prevention, and care coordination ------------------------------Appreciate the need for consensus and collaboration in developing systems to manage information for patient care

Appreciate the contribution of technological alert systems

Participant Responses

Are the competency definitions relevant to APNs? All of nursing?

Which of the prelicensure KSAs are also relevant objectives for APN education?

What new KSAs, if any, should be added at the graduate level?

Will KSAs vary by specialty and role or can they encompass all APNs?

Graduate Education: Next Steps

Draft 2 under review by all participants and their organizations

Feedback received in November, awaiting full analysis

Dissemination