quality and safety education for nurses
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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, - PowerPoint PPT PresentationTRANSCRIPT
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