A new vision for quality and safety: Developing new science to change practice

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A new vision for quality and safety Developing
new science to change practice

• Gwen Sherwood, PhD, RN. FAAN
• University of North Carolina at Chapel Hill
• School of Nursing
• Professor and Associate Dean for Academic Affairs
• Shandong University October 2011

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Knowledge development

• We identify and integrate knowledge in nursing in
  many ways.
• Often knowledge development happens because of a
  gap, recognition that we are not providing
  optimal care, or we realize knowledge in other
  fields may be applied to nursing and healthcare.

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Sources of knowledge

• Knowledge development comes from
• Empirical
• Affective
• Legal and ethical
• Personal (Carper, 1978
• May come from theoretical concepts or
  observations in practice that are tested by
  research

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Building an evidence base

• When knowledge is accepted into practice or
  education, it begins a paradigm shift as the
  ideas are adopted across the profession.
• Example of new knowledge to change the paradigm
• Quality and safety data challenged traditional
  practices in health care
• Proposed new responsibilities for nurses

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Data IOM Quality Chasm Series

• To Err Is Human Building a Safer Health System
  (2000) (all are available www.IOM.org)
• 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
  (2006)

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Operational Definitions

• Quality Improvement (QI) using data to monitor
  outcomes of care processes which help guide
  improvement methods to design and test changes in
  the system to continuously improve the quality
  and safety. It is measuring what is the reality
  and comparing with benchmarks or the ideal.
• Safety science Minimize risk of harm to
  patients and providers through both system
  effectiveness and individual performance by
  applying human factors in the new safety science

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Quality in Health Care

• U.S. hospitals began adopting quality improvement
  and safety science methods in the late 1990s,
  yet we are only now integrating Quality
  Improvement in nursing curriculum.
• Poor communication contributes to 70 of health
  care errors, yet nurses and physicians have few
  educational experiences together.

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Staggering reports of poor quality from around
the world

• Data in U.S. shows that
• On average a hospital patient may have at least
  one medication error per day
• At least 1.5 million preventable adverse drug
  events occur each year
• Contributes to the loss of trust in the system
• Identifying and Preventing Medication Errors
• (IOM, Cronenwett et al 2006)

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New ways to think about Quality

• Health care lags behind other high performance
  industries in quality improvement and safety
  monitoring.
• Hospitals are applying system perspectives to
  question traditional practices and measure
  outcomes to analyze errors to understand why
  something happened
• Nurses need knowledge, skills and attitudes to
  apply systems thinking.

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Quality and Safety are Global Concerns

• United Kingdom The Center for Advancement of
  Inter-professional Education
• Japan The National Institute for Public Health
• World Health Organization World Alliance for
  Patient Safety and Collaborating Centre
• Similar work in Australia and Sweden

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China

• Are these ideas relevant in China?
• Describe the state of application of quality and
  safety in China?
• What are quality and safety issues in health
  care?
• What are sources of information?

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Emphasis on improving quality of health care

• Focus on quality improvement in health care
  organizations
• Improves patient care outcomes
• Helps improve the work environment
  people want to work in organizations that
  emphasize quality

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Survey Quality impacts the work environment

• Hospitals nationally recognized for quality
• healthier work environments
• higher levels of job satisfaction .
• (American Association of Critical-Care Nurses
  (AACN), CQ HealthBeat)

Quality affects nurse satisfaction and
retention. It makes economic sense.
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6 competencies to transform systems to improve
quality and safety
Informatics
Teamwork And collaboration
Patient centered care
Quality improvement
Safety
Evidence Based practice
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Quality and Safety Education for Nurses (QSEN)

• Principal Investigator Linda Cronenwett
• Co-Investigator Gwen Sherwood
• National expert panel and pedagogical experts
• Funded by the Robert Wood Johnson Foundation for
  the University of North Carolina at Chapel Hill
• 2005-2007 Pre-licensure Education
• 2007-2009 Graduate Education and Pilot
• School Collaborative
• 2009-2012 Faculty Development
• www.qsen.org

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To build the evidence on quality and safety
education

• National Survey of Schools for current
  application
• Focus groups to assess survey findings
• 15 Pilot School Collaborative
• Delphi Technique to determine placement in
  curriculum
• Student Self Assessment Survey
• Faculty Development
• Research to confirm

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Framework

• All health professionals should be educated to
  deliver patient-centered care as members of
  interdisciplinary teams, emphasizing
  evidence-based practice, quality improvement,
  safety, and informatics.
• Committee on Health Professions Education
• Institute of Medicine (2003)

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Survey of Schools to determine what was being
taught

• Faculty report needing the most help developing
  content and learning experiences and report
  students have less achievement in these areas
• Evidence Based Practice
• Quality Improvement
• Informatics

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QSEN Survey Data

• Patient-centered care, Teamwork and
  Collaboration, and Safety ranked highest for
• Inclusion in content and learning experiences
• Satisfaction with students competency
  achievement, and
• Faculty expertise to teach

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However, Focus Group Feedback

• Faculty reported lack of knowledge of many KSAs
  (particularly safety, informatics and QI) were
  not doing it but we want to - tell us how
• Students/new grads said Not only did we not
  learn this content, our faculty could not teach
  it
• Faculty report that nursing students may graduate
  without having had a meaningful patient-centered
  conversation with a physician
• Reported in Nursing Outlook, May June 2007

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Could we teach the competencies?

• 15 schools selected for a Learning Collaborative
• Complete content mapping to determine state of
  their curriculum matches with the KSAs that
  define the competencies
• Design innovative strategies to incorporate into
  curriculum
• Assess student achievement and pedagogies
• Share their experiences
• Achieve consensus on graduate KSAs

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Competency definitions

• 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 patients preferences, values, and
  needs
• Nursing Outlook, 2007

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Current clinical applicationsPatient-centered
Care

• Patients and family are partners in care
• Diversity
• Multicultural
• Values and health beliefs

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Competency Definitions

• 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
• Nursing Outlook, 2007

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Clinical application Human factors

• Care delivered by interdisciplinary teams yet
  education geared towards individual
  responsibilities in solo experiences
• Challenges to teamwork
• Complex care coordination,
• Safe handling between providers,
• Communication across hierarchy
• Standardized communication techniques insure
  sharing critical information (SBAR)

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Competency definitions

• Evidence-based practice
• Integrate best current evidence with clinical
  expertise and patient/family preferences and
  values for delivery of optimal health care
• Nursing Outlook, 2007

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Practice realitiesEvidence-based practice

• Standards based on evidence and known best
  practices
• Quality assesses actual care patients receive
  against established benchmarks

• Goal Knowledge workers who ask questions about
  practice and constantly search for new evidence
• Involve students and faculty in data base
  searches

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Competency definitions

• 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
• Nursing Outlook, 2007

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Applications in practiceQuality improvement

• Quality improvement strategies may use the
  following
• Satisfaction measures
• Nurse sensitive measures
• Compare benchmarks with other systems

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Competency definitions

• Safety
• Minimize risk of harm to patients and providers
  through both system effectiveness and individual
  performance
• Nursing Outlook, 2007

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New views of Safety

• Safety science applying human factors to system
  analysis of error and adverse events
• just culture open reporting and learning from
  adverse events and near misses
• Root cause analysis to investigate incidents for
  system design flaws to minimize error potential

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Competency definitions

• Informatics
• Use information and technology to communicate,
  manage knowledge, mitigate error, and support
  decision making
• Nursing Outlook, 2007

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Informatics in the work place

• Electronic record systems
• Computer order entry systems that provide
  decision support and help flag errors
• Search for and evaluate information sources
• Evaluate technologies for their potential to
  cause or mitigate error.
• Design and evaluate relevant products

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Delphi Study for placement of competencies in the
curriculum (N18 QSEN experts)

• Implement as curricular threads
• Early curriculum individual patient
• Later teams and systems
• Advanced courses complex concepts
• Teamwork and collaboration
• Evidence-based practice
• Quality improvement
• Informatics
• Barton et al, Nov-Dec 2009 Nursing Outlook

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Student Evaluation Survey (SES)Nov-Dec 2009
Nursing Outlook

• 17 schools ADN, BSN, diploma, students 575
• Content covered least
• Teamwork and collaboration, Quality improvement
• Least skills
• Evidence based practice
• Reporting errors for root cause analysis
• Least attitude
• Use quality improvement tools
• Locate evidence reports for clinical practice
  guidelines
• Evaluate the effect of practice changes using QI

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How did students learn?
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TeamSTEPPS Team Strategies and Tools to Enhance
Performance and Patient Safety

• Multi-media public domain curriculum from
  AHRQ.gov to teach team coordination competencies
  based on human factors

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TeamSTEPPS Curricular Framework
Skills BehaviorsDo
team performance is a science consequences of
errors are great
AttitudesAffectFeel
KnowledgeCognitions Think
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Four Cohorts N 438Matched nursing (196) and
medicine (233)

• Small Groups, 2 strategies
• 10 High Fidelity Human Simulation
• (n 80)
• 10 Role-Play
• (n 79)

• Large Groups, 2 strategies
• Lecture Audience Response
• (n 139)
• Traditional Lecture
• (n 140)

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4 Assessment Tools

• 12- item teamwork knowledge test
• 36-item teamwork attitudes instrument
• 10-item standardized patient (SP) evaluation of
  four-student teamwork skills
• 10-item modification of Malec et al. (2007, Sim
  Healthcare 24-10) Mayo High Performance Teamwork
  Scale (HPTS).

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Sample CHIRP Attitudes Items
I do not agree at all I somewhat agree I fairly much agree I very much agree I completely agree
1 2 3 4 5
My Attitude My Attitude My Attitude My Attitude My Attitude My Attitude My Attitude My Attitude My Attitude My Attitude
Statement Before Activity Before Activity Before Activity Before Activity Before Activity After Activity After Activity After Activity After Activity After Activity
1 I must consider the interests of every professional, patient, and family member involved in a medical decision. 1 2 3 4 5 1 2 3 4 5
2 Pharmacists, nurses, physicians, social workers and other health care professionals are of equal importance in providing patient care. 1 2 3 4 5 1 2 3 4 5
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Sample Webcast Evaluation Items
I do not agree at all I somewhat agree I fairly much agree I very much agree I completely agree
1 2 3 4 5
Statement Response Response Response Response Response
I should work at recognizing multiple sources of potential errors in every patient case. 1 2 3 4 5
It is okay for team members to monitor each others actions. 1 2 3 4 5
Each healthcare team member should challenge a decision if they are uncomfortable with it. 1 2 3 4 5
The podcast made me rethink my approach to patient care. 1 2 3 4 5
The podcast was useful for my professional development. 1 2 3 4 5
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Teamwork Knowledge Results
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Results

1. High fidelity interactive training was not more
   effective a low fidelity environment.
2. Participation in interactive training in small
   groups was not more effective than in large
   groups.
3. Large group interactive training exercises were
   not more effective than training with only
   lectures without interactive exercises.

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What is the impact of an educational
intervention using video and interactive small
groups on interprofessional teamwork KSAs?

• Study 2 on the best methods to teach teamwork
  within a safety framework.

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Framework Effective Team Leaders

• Organize the team
• Articulate clear goals
• Base decisions on collective member input
• Empower members to speak up and challenge, when
  appropriate, call a huddle
• Skillful at conflict resolution
• Team Activities
• Briefs planning
• Huddles problem solving
• Debriefs process improvement

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Figure 2. Research Design for UNC Year Two
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Design

• All students pre-test and one hour TeamSTEPPS
  Podcast/Webcast lecture
• Small groups trained facilitators led case study
  using low fidelity simulation role-play, watched
  video and completed a rating scale of team
  behaviors, and discussed observations, and then
  completed the post-test.
• Control group completed the post-test
  instruments before completing the interactive
  exercises.
• Experimental group completed the post-test
  instruments after the interactive exercises

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Results

• Both groups improved at the same rate
• Nurses improved at higher levels than medicine
• Achieved the goals of
• Improve Communication
• Improve Respect for other Disciplines
• Improve Patient Safety

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There are always questions!

• Which methods promote sustained behavior change
  over time?
• When is the best time to place in the curriculum?
• Which are the best matches for level of education
  across the health professions?
• What instruments are needed to produce more
  discreet metrics?

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Paradigm Shift

• Many other studies are testing other parts of the
  theoretical concepts for the 6 competencies
  defining quality and safety in health care
• No single study confirms a theoretical model, but
  synthesis of the results can be used to change
  education and practice
• By applying standards for evaluating evidence, we
  can make decisions for change.

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Evidence based changes in nursing

• Policy changes
• The 6 quality and safety competencies are now
  integrated in the national standards for nursing
  education at both the National League for Nursing
  and at the Association for Colleges of Nursing
• Curricular changes
• Many schools have adopted the framework as the
  organizing thread for their curriculum
• Hospitals are implementing changes in nurse roles
  and responsibilities

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Education and practice

• Research derives from question in practice
• Testing for confirmation to determine evidence
  based helps lead to changes in education and
  practice.
• Working together in partnership both education
  and practice can improve health outcomes