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

1. 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

2. 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.

3. 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

4. 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

5. 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)

6. 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

7. Quality in Health Care • U.S. hospitals began adopting quality improvement and safety science methods in the late 1990’s, 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.

8. 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)

9. 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.

10. 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

11. 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?

12. 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

13. 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.

14. 6 competencies to transform systems to improve quality and safety Informatics Teamwork And collaboration Patient centered care Quality improvement Safety Evidence Based practice

15. 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

16. 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

17. Framework All health professionals should be educated to deliverpatient-centered careas members ofinterdisciplinary teams,emphasizingevidence-based practice,quality improvement, [safety],andinformatics. Committee on Health Professions Education Institute of Medicine (2003)

18. Survey of Schools to determine what was being taught • Faculty reportneeding the most help developing content and learning experiences and report students have less achievement in these areas: • Evidence Based Practice • Quality Improvement • Informatics

19. QSENSurvey Data • Patient-centered care, Teamwork and Collaboration, and Safetyranked highest for: • Inclusion in content and learning experiences • Satisfaction with students’ competency achievement, and • Faculty expertise to teach

20. However, Focus Group Feedback • Faculty reported lack of knowledge of many KSAs (particularly safety, informatics and QI); “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 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

21. 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

22. 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 patient’s preferences, values, and needs • Nursing Outlook, 2007

23. Patients and family are partners in care Diversity Multicultural Values and health beliefs Current clinical applications:Patient-centered Care

24. 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

25. 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)

26. 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

27. 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 Practice realities:Evidence-based practice

28. 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

29. Quality improvement strategies may use the following: Satisfaction measures Nurse sensitive measures Compare benchmarks with other systems Applications in practice:Quality improvement

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

31. 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

32. Competency definitions: • Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making Nursing Outlook, 2007

33. 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

34. Delphi Study for placement of competencies in the curriculum (N=18 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

35. 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

36. How did students learn?

37. 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

38. TeamSTEPPS Curricular Framework Skills Behaviors“Do” …team performance is a science… consequences of errors are great… AttitudesAffect“Feel” KnowledgeCognitions “Think”

39. 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)

40. 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 2:4-10) Mayo High Performance Teamwork Scale (HPTS).

41. Sample CHIRP Attitudes Items

42. Sample Webcast Evaluation Items

43. Teamwork Knowledge Results

44. Results: • High fidelity interactive training was not more effective a low fidelity environment. • Participation in interactive training in small groups was not more effective than in large groups. • Large group interactive training exercises were not more effective than training with only lectures without interactive exercises.

45. 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.

46. 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

47. Figure 2. Research Design for UNC Year Two

48. 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

49. 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

50. 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?