Quality and Safety in Nursing: Using quality as a tool to improve practice outcomes

1. Quality and Safety in Nursing: Using quality as a tool to improve practice outcomes Denise Hirst, MSN, RN Fall 2008

2. Objectives • Identify emerging views of quality in health care • Describe the current safety crisis and key elements from the IOM report. • Discuss the four key questions that need to be considered when we explore safety. • Identify the types of errors and provide examples. • Discuss the impact of the blame culture and how to avoid it. • Examine leadership strategies for managing change in a culture focused on quality

3. Perspectives on quality • What are examples from recent media reports that reflect quality monitoring and/or lapses in various industries? • What are economic consequences? • What are ethical considerations?

4. How does the United States measure up?

5. The United States is worse on key measures American College of Physicians, Ann Intern Med 2008;148:55-75

6. Quality and Safety • Quality and safety are in a sense inseparable • Creating a culture of safety is part of building a system of continuous quality improvement

7. Quality carries a moral and ethical imperative • People become nurses in order to relieve suffering and contribute to the overall health of communities and individuals • Quality care is an essential value

8. There is also an economic imperative • As nurses work in systems where quality is eroded, satisfaction diminishes • Lower satisfaction contributes 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

9. Quality: Factors to consider • What is the role of technology and informatics • How do nurses acquire Interdisciplinary team skills to achieve goals of care • How do we include patients and families as partners in care • What are strategies for improving the way health professionals must work together to achieve quality outcomes

10. Raising the Bar: the Framework All health professionals should be educated to deliver patient-centered careas members of aninterdisciplinary team,emphasizingevidence-based practice, quality improvementapproaches, andinformatics. Committee on Health Professions Education Institute of Medicine (2003)

11. Emphasis on improving quality of health care Focus on quality improvement in healthcare organizations Improves patient care outcomes Helps improve the work environment: people want to work in organizations that emphasize quality

12. Quality and Safety Education for Nurses (QSEN: www.qsen.org) • Principal Investigator: Linda Cronenwett, PhD, RN, FAAN • Co-Investigator: Gwen Sherwood, PhD, RN, FAAN • Project Manager: Denise Hirst, MSN, RN • Librarian: Jean Blackwell • National expert panel and pedagogical experts • Funded by the Robert Wood Johnson Foundation for the University of North Carolina at Chapel Hill • 2005-2007 Phase I Pre-licensure Education • 2007-2009 Phase II Graduate Education and Pilot School Collaborative • 2009-2012 Phase III Partnered with American Academy of Colleges of Nursing to disseminate information to faculty and educators Reported in special issue: Nursing Outlook, May 2007

13. New challenges To achieve the goals of care, health professionals must examine new views of quality and safety science for redesigning how care is delivered, monitored, and improved.

14. What are the leadership challenges for leading this change?

15. Nurses’ Role Redefined • Continuous quality improvement • Encourages a culture of inquiry • Welcomes questions • Investigates outcomes and critical incidents from a system perspective Workers who are engaged in their work ask critical questions to continually seek to improve outcomes of care.

16. Quality impacts the work environment Nurses who work in hospitals recognized for quality report healthier work environments and higher levels of job satisfaction than those who work in non-recognized settings. (American Association of Critical-Care Nurses (AACN), reported in CQ HealthBeat ) Quality is a factor in nurse satisfaction and retention.

17. 6 competencies to transform systems are not linear but are broad and overlapping Teamwork And collaboration Informatics Patient centered care Quality improvement Safety Evidence Based practice

18. Quality improvement: Using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems

19. What are the knowledge, skills, and attitudes nurses need in clinical settings to work in quality-focused settings? Quality management is comparing the outcomes of care in the local setting with evidence based industry benchmarks. Efforts are then focused on leading change to improve identified outcomes.

20. Quality Improvement • Knowledge • Describe strategies for learning about the outcomes of care in the setting in which one is engaged in practice • Skills • Seek information about outcomes of care for populations served in care setting • Seek information about quality improvement projects in the care setting • Attitudes • Appreciate that continuous improvement is an essential part of the daily work of all health professionals

21. Implications for nursing • Focus on quality and safety requires new knowledge, skills and attitudes about how care is delivered, monitored, and improved. • Preparing nurses to work to work in quality focused settings. • Staff development in quality improvement processes, safety and error prevention techniques, and informatics.

22. Developing Quality Improvement Skills • Knowing the specific steps to interpret integrative literature reviews to identify the evidence to support data based care protocols. • Learning new quality improvement terminology such as variance reports, benchmarks, dashboards, report cards, statistical control charts, and satisfaction measures.

23. Quality and Safety: can they be separated? • Safety science is more than the “5 rights” of medication administration, assessing risks for falls, and monitoring the environment. • It goes beyond individual actions to prevent errors through system re-design. • Health care is adapting innovations from the high performance industries to build cultures of safety by applying human factors and safety science concepts

24. The Institute of Medicine To Err Is Human (1999) Safety In Healthcare Delivery Institute of Medicine. (1999). To Err Is Human. Washington, DC: National Academies Press.

25. A Safety Crisis • The IOM report on safety opened the door to acknowledge there is a healthcare safety crisis, for example data indicated in 1999:Approximately 44,000 to nearly 100,000 patients die annually in U.S. hospitals due to error. • What is your reaction to this? Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

26. Key Terms • Safety: Freedom from accidental injury • Error: Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

27. Some Elements of the IOM Safety Report Two primary dimensions to consider: • Safe care is consistent with current knowledge and customized/individualized to meet patient needs and requirements • Factors within external environment also have an impact on safety. Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

28. Safe Care=Quality Care? Just because care is considered safe does not mean that it is of a higher quality.BUT There is a greater chance that the care is of higher quality. Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

29. Need for a Framework • To understand more about safety and how to respond we need a standard framework and terminology. • We need to know more about the safety issue. Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

30. Types of Errors • Diagnostic • Treatment • Preventive • Other Many errors go undocumented or are not reported due to staff fear of reprisal, lack of adequate systems to report, limited staff education about safety and report process, and lack of computerized surveillance systems. Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

31. Other Types of Errors • Active error • Adverse error • Error of commission • Error of execution • Error of planning • Iatrogenic injury • Latent error • Near-miss • Sentinel event Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

32. Errors

33. Patient Role in Errors • Patients make errors in their own care or during self-management. • Patient noncompliance may lead to errors (accidental or unintentional non-adherence to a therapeutic regimen) Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

34. Technology • How might medical technology and information technology have an impact on healthcare safety? What are positive and negative impacts? Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

35. The Blame Culture • What is the Blame Culture? • Why is this important in the IOM report and its recommendations for change? • How might this be applied to nursing? Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

36. “Building safety into processes of care is a more effective way to reduce errors than blaming individuals.”(IOM, 1999, p.4) Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

37. Mandatory Reporting System • The IOM recommends a mandatory reporting system. What do you think about this? Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

38. Major Sources of Adverse Event Data • Voluntary and mandatory reporting • Document review • Automated surveillance • Monitoring patient progress to identify circumstances when adverse events might occur Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

39. Root Cause Analysis Definition of Root causes: • Specific underlying causes. • Causes that can reasonably be identified • Causes management or practitioners have control to fix. • Causes for which effective recommendations for preventing recurrences can be made. Should include: “failed and successful defenses and recoveries for the patient; outcomes for the patient; and lessons learned and ways to improve patient safety” (IOM, 2004, p. 160). Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

40. Near-Misses • Errors of commission or omission that could harm a patient but do not Think about the times that you almost made an error. We all have these experiences. What do you do to learn from these experiences? Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

41. Common Care-Management Problems • Failure to monitor, observe, or act • Delay in diagnosis • Incorrect assessment of risk • Loss of information during transfer to other healthcare staff • Failure to note faulty equipment Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

42. More Common Care-Management Problems • Failure to carry out preoperative checks • Deviation from an agreed protocol without clinical justification • Failure to seek help when necessary • Use of incorrect protocol • Treatment given to wrong body site • Wrong treatment plan Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

43. Medication Administration Recommendations • Use standard processes for medication doses, dose timing, and dose scales in a given patient unit. • Standardize prescription writing and prescribing rules. • Limit the number of different kinds of common equipment • Implement physician order entry Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

44. Medication Administration Recommendations • Use pharmaceutical software • Implement unit dosing • Central pharmacy should supply high-risk intravenous medications • Use special procedures and written protocols for use of high-risk medications on patient units • Do not store concentrated solutions of hazardous medications on patient units Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

45. Medication Administration Recommendations • Ensure the availability of pharmaceutical decision support • Include pharmacist during rounds of patient care units • Make relevant patient information available at the point of patient care • Adopt a system-oriented approach to medication error reduction • Improve patients’ knowledge about their treatment (IOM, 1999, pp. 160-164) Teaching IOM – Instruction Materials sponsored by the American Nurses Association, To Err is Human (1999) Safety in Healthcare Delivery

46. The call to leadership • To change practice calls for transformational leadership to achieve the collective purpose • Ordinary methods will not create behavior change • What is in your tool kit to create new work environments where quality is valued?

47. IOM, Keeping Patients Safe • Calls for relational styles of leadership • Latent working conditions are a major contributor to error • Poor working relationships and communication are at the core of many adverse events • What are ways to build a quality focused team?

48. 5 Essential Management Strategies • Balancing the tension between efficiency and reliability • Creating and sustaining trust • Actively managing the process of change • Involving workers in work design and work flow decision making • Creating a learning organization

49. A positive approach to change Appreciative Inquiry • A flexible process for engaging people in building the kind of organization they want to work in • Seeks a focus on what is right rather than focusing on gap analysis or what is wrong, what is missing

50. Appreciative Inquiry • Is about appreciating and valuing • Recognizes the best in people and the organization, affirms strengths • Is about inquiring • Explores, discovers, asks questions, sees new potential • Looks at root causes for success and designs ways to replicate • Root cause analysis looks for deficits and causes of failure