Transcript QSEN PowerPoint Template

State of the Science of Safety and Quality:
Call to Action
Jean Johnson, PhD, RN, FAAN
Dean and Professor
George Washington University
This program generously funded by the Robert Wood Johnson Foundation
American Association of Colleges of Nursing. © 2013 - All Rights Reserved.
Learner Objectives
•
At the completion of the session participants will be able to:
 Demonstrate awareness of the devastating effects of
adverse outcomes on patients/families and healthcare
professionals.
 Describe the history of the patient safety movement and
the effect on health policy and regulatory standards.
 Discuss the Quality and Safety Education in Nursing
(QSEN) competencies and the benefits of creating an
education culture of Quality and Safety.
American Association of Colleges of Nursing. © 2013 - All Rights Reserved.
Why are we concerned about
quality of health care? Don’t we
have the best in the world?
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Institute Of Medicine’s (IOM) Quality Chasm Series
American Association of Colleges of Nursing. © 2013 - All Rights Reserved.
US Health System
• US health system is the most expensive
• US Scored last on dimensions of access, patient safety,
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coordination, efficiency, and equity
Compared to Australia, Canada, Germany, the Netherlands,
New Zealand, the United Kingdom (Commonwealth Foundation, 2010)
US ranks 49th world wide in life expectancy at 78.24 year
(Monaco is 89.78) (CIA report)
Access to timely health care remains a challenge
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Medicare Study
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One out of every seven hospital patients with Medicare
experienced an adverse event in 2008 (about 134,000
Medicare recipients a month)
At least 44% of the mistakes were preventable
One month of those adverse events cost the federal
government around $324 million dollars
Office of the Inspector General, DHHS, 2010
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Colorado Study
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At least 1 million patient safety incidents occurred in Medicare patients
from 2006-2008
Costing $8.9 billion
1 in 10 patients experiencing a patient safety incident died
Of 15 monitored events, 8 were worse than previous years
decubitus ulcer (bed sores)
iatrogenic pneumothorax (collapsed lung)
Postoperative hip fracture
post-operative physiologic and metabolic derangements, postoperative
pulmonary embolism (potentially fatal blood clots forming in the lungs) or
deep vein thrombosis (blood clots in the legs)
 post-operative sepsis
 transfusion reaction
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HealthGrades, 2010
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Colorado Study
• Most common patient safety incidents (rate per 1000
patients)
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Failure to rescue (92.71)
Decubitus ulcer (36.05)
Post-operative respiratory failure (17.52)
Post-operative sepsis (16.53)
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North Carolina Study
• 25.1 harms per 100 admissions
• Types of harms
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Consequence of procedures (186)
Medications (162)
Nosocomial infections (87)
Other therapies (59)
Diagnostic evaluations (7)
Falls (5)
63% of harms were preventable
Landrigan, Gareth, Bones, Hackbarth, Goldmann, and Sharek, 2010
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Deaths from Medical Error in Perspective
(CDC, 2009)
• Heart disease: 616,067
• Cancer: 562,875
• Stroke (cerebrovascular diseases): 135,952
• Chronic lower respiratory diseases: 127,924
• Accidents (unintentional injuries): 123,706
• MEDICAL ERROR: 98,000
• Alzheimer's disease: 74,632
• Diabetes: 71,382
• Influenza and Pneumonia: 52,717
• Nephritis, nephrotic syndrome, and nephrosis: 46,448
• Septicemia: 34,828
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In the past year (2010)…
• USA Today - lax safety practices in 5000
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ambulatory surgical centers
NYT – some hospital infection rates rise
USA Today – only 20% of USA hospitals using WHO
surgery checklist
Wall Street Journal – Near misses creeping up
NYT – look- alike tubes kill patients
American Association of Colleges of Nursing. © 2013 - All Rights Reserved.
National Quality Strategy
• Better Care: Improve the overall quality, by making
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health care more patient- centered, reliable,
accessible, and safe.
Healthy People and Communities: Improve the
health of the United States population by supporting
proven interventions to address behavioral, social, and
environmental determinants of health in addition to
delivering higher-quality care.
Affordable Care: Reduce the cost of quality health
care for individuals, families, employers, and
government.
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What is quality care?
• S afe
• T imely
• E fficient
• E quitable
• E ffective
• P atient-Centered
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Nurses at the “Sharp End” Health Systems
Patients
Complex Needs
Nurses
Human Factors
Perceptions
Critical Thinking
Health Care Organizations
Working Conditions
Organizational Culture
Organizational Climate
Quality
Improvement
External Drivers
Physicians
Teamwork
Communication
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Cost Containment
Benchmarks
Return to
Normal
Technical
van der Schaaf- modified for healthcare
Close Call
Organizational
Human
Factors
Patient
Factors
Dangerous
Situation
Adequate
defenses
ERROR
Developing
Errors
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(Inadequate
Defenses)
Swiss Cheese Model
Goal Conflicts
7'
Incomplete
Proce ures
Dou e Binds
Mixed
Mes ages
Production
Inadequate
Tr ning
Attention
Distr ctions
Clumsy
Tech ology
LATENT
AILURES
0
to
ti; o
oii
DEFENSES
Modified from Reason. J99 J © J99 J, James Reason
Managing Healthcare Risk – The Three Behaviors
Normal Error
Product of our
current
system design
At-Risk
Behavior
Unintentional
Risk-Taking
Manage through:
Manage through changes
in:
• Understanding our at-risk
behaviors
• Processes
• Removing incentives for
at-risk behaviors
• Procedures
• Training
• Design
• Environment
Normal Error
Reckless
Behavior
Intentional RiskTaking
Manage through:
• Disciplinary action
• Creating incentives for
healthy behavior
• Increasing situational
awareness
Negligence?
*David Marx – Just Culture
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Recklessness
Reporting Errors and Near Misses
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What happens after an error or near miss?
 Reporting systems in place, RCA?
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How are patients and families informed of an
unanticipated outcome?
Who is accountable for patient safety?
What is the process in your school of nursing?
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Quality and Safety Education
in Nursing (QSEN)
“We can’t hope to make lasting changes in the ability of health
care systems to improve without changes in the ways we
develop future health professionals.
Those changes require
faculty and schools to change.”
Paul Batalden
Dartmouth College
QSEN Advisory Board
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QSEN Competencies
• Patient/Family Centered Care
• Teamwork and Collaboration
• Safety
• Evidence-based Practice
• Quality Improvement
• Informatics
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Patient/Family Centered Care
• New - Recognize the patient or designee
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as the source of control and full partner
in providing compassionate and
coordinated care based on respect for
patient’s preferences, values and
needs
Old – Listen to patient and demonstrate
compassion and respect.
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Collaboration and Teamwork
Old – Work side by side with other HC
professionals while performing nursing
skills.
New - Function effectively within
nursing and inter-professional teams,
fostering open communication, mutual
respect, and shared decision-making to
achieve quality patient care
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Quality Improvement
Old – Routinely updating nursing
policies and procedures
New - Use data to monitor outcomes of
care processes and improvement
methods to design and test changes to
continuously improve quality and safety
of health care systems
American Association of Colleges of Nursing. © 2013 - All Rights Reserved.
Evidence-Based Practice
Old – Adhere to internal policies to
standardize skills execution.
New - Integrate best current evidence
with clinical expertise and
patient/family preferences and values
for delivery of optimal health care.
American Association of Colleges of Nursing. © 2013 - All Rights Reserved.
Safety
Old – focus on individual performance
to keep patients safe.
New - Minimize risk of harm to patients
and providers through both system
effectiveness and individual
performance
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Health Informatics
Old – timely and accurate
documentation
New - Use information and technology
to communicate, manage knowledge,
mitigate error, and support decisionmaking
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Defining Change
What do you want to
accomplish?
Transformation
Create a culture of quality
Substantial change
Creating substantive content in
quality and patient safety
Tinkering at the margins
Small changes to curriculum
The Lewis Blackman story
as told by his mother
https://www.youtube.com/watch?v=WElE_hR
ucpo
American Association of Colleges of Nursing. © 2013 - All Rights Reserved.
American Association of Colleges of Nursing. © 2013 - All Rights Reserved.
CHANGE THE WORLD
OF HEALTH CARE
 Start where you are
 Use what you have
 Do what you can
» A. Ashe
American Association of Colleges of Nursing. © 2013 - All Rights Reserved.