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Developing Competencies For Special Populations:

A Mindset For Quality And Safety

Gwen Sherwood Professor & Associate Dean For Academic Affairs

University Of North Carolina at Chapel Hill School Of Nursing

Co-investigator, Quality and Safety Education for Nursing (QSEN) Gwen.sherwood@unc.edu

Infusion Nursing Society November 2013

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•  Count how many times the team in white passes the ball?

Reflection: Opening our mindset to purpose

•  Briefing: Why am I here? •  Huddle: What can I contribute to the

purpose? •  Debriefing: What do I take with me? 3

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Majority of errors in health care are the result of how health care professionals communicate and work together.

Challenges in healthcare outcomes demand examination of new competencies to improve patient care quality and safety.

Issue of concern: The US institute of medicine (IOM) reports the critical role of teamwork and collaboration in quality and safety outcomes (IOM 1999, 2003)

Root Cause Analysis of Sentinel Events Reviewed by The Joint Commission (2009-2011)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

2009

2010

2011

Human Factors

Leadership

Communication

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Our time together today….Objectives

Examine imperative to develop core competencies for quality and safety for infusion nursing practice and education

Define the six QSEN competencies applied to infusion nursing practice

Intersect the QSEN competencies with the four core competency domains of interprofessional education (IPE).

Apply reflective practice in novice to expert competency development.

Population focus: There are some patients whom we

cannot help. There are none whom we cannot harm. A. L. Bloomfield

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Staggering evidence of health care quality

Medical errors are the leading cause of unexpected deaths in health care settings

More people die from medical error than from AIDS, breast cancer and motor vehicle accidents

Error causes include human factors, leadership and poor communication (The Joint Commission)

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Global reports of issues in

quality of care and patient

safety.

•  The WHO World Alliance for Patient Safety 9 universal safety precautions:

•  Tubing misconnection, •  confusing drug names, •  medication administration, •  patient identification, •  wrong site/procedure, •  hand hygiene, •  injection devices, •  proper solution mixtures, and •  communication among providers.

•  Health care is behind other high performance industries (ex. aviation)

•  System approach: –  Just Culture refocuses individual blame with

analysis of causes of errors to identify contributing factors

A new Mindset: Prevent errors before they happen by focusing on system design/prevention

To improve health care quality and safety:

All health professionals must be prepared with new core competencies to be able to deliver

patient-centered care as members of interdisciplinary teams,

emphasize evidence-based practice, quality improvement, safety and informatics.

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University of North Carolina - Chapel Hill

School of Nursing

Quality and Safety Education for Nurses: National project to integrate quality and safety competencies into nursing education.

Linda Cronenwett, PI Gwen Sherwood, Co-Investigator Expert Faculty and Advisory Board

Collaborated with AACN for Train the Trainer and Graduate Competencies Transitioned to Case Western Reserve University 2012

Funded by The Robert Wood

Johnson Foundation 2005-2012

6 quality and safety competencies

Patient Centered Care Teamwork

and Collaboration

Evidence Based

Practice Quality

Improvement

Safety

Informatics

Patient centered care

Family as partner, accurate assessment

Teamwork and collaboration

Interprofessional communication, mutual support

Evidence based practice

Seeking and applying best practices

Quality improvement

System analysis and improvements

Informatics Decision support

Safety Mindset to prevent errors before they happen, report, analyze

A new mindset: Competencies to improve safety

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The new health professional A Quality Culture: “A new way of thinking”

Engages in their work with the patient as the focus

Encourages inquiry and reflection to make sense of experience

Applies evidence based standards and interventions

Investigates outcomes and critical incidents from a system perspective

Continually seeks to improve care

How do we change practice outcomes through competency development?

Competency

….the capability to apply a set of related knowledge, skills, and abilities to successfully perform functions or tasks in a defined work setting.

…the basis for skill standards that specify the level of knowledge, skills, and abilities needed for success, as well as potential measurement criteria for assessing competency attainment.

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Goal: Change mindset Change Behavior Improve outcomes

Competency KSAs

Knowledge

Attitudes

Skills

Example: Safety Knowledge Skills Attitudes

Discuss 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 20

Competency development involves advancing clinical judgment, reflection to

improve, and awareness of context.

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Define: 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.

Patient Centered Care:

Mindfully engages to apply knowledge of patient for values, beliefs, preferences

Treat patient and family as

an ally Negotiate with

patients Participate in continuum of

care

•  Patient Centered Care

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Questions for Patient centered care:

What is the most important thing I can do right now for this patient?

What are unique cultural or personal influences?

How can I more effectively communicate with this patient and family? •  (Day & Smith, 2007).

Evidence-based practice:

Define: Integrate best current

evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care

Expectation: •  Practices from a spirit

of inquiry. Base care standards on evidence.

•  Applies technology to search evidence for best care approaches and clarify decisions.

Evidence Base Practice What questions should I ask about the care I am giving ?

Why did I choose the care plan I am following?

What is the level of evidence for the care I am providing?

How can I balance evidenced based care with patient and family preferences?

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Quality improvement: Define 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

Expectation: •  Quality improvement

integrated into nursing role and identity

•  Uses quality tools,

evidence, patient preferences, and benchmark data to assess current practice and design continuous quality improvements

Quality Improvement questions foster inquiry

What tools am I able to use to measure nursing outcomes?

How does the care in my area compare with industry benchmarks and nursing sensitive measures?

How can I use evidence based practice standards to narrow the gap between desired care and reality?

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Informatics: Define: Use information and

technology to communicate, manage knowledge, mitigate error, and support decision making

Expectation: Use electronic record

systems Search for and evaluate

information sources Navigate computer decision

supports Help design and evaluate

relevant products

Use EHR

Search for evidence

Navigate decision support

Apply safety design

Evaluate/design technology

Examples Informatics

Safety:

Define: Minimize risk of harm

to patients and providers through both system effectiveness and individual performance

Expectation: Awareness of actions that

may put patients at risk for possibility of error

Implements, works with system alerts for safety

Seeks solutions to work arounds and evaluates short cuts

Develop safety allies

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Questions related to safety:

Prevent diseases before they happen: Prevent mistakes before they happen

Where is the next error likely to occur?

What are system alerts or safe guards to prevent the next error?

What safety questions should I ask about work-arounds and short-cuts?

How do I handle uncertainty about care decisions?

Reasons Error Model is like Swiss Cheese

Most accidents are due to: •  organizational

influences, •  unsafe

supervision, •  preconditions for

unsafe acts, and •  the unsafe acts

themselves.

Organizational defenses line up to prevent failure like a series of barriers, in which the holes

represent individual weaknesses in

individual parts of the system

A Trajectory of Accident

Opportunity: all the holes line up

momentarily, and the system as a whole produces

failures

Active failures: unsafe acts

directly linked to an accident,

such as worker error.

Latent failures: factors in the system that may have been dormant for a long time until they finally contributed to the accident.

Latent failures span the first three levels of

failure in Reason's model.

Preconditions safety: worker fatigue, poor

communication practices.

Unsafe supervision:

inexperienced personnel in a

complex situation

Organizational influences:

Reduced staff education resources

Active and Latent Failures in the system

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Competency Definition Cronenwett, Sherwood, Barnsteiner et al, 2007

•  Teamwork and collaboration:

•  Function effectively in nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care

Teamwork and Collaboration: KSAs are built on ability to

•  Use personal strengths to foster effective team functioning (EQ)

•  Shift leadership as needed •  Include patient and family as members of the health

care team

Teamwork Behaviors for Collaboration

Organize team

Resolve conflict

Base decisions on group input

Empower members to

speak up

Clarify goals

Share leadership

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Teamwork competency: Ability to work with other professionals in the context of a team where each

member has a clearly defined role •  Apply adult learning principles to develop

interpersonal, group, inter-group, organizational and inter-organizational relationships to enable professionals to

•  learn together •  learn from each other, and •  learn about each other's roles, in order

to •  improve collaboration and quality of

care

…through evidence based content, skills, and pedagogies to prepare health professionals for interprofessional teamwork.

Interprofessional Education: a bridge to improve quality and safety: “When students [or providers] from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes” (WHO, 2010)

Interprofessional Education Competency

•  level of cooperation, coordination and collaboration that characterizes the relationships between professions in delivering patient-centered care

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Reprinted with permission from The Association of American Medical Colleges (AAMC). Core Competencies for Interprofessional Collaborative Practice.

Interprofessional Collaborative Practice Domains: Core Competencies for Interprofessional Collaborative Practice

IPE Competencies Values/Ethics •  Work with individuals of other professions to maintain a climate of

mutual respect and shared values

Roles/Responsibilities •  Use the knowledge of one’s own role and the roles of other professions

to appropriately assess and address the health care needs of the patients and populations served.

Interprofessional Communication •  Communicate with patients, families, communities, and other health

professionals in a responsive and responsible manner that supports a team approach to maintaining health and treatment of disease.

Interprofessional Teamwork and Team-based Care •  Apply relationship building values and team dynamic principles

effectively in differing team roles to plan and deliver patient/population care that is safe, timely, efficient, effective, and equitable.

Interprofessional Teams

Evidence Based

Practice

Patien

t

Center

ed C

are

Quality Improvement

Informatics

(IOM Core Competencies, 2003; QSEN, 2007)

Safety

Roles & Responsibilities

Com

mun

icat

ion

Teamw

ork

Values & Ethics (IPEC, 2011)

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Team Strategies and Tools to Enhance Performance and Patient Safety

Behaviors and attitudes in Teamwork and collaboration

•  Who has critical information to share with the team?

•  Standardized communication: –  Shared mental models of what is to happen – Checklist of critical information insures care

coordination in transition of providers –  SBAR (situation, background, assessment,

recommendation) – Check back: repeat back – Call out: make sure everyone has the information – Mutual support: watch each other’s back – Handoffs/Handovers during transitions in care

Please Use CUS Words but only when appropriate!

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Clinical judgment

noticing

interpreting

responding

reflecting

Developing competencies: Clinical judgment model (Tanner, 2006)

• Noticing: Begins with a perceptual grasp of the situation

• Interpreting: Developing sufficient understanding to respond

• Responding: Deciding on what to do appropriate to the situation

• Reflecting: Attending to the patient’s responses while caring for them and assessing the outcomes afterwards. Tanner, 2006

Developing critical analysis

Reflection: It is like throwing light on a situation to see it more clearly, to reframe,

To refocus on what is right

Reflection

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•  How do I assure I learn from my experiences?

•  Cycles of interpretation that consider assumptions, values and beliefs

•  Carefully analyze my view of what happened

–  Consider in relation to self, others and the situated context

Reflection: Mindful Learning

Consciousness of context

Consciousness of others

Emotional Intelligence: What is the influence in Interprofessional Collaboration?

Consciousness of self

Use theory bursts for content

Outline case and learning objectives

Develop scenario, characters, setting, clinical situation, symptoms, and details such as lab data, physician orders, medications, diet, treatments

Develop questions and also allow time for their questions

Unfolding Case Studies: Engaging Learners

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What stands out?

What are you concerned about for the patient?

What action will you take? Why? What else could it be?

What competencies are evident in case analysis?

Where are potential quality and safety issues?

Engaging learners with questions

Transforming health care

Health professionals are willing to lead quality and safety improvements when they have the knowledge, skills and attitudes required.

Developing quality and safety competencies can help all team members to contribute to improving health care outcomes.

•  Annotated bibliography on www.qsen.org

•  Sherwood & Barnsteiner (Eds): Quality and Safety Education: A Competency Based Approach. Ames, Iowa: Wiley. 2012

•  Sherwood & Horton-Deutsch (Eds): Reflective Practice: Transforming Education and Improving Outcomes. Indianapolis: Sigma Theta Tau Press. 2012

•  Freshwater, D., Taylor, B., & Sherwood, G. (Eds): International textbook of Reflective Practice in Nursing. Oxford, England: Blackwell Publishing & Sigma Theta Tau Press. 2008.

References

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