Developing Competencies For Special Populations: A Mindset ...
Transcript of Developing Competencies For Special Populations: A Mindset ...
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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) [email protected]
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