Chapter 2 Quality and Safety Models

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Safety First...... 2

The Ideal Work Environment...... 2

Nursing Exemplars That Support Quality Health Care ...... 3

Adequate Staffing for Nurses ...... 4

Quality and Safety Competencies in Nursing Education...... 5

Rapid-Cycle Change and Continuous Quality Improvement...... 6

Strategies and Tools to Enhance Performance and Patient Safety (STEPPS).. 7

Theoretical Perspectives in Safety and Quality...... 7

Methods of Change...... 8

Models for Change...... 9

Change Theories...... 9

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II. Quality and Safety Models

A. Safety First 1. Creating a safe nursing practice environment a) Can be complicated b) Must include (1) Many levels of discipline (2) Effective Communication (3) Collaboration (4) Attention to problem solving 2. Integrating safety awareness into nursing school curricula 3. Examples of transforming care a) TCAB b) Hygiene compliance B. The Ideal Work Environment 1. Optimal conditions a) Adequate staffing b) Positive collaborative environment c) Supportive nursing culture d) Resources that encourage ongoing learning 2. Poor conditions a) Staffing shortages b) Poor communication among healthcare teams c) Long hours of practice 3. Quality and Safety Education in Nursing (QSEN) a) American Association of Colleges of Nursing (AACN) b) Specific competencies and associated educational activities c) Focused on ensuring positive communication and collaboration d) Two-day conference that culminates in a certificate e) Integrated into nursing education

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f) Competencies: (1) Patient-centered care (2) Teamwork and collaboration (3) Evidence-based practice (4) Quality improvement (5) Safety and informatics g) Patient-centered care (1) Shared decision making between healthcare providers and patients h) SBAR communication tool (1) Describe the patient’s situation (2) Provide a brief history of the illness and any pertinent contextual information (3) Provide an objective assessment (4) Provide a recommendation i) Evidence-based practice and quality improvement (1) Evidence for providing interventions (2) Continual focus on monitoring quality 4. Magnet recognition a) American Nursing Credentialing Center b) Awarded to healthcare organizations (1) Two years of evidence of (a) Educational and research support for nurses (b) Support from colleagues, administrators, and physicians C. Nursing Exemplars That Support Quality Health Care 1. Common elements of quality monitoring models in health care a) Viewing safety and quality as a nonlinear process b) Having benchmarks for progress c) Using best practices based on the best evidence d) Incorporating a team of all levels of nurses e) Involving all pertinent healthcare team members

2. Focus on Magnet area to improve safe quality care 3. Need to raise the awareness of safety education 4. COPA Model for Nursing Practice a) Competency Outcomes and Performance Assessment Model b) Eight core practice competencies (1) See Box 2-1 THE COMPETENCY OUTCOMES AND PERFORMANCE ASSESSMENT MODEL, p. 21 (2) Focused on active learning c) Replace passive learning outcomes with active, engaging learning outcomes (1) In education (2) In practice environments d) Safety-focused competencies (1) Assessment and intervention skills (a) Engage a discussion about health promotion goals with patient and family (2) Communication and critical thinking skills (a) Actively talking, listening, and demonstrating care practices (b) Adapt nursing practice to patient and family needs (3) Human care and relationship skills (a) Mentoring and feedback D. Adequate Staffing for Nurses 1. Nurses have a right to refuse an unsafe assignment with too many patients a) Know the chain of command b) Be confident and speak up to a nurse in charge 2. Unreasonable expectations for nurses a) All levels of nurses and administrators are responsible b) Nurses must become adept at articulating the language of acuity and staffing numbers 3. Need for standards/mandates for patient safety and nurse staffing ratios

a) Nurses are caring for high acuity patients for shorter periods of time b) High patient turnover 4. Numbers can be deceiving a) New admitted patients (1) Labor-intensive admission process and assessment b) Patients discharged to home (1) Extensive preparation and paperwork 5. Courts don’t look at staffing numbers when a lawsuit is filed 6. Steps to take if an assignment seems overwhelming a) Contact the direct supervisor b) Chain of command should be well known 7. Need for legislation to regulate safe care ratios 8. Stress causing nurses to leave nursing altogether a) More patients with higher acuity b) Rapid patient turnaround c) Replacing older nurses with less experienced nurses to save money 9. Proven benefits of higher staffing ratios a) Decreased length of stay and fewer reported infections b) Improved functional status c) Lower mortality rates d) Fewer pressure sores e) Less use of restraints and long-term catheters f) Less antibiotic use E. Quality and Safety Competencies in Nursing Education 1. Real-life clinical nursing demands missing from nursing education a) Having a full patient assignment b) Handling difficult family members c) Reporting concerns to doctors 2. Patient simulation a) Present scenarios with simulated patients b) Builds on classroom knowledge

c) Helps build confidence d) Identifies strengths and weaknesses in communication e) Evidence of the benefits in medication safety 3. Quality and safety education is a continuous process a) Criteria of Magnet status b) Scholarly approach to nursing c) Example: New Zealand (1) Sabbatical program for nurses (a) One month paid leave (b) Explore a new area of knowledge 4. Changes to improve nursing care a) Should be based on evidence and the uniqueness of each setting b) Range of changes (1) Implementing daily huddles (2) System-wide changes F. Rapid-Cycle Change and Continuous Quality Improvement 1. Rapid-Cycle Change a) Nurses decide what safety concerns exist and propose a solution b) Based on other models 2. Continuous Quality Improvement (CQI) a) Focused on transforming healthcare settings b) Circular pattern (1) Intervention (2) Evaluation (3) Reassessment of the intervention/change 3. Change is dynamic, not an endpoint 4. Process is nonpunitive and involves all levels of personnel G. Strategies and Tools to Enhance Performance and Patient Safety (STEPPS) 1. Franciscan Sisters of Saint Mary (SSM) Health Care System 2. Model for addressing critical safety and quality problems in health care

3. Multiple providers of healthcare teams must act in a coordinated manner 4. Need for STEPPS greater than ever for four reasons a) Disorganized or fragmented care b) Multiple initiatives for the same patient c) Implementation of electronic health records d) Care-giving providers are at the heart of a safe work culture 5. Means of measuring success of the program a) The number of sentinel events b) Nurse turnover rate c) Provider satisfaction d) Scores on the safety culture and global trigger tool surveys 6. Focus of the program a) Communication between nurses and physicians b) Ensuring that all team members focus on providing quality care 7. Tools used in the program a) Electronic medication delivery b) Continuous safety and quality monitoring c) Feedback to all team members H. Theoretical Perspectives in Safety and Quality 1. Integrate “all at once” a) Ability to assess in a prioritized manner the patient’s... (1) Physiological status (2) Social awareness (3) Psychological awareness (4) Environmental awareness (5) Spiritual awareness b) To provide such care, the nurse must.... (1) Understand the coping and adjustment of the patient and family (2) Identify resources from within and outside of the hospital setting (3) Know how to communicate with the patients

(4) Support staff 2. Hierarchy of goal setting a) Critical for nurses to master b) Need for a clear understanding of the patient and family 3. Quality nursing care a) Difficult to quantify b) Integrates a variety of factors (1) The patient and family (2) Scientific and intuitive knowledge (3) Spiritual, cultural, psychological, family, community, and situational c) Should be defined by the patient, family, and nurses d) Range of perspectives/definitions (1) See Table 2-1 QUALITY MEASURES FROM VARIOUS PERSPECTIVES, p. 30 (2) Not a problem (3) All perspectives must be known and respected (4) Need for continuous communication I. Methods of Change 1. Resistance to change a) Fear of the unknown b) The familiar is comfortable c) Barrier for progress of safe nursing care 2. Need to implement evidence-based practice a) Best practices in nursing based on research J. Models for Change 1. Basic concepts of change models a) Top-down dictums for change do not work b) Change is difficult and frightening c) If well implemented, stakeholders will adapt (1) Need for a transition that is respectful of the workers

(2) Need for support throughout the change period 2. Examples of models of change a) TCAB b) The STEPPS program c) Implementing safe-staffing models 3. Common elements of change models a) All critical persons are equally involved b) The pace of the program is appropriate c) A process for planning, implementing, and evaluating is used K. Change Theories 1. Lewin’s force-field analysis (1951) a) Provides a framework for problem solving and planned change b) Opposing forces (1) Status quo when both sides are equal (2) Change when one side is stronger c) Driving forces equal to restraining forces produce equilibrium d) Change is framed in relation to the culture in which one is working 2. Havelock’s modified Lewin phase series of change (1973) a) Building a relationship b) Diagnosing a problem c) Acquiring the relevant resources d) Choosing the solution e) Gaining experience f) Stabilizing and undergoing self-renewal 3. Smith’s seven levels of change (2002) a) Being effective: doing the right thing b) Being efficient: Doing things right c) Improving: Doing the right things better d) Cutting: Doing away with things e) Copying: Doing things other people are doing f) Being different: Doing things no one else is doing

g) Doing the impossible: Doing things that cannot be done 4. Using and adapting these change models a) Need for support from all levels of management b) Engage in identifying strengths and weaknesses 5. Amer Hybrid Model of Change a) See Table 2-2 AMER HYBRID MODEL OF CHANGE, p. 38 b) Scoring system c) Five elements (1) Communication (2) Culture (3) Collaboration (4) Common goals (5) Ability to appreciate one another’s perspective 6. Necessary components of a standard model of change a) The practice environment of the nurse b) Support staff and administrative collaboration and communication c) Patient perspectives d) The openness of nurses to change

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