Final Exam
Leapfrog Group
-national nonprofit organization driving a movement in the quality and safety of American health care --> building a movement for transparency! -only national initiative to collect information from hospitals for the purpose of public reporting
Example of AIM statement
Decrease the rate of hospital acquired CAUTI's for patients in the ICU from 23 infections per 1,000 catheter days to less than 5 infections per 1,000 catheter days by May 1
AIM statement
-time specific and measurable; clear, realistic, concise, meaningful -what are we trying to accomplish? -what is the problem? -how good? #'s/objective -for whom? Specific population -when? -where?
IOM: The 6 Aim for Quality
(STEEEP) -safety -timeliness -effectiveness -equity -efficiency -patient-centeredness
Creating a safe culture
-assess current environment using tools from AHRQ (q6 months), safety attitude questionnaire SAQ -leaders play an extraordinary role in patient safety -walk rounds: spend time visiting with staff asking about safety issues -schedule presentations from staff working on key projects r/t safety -include executives on safety performance improvement teams -board of directors should discuss national best practices and safety -engage physicians, patients and families (flattery hierarchy) -encourage the filing of incident reports.. non punitive! -patient safety committee and safety action teams -safety briefings/bebriefings -nursing practice environment is critical to patient safety, quality of care and nurse retention
Learn Global, Act Local, and Be Vocal
-"Procedural and technical greatness in a sea of dangerous system failures" -Expensive "Disease Management" system... U.S. is behind in IT, primary care, team based care -"Learn Global": we must look for best practices beyond the borders of our country and industry -"Act Local": recognize our performance gaps, bring awareness to action -"Be Vocal": DO NOT allow processes which have evolved over time harm patients and caregivers (research + motivation/passion= action) -the patient comes first -change way in which patients expect care: preventative care -must be transparent- should be death certificate spot to show it was from poor care/preventable in order to study these occurrences
AACN Baccalaureate Essentials
-**will understand and use quality improvement concepts, processes, and outcome measures -**should be able to apply concepts of quality and safety to identify clinical questions and describe the process of changing current practice -integrate reliable evidence to inform practice and make clinical judgments -in collaboration with other team members, graduates participate in documenting and interpreting evidence for improving patient outcomes
collaboration and communication research
--collaboration: process of joint decision making among independent parties, involving joint ownership of decisions and collective responsibility for outcomes -one of the most important aspects of collaboration is clear and appropriate communication, without which true collaboration is impossible -collaborative communication enhances nurse, physician, and patient satisfaction as well as improves patient safety and outcomes by building teamwork and positive work relationships*** -maladaptive behaviors such as ineffective communication patterns result in burnout and job dissatisfaction --> often, this leads to increased turnover of nursing personnel, together with decreased quality of patient care -disconnect in communication styles leads to dysfunctional physician nurse communication and a significant increase in errors in patient care, inconsistency in the plan of care, medication errors, falls, increased hospital-acquired infections, failure to rescue/mortality, and increased lengths of stay -fostering adaptive communication skills through development, initiation, and maintenance of an ongoing staff education program** -exit interviews of new graduate nurses who resigned during their first year of employment revealed 2 major issues: communication problems with patients/staff and perceived lack of support/mentoring from unit staff -poor communication and lack of teamwork or collaboration have been cited as persistent problems in healthcare
IHI Campaign to Save Lives
-100,000 Lives Campaign: -Deploy Rapid Response Teams at the first sign of patient decline -Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction to prevent deaths from heart attack -Prevent Adverse Drug Events (ADEs) by implementing medication reconciliation -Prevent Central Line Infections by implementing a series of interdependent, scientifically grounded steps called the "Central Line Bundle" -Prevent Surgical Site Infections by reliably delivering the correct perioperative antibiotics at the proper time -Prevent Ventilator-Associated Pneumonia by implementing a series of interdependent, scientifically grounded steps including the "Ventilator Bundle"
appropriate staffing research
-AACN and the ANA recognize that appropriate staffing is more than the nurse-to-patient ratio; it also includes skill mix -nurse advancement system is a means to achieving an appropriate staffing mix by rewarding nurses who remain at the bedside -pressing need in the field of nursing is the identification of optimal staffing levels to ensure patient safety -nurse staffing has clearly been linked to patient safety, care quality, and cost... a commonly cited statistic is that each additional surgical patient that is added to a nurse's workload increases the patient's odds of dying by 7% -many traditional workload measurement systems, such as nurse to occupied bed ratios, diagnosis-related group (DRG) models, and intensity (timed task-based) models, do not take into account the substantial nonpatient-focused workload that impacts nursing today*
**meaningful recognition: formal nurse advancement process
-An advancement ceremony open to all nurses, their invitees, and top hospital management whereby each nurse is individually recognized for his or her accomplishments -Public acknowledgement of advancement through a new title with advanced clinician status (clinician levels II-VI)
Negotiation and Conflict Management
-avoidance -accommodation -competition -compromise (none of these are effective) **collaboration: Institutions... ongoing awareness of the importance of collaborative negotiation
CMS: Hospital Acquired Condition Data
-HACs Initiative was associated with improvements in CLABSI and CAUTI trends, conditions for which there is strong evidence that better hospital processes yield better outcomes -HACs Initiative was not associated with improvements in HAPU or injurious fall trends, conditions for which there is less evidence that changing hospital processes leads to significantly better outcomes ****Initiatives focusing on areas with a well-developed evidence base for prevention and areas amenable to standardization are more likely to be successful in driving improvement -large, urban, public, major teaching hospital with a high percentage of poor patients had a 62 percent chance of receiving a HAC penalty, while a small, rural, for-profit, nonteaching hospital with few poor patients had a 9 percent chance of getting the penalty
examples of meaningful recognition
-ID badge inscribed with clinician level and education level -significant salary increase with each level of advancement -publication of clinicians' advancement in a systemwide newsletter -recognition programs require commitment and engagement of senior leadership.
leapfrog results
-In the first year, 200 hospitals reported, and Leapfrog published the results on its website -This year, over 2,000 hospitals have reported to the Leapfrog Hospital Survey (new measures include medication safety and infections)
Developing Change Ideas
-best sources are the people involved in the process to be improved (subject-matter experts) and patients! -adapting ideas for testing from other organizations or industries can be creative and useful -literature, best practices/guidelines
Prioritization/Delegation/Assignment overview
-R.N.'s accountability has moved beyond task orientation to leadership practices that ensure better outcomes for patients, families and populations -ineffective delegation has been a significant source of missed care -better delegation and supervision skills would prevent errors and omissions as well as unobserved patient decline -need innovations in care delivery/redesign
ongoing awareness of the importance of -collaborative negotiation-
-both parties work together to find a mutually agreeable solution -innovative thinking that leads to finding new opportunities to benefit both parties -appreciative inquiry and self-reflection -negotiation requires training and must be practiced
Deadly Deliveries: Hospitals Know How To Protect Mothers, They Just Aren't Doing It (article)
-There is NO national tracking system for childbirth complications or requirements that U.S. maternity hospitals follow best practices -examples: failure to provide timely BP treatment, 60% of deaths from preeclampsia were preventable, 93% of women who bled to death during childbirth could have been saved -other countries have reduced deaths by aggressively monitoring care and learning from mistakes....the result has been a steady decline in maternal harm in the rest of the developed world but the U.S. rate is climbing -growing recognition by hospitals that they need to adopt standardized practices to save mothers' lives --> AIM Program (2014): "Safety Bundles" to manage BP and bleeding
Institute of Medicine (IOM)
-a private, nonprofit organization created by the federal government to provide science-based advice on matters of medicine and health -works outside the framework of government to provide evidence-based research and recommendations for public health and science policy
Psychological safety
-anyone can ask a question without looking stupid -anyone can ask for feedback without looking incompetent -anyone can be respectfully critical without appearing negative -anyone can suggest innovative ideas without being perceived as disruptive
QSEN: Quality and Safety Education for Nurses
-meet the challenge of preparing future nurses to continuously improve the quality and safety of the healthcare systems within which they work -using the Institute of Medicine competencies, QSEN faculty and a National Advisory Board have defined quality and safety competencies for nursing in nursing pre-licensure programs
AACN Standards for Healthy Work Environment
-calls attention to work environments that contribute to medical errors, ineffective delivery of care, work conflict, stress, and burnout of nurse and health care providers in an effort to provide an organizational approach to the problem -evidence based and relationship centered principles of professional performance -each standard is considered essential... studies show that effective and sustainable outcomes do not emerge when any standard is considered optional -align with core competencies for health professionals recommended by the IOM -standards should be used as foundation for thoughtful reflection and engaged dialogue about the current realities of the work environment
appropriate staffing research part 3
-findings indicated that an increase of 1 RN hour per patient day led to an 8.9% decrease in the chance of pneumonia and a 10% increase in the percentage of RNs in the staff was associated with a 9.5% decrease in pneumonia -the percentage of RNs was predictive of the total number of adverse events: every 1% increase in the RN percentage of staff would lead to a 3.38% decrease in the total number of adverse events experienced by patients
Accountability
-hold people accountable for actions, but not for flaws in processes or systems -each person is accountable as a team member
Health Care Improvement Goals
-improving health information technology capacity -incentives for improving primary care (patient-and-family centered medical homes) -interdisciplinary Care -SHARE best practices (learn from safety practices in other industries) -leaders must own patient safety "Healthcare professionals need to be cared for themselves...for them to deliver total care, they need to feel that their leaders believe that their lives and well-being are every bit as important as their patients"
Prioritization
-in the nursing process, following specific steps to determine the client's most important needs -understanding purpose for care, goals
National statistics for death due to medical error
-include "preventable complication" on death certificate -hospitals investigate to determine potential contribution of error -standardize data collection and reporting to build national picture of problem --> share data nationally/internationally -create a culture of learning -recognition of the role of medical error in patient death would heighten awareness -collaborations and investments in research and prevention
Leapfrog Hospital Safety Grade
-launched in 2012 -system uses national performance measures from the Centers for Medicare & Medicaid Services (CMS), the Leapfrog Hospital Survey and other supplemental data sources. -using 28 evidence-based measures of patient safety -taken together, the performance measures produce a single letter grade representing a hospital's overall performance in keeping patients safe from preventable harm and medical errors -the Leapfrog Hospital Safety Grade empowers regular people to find a safer hospital in their community by using the easy-to-understand A, B, C, D, F grading system Must report falls, patient satisfaction rates, etc in order to get paid by CMS --> must follow best practice guidelines
Creating a Safe Culture
-leaders must identify what is possible and establish aims that challenge staff to meet these levels of performance -understand the system properties that led to the error and redesign the system -feedback must be given to all employees about action -reduce reliance on human factors, increase standardization -use simulation to improve important elements of teamwork.. listening, communicating, respect and role clarity -standardize communication tools.. SBAR -PDSA Model for Improvement -using validated tools to measure adverse events: global trigger tool
global trigger tool
-looks at outcomes, issues in acute care -recommended by IHI to identify adverse events in hospitalized patients examples: •Code/arrest/rapid response team •Transfusion or use of blood products •Acute dialysis •Positive blood culture •X-ray or Doppler studies for emboli or DVT •Decrease of greater than 25% in hemoglobin or hematocrit •Patient fall •Pressure ulcers •Readmission within 30 days •Restraint use •Healthcare-associated infection •In-hospital stroke •Transfer to higher level of care •Any procedure complication •Surgical Module Triggers •Return to surgery •Change in procedure •Admission to intensive care post-op •Intubation/reintubation/BiPap in Post •Anesthesia Care Unit (PACU) •X-ray intra-op or in PACU •Intra-op or post-op death •Mechanical ventilation greater than 24 hours post-op •Intra-op epinephrine, norepinephrine, naloxone, or romazicon •Post-op troponin greater than 1.5ng/ml •Injury, repair, or removal of organ •Any operative complication •Clostridium difficile positive stool •Partial thromboplastin time greater than 100 seconds •International Normalized Ratio (INR) greater than 6 •Glucose less than 50 mg/dl •Rising BUN or serum creatinine greater than 2 times baseline •Vitamin K administration •Benadryl (Diphenhydramine) use •Romazicon (Flumazenil) use •Naloxone (Narcan) use •Over-sedation/hypotension Abrupt medication stop
Strategies to reduce death from medical error
-making errors more visible when they occur -remedies to rescue patients... rapid response teams -follow principles that take human limitations into account -routinely discuss prevention strategies, disseminate lessons
Regional Health Commission overview
-national model for improving access to health care services for the uninsured -improve health care access -reduce health disparities -improve health outcomes
QSEN: Novice Nurse Essential Skills
-new nurse needs to understand basic improvement cycles and methodologies -new nurse needs to have participated in a test of change and measurement -new nurse should participate in real-time improvements -associated skills should be learned in a clinical setting -new nurse should have experience with interprofessional teamwork and collaboration
Institute of Medicine (IOM) reports
-numbers grossly underreported: 78%, not 51% of iatrogenic deaths were preventable -$3.5 trillion a year for care -ranked 27th by the WHO -despite this evidence and repeated calls to action over the past decade, health care has proved resistant to safety improvement
appropriate staffing research part 2
-nursing leadership cannot help nurses to prioritize what needs to be done day to day, but they can help to identify areas of waste, processes in need of improvement -environmental complexity, the presence of non-nursing support, patient turnover and organizational characteristics are the least studied factors influencing nursing workload but are critical factors to consider because these measures reflect the hectic and complex nature of health care -most researchers agree that nurses spend a greater portion of their day performing indirect nursing and non-nursing tasks than direct care, but these are left out of most existing measurement -must redesign the care process to improve efficiency and skills of each provider -sufficient numbers and the right mix of nurses are needed to provide vigilant surveillance of patients by anticipating problems, observing for clinical cues, and implementing measures to reduce the probability of an adverse event
IHI and its partners in the campaign encouraged hospitals and other health care providers to take the following steps to reduce harm and deaths:
-pevent pressure ulcers by reliably using science-based guidelines for prevention of this serious and common complication -reduce MRSA infection through basic changes in infection control processes throughout the hospital -prevent harm from high-alert meds starting with a focus on anticoagulants, sedatives, narcotics, and insulin -reduce surgical complications by reliably implementing the changes in care recommended by the Surgical Care Improvement Project (SCIP) -deliver reliable, evidence-based care for CHF to reduce readmission
charter
-problem to be addressed -rationale: why does the current system/process need improvement? -supportive background information is provided (reference literature/best practices; positive and negative impact on patients is clear) -expected outcomes/benefits
The State of Health Care Today (issues)
-providers are becoming more specialized --> gaps in communication and care -lack of teamwork and collaboration -populations are aging, with disease burden shifting toward chronic conditions -patients and families are better informed, wanting more personalized care -complicated procedures and expensive treatments are more available and desired -lack of standardization... application of EBM
context of caring
-research evidence and EB theories -clinical expertise and evidence from assessment of pt history and conditions, HC resources -patient preferences and values . . . clinical decision making -> quality patient outcomes
**Iatrogenesis/Iatrogenic
-result of diagnostic and therapeutic procedures -relating to illness caused by medical exam/treatment -side effects or drug interactions -medical error/negligence
Teamwork and Communication
-safety briefings and timeouts -debriefing -communicate clearly: structured communication -manage risk: designated work or phrase that indicates there is perceived risk -team members explicitly give permission to hold each other accountable across a flat hierarchy ex: briefings every 4 hours, communication: can I have some clarity? Why are we doing this?
HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems
-shaped by 3 broad goals -survey is designed to produce comparable data on the patient's perspective on care that allows objective and meaningful comparisons between hospitals on domains that are important to consumers -public reporting of the survey results is designed to create incentives for hospitals to improve their quality -public reporting will serve to enhance accountability in health care by increasing the transparency of the quality of hospital care provided in return for the public investment
effective decision making research
-shared governance, nurses on committees are involved with decision making regarding positive patient outcomes and nurse satisfaction and retention -staff nurses are leaders and members of interdisciplinary committees such as pharmacy, quality/safety improvement, ethics, pain management, and infection control*** -through the shared governance council model, staff nurses were empowered in an organization that encouraged professional autonomy over practice, effective communication, and development of leadership skills -providing an environment that allows for nurse autonomy in decision making, participation in unit and hospital governance, and participative management may be the best strategy for retaining nurses in the hospital setting
AACN Standards for a Healthy Work Environment overview
-standards represent evidence-based and relationship-centered principles of professional performance -each standard is considered ESSENTIAL (effective and sustainable outcomes do not emerge when any standard is considered optional) -they support the education of all health professionals to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics
Reliability
-the ability of a system to successfully produce a product to specification repeatedly. In the case of health care, that product is *safe, efficient, person-centered care* -standardize (protocols/guidelines), simplify, reduce autonomy, highlight deviation from practice -reliability in health care is defined as patients getting the intended tests, medications, information and procedures at the appropriate time and in accordance with their values and preferences
How does staffing impact patient safety and quality of care?
-there is research identifying a relationship between adverse outcomes and the number of RN's in the skill mix on an inpatient unit -a number of studies show the use of mandatory nurse-patient ratios does not improve patient outcomes -studies have reported implementation of nurse patient ratios having a positive effect on nurse satisfaction Results show that nurse patient ratios and the quality of the nurse practice environment (i.e. managerial support of nursing care, good relations between doctors and nurses, nurse participation in decision-making and organizational priorities on quality of care) are significantly associated with intention-to-leave the hospital
Transparency
-transparency among -clinicians- exists when there is no fear of giving suggestions, pointing out problems or providing feedback -transparency with -patients-, specifically after an adverse event, involves clearly describing what happened and what will be done to prevent -transparency among -organizations- includes sharing good practices and applying lessons -transparency with the -community- requires information sharing so patients can make informed decisions
Delegation
-working through others -nurse always retains accountability -NEVER delegate nursing process
Change Concepts
1. Eliminate waste 2. Improve workflow 3. Optimize inventory 4. Enhance the provider-customer relationship 5. Change the work environment 6. Manage time 7. Manage variation 8. Design systems to prevent errors 9. Focus on the design of products and service
Step 4: Testing Changes
1. Plan: -questions & predictions -who/what/where/when? 2. Do/Implementation -observe the test -document results 3. Study -draw run charts -analyze the data 4. Act -refine the change and plan for the next cycle
The Joint Commission on Accreditation of Healthcare Organizations analyzed 2,455 sentinel events from hospitals across the United States and reported through root cause analysis over --- of the events were due to communication failures, and approximately --- of the patients involved died
70% 75%
AACN list of standards for healthy work environment
1. Skilled Communication: nurses must be as proficient in communication skills as they are in clinical skills 2. Effective Decision Making: nurses must be valued and committed partners in making policy, directing and evaluating clinical care and leading organizational operations 3. Appropriate Staffing: staffing must ensure the effective match between patient needs and nurse competencies 4. Meaningful Recognition: nurses must be recognized and must recognize others for the value each brings to the work of the organization 5. Authentic Leadership: nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage others in its achievement
AACN Standards: listed
1. Skilled Communication: nurses must be as proficient in communication skills as they are in clinical skills 2. True Collaboration: nurses must be relentless in pursuing and fostering true collaboration 3. Effective Decision Making: nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations 4. Appropriate Staffing: staffing must ensure the effective match between patient needs and nurse competencies 5. Meaningful Recognition: nurses must be recognized and must recognize others for the value each brings to the work of the organization 6. Authentic Leadership: nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement
National Patient Safety Foundation Goals
1. medical education reform: preparing physicians to function in a new culture (flatten hierarchy) 2. multidisciplinary teams must deliver care working to integrate platforms 3. health care workers need to work in safe environments and find joy and meaning in their work 4. patients must become full partners in all aspects of designing and delivering health care 5. transparency must be a practiced value in everything we do
3 questions
1. what are we trying to accomplish? 2. how will we know a change is an improvement? 3. what change can we make that will result in an improvement?
Leapfrog launched the Leapfrog Hospital Survey in 2001, asking hospitals to voluntarily and publicly report on their performance on a set of three "leaps":
1. whether the hospital had Computerized Physician Order Entry (CPOE) 2. whether their ICUs were staffed appropriately with intensivists 3. whether the hospital had enough surgical volume to safely perform certain high-risk procedures
Incident reports
10-20% are actually written, most often not --> need them to keep track of near misses
Medical Error is the
3rd leading cause of death (not counting outpatient, rehab, or home care)
What type of culture contributes to poor safety in HC environments
Culture of individual experts and hierarchy
outcome measure
A measure that indicates the result of the performance (or nonperformance) of a function or process Where are we going? AIM Ex: Rate of hospital-acquired pneumonia per 1,000 catheter days in the ICU
IHI, Institute for Healthcare Improvement
A nonprofit organization dedicated to leading the improvement of healthcare throughout the world. Its goals include health care for all with no needless deaths, no needless pain or suffering, no helplessness in those served or serving, no unwanted waiting, and no waste.
Fishbone diagram
A visual identification of many potential causes of a problem
Balancing measures
Are the changes we are making to one part of the system causing problems in other parts of the system? What else is happening? Ex: Patient and staff satisfaction scores
briefing and debriefing for safety
Briefing: every team member should know what is going on with each patient Debriefing: not who did it, but what happened
evidence-based practice
Conscientious, explicit, & judicious use of theory derived, research based information in making decisions about care delivery to individuals or groups of patients & in consideration of individual needs & preferences (of patient and clinician)
Assignment
Distribution of work
Continuous Learning
Entails the proactive and real-time identification and prevention of defects and harm -searching for better ways of working toward and achieving results that improve the lives of patients, families and staff -clinical and operational data of importance to patients, families and staff are shared widely and transparently -learning generated by what is working and what is failing -huddles, learning boards, structured communication -patients and families are active team members -learning and improvement is part of the culture -timely feedback to health care team
process measure
Focuses on a process that leads to a certain outcome What are we doing? Ex: average number of times patients receive recommended oral care in 24 hours
Center for Medicare & Medicaid Services, CMS
Hospital Acquired Conditions Reduction Program (CMS covers all medicaid and medicare pts, funds hospitals --> CMS says if you have these things, we will not pay) *Part of the ACA: identified complications, "never events", that could be prevented with the use of evidence-based guidelines -Injury from falls, hospital-acquired pressure ulcers, catheter-associated urinary tract infections, and central line-associated bloodstream infections, Surgical Site Infections, and infections caused by c. dif and MRSA were among the never events covered by the HACs Initiative -2015: CMS reduces payment to hospitals that fall into the top quartile of infection/injury by 1% -March 2019: 800 hospitals across the U.S. will have payments reduced GOAL: Reduce Hospital Acquired Conditions, HAC's -total decrease in the HAC rate from 98 to 78/1,000 discharges -1.78 million fewer HAC in the years 2015-2019 -ultimately, would save 53,000 lives and 19.1 billion over 5 years
step 2: establish measures
How will we know a change is an improvement? "Family of Measures" -outcome measure -process measures -balancing measure
Process Improvement
Improvement and Measurement: enhancing work processes and patient outcomes using standard improvement tools -clinical, cultural and operational defects -must first understand the system -identify where the defects are occurring and identify opportunities to improve the process
IHI Framework for Safe, Reliable and Effective Care
Learning system: -leadership -transparency -reliability -Improvement and measurement -continuous learning Culture -leadership -psychological safety -accountability -teamwork and communication -negotiation
Model for Improvement
Plan, Do, Study, Act cycle
Nursing Shortage
The deepening nursing shortage cannot be reversed without healthy work environments that support excellence in nursing practice
**The AACN recognizes the inextricable links among
quality of the work environment, excellent nursing practice and patient care outcomes
appropriate staffing
The health care organization has staffing policies to support the professional obligation of nurses to provide high quality care •Nurses participate in staffing process, including matching competencies with patients' assessed needs** •Evaluate the effect of staffing decisions on patient and system outcomes •Outcome data is used to develop more effective staffing models** •Support services are provided at every level to ensure nurses can optimally focus on the priorities of patient and family care •Adopts technologies that increase effectiveness of nursing care delivery •Nurses are engaged in the selection, adaptation and evaluation of these technologies
effective decision making
The health care organization provides access to ongoing education and development programs to assure collaborative decision making •Perspectives of patients and their families are included in every decision •Team members share accountability for effective decision making •Structured forums involving all disciplines to facilitate data-driven decisions •Processes that ensure respect for the rights of every individual, incorporate all key perspectives and designate clear accountability •Objectively evaluate the results of decisions, including delayed decisions and indecision**
authentic leadership
The health care organization provides support and education for educational programs to ensure nurse leaders develop and enhance knowledge/abilities in the Healthy Work Environment Standards •Leaders translate the vision of a healthy work environment at the point of care** •Leaders lead the design of systems necessary to implement and sustain the standards for a healthy work environment •Organizations provide the necessary time and financial support •The leadership contribution of creating and sustaining a healthy work environment is a criterion in each nurse leader's performance appraisal** •Nurse leaders must demonstrate sustained leadership in creating and supporting a healthy work environment to achieve professional advancement
True Collaboration
The health care organization provides team members with support for and access to education programs that develop collaborative skills •Creates and evaluate processes that define each member's accountability and how unwillingness to collaborate will be addressed •Ensures the decision making authority of nurses is acknowledged •Provides unrestricted access to structured forums to resolve disputes among all critical participants •Every team member embraces a culture of true collaboration •Nurse leaders and medical directors are equal partners •Team members master skilled communication, essential for collaboration
skilled communication
The health care organization provides team members with support for and access to education programs that develop critical communication skills: •Protect and advance collaborative relationships •Invite and hear all relevant perspectives •Mutual respect to build consensus •Holding others accountable •Formal processes that ensure effective information sharing •Includes communication as a criterion in its formal performance appraisal system •Team members demonstrate skilled communication to qualify for professional advancement
meaningful recognition
The healthcare system has a comprehensive system in place that includes formal processes and structured forums that ensure a sustainable focus on recognizing all team members •Recognition system reaches from the bedside to the board room •Includes processes which validate that recognition is meaningful to those being acknowledged •Team members understand that everyone is responsible for playing an active role in the organization's recognition program •The health care system regularly evaluates the recognition system, ensuring effective programs that help to move the organization toward a sustainable culture of excellence that values meaningful recognition*
Step 3: Developing Changes
What change can we make that will result in an improvement? -process analysis tools: cause and effect diagram, line graphs -clear and well defined -benchmarking -technological solutions -creative thinking, best practices -barriers are defined/solutions -identify key stakeholders and their role
safety attitude questionnaire
assesses safety culture among healthcare providers Questions: -nurse input is well received in this clinical area -in this clinical area, it is difficult to speak up if I perceive a problem with patient care -disagreements in this clinical area are resolved appropriately (i.e., not who is right, but what is best for the patient) -I have the support I need from other personnel to care for patients -it is easy for personnel here to ask questions when there is something that they do not understand -the physicians and nurses here work together as a well-coordinated team -my suggestions about safety would be acted upon if I expressed them to management -I would feel safe being treated here as a patient -medical errors are handled appropriately in this clinical area -I know the proper channels to direct questions regarding patient safety in this clinical area -I receive appropriate feedback about my performance -In this clinical area, it is difficult to discuss errors -I am encouraged by my colleagues to report any patient safety concerns I may have -the culture in this clinical area makes it easy to learn from the errors of others
Organizational factors such as inadequate staffing, heavy workloads, job dissatisfaction, turnover, and absenteeism are also associated with
compassion fatigue, nursing burnout, and higher rates of attrition
**iatrogenic complications on care are critical...
complications w/ tx, lack of diagnosis, etc
resonant leadership
focuses on understanding the needs of individuals
IHI encourages use of the ---- to objectively determine and monitor adverse events
global trigger tool (Adverse Event rate was found to be 68.1 per 1000 patient days or 50.8 per 100 encounters and 39.8 % of admissions were found to experience > 1 AE, 2009)
Siloed care
individual tests/procedures ordered by different providers --> med interactions because providers are not talking to one another
Caregivers need to be taken care of because
it will result in better pt outcomes
authentic leadership emphasizes
leader insight, transparency, and congruence in their actions and personal or expressed beliefs
---- is critical in building quality work environments, implementing new models of care, and bringing health and wellbeing to a strained nursing workforce.
leadership -various leadership styles can impact patient outcomes through the positive and negative influences on nursing staff and their work environment -leadership has been shown to influence nursing workforce outcomes, such as job satisfaction and burnout -leadership styles can be generally categorized as focusing on human relationships or task completion**
transformational leadership
maximizes the potential of followers through encouragement of innovation, creativity and intellectual stimulation
relationship focused leadership styles (better)
transformational resonant authentic
harm remains common, with little evidence of
widespread improvement (2010)
QSEN competencies
•Patient-centered care •Evidence-based practice •Teamwork and collaboration •Safety •Quality improvement •Informatics -the new nurse needs to understand basic improvement cycles and methodologies and have participated in a test of change/measurement
CMS: Hospital Acquired Conditions Status
•2014-2016: Rate dropped by 8% •350,000 fewer conditions •8,000 fewer inpatient deaths •National savings of almost $3 billion •New baseline rate for hospital acquired conditions= 90/1,000 discharges......down from 98/1,000 discharges •VAP down 32% •CLABSI down 31% •Postoperative thromboembolism down 21% •Adverse drug events down 15% •C. difficile down 11% ***2017 Data: 17% reduction in the number of Hospital Acquired Conditions between 2014 and 2017. This translates into 87,000 lives saved and a savings of $19.9 billion to the health care system
Characteristics of High Performing teams
•Complementary skills •Committed to a common purpose •Mutual accountability •Smaller teams/consistent schedule •Increase familiarity •Reward and Recognize!!!
Informatics overview
•Inform clinical practice •Interconnect clinicians •Personalize care •Improve population health •Telehealth •Innovations to improve your impact!
Unhealthy environments contribute to
•medical errors •ineffective delivery of care •conflict/stress among health care professionals •burnout •turnover