1 Leadership and Management Ch. 1

Key Findings of the IOM:

-Nurses should practice to the full extent of their education and training -Nurses should achieve higher levels of education and training -Nurses should be full partners, with physicians and other health care professionals -Effective workforce planning and policymaking require better data collection and information infrastructure

Consumer Bill of Rights (1997)

1) Information disclosure 2) Choice of providers and plans 3) Choice of health care providers that is sufficient to ensure access to appropriate high-quality care 4) Access to emergency services 5) Participation in treatment decisions 6) Respect and nondiscrimination; confidentiality of health information 7) Complaints and appeals 8) Consumer responsibilities

Levels of Evidence

1) Strongest level of evidence: Evidence from a systematic review or meta-analysis of randomized controlled trials, or evidence-based clinical practice guidelines based on systematic reviews or meta-analysis 2) Evidence from at least one well-designed RCT 3) Evidence from well-designed controlled trials without randomization 4) Evidence from well-designed caste-control or cohort studies 5) Evidence from systematic reviews of descriptive and qualitative studies 6) Evidence from a single descriptive or qualitative study 7) Evidence from expert opinions-weakest level of evidence p. 15

1. Care is based on continuous healing 2. Care is customized according to patient need&values 3. Patient is the source of control 4. Knowledge is shared, info flows freely 5. decision making is evidence based 6. Safety is a system property 7. Transparency is necessary 8. Needs are anticipated 9. Waste is continuously decreased 10. Cooperation among clinicians is a priority

10 rules for health-care delivery in the 21st century: p. 6

evidence-based practice, quality improvement, nursing research

3-leg stool of nursing practice: p. 16

1) Identify clinical question (PICOT) 2) Collect best evidence relevant to the question using key words from the PICOT questions 3) Critically appraise the evidence before using it, be evaluating the studies for validity, reliability, and applicability 4) Evidence should be integrated with the other aspects of evidence-based practice 5) Evaluate their practice decision or change to determine whether it affected the patient's outcome

5 step approach to integrate evidence into practice:

Peter Principle

A principle of organizational life according to which every employee within a hierarchy tends to rise to his or her level of incompetence

multidisciplinary

A team in which members function independently and then share information with each other p. 11

ADN, BSN, diploma program

ADN Programs were created because of the nursing shortage and BSN programs were taking too long.

90

An estimated __ million Americans have difficulty understanding health information

Safety culture

An organization's care processes and workforce are focused on improving reliability and safety of care for patients "No blame" for errors

Bill Clinton

Appointed the Advisory Commission non Consumer Protection and Quality in the Health Care Industry to advise him on changes occurring in the health care system and to make recommendations on how to promote and ensure health care quality as well as protect consumers and professionals in the health-care system.

Human errors

Are acts of omission or commission leading to an undesirable outcome or the potential for an undesirable outcome

Safe

Avoiding injuries to patients from the care that is intended to help them

Efficient

Avoiding waste, including waste of equipment, supplies, ideas, and energy

Informatics

Communicate, manage knowledge, mitigate error, and support decision making using information technology p. 19

sensitive, responsive, understandable, effective

Communication should be:

High reliability

Consistent performance at high levels of safety over time p.22

lack of infrastructure and absence of leadership

Constraints to quality improvement in healthcare p. 17

interdisciplinary

Cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable p. 10

safe, effective, patient-centered, timely, efficient, equitable

Crossing the Quality Chasm report 6 aims for health-care improvement: p. 5

unprocesssed

Databases consist of original studies of excellent to poor quality.

listening actively, encouraging input from others, and respecting opinions of all team members

Effective communication requires: p. 13

1) sensitivity to operations 2) reluctance to simplify 3) preoccupation with failure 4) difference to expertise 5) resilience

Five characteristics fundamental to designing processes and systems for high-reliability organizations p.22

1. Balancing the tension between production efficiency and reliability 2. Creating and sustaining trust throughout the organization 3. Actively managing the process of change 4. Involving workers in decision making pertaining to work design and flow 5. Using knowledge management practices to establish the organization as a learning organization

Five management practices that consistently contribute to the success of patient safety initiatives in spite of a high risk for error.

1) providing leadership 2) respecting human limits in the design process 3) promoting effective team functioning 4) anticipating the unexpected 5) creating learning environment

Five principles are necessary for the design of a safe healthcare environment: p. 22

nursing research, the relationship with quality improvement, clinical practice guidelines, and evidence based management

Fundamental elements of evidence-based practice:

human errors and human factors, standardized protocols and practice, safety culture, high reliability organizations

Fundamental elements of safety

generating, testing, or evaluating knowledge and developing reliable ecidence about issues important to the nursing profession

Goals of nursing research:

preprocessed

Have been reviewed before inclusion, are updated regularly, and consist of the most methodologically sound and clinically important studies.

1) provide patient-centered care 2) work in interdisciplinary teams 3) employ evidence-based practice 4) apply quality improvement 5) use informatics (6 safety is included with QSEN not IOM)

Health Professions Education: A Bridge to Quality Care report: (provide nurses with KSA to improve quality and safety ) 5 essential competencies necessary for all future graduates of health professions education programs, regardless of discipline

patient

Health-care professionals must shift from disease-centered paternalistic care to ensuring that the __ is the source of control and facilitating shared decision making

Care process

How nursing care is provided:

Florence Nightingale

How to create an optimal healing environment p.10

To Err Is Human

Identified medical errors as the leading cause of injury and unexpected death in health-care settings in the US - Created systems to reduce these errors THREE DOMAINS: 1. patient safety 2. practice w current medical knowledge 3. meeting values and expectations

Patient-centered care

Identify, respect, and care about patients' differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health

evidence-based practice

Integrating best research with clinical expertise and patient values for optimum care, and participating in learning and research activities to the extent feasible p. 13

commission

Involve doing something wrong or committing an error, such as a nurse giving a patient the wrong medication

omission

Involve failing to do the right thing or omitting something that results in an error, such as a nurse forgetting to give a patient a prescribed medication

Quality Improvement

Is a cyclical process designed to monitor and evaluate workflow and work processes. Uses benchmarks to measure practice against established standards and provides methods to improve nursing practice continually. Skills to be competent in quality improvement: 1. Having been a member of an interdisciplinary team 2. Improving the quality of one's own performance through self-assessment and personal change. 3. Designing and testing interventions to change the process of care with the objective of improving quality. 4. Identify errors and hazards in care and to assess current practices and compare them with relevant better practices, not provide efficient care.

Human factors engineering

Is a science that studies human capabilities and limitations and applies knowledge gleaned to the design of safe, effective processes and systems for humans with the goal of achieving effective, efficient, and safe care *used to decrease error in human care* Assume that well designed processes and systems take into account human capabilities and limitations outside the control of those working with the processes and systems

optimal healing environment

Is an environment that supports patient healing by addressing the social, psychological, physical, spiritual, and behavioral components of healthcare and enabling the body's capacity to heal itself

Institute of Medicine (IOM)

Is an independent nonprofit organization that works outside the federal government to provide unbiased and authoritative advice on health and health care decision makers and the public.

Documentation

Is any written or electronically generated information about a patient that describes the care provided to that patient and offers an accurate account of what occurred and when it occurred

cultural competence

Is defined as the attitude, knowledge, and skills necessary for providing quality care to diverse populations

Information management

Is the process of collecting, analyzing, monitoring, summarizing, and communicating necessary information for health care.

diversity

Is the range of human variation, including age, race, gender, disability, ethnicity, nationality, religious and spiritual beliefs, sexual orientation, political beliefs, economic status, native language, and geographical background

teamwork and collaboration

Is to function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care

AHRQ (Agency for Healthcare Research and Quality) NQF (National Quality Forum) TJC (The Joint Commission) Institute for Healthcare Improvement (IHI)

Key organizations committed to the patient safety movement: p. 21

elderly low-income

Low literacy skills are most prevalent among the __ and __

Evidence-based management

Making decisions through the conscientious, explicit, and judicious use of the best available evidence from multiple sources p. 16

210,000

Particular study contended that health care is experiencing a major epidemic of patient harm. Found that there are, at a minimum, ___ lethal preventable adverse events anually

Equitable

Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status

Effective

Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit Avoiding overuse, underuse, and misuse of care

Timely

Reducing waits and sometimes harmful delays for both those who receive and those who give care

interprofessional

Refers to members with specific disciplinary training and diverse perspectives working collaboratively in planning and implementing patient-centered care *teamwork and collaboration* p. 11

Standardized practice

Reflects current research findings and best practices and outlines the minimally accepted actions expected from health-care professionals

Outcomes of Care

Results of all the nursing care provided and reflect the effectiveness of nursing activities:

nursing research

Rigorous __ provides one of the best sources for evidence based practice.

Nursing Research

Systematic inquiry that uses disciplined methods to answer questions and solve problems

Clinical practice guidelines

Systematically developed statements to assist practitioners and patient decisions about appropriate healthcare for specific clinical circumstances (The National Guideline Clearing House, Registered Nurses' Association of Ontario)

patient safety, practice consistent with current medical knowledge, and meeting customer-specific values and expectations

The IOM identified three domains of quality:

1) Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety 2) Identifying and learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems 3) Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care 4) Implementing safety systems in health care organizations to ensure safe practices at the delivery level

The IOM outlined the following four-tiered approach to quality improvement:

education

The IOM recognized health professions __ as the primary tactic to narrow the quality gap.

2006

The Technology Informatics Guiding Education Reform (TIGER) was launched in __ to create a vision for the future of nursing in the digital age.

Reliability science

The ability of an operation to be failure or defect free over time Employing deliberate strategies that make it difficult for nurses to do the wrong thing and easy to do the right thing p. 21

health literacy

The ability to read, understand, and act on health care information

quality

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

safety

The freedom from accidental injury p. 20

advocacy, empowerment, self-management, cultural competence, health literacy, and an optimal healing environment

The fundamentals of the patient centered care core competency includes: p. 8

2000

The modern patient safety movement began in __ when the IOM published its landmark report, To Err Is Human: Building a Safer Health System

98,000

The publication To Error Is Human stated that as many as how many patients die each year from preventable medical mistakes? A.10,000 B.46,000 C.72,000 D.98,000

care coordination

To establish and support a continuous healing relationship, enabled by an integrated clinical environment and characterized by the proactive delivery of evidence-based care and follow up p. 12

critical pathways

Tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. Designed for a specific care type, a pathway is used to manage the care of a patient throughout a projected length of stay.

setting

Where nursing care is provided:

advocacy

a process of analyzing, counseling, and responding to patients' care and self determination preferences

empowerment

patients' perceptions of access to information, support, resources, and opportunities to learn and grow that enable them to optimizes their health and gain a sense of meaningfulness, self-determination, competency, and impact on their lives

Patient-centered

providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions

disparity

racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention *encompasses unequal delivery of care, access to care, and/or outcomes of care based on ethnicity, geography, or gender

QSEN Goal

stands for Quality and Safety Education for Nurses, a project for preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems within which they work p.7

Self-management

to ensure that the sharing of knowledge between clinicians and patients and their families is maximized, that the patient is recognized as the source of control, and that the tools and system supports that make self-management tenable is available (critical to the success of chronic illness programs)