Chapter 1 Core Competencies for Safe and Quality Nursing Care

The nursing core competency of informatics is defined as the..

"use information and technology to communicate, manage knowledge, mitigate error, and support decision making". The incorporation of informatics in health care is inevitable and nurses must develop the skills for entering patients' data and retrieving information for clinical decision making and quality improvement.

How nursing care is provided.

Care Process

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

Interprofessional

Freedom from accidental injury.

Safety

The fundamental elements of patient-centered care includes..

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

Safety Culture

an organization's care processes and workforce are focused on improving reliability and safety of care for patients

Documentation is critical to the nursing profession in the following areas:

-Communicating within the health-care team and with other professionals. -Credentialing, legal, regulation, and legislation. -Reimbursement. -Research, quality process, and performance improvement.

The skills related to EBP include:

-Know where and how to find best possible sources of evidence. -Formulate clear clinical questions. -Search for relevant answers to those questions from the best possible sources of evidence, including those that evaluate or appraise the evidence for its validity and usefulness with respect to a particular patient or population. -Determine when and how to integrate these new findings into practice.

The skills r/t the patient centered care competency identified by the IOM include..

-Share power and responsibility with patients and caregivers. -Communicate with patients in a shared and fully open manner. -Take into account patients' individuality, emotional needs, values, and life issues. -Implement strategies for reaching those who do not present for care on their own, including care strategies that support the broader community. -Enhance prevention and health promotion.

To use evidence effectively to answer a clinical question and inform care delivery, nurses should ask the following questions:

1. Are the results of the study valid? 2. What are the results? 3. How can I apply these results to patient care?

The IOM identifies 5 management practices that consistently contribute to the success of patient safety initiatives in spite of a high risk for error.

1. Balancing the tension b/w 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.

The IOM recognized health professions education as the primary tactic to narrow the quality gap. Thus, its report Health Professions Education: A Bridge to Quality outlined 5 essential competencies necessary for all future graduates of health professions education programs, regardless of discipline.

1. Provide patient-centered care 2. Work in interdisciplinary teams 3. Employ evidence-based practice 4. Apply quality improvement 5. Use informatics In response, the QSEN faculty adapted the IOM competencies for the nursing profession and identified the knowledge, skills, and attitudes for each competency that should be developed in prelicensure nursing education.

5 principles necessary for the design of a safe health care environment:

1. Providing leadership 2. Respecting human limits in the design process 3. Promoting effective team functioning 4. Anticipating the unexpected 5. Creating a learning environment

Asserting that the US health-care system was in need of major restructuring, the IOM called for an overhaul by outlining six aims for health-care improvement in the 21st century in its 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, that health care should be..

1. Safe [Avoiding injuries to patients from the care that is intended to help them.] 2. 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.] 3. Patient-Centered [Providing care that is respectful of and responsive to individual patients' preferences, needs, and values, and ensuring that patients' values guide all decisions.] 4. Timely [Reducing waits and sometimes harmful delays for both those who receive and those who give care.] 5. Efficient [Avoiding waste, in particular of equipment, supplies, ideas, and energy.] 6. Equitable [Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, & socioeconomic status.] The IOM believed that addressing these performance characteristics would lead to narrowing the quality gap.

5 characteristics fundamental to designing processes and systems for high-reliability organizations

1. Sensitivity to operations (leaders and staff must be constantly aware of risks to patient safety and focus on preventing them) 2. Reluctance to simplify (avoiding overly simple explanations of failures is essential to understand the true reasons that patient safety is in jeopardy) 3. Preoccupation with failure (leaders and staff must view near misses as evidence that systems should be improved rather than as proof that the system is working effectively) 4. Deference to expertise (leaders and managers must listen and respond to the insights of frontline staff) 5. Resilience (leaders and staff must be educated and prepared to respond when system failures do occur)

IOM's 3 domains of quality:

1. patient safety 2. practice consistent with current medical knowledge 3 meeting customer-specific values and expectations

What are the QSEN competencies [adapted the five competencies outline in Health Professions Education: A Bridge to Quality]?

1. provide patient centered care 2. work in interdisciplinary teams 3. employ evidence based practice 4. apply quality improvement 5. use informatics and added a 6th competency, SAFETY!

Anticipating the unexpected (principles necessary for the design of a safe health care environment)

Adopt a proactive approach. Identify threats to safety before an accident can occur, and redesign processes to prevent accidents.

A process of analyzing, counseling, and responding to patient's care and self-determination preferences.

Advocacy

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.

Care Coordination

Tools for clinicians to improve the quality and process of care delivery and patient outcomes and to reduce variations in care and health-care costs.

Clinical Practice Guidelines

A key aspect of teamwork and collaboration. Involves communicating with patients, families, and other HCPs by using effective techniques and tools.

Communication

The attitude, knowledge, and skills necessary for providing quality care to diverse populations.

Cultural Competence

Acts of commission involve..

DOING something wrong or COMMITTING an error, such as a nurse giving a patient the wrong medication.

Respecting human limits in the design process (principles necessary for the design of a safe health care environment)

Design jobs for safety and avoid reliance on memory and on vigilance. Simplify & standardize work processes.

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.

Disparity

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"

Diversity

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

Empowerment

Making decisions through the conscientious, explicit, and judicious use of four sources of information: practitioner expertise and judgment, evidence from the local context, a critical evaluation of the best available research evidence, and the perspectives of those people who might be affected by the decision.

Evidence Based Management

Acts of 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.

Optimal Healing Environment definition

Florence Nightingale emphasizes the importance of the environment in what she called the "reparative process". Flo suggests nurses should focus on "proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet". An optimal healing environment is an environment that supports and stimulates patient healing by addressing the social, psychological, physical, spiritual, and itself. Patient centered care involves creating and maintaining an environment that fosters healing, is safe and clean, guards patient privacy, engages all the human senses with color, texture, artwork, music, aromatherapy, views of nature, and comfortable lighting; and considers the experience of the body, mind, and spirit of all who use the facility.

The degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.

Health Literacy

assisting patients and their families in reading, understanding, and/or acting on healthcare information.

Health Literacy

Create processes, systems, and a culture that radically reduce system failures and/or effectively respond when failures do occur.

High Reliability Organization

Acts of omission or commission leading to an undesirable outcome or the potential for an undesirable outcome.

Human Error

Human errors and factors

Human errors are acts of omission or commission leading to an undesirable outcome or the potential for an undesirable outcome.

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

Informatics

The process of collecting, analyzing, monitoring, summarizing, and communicating necessary information for healthcare.

Information Managment

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

Interdisciplinary Teams

Providing leadership (principles necessary for the design of a safe health care environment)

Make pt. safety a priority objective and everyone a responsibility. Make sure assignments are CLEAR with an expectation of safety oversight and that there are effective mechanisms for identifying and dealing with unsafe practitioners.

Describes a team in which members function independently and then share information with each other.

Multi-Disciplinary Team

Care coordination definition

Nurse leaders and managers as well as nurses coordinate care delivery as members of interprofessional and intraprofessional teams. Care coordination is a priority area needed for health-care quality improvement. Organizing the components of the plan of care, coordinating the implementation of the plan of care, advocating for the delivery of dignified human care, and documenting the coordination of care.

A systematic inquiry that uses disciplined methods to answer questions or solve problems.

Nursing Research

Supports and stimulates patient healing by addressing the social, psychological, physical, spiritual, and behavioral components of healthcare and enabling the body's capacity to heal itself.

Optimal Healing Environment

Standardized protocols and practice

Standardized protocols can decrease preventable adverse events and medical errors. Common standard protocols are used to prevent mislabeling of radiographs, prevent wrong-site or wrong-patient procedure, and for labeling, packaging, and storing medications. Standardized practice reflects current research findings and best practices and outlines the minimally accepted actions expected from HCPs.

Care process

The care process focuses on HOW nursing care is provided. Examples of care process include models of care delivery such as primary care, Transforming Care at the Bedside (TCAB), and care management. The care process also encompasses critical pathways, standardized clinical guidelines, actual physical care of patients, assessment, intervention, patient education, timeliness of care, counseling, and leadership and management activities.

Outcomes of Care

The outcomes of care include the RESULTS of all the nursing care provided and reflect the effectiveness of nursing activities. Examples of outcomes of care include length of stay, infection rates, patients' falls, postprocedure complications, and failure to rescue.

Promoting effective team functioning (principles necessary for the design of a safe health care environment)

Train HCPs expected to work in interprofessional teams with others who will be working with them.

Creating a learning environment (principles necessary for the design of a safe health care environment)

Use simulation whenever feasible. Encourage transparency & reporting of errors without reprisals and implement mechanisms for feedback and learning from errors. Develop a culture in which communication flows freely.

Although HCPs have an obligation to provide safe and quality care, nurses have been directly linked to ensuring patient safety and quality care outcomes. The national QSEN initiative was organized with the purpose of..

adapting the IOM competencies for nursing specifically to serve as guides for curricular development in formal nursing education, transitions to practice, and continuing education programs. In addition, the competencies provide a framework for regulatory bodies that set standards for licensure, certification, and accreditation of nursing education programs.

What is the Institute of Medicine (IOM)?

an independent nonprofit organization that works outside of the federal government to provide unbiased and authoritative advice on health and health care to decision makers and the public. The IOM brings together experts and stakeholders to provide the nation with unbiased, evidence-based guidance on health-related issues.

Disparity

another issue related cultural competence and encompasses unequal delivery of care, access to care, and/or outcomes of care based on ethnicity, geography, or gender.

Nursing research

answering questions or solving problems by generating, testing, or evaluating knowledge and developing reliable evidence about issues important to the nursing profession. Rigorous nursing research provides one of the best sources for evidence-based practice.

The fundamental elements of teamwork and collaboration include..

care coordination and communication.

Information management

collecting, analyzing, monitoring, summarizing, and communicating necessary to implement EBP.

Documentation

communicating all interactions with patients, including assessments, interventions, evaluations, and outcomes of care, in the patient's health record. Nurses have a professional responsibility to document care planning, actual care provided, and patient outcomes.

High reliability organizations

create processes, systems, and a culture that radically reduce system failures and/or effectively respond when failures do occur.

Evidence-based management

developing management strategies informed by rigorous research based on empirical evidence.

Structure or care environment

essentially means the setting WHERE nursing care is provided. Examples include the physical environment (i.e., the unit, a patient room, a surgical suite, outpatient clinic, or a patient's home), equipment, staffing (including staff mix and staffing ratios), policies and procedures, the organizational culture, and management of the organization.

The strongest level of evidence is..

evidence from a systematic review or meta-analysis of randomized controlled trials (RCT), or evidence-based clinical practice guidelines based on systematic reviews or meta-analysis.

The weakest level of evidence is..

evidence from expert opinions.

Clinical practice guidelines

following and/or developing guidelines that gather, appraise, and combine evidence to address relevant issues while balancing risk and benefits. Tools for clinicians to improve the quality and process of care delivery and patient outcomes and to reduce variations in care and health-care costs.

The definition of the nursing core competency of team work 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.

The fundamental elements of safety include..

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

The IOM defines patient-centered care as..

identify, respect, and care about patients rather than 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 health lifestyles, including a focus on population health.

Informatics

includes the development and application of information technology systems to health-care problems, research, and education. Successful use of informatics allows health-care professionals to manage knowledge and information, communicate more effectively, and reduce more errors than in the past.

Self-management definition

increasing the skills and confidence of patients in managing their health problems. The major aim of self-management is to ensure that the sharing of knowledge b/w 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".

The fundamental elements of informatics are

information management and documentation.

Communication definition

key aspect of teamwork and collaboration. It involves communicating with patients, families, and other HCPs by using effective techniques and tools. Communication, whether verbal or nonverbal, should be sensitive, responsive, understandable (i.e., avoiding discipline specific jargon), and most importantly, EFFECTIVE. [Effective communication is accurate and timely and enhances quality of care. Effective communication requires active listening, encouraging input from others, and respecting opinions of all team members.]

There is a critical link between effective communication and patient safety. The Joint Commission cites communication errors as..

leading cause of medical errors. Nurses need to create an atmosphere in which patients and their families feel valued, like an important part of the health-care team, and comfortable sharing personal information.

The IOM's first report, To Err is Human, was groundbreaking in that it identified..

medical errors as the leading cause of injury and unexpected death in health-care settings in the US. The purpose of the report was to present a strategy to improve health-care quality over the following 10 years. Contending that preventable adverse events result in up to 98,000 deaths annually, the IOM identified 3 domains of quality: patient safety, practice consistent w/current medical knowledge, and meeting customer-specific values and expectations. Additionally, the IOM determined that patient safety is a critical component of quality.

Relationship with quality improvement

monitoring and evaluating workflow and work processes using benchmarks to measure practice against established standards. Can include data collection and analysis but has no theoretical foundation.

The fundamental elements of evidence based practice are..

nursing research, the relationship w/quality improvement, clinical practice guidelines, and evidence based management.

"PIEQIS"

patient centered care interdisciplinary teams EBP quality improvement safety "PIEQIS"/pie crust haha

The IOM determined that ______ ______ is a critical component of quality.

patient safety

The overall goal for the QSEN project is to..

prepare future nurses with the knowledge, skills, and attitudes necessary to continuously improve the quality and safety of the health-care systems within which they work.

Evidence Based Practice

promotes best practices, clinical expertise, patients' values, and patients' circumstances in health-care decisions and avoids underuse, misuse, and overuse of care. IOM defines evidence based practice as, "integrating best research with clinical expertise and patient values for optimum care, and participating in learning and research activities to the extent feasible".

Empowerment definition

providing patients with access to information, support, resources, and opportunities that allow them to optimize their health and take part in decision making. As patient of patient-centered care, nurses are called to empower patients and their families to engage in self-care, decision making, and developing a plan of care. Empowerment is defined as, "patients' perceptions of access to information, support resources, and opportunities to learn and grow that enable them to optimize their health and gain a sense of meaningfulness, self-determination, competency, and impact on their lives".

Disparity definition

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.

patient centered care

recognition of the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patients' preference, values, and needs.

High reliability

refers to consistent performance at high levels of safety over time.

Advocacy definition

representing and/or speaking for patients when they cannot speak for themselves. Nurses have an ethical obligation to advocate for patients. The ANA Code of Ethics asserts, "the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient."

Human factors enginerring

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. Assumes that well designed processes and systems take into account human capabilities and limitations outside the control of those working with the processes and systems. Such limitations can be physical (such as noise, climate, lighting) cognitive (involving short-term memory capacity and fatigue), and organizational (such as job and task design). Poorly designed processes and systems can result in increased potential for errors and decreased patient safety.

The fundamental elements of quality improvement include..

structure or care environment, care process, and outcomes of care.

Reliability science

the ability of an operation to be failure or defect free over time. Reliability science is employing deliberate strategies that make it difficult for nurses to do the wrong thing and easy to do the right thing. By designing simplistic processes & systems that are standardized and redundant, defy error, avoid reliance on memory, and employ continuous vigilance, the goal of safe, quality pt. care can be realized. Simplicity and standardizing care can reduce the probability of errors by decreasing variability of care.

What is a major barrier to patient-centered care?

the ability to read, understand, and act on healthcare information or HEALTH LITERACY. The IOM defines health literacy as "the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.

Cultural Competence

the attitude, knowledge, and skills necessary for providing quality care to diverse populations. Nurses have a moral mandate to provide culturally competent care to all, regardless of gender, age, race, ethnicity, or economic status. Part of cultural competence consists of understanding and respecting diversity.

Low literacy skills are most prevalent among..

the elderly and the low income population. Unfortunately, those people most in need of health care are the least able to read and understand information for self-management.

The ANA's Code of Ethics for Nurses with Interpretive Statements establishes a primary commitment to the patient and the family and requires nurses to ensure the plan of care reflects..

the patient's wishes and individuality. In addition, nurse leaders and managers should work to ensure that the relevant parties are involved and have a voice in decision making about patient care issues.

Diversity definition

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. Diversity is more than having different religious views, cultural beliefs, and ethnic backgrounds; diversity can also include generational and gender differences.

What is the goal in a safety culture?

to balance accountability with the notion of "no blame" for errors. Transparency is critical in a safety culture. Staff must feel comfortable to report errors, near misses, and potential for errors.