Building on Strength:
Blending TCAB and QSEN
Our Team
•
•
•
•
•
2
Deborah Struth, MSN, RN
Cheryl Carr, MSN, RN, CNE
Wendeline Grbach, MSN, RN, CCRN, CNLC
Alex Saladino, PhD
Linda Kmetz, PhD, RN
A Wonderful Opportunity…..
Doesn’t mean there won’t be
Challenges
3
4
5
6
TCAB Academic Partners – The Faculty
Team Facilitator: Patricia Chiverton, EdD, RN, FANP Dean, University of Rochester School of Nursing
7
Deborah Struth, MSN, RN
UPMC Shadyside School of Nursing
Berni Jordan, PhD, CRNP, FHCE
University of Pittsburgh School of Nursing
Kim Amer, PhD, RN
DePaul University
Linda Leach, PhD, RN
UCLA School of Nursing
Lorie Judson, PhD, RN
California State – LA
Deborah Cantero, MSN, ARNP
University of South Florida
Connie Overman BSN, RN
Sacramento State University
Geri L Wood, PhD, RN, FAAN
University of Texas, Houston
Bernadette Curry, PhD, RN, Dean
Molloy College
Denise Cundy
South Dakota State University
Linda Carpenter
University of Texas, Austin
Shelley Mitchell, MS, RN
Austin Community College
Carrie Thompson
Fox Valley Community College
Jen Basler
University of Wisconsin
UPMC Shadyside’s Faculty
Transformational Journey
• TCAB Team
• Faculty Retreat
• Test of Change Methodology
in Curriculum
• Deep Dive
• Faculty Vitality
Survey
8 UPMC Shadyside
School of Nursing
Patient Safety Objectives Addressed
through the ACGME Prism
• The resident will be able to :
– Recognize and understand team behaviors that
strengthen/weaken patient safety.
– Incorporate effective team behaviors into their practices.
– Identify errors in their practices, analyze them and learn from
them.
– Develop system-based strategies to prevent recurrence of
errors.
– Recognize and understand communication behaviors that
strengthen/weaken patient safety.
– Incorporate effective communication behaviors into their
practices.
– Provide appropriate disclosure to patients when errors occur.
QSEN
• Assumptions
– Each competency is broad and contains elements
of the others
Patient-centered care
Teamwork/collaboration
Quality improvement
11 UPMC Shadyside
School of Nursing
Safety
Informatics
Evidence-based
practice
Example: Teamwork and Collaboration
Function effectively within nursing and inter-professional teams, fostering
open communication, mutual respect and shared decision-making to achieve
quality patient care.
Knowledge
Skills
Describe examples of the
impact of team functioning on
safety and quality of care
Follow communication practices
that minimize risks associated
with handoffs among providers
and across transitions in care
Explain how authority
gradients influence
teamwork and patient
safety
Identify system barriers and
facilitators of effective team
functioning
UPMC Shadyside
School of Nursing
Assert own perspective
(using SBAR or other team
communication models)
Participate in designing systems
that support effective teamwork
Attitudes
Appreciate the risks
associated with handoffs
among providers and across
transitions in care
Value the influence of system
solutions in achieving effective
team functioning
Example: Safety
Minimizes risk of harm to patients and providers through both system
effectiveness and individual performance.
Knowledge
Discuss effective strategies for
reducing reliance on memory
Describe processes used in
understanding causes of
error and allocation of
responsibility (such as, root
cause analysis)
Skills
Use appropriate strategies for
reducing reliance on memory
(such as, forcing functions and
checklists)
Use organizational error
reporting systems for near
miss and error reporting
Engage in root cause analysis
rather than blaming when errors
or near misses occur
UPMC Shadyside
School of
Attitudes
Appreciate the cognitive and
physical limits of human
performance
Value own role in preventing
errors
Value vigilance and monitoring
(even of own performance of
care activities) by patients,
families, and other members of
the health care team
Blending:
• Transforming Care at the
Bedside (TCAB)
–
–
–
–
–
14
Patient Centered Care
Value Adding
Vitality and Teamwork
Safety and Reliability
Transformational
Leadership
• Quality and Safety
Education for Nurses
(QSEN)
–
–
–
–
–
–
Safety
Patient-centered care
Teamwork/collaboration
Informatics
Quality improvement
Evidence-based practice
TCAB:
• “While there were a wide range of changes
being tested, sustained, and spread in
participating hospitals, participants repeatedly
emphasized in our interviews that the change in
unit culture and engagement of front line staff in
improvement activities were central to their
TCAB experience…no single innovation made
a difference. Rather it was the process of
TCAB, that made a difference.” Jack Needleman, PhD, FAAN
15
Initial Areas of Program
Development
• Incorporation of Crew Resource Management
principles
• Investigation of clinical education utilizing Work
Sampling Methodology of faculty and students
• Curricular additions of Human Patient Simulation
• Incorporation of teamwork and safety utilizing
TeamSTEPPS curriculum
16
UPMC Shadyside
School of Nursing
N101: Introduction to Professional Nursing
Teaching Activities
• Relationship-Based Care
introduced and integrated
throughout course
• Lab: Hospital of the Future:
emphasizes need for effective
communication, teamwork, rapid
response, a caring and healing
environment, and TCAB initiatives
Relationship-Based Care: A Model for
Transforming Practice Creative Health Care
Management. Koloroutis, Mary, (2004).
17
UPMC Shadyside
School of Nursing
N102: Introduction to Nursing
Practice Strategies
Teaching Activities
• SBAR-R
• 60 Second “Situational
Assessment”
• High-fidelity Patient
Simulation
18 UPMC Shadyside
School of Nursing
“60
Second”
Situational
Assessment
Tool
19
UPMC Shadyside
School of Nursing
S B A R
REPORTING
SBAR-R
SB
A
AR
ASSESSMENT
Most recent vital signs:
BP ________________________
Pulse ______________________
Respirations ________________
Temperature ________________
The patient IS or IS NOT on oxygen
Any changes from prior assessments:
BE F ORE C AL L I NG
1. Assess the patient
2. Review the chart for the appropriate
physician to call
3. Know the admitting diagnosis
4. Read the most recent Progress Notes
and the assessment from the prior
shift.
5. Have available when speaking with
the physician:
Chart, Allergies, Meds, IV fluids,
labs/results, Code status
S
SITUATION
State your name and unit I am calling
about:
(Patient Name & Room Number)
The problem I am calling about is:
Briefly state the problem,
- what it is,
- when it happened or started and,
- how severe
B
BACKGROUND
State the admission diagnosis and
date of admission
20
UPMC Shadyside
School of Nursing
Mental Status
Respiratory rate/ quality
Retraction / use of accessory muscles
Skin Color
Pulse/ BP rate/ quality
Rhythm changes
Neuro changes
Pain
Wound drainage
Musculoskeletal (joint deformity, weakness)
GI/ GU (Nausea/ Vomiting/ Diarrhea/ Output)
R
R E C OMM E N D A T I ON
Do you think we should…:
(State what you would like to see done)
Transfer the patient to ICU or PICU?
Come to see the patient at this time?
Talk to the patient and/ or family about the code status?
Ask for a consultant to see the patient now?
Use “CUS” words:
Concern - Uncomfortable - Safety
Other suggestion?
Are any tests needed?
Do you need any tests like
CXR
CBC
ABG
BNP
EKG
Others?
If a change in treatment is ordered, then ask:
How often do you want vital signs?
State the pertinent medical history
A Brief Synopsis of the treatment to
date
If then the patient does not improve, when would
you want us to call again?
N300: Nursing Practice Strategies
Pediatrics/Obstetrics/Mental Health/Critical Care
• Eight-hour day high-fidelity high
risk simulation experiences
every 8 weeks
• Student and faculty members
utilize SBAR-R for
communication pathways
throughout the scenarios
• Pre- and post-test evaluations
related to problem-based
scenario with improvements
noted
21
UPMC Shadyside
School of Nursing
N400: Professional Role Transitions
Teaching Activities
• Student driven test of change
projects designed to identify
practice system vulnerabilities
which impact patient safety and
develop action plans for best
practice solutions
• Students utilize SBAR-R
when collaborating with healthcare team members
• Students perform open chart audits to identify patient risk using
Global Triggers tool
22
UPMC Shadyside
School of Nursing
N200 Level Courses: PDA Time
Study
• Goal: Redesign of Clinical Education into
Structured Standardized Clinical Education
Curricula
• PI Methodology
–
–
–
–
–
23
Collect data regarding current process – TCAB
Validate assumptions – TCAB Observation Process
Involve workers in redesign
Prototype: Rapid Cycle Tests of Change
Adopt, Adapt or Abandon
Definitions
• TCAB: All care processes are free of waste and
promote continuous flow – Muda
– Value added nursing care
– Necessary but not necessarily value added
– Non-value added nursing care
24
What the study is…
• A form of work/self sampling designed to
give minutes back to the clinical instructor
and the student
• Using the latest technology, adapted for the
education environment.
25
What is getting in the way?
•
•
•
•
26
Barriers
Work around
Broken processes
Time eaters
Faculty Engagement
• Presented study idea at Nursing 200 (Medical
Surgical Nursing) Faculty Retreat
27
Time Study Features
•
•
•
•
•
•
28
Easy to use interface redesigned for
education
Study is conducted with minimal
distraction
Detailed category list developed by
instructors
Over 80 hospitals currently using for RN
studies
Statistical software automatically provides
analysis-in the form of pie charts, stack
charts, pareto charts and tabular output
Original program designed for IHI TCAB
initiatives
Randomly Selected Clinical Instructors
and Students
29
Methodology
• Each week, 2 random faculty and 2 random students
carry a PDA to their clinical site.
• 8 hour day on Wednesday and Thursday
• The PDAs are returned to the school for downloading
of data and subsequent “turnaround” to the next 4
people carrying them.
• System analyst assists in organizing the data into
graphs and pareto charts.
30
Data Points
• Approximately 10-14
data points are
captured in an 8 hour
clinical day
• Goal – 300 data
points/semester
31
How Medical-Surgical Clinical Faculty Spend their Time: UPMC Shadyside Work Sampling Data through 060608
Necessary
40.9%
Value-Adding
41.8%
Non-Value-Adding
17.3%
32
Necessary Activities Completed by the Instructor
(These activities are necessary, but not necessarily value added)
Observing Student Meds Prep/Admin
Documentation
Clinical Conference
Admin/ Training
Teaching Student Documentation
Computer Data Entry
Deliver Supplies
33
Necessary Activities Completed by the Instructor
(These activities are necessary, but not necessarily value added)
97.7
80
99.5
100.0
100
94.0
88.9
90
Occurrence
67.6
70
60
40
50
35.2
40
30
20
20
10
0
0
Observing Student
Meds Prep/Admin
34
Documentation
Clinical Conference
Admin/ Training
Teaching Student
Documentation
Computer Data Entry
Deliver Supplies
Percentage (Total)
80
60
How Student Nurses Spend their time on MedicalSurgical Units: Work Sampling through 060608
Necessary
28.2%
Value-Adding
43.9%
Non-Value-Adding
27.8%
35
Value Added Direct Care Activities Completed by the Student: Work Sampling Data Through 060608
Prepare Meds
Bedside Procedures
Give Meds
Care Conference
Vital Signs
Chart Review
ADL
Assessment
Comm. w/ CareTeam
Patient Services
Care Rounds
Teaching Care Processes
Comm. w/ Patient
Escort Patient
Report
Wound Manage
ICE / Beverage
Comm. w/ Family
Incontinence
36
37
Pr
ep
ar
e
ed
s
M
ss
e
A
DL
C
ev
e
ra
ge
m
.w
/F
am
In
ily
co
nt
in
en
ce
om
/B
an
ag
e
40
98.1
99.0
68.6
73.3
80
61.9
54.3
60
45.7
31.9
40
10
16.7
20
0
0
Percentage (Total)
96.7
E
M
84.8
95.2
IC
81.4
92.9
ep
or
t
78.1
90.5
R
30
87.6
W
ou
nd
ss
m
m
.w
en
t
/C
ar
eT
Pa
ea
tie
m
nt
Se
rv
ic
Te
es
C
ac
ar
hi
e
ng
R
ou
C
nd
ar
e
s
Pr
oc
C
es
om
se
m
s
.w
/P
at
ie
Es
nt
co
rt
Pa
ti e
nt
om
A
oc
ed
ur
es
G
iv
e
C
M
ar
ed
e
s
C
on
fe
re
nc
e
Vi
ta
lS
ig
ns
C
ha
rt
Re
vi
ew
ed
si
de
Occurrence
20
C
B
Pr
Value Added Direct Care Activities
Completed by the Student
120
99.5 100.0
100
Non-Value Added Activities Completed by the Student: Work Sampling Data through 060608
Look for Equipment
Look for Info
Look for Person
Look for Supplies
Other
Personal Time
Waiting Delay
Waiting Instructor
Waiting Student
38
The Redesign:
• Improvement Specialists to observe and clarify PDA
data.
• Situational Assessment adapted to meet clinical
judgment expectations of the student nurse in the
medical-surgical environment.
• Dissemination
• Redistributing clinical unit based hours to simulation
center
• N200 level team to design idealized medical-surgical
clinical curricula, incorporating QSEN competencies
39