A new vision for quality and
safety: Developing new
science to change practice
Gwen Sherwood, PhD, RN. FAAN
University of North Carolina at Chapel Hill
School of Nursing
Professor and Associate Dean for Academic Affairs
Shandong University October 2011
Knowledge development

We identify and integrate knowledge in
nursing in many ways.

Often knowledge development happens
because of a gap, recognition that we are
not providing optimal care, or we realize
knowledge in other fields may be applied
to nursing and healthcare.
Sources of knowledge

Knowledge development comes from:
Empirical
 Affective
 Legal and ethical
 Personal (Carper, 1978


May come from theoretical concepts or
observations in practice that are tested by
research
Building an evidence base

When knowledge is accepted into practice
or education, it begins a paradigm shift as
the ideas are adopted across the
profession.

Example of new knowledge to change the
paradigm
Quality and safety data challenged traditional
practices in health care
 Proposed new responsibilities for nurses

Data: IOM Quality Chasm Series

To Err Is Human: Building a Safer Health System
(2000) (all are available www.IOM.org)

Crossing the Quality Chasm: A New Health System
for the 21st Century (2001)

Health Professions Education: A Bridge to Quality
2003

Patient Safety: Achieving a New Standard for Care
(2004)

Identifying and Preventing Medication Errors (2006)
Operational Definitions

Quality Improvement (QI): using data to monitor
outcomes of care processes which help guide
improvement methods to design and test changes
in the system to continuously improve the quality
and safety. It is measuring what is the reality and
comparing with benchmarks or the ideal.

Safety science: Minimize risk of harm to patients
and providers through both system effectiveness
and individual performance by applying human
factors in the new safety science
Quality in Health Care

U.S. hospitals began adopting quality
improvement and safety science methods
in the late 1990’s, yet we are only now
integrating Quality Improvement in nursing
curriculum.

Poor communication contributes to 70% of
health care errors, yet nurses and
physicians have few educational
experiences together.
Staggering reports of poor quality from
around the world
Data in U.S. shows that:
 On average a hospital patient may have at
least one medication error per day
 At least 1.5 million preventable adverse
drug events occur each year
 Contributes to the loss of trust in the
system

Identifying and Preventing Medication Errors
(IOM, Cronenwett et al 2006)
New ways to think about Quality

Health care lags behind other high
performance industries in quality
improvement and safety monitoring.

Hospitals are applying system perspectives
to question traditional practices and
measure outcomes to analyze errors to
understand why something happened

Nurses need knowledge, skills and attitudes
to apply systems thinking.
Quality and Safety are Global
Concerns

United Kingdom: The Center for Advancement of
Inter-professional Education

Japan: The National Institute for Public Health

World Health Organization World Alliance for
Patient Safety and Collaborating Centre

Similar work in Australia and Sweden
China

Are these ideas relevant in China?

Describe the state of application of quality
and safety in China?

What are quality and safety issues in
health care?

What are sources of information?
Emphasis on improving
quality of health care
Focus on quality improvement in health care
organizations
Improves patient care outcomes
Helps improve the work
environment: people want to work in
organizations that emphasize quality
Survey: Quality impacts the work
environment
Hospitals nationally recognized for quality
 healthier work environments
 higher levels of job satisfaction .

(American Association of Critical-Care Nurses (AACN), CQ HealthBeat)
Quality affects nurse
satisfaction and retention.
It makes economic sense.
6 competencies
to transform systems to improve
quality and safety
Patient
centered
care
Evidence
Based
practice
Quality and Safety Education for
Nurses (QSEN)

Principal Investigator: Linda Cronenwett
 Co-Investigator: Gwen Sherwood
 National expert panel and pedagogical experts

Funded by the Robert Wood Johnson Foundation for the
University of North Carolina at Chapel Hill
2005-2007 Pre-licensure Education
2007-2009 Graduate Education and Pilot
School Collaborative
2009-2012 Faculty Development


www.qsen.org
To build the evidence on quality
and safety education







National Survey of Schools for current
application
Focus groups to assess survey findings
15 Pilot School Collaborative
Delphi Technique to determine placement
in curriculum
Student Self Assessment Survey
Faculty Development
Research to confirm
Framework
All health professionals should be
educated to deliver patient-centered
care as members of interdisciplinary
teams, emphasizing evidence-based
practice, quality improvement,
[safety], and informatics.
Committee on Health Professions Education
Institute of Medicine (2003)
Survey of Schools to determine
what was being taught
 Faculty
report needing the most
help developing content and
learning experiences and report
students have less achievement in
these areas:
 Evidence
Based Practice
 Quality Improvement
 Informatics
QSEN Survey Data

Patient-centered care, Teamwork and
Collaboration, and Safety ranked
highest for:
 Inclusion in content and learning
experiences
 Satisfaction with students’
competency achievement, and
 Faculty expertise to teach
However, Focus Group Feedback



Faculty reported lack of knowledge of many KSAs
(particularly safety, informatics and QI); “we’re not
doing it – but we want to - tell us how”
Students/new grads said ‘Not only did we not learn
this content, our faculty could not teach it”
Faculty report that nursing students may graduate
without having had a meaningful patient-centered
conversation with a physician

Reported in Nursing Outlook, May June 2007
Could we teach the competencies?

15 schools selected for a Learning
Collaborative
Complete content mapping to determine state
of their curriculum matches with the KSAs that
define the competencies
 Design innovative strategies to incorporate
into curriculum
 Assess student achievement and pedagogies
 Share their experiences


Achieve consensus on graduate KSAs
Competency definitions:
 Patient-centered
care:
Recognize the patient or designee
as the source of control and full
partner in providing
compassionate and coordinated
care based on respect for patient’s
preferences, values, and needs

Nursing Outlook, 2007
Current clinical applications:
Patient-centered Care

Patients and family
are partners in care

Diversity

Multicultural

Values and health
beliefs
Competency Definitions
 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

Nursing Outlook, 2007
Clinical application:
Human factors

Care delivered by interdisciplinary teams
yet education geared towards individual
responsibilities in solo experiences

Challenges to teamwork:
 Complex care coordination,
 Safe handling between providers,
 Communication across hierarchy

Standardized communication techniques
insure sharing critical information (SBAR)
Competency definitions:
 Evidence-based
practice:
Integrate best current
evidence with clinical
expertise and
patient/family preferences
and values for delivery of
optimal health care
Nursing Outlook, 2007
Practice realities:
Evidence-based practice

Standards based on
evidence and known
best practices

Quality assesses
actual care patients
receive against
established
benchmarks

Goal: Knowledge
workers who ask
questions about
practice and
constantly search for
new evidence

Involve students and
faculty in data base
searches
Competency definitions:
 Quality
improvement:
Use data to monitor the outcomes
of care processes and use
improvement methods to design
and test changes to continuously
improve the quality and safety of
health care systems
Nursing Outlook, 2007
Applications in practice:
Quality improvement
Quality improvement strategies may use the
following:
 Satisfaction measures
 Nurse sensitive measures
 Compare benchmarks with other systems
Competency definitions:

Safety:
Minimize risk of harm
to patients and
providers through both
system effectiveness
and individual
performance
Nursing Outlook, 2007
New views of Safety

Safety science: applying human factors to
system analysis of error and adverse events

“just culture:” open reporting and learning
from adverse events and near misses
 Root
cause analysis to investigate
incidents for system design flaws to
minimize error potential
Competency definitions:
 Informatics:
Use information and technology
to communicate, manage
knowledge, mitigate error, and
support decision making
Nursing Outlook, 2007
Informatics in the work place

Electronic record systems

Computer order entry systems that provide
decision support and help flag errors

Search for and evaluate information sources

Evaluate technologies for their potential to cause
or mitigate error.

Design and evaluate relevant products
Delphi Study for placement of
competencies in the curriculum
(N=18 QSEN experts)

Implement as curricular threads

Early curriculum: individual patient
Later: teams and systems
Advanced courses: complex concepts






Teamwork and collaboration
Evidence-based practice
Quality improvement
Informatics

Barton et al, Nov-Dec 2009 Nursing Outlook
Student Evaluation Survey (SES)
Nov-Dec 2009 Nursing Outlook




17 schools ADN, BSN, diploma, students = 575
Content covered least
 Teamwork and collaboration, Quality improvement
Least skills:
 Evidence based practice
 Reporting errors for root cause analysis
Least attitude:

Use quality improvement tools

Locate evidence reports for clinical practice guidelines

Evaluate the effect of practice changes using QI
How did students learn?
TeamSTEPPS: Team Strategies and Tools to
Enhance Performance and Patient Safety
Multi-media public domain curriculum from
AHRQ.gov to teach team coordination
competencies based on human factors
TeamSTEPPS Curricular Framework
Skills
…team
performance is
a science…
consequences
of errors are
great…
Knowledge
Cognitions
“Think”
38
Behaviors
“Do”
Attitudes
Affect
“Feel”
Four Cohorts N = 438
Matched nursing (196) and medicine (233)

Small Groups, 2
strategies
10 High Fidelity
Human Simulation
(n = 80)
10 Role-Play
(n = 79)

Large Groups, 2
strategies
Lecture & Audience
Response
(n = 139)
Traditional Lecture
(n = 140)
4 Assessment Tools

12- item teamwork knowledge test

36-item teamwork attitudes instrument

10-item standardized patient (SP)
evaluation of four-student teamwork skills

10-item modification of Malec et al. (2007,
Sim Healthcare 2:4-10) Mayo High
Performance Teamwork Scale (HPTS).
Sample CHIRP Attitudes Items
I do not
I
agree at all somewhat
agree
1
#
2
Statement
I fairly
much
agree
I very
much
agree
I
completely
agree
3
4
5
My Attitude
Before After
Activity Activity
1 I must consider the interests of every
1 2 3 4 51 2 3 4 5
professional, patient, and family member
involved in a medical decision.
2 Pharmacists, nurses, physicians, social 1 2 3 4 5 1 2 3 4 5
workers and other health care
professionals are of equal importance in
providing patient care.
Sample Webcast Evaluation Items
I do not
agree at
all
I
somewha
t agree
I fairly
much
agree
I very
much
agree
I
completel
y agree
1
2
3
4
5
Statement
Response
I should work at recognizing multiple sources of
potential errors in every patient case.
1 2 3 4 5
It is okay for team members to monitor each
other’s actions.
1 2 3 4 5
Each healthcare team member should challenge a
decision if they are uncomfortable with it.
1 2 3 4 5
The podcast made me rethink my approach to
patient care.
1 2 3 4 5
The podcast was useful for my professional
development.
1 2 3 4 5
Teamwork Knowledge Results
Knowledge test results
12
Mean score
10
8
Pre-test
Post-test
6
4
2
0
Simulation
Role play
ARS
Training condition
Lecture
Results:
1.
High fidelity interactive training was not
more effective a low fidelity environment.
2.
Participation in interactive training in small
groups was not more effective than in large
groups.
3.
Large group interactive training exercises
were not more effective than training with
only lectures without interactive exercises.

Study #2 on the best
methods to teach
teamwork within a
safety framework.
What is the impact of an educational
intervention using video and interactive small
groups on interprofessional teamwork KSAs?
Framework: Effective Team Leaders
•
•
•
•
Organize the team
Articulate clear goals
Base decisions on collective member input
Empower members to speak up and
challenge, when appropriate, call a huddle
• Skillful at conflict resolution
• Team Activities:
• Briefs – planning
• Huddles – problem solving
• Debriefs – process improvement
Figure 2. Research Design for UNC Year Two
March 3
Experimental Group n = 80 Medical
Students and n = 80 Nursing Students
at separate time. 6 groups (1B-5B, 1A)
of approximately 32 students each.
Each group will be further subdivided
into 4 role-play groups of 8 students
each. (Note: Group 1B will follow this
sequence on March 3 because of
Accelerated Nursing schedule)
Knowledge Test, Part One
March 6
Control Group n = 80 Medical Students
and n = 80 Nursing Students. 4 groups
(2A-5A) of approximately 32 students
each. Each group will be further
subdivided into 4 role-play groups of 8
students each.
Control Group will receive
combined Knowledge Test, Parts
One and Two, as well as the
Retrospective Teamwork Attitudes
Pre-Posttest.
Educational Interaction:
All n = 340 students over the course of a week:
1. Podcast followed by the Podcast Evaluation
Instrument
2. Group role-play exercises (4 students on, 4
students observing/scoring the
Video&RolePlay Checklist, then switch and
repeat).
3. Students view and rate aspects of a prepared
teamwork video scenario using a duplicate
Video&RolePlay Checklist .
Knowledge Test, Part Two plus the
Retrospective Teamwork Attitudes
Pre-Posttest.
Experimental Group Finished
Control Group
Finished
Course
Evaluation
Design

All students: pre-test and one hour TeamSTEPPS
Podcast/Webcast lecture
•
Small groups: trained facilitators led case study using low
fidelity simulation role-play, watched video and completed a
rating scale of team behaviors, and discussed observations,
and then completed the post-test.

Control group: completed the post-test instruments before
completing the interactive exercises.

Experimental group: completed the post-test instruments
after the interactive exercises
Results

Both groups improved at the
same rate

Nurses improved at higher
levels than medicine

Achieved the goals of



Improve Communication
Improve Respect for other
Disciplines
Improve Patient Safety
There are always questions!

Which methods promote sustained behavior
change over time?

When is the best time to place in the
curriculum?

Which are the best matches for level of
education across the health professions?

What instruments are needed to produce
more discreet metrics?
Paradigm Shift

Many other studies are testing other parts of the
theoretical concepts for the 6 competencies
defining quality and safety in health care

No single study confirms a theoretical model, but
synthesis of the results can be used to change
education and practice

By applying standards for evaluating evidence,
we can make decisions for change.
Evidence based changes in nursing

Policy changes:


Curricular changes


The 6 quality and safety competencies are
now integrated in the national standards for
nursing education at both the National League
for Nursing and at the Association for
Colleges of Nursing
Many schools have adopted the framework as
the organizing thread for their curriculum
Hospitals are implementing changes in
nurse roles and responsibilities
Education and practice

Research derives from question in practice

Testing for confirmation to determine
evidence based helps lead to changes in
education and practice.

Working together in partnership both
education and practice can improve health
outcomes