Developing and Maintaining Quality
and Safety Competencies
Linda Cronenwett, PhD, RN, FAAN
Professor and Former Dean
Co-Director, RWJF Executive Nurse Fellows
THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL
General Aim for Health Professions
(Paul Batalden, IHI Co-Founder)
To prepare health professionals — as part of their usual
professional formation — to lead the continual
improvement of the quality, safety and value of health
care:
 to know how to identify good care from the scientific
evidence
 to know the actual measured performance in the
context where the health professional is
learning/practicing, and the nature of the gaps — if any
— between good care and actual local care, and
 to know what activities are necessary — if any — to
close the gap(s).
What is the new work of nursing and other
health professionals?
Quality and safety cultures require new
ways of thinking, specifically inviting
nurses and others to:
 Keep the patient experience of care the




primary focus for all decisions
Understand and apply the basics of safety
sciences
Use systems thinking
Adhere to evidence-based guidelines and
interventions
Embrace continuous quality improvement
as part of daily work
Continuum of Systems Thinking
What does it mean to be a good nurse?
I will
turn my
patient
I will post a
note above
the bed to
remind others
I will ask other
nurses about
products to
prevent ulcers
I will look at
the ulcer
rate on our
unit
I will compare
our unit ulcer
rate with
benchmarks
From: M. Dolansky & S.Moore. Systems
Thinking Scale, available at:
http://fpb.case.edu/systemsthinking/sts.shtm
End goal (Cronenwett)
I will work with others
to improve our unit’s
ulcer rate
Patient Centered Care
QSEN Definition:
Gaps:
• Need to know patient
values and preferences
Recognize the patient or
designee as the source of • Need to welcome patient
and families as partners in
control and full partner in
providing compassionate ensuring safety
• Need to ensure that patient
and coordinated care
and family needs are
based on respect for
microsystem’s top priority
patient's preferences,
• Need to coordinate
values, and needs.
complex care with multiple
caregivers
Teamwork and Collaboration
QSEN Definition:
Gaps:
• Need training in team and
Function effectively in
nursing and interprofessional teams,
fostering open
communication, mutual
respect, and shared
decision-making to achieve
quality patient care
team-based care
• Need to value patient and
family members as
essential parts of the health
care team
• Need to appreciate the role
of communication in errors
and near misses
• Need to value and earn
respect of team members
Evidence-based Practice
QSEN Definition:
Gaps:
• Need to approach practice
Integrate best current
evidence with clinical
expertise and
patient/family
preferences and values
for delivery of optimal
health care
with a spirit of inquiry
• Need to know how to
identify good care from
scientific evidence
• Need to scan sources of
new knowledge relevant to
one’s practice
• Need to develop expertise
in balancing evidence,
clinical expertise and
patient values and
preferences when planning
care
Quality Improvement
QSEN Definition:
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
Gaps:
• Need to own accountability
for practice of one’s
microsystem
• Need to know how the
actual care in one’s
microsystem compares to
best practice
• Need to use quality
improvement methods to
close gaps between actual
local care and good care
Safety
QSEN Definition:
Minimize risk of harm
to patients and
providers through
both system
effectiveness and
individual
performance
Gaps:
•
•
•
Need to know how to create
and support “just cultures”
and “safety cultures”
Need to learn from open
reporting about adverse
events, errors, and near
misses
Need to support a culture
that holds teammates
accountable for reliable
attention to safety practices
Informatics
QSEN Definition:
Gaps:
• Need improved EHRs and
Use information and
technology to
communicate, manage
knowledge, mitigate
error, and support
decision making
alert systems
• Need to understand the
errors that are likely to be
introduced with new
technologies and minimize
risks
• Need involvement in design
and evaluation of knowledge
management and
communication systems
Embracing System-Level Quality and Safety
 What does it take to embrace
continuous improvement efforts as a
part of one’s daily work?
Answers (like the problem) found at both
individual and systems levels
Current Definitions of Daily Work
 What constitutes daily work?
 What constitutes “add-on work”?
For:
 APRNs
 Nurses in basic practice
 Nurses in administrative positions
 Faculty members
Triangle of Professional Aims
Better
professional
development
Better outcomes
(individuals, communities)
(competence, joy, mastery)
Better
system
performance
(quality, safety, value)
From Batalden & Foster (2012). Sustainably improving health care.
Radcliffe: London and New York.
Professional Aims: Current Silos
Nursing Careers
Better outcomes
Better system performance
Better professional development
Cronenwett, L. & Ironside, P. (2012). Triangle synergies in a national quality and
safety education initiative in nursing. In Batalden & Foster (Eds). Sustainably
improving health care. Radcliffe: London and New York, pp. 159-174.
Barriers to Linking Aims Among Faculties
 Limited (if any) accountability for patients




or systems of care
Limited (if any) understanding of
improvement science
Collegiate institutional rewards not aligned
with patient care or system performance
Scientists rewarded for laser focus on
research and scholarship
Relatively new discipline to academe
Barriers to Linking Aims for Practitioners
 Education focused almost solely on
patient care
 Limited (if any) accountability for
professional development
 Limited preparation for leading system
improvements
 Freedom to engage in precepting students
limited by employers
Barriers to Linking Aims for Administrators
 Limited (if any) accountability for




professional development
Limited (if any remaining) expertise in
patient care
Need to exert self in midst of other
powerful administrators
Salaries make movement across the
Triangle unlikely
Focus on continued professional
development of staffs rather superficial