Download - Building on Strength: Blending TCAB and QSEN
Building on Strength:
Blending TCAB and QSEN
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Our Team
• Deborah Struth, MSN, RN • Cheryl Carr, MSN, RN, CNE• Wendeline Grbach, MSN, RN, CCRN, CNLC• Alex Saladino, PhD• Linda Kmetz, PhD, RN
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A Wonderful Opportunity…..
Doesn’t mean there won’t be Challenges
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TCAB Academic Partners – The FacultyTeam Facilitator: Patricia Chiverton, EdD, RN, FANP Dean, University of Rochester School of Nursing
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
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UPMC Shadyside’s Faculty Transformational Journey
• TCAB Team• Faculty Retreat• Test of Change Methodology
in Curriculum• Deep Dive• Faculty Vitality
Survey
UPMC ShadysideSchool 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.
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QSEN
• Assumptions– Each competency is broad and contains elements
of the others
Patient-centered care Safety
Teamwork/collaboration Informatics
Quality improvement Evidence-based
practice
UPMC ShadysideSchool of Nursing
Example: Teamwork and CollaborationFunction effectively within nursing and inter-professional teams, fostering
open communication, mutual respect and shared decision-making to achieve quality patient care.
Knowledge Skills Attitudes
Describe examples of the impact of team functioning on safety and quality of care
Explain how authority gradients influence teamwork and patient safety
Identify system barriers and facilitators of effective team functioning
Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care
Assert own perspective (using SBAR or other team communication models)
Participate in designing systems that support effective teamwork
Appreciate the risks associated with handoffs among providers and across transitions in care
Value the influence of system solutions in achieving effective team functioning
UPMC ShadysideSchool of Nursing
Example: SafetyMinimizes risk of harm to patients and providers through both system
effectiveness and individual performance.
Knowledge Skills Attitudes
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)
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
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
UPMC ShadysideSchool of Nursing
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Blending:
• Transforming Care at the Bedside (TCAB)– 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
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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
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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
UPMC ShadysideSchool of Nursing
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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
UPMC ShadysideSchool of Nursing
Relationship-Based Care: A Model for Transforming Practice Creative Health Care
Management. Koloroutis, Mary, (2004).
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N102: Introduction to Nursing Practice Strategies
Teaching Activities• SBAR-R • 60 Second “Situational
Assessment”• High-fidelity Patient
Simulation
UPMC ShadysideSchool of Nursing
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“60 Second”Situational Assessment Tool
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SBAR-RS B A R REPORTING
S S I TU A T ION
B B A C K GR OU ND
A A S S E S S ME NT
R RECOMMENDATION
SB AR
B E F O R E C AL L I N G 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
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
State the admission diagnosis and date of admission
State the pertinent medical history
A Brief Synopsis of the treatment to date
Most recent vital signs: BP ________________________
Pulse ______________________
Respirations ________________
Temperature ________________
The patient IS or IS NOT on oxygen
Any changes from prior assessments: 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)
Do you think we should…: ( S ta te wh a t y ou wo u ld l i k e t o se e do ne ) 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 ABG EKG CBC BNP Others?
If a change in treatment is ordered, then ask: How often do you want vital signs?
If then the patient does not improve, when would you want us to call again?
UPMC ShadysideSchool of Nursing
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N300: Nursing Practice StrategiesPediatrics/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
UPMC ShadysideSchool of Nursing
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N400: Professional Role Transitions
Teaching Activities• Student driven test of change
projects designed to identify practice system vulnerabilitieswhich 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
UPMC ShadysideSchool of Nursing
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N200 Level Courses: PDA Time Study
• Goal: Redesign of Clinical Education into Structured Standardized Clinical Education Curricula
• PI Methodology– 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
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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
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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.
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What is getting in the way?
• Barriers• Work around• Broken processes• Time eaters
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Faculty Engagement
• Presented study idea at Nursing 200 (Medical Surgical Nursing) Faculty Retreat
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Time Study Features
• 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
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Randomly Selected Clinical Instructors and Students
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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.
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Data Points
• Approximately 10-14 data points are captured in an 8 hour clinical day
• Goal – 300 data points/semester
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How Medical-Surgical Clinical Faculty Spend their Time: UPMC Shadyside Work Sampling Data through 060608
Necessary40.9%
Non-Value-Adding17.3%
Value-Adding41.8%
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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
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Necessary Activities Completed by the Instructor(These activities are necessary, but not necessarily value added)
35.2
67.6
88.994.0
97.7 99.5 100.0
0
20
40
60
80
Observing StudentMeds Prep/Admin
Documentation Clinical Conference Admin/ Training Teaching StudentDocumentation
Computer Data Entry Deliver Supplies
Occ
urre
nce
0
10
20
30
40
50
60
70
80
90
100
Per
cent
age
(Tot
al)
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Necessary28.2%
Non-Value-Adding27.8%
Value-Adding43.9%
How Student Nurses Spend their time on Medical-Surgical Units: Work Sampling through 060608
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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
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Value Added Direct Care Activities Completed by the Student
16.7
31.9
45.7
54.3
61.9
68.673.3
78.181.4
84.887.6
90.5 92.9 95.2 96.7 98.1 99.0 99.5 100.0
0
10
20
30
40
Prepar
e M
eds
Bedsi
de P
roce
dures
Give
Med
s
Care
Confe
rence
Vital S
igns
Chart
Revie
wADL
Asses
smen
t
Comm
. w/ C
areT
eam
Patie
nt S
ervi
ces
Care
Rounds
Teac
hing C
are
Proce
sses
Comm
. w/ P
atie
nt
Escort
Patie
nt
Repor
t
Woun
d Man
age
ICE /
Bever
age
Comm
. w/ F
amily
Inco
ntin
ence
Oc
cu
rre
nc
e
0
20
40
60
80
100
120
Pe
rce
nta
ge
(T
ota
l)
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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
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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