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


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


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


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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


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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


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


19 UPMC ShadysideSchool of Nursing

“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?


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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


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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


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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

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Give

Med

s

Care

Confe

rence

Vital S

igns

Chart

Revie

wADL

Asses

smen

t

Comm

. w/ C

areT

eam

Patie

nt S

ervi

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Care

Rounds

Teac

hing C

are

Proce

sses

Comm

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atie

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Escort

Patie

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Repor

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Woun

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ICE /

Bever

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Comm

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amily

Inco

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Oc

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0

20

40

60

80

100

120

Pe

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(T

ota

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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

Documents

Building on Strength: Blending TCAB and QSEN