Application of QSEN as a Curriculum Model for Linking Doctor of Nursing Practice (DNP) Capstones to Quality & Safety Carol M. Patton, Dr. PH, RN, CRNP, FNP-BC, CNE, Healthcare Informatics Certificate, Parish Nurse, DNP(c) 724 825 3145 EDT patton@windstream.net

Purpose The purpose of this presentation is to enable the learner to discuss evidence-based findings of the DNP Capstone project, examine the American Association of Colleges of Nursing (AACN) DNP essentials regarding guidance for the DNP Capstone and examine linkages between DNP Capstone Projects to Quality and Safety Education for Nurses (QSEN) to improve patient quality and safety in a variety of healthcare environments.

Objectives At the end of this session the participant will: Identify two strategies for linking DNP Capstone Projects to quality and safety initiatives in diverse healthcare delivery settings Have increased awareness and sensitivity to QSEN for DNP Capstone Projects focusing on patient- centered care, teamwork and collaboration, evidence-based practice, quality improvement & safety, and informatics

Objectives (Continued) Examine a model for engaging DNP learners in conversation with diverse healthcare delivery settings related to DNP Capstone Projects linked to QSEN initiatives Examine strategies to assist learners to link with a variety of healthcare organizations in which to develop strategies and partner with healthcare personnel for the DNP Capstone Project

AACN DNP Essentials Related to the DNP Capstone Project – Requirements for DNP Programs Essential 1 1. Scientific underpinnings for practice: Programs must provide adequate content on life processes and functions of the body.

Essential 2 2. Organizational and systems leadership for quality improvement and systems thinking: DNP graduates must be knowledgeable about patients on individual, population and community levels to help create new health care delivery models.

Essential 3 3. Clinical scholarship and analytical methods for evidence-based practice: DNP graduates must be able to put research into practice.

Essential 4 4. Information systems or technology and patient care technology for the improvement and transformation of health care: DNP graduates should know how to evaluate programs and information systems to best care for patients as well as to evaluate ethical and legal issues surrounding health care technology.

Essential 5 5. Health care policy for advocacy in health care: DNP programs should prepare graduates to take on leadership roles in political action to promote patient care as well as the nursing profession.

Essential 6 6. Interprofessional collaboration for improving patient and population health outcomes: DNP programs should contain content to prepare students for working in and creating collaborative health care teams.

Essential 7 7. Clinical prevention and population health for improving the nation’s health: DNP graduates should be able to provide risk reduction and illness prevention for patients and families as well as entire populations.

Essential 8 8. Advanced nursing practice: DNP programs should provide education for mastery in one specialty area of nursing practice.

Overview of Quality & Safety Education for Nurses (QSEN) The overall goal for the Quality and Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses who have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems in which they work.

Quality and Safety Education for Nurses (QSEN) Competencies (continued) 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” ( Cronenwett et al.,2007, p. 123). Teamwork and Collaboration – “Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care” ( Cronenwett et al., 2007, p.125).

Quality and Safety Education for Nurses (QSEN) Competencies (continued) 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” ( Cronenwett et al., 2007, p. 127). Safety – “ Minimize risk of harm to patients and providers through both system effectiveness and individual performance” ( Cronenwett et al., 2007, p. 128). Informatics – “Use information and technology to communicate, manage knowledge, mitigate error, and support decision making” ( Cronenwett et al., 2007, p. 128).

Quality and Safety Education for Nurses (QSEN) Competencies (continued) Evidence-Based Practice – “ Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care” ( Cronenwett et al., 2007, p. 126).

Definition of “High Reliability Theory” There is no one definition! Reliability is defined as “failure-free operation over time” (Garvin).

Origins of High Reliability Theory (HRO) Came to healthcare organizations from naval aviation industry and the nuclear power industry We know the way High Reliability Theory is used in other industries cannot be directly replicated in healthcare These industries found it necessary to identify weak danger signals and respond to these danger signals

Normal Accident Theory (NAT) Term was coined by Charles Perrow Focuses on investigation of normal accidents in “high-risk systems” A “normal accident” occurs in a complex system that has so many parts that it is likely that something is wrong with more than one part of the system at any given time A “well-designed system” includes redundancy, so that each fault by itself does not prevent proper operation

Swiss Cheese Model “SWISS CHEESE MODE” OF SYSTEM FAILURE

What Drives & Underpins High Reliability Theory Desire to create a culture of safety with the patient at the center of care Practicing “mindfulness” and striving for perfection with each and every patient encounter Being “mindful” means even one small failure in a safety process or procedure has potential to result in a sentinel event or adverse outcome

Concept of “Mindfulness” Originally described and coined in 2007 by University of Michigan professors, Karl Weick and Kathleen Sutcliffe “Mindfulness involves the constant searching by staff for the smallest indication of a flaw or hazard that has potential to lead to failure if some action is not taken to solve or prevent the potential problem” (Blouin, nd) Mindfulness leads organizations to find flaws or holes in the Swiss cheese at early stages to intervene early and prevent near or sentinel events

The Goal of the High Reliability Organization (HRO) Perfection Considerations: 99% is never good enough 1 % error is unacceptable Safety must be a culture of the healthcare organization Link organizational mission and philosophy translated into the strategic plan

High Reliability Organizing Concepts There are five concepts that create the state of “mindfulness” needed to reliability Mindfulness is a prerequisite for safety

Sensitivity to Operations Preoccupation with Failure Five Characteristics to Guide Thinking in a High Reliability Organization Sensitivity to Operations Preoccupation with Failure Deference to Expertise Resilience Reluctance to Simplify

Sensitivity to Operations Reduces the number of errors Allows errors to be quickly identified and remedied

Preoccupation with Failure “Near Misses” or “Good Catches” are viewed as invitations for improvement Events caught early to prevent failure as a result of constant, continuous vigilance prevents catastrophe

Deference to Expertise Do not rely only on the healthcare professional but listen to patients and families There is other essential information to provide ideal care Defer to whoever has expertise or knowledge that is most relevant to the choices being made

Resilience Quickly contain errors and improvise when errors or challenges occur Systems that can function even when there are unintended outcomes Nimble to respond to unexpected consequences when there are system failures

Reluctance to Simplify Refuse to simplify or ignore explanations for difficulties and problems they face Recognize that systems can fail and in ways that have never happened before Recognize there is no way to avoid every potential error that will occur in the future due to complexity of the health care system

Characteristics in Healthcare Systems Requiring High Reliability Performance by Nurses Hypercomplexity Tight coupling Extreme hierarchical differentiation Multiple decision makers in a complex communication network High degree of accountability

Two DNP Capstone Exemplars Based on QSEN & National Quality & Safety Initiatives through Centers for Medicare & Medicaid (CMS)

Communication Strategies to Link DNP Students with Healthcare Organizations

Conclusions Evolution of the DNP in Nursing Practice Development of the DNP role Variations & Challenges in DNP-prepared practitioners Achieving clinical value Practice focus of the DNP Evolution to revolution

The Journey to Exemplary Capstone Projects

Questions