Quality Education for SENiors

Marsha Lewis, PhD, RN Bethany Robertson, DNP, RN Gerri Lamb, PhD, RN, FAAN Corrine Abraham, MN, RN

It’s been a busy year 100 seniors QSENed

- Recognize QI process and tools when they see them

- Aware of and can search national quality initiatives: IHI, JCAHO, NQF

- Can conduct simple PDSA process using appropriate tools, run charts, fishbone, …

30+ faculty/4 courses - Speak “TeamSTEPPs” language - Experience facilitating QI process - Ask quality-centric questions in clinical

“Begin with the end in mind” Covey,1989

Focus our pilot work on the senior spring semesterWhat competencies do our students need to transition from Emory student to practicing RN?

Back this up a bit and try some small experiments in the junior year

What groundwork do we need to establish to build toward terminal competencies?

The timing was perfect“Getting into the habit of quality” Emory Health Sciences Update March 2008

Fred Sanfilippo, MD, PhDExecutive VP and CEOEmory Woodruff Health Sciences Center

A Comprehensive Model for Teaching QSEN

Success in AchievingQSEN

Competencies

Curriculum

FacultyDevelopment

ClinicalPartners

StudentEngagement

I. Curriculum

Quality and safety as central themes Strong connection between

classroom and clinical Experience analyzing teamwork, QI,

in addition to reflective exercises Role model QI thinking – flexibility,

feasibility, always “OFIs”, evidence

An Integrated Curriculum

Nursing PracticePatient-Centered Care

Across the Care Continuum

(ClinicalExperiences)

Classroom

ProfessionalDevelopment

Classroom &Clinical

Seminars

Simulations

Integrating Across PD Class, Seminar and Clinical Groups

PD Class PD Seminar

Role Transition&

CommunityClinical Groups

PTQSConceptsPrinciplesTools

Students-MentorspracticeConcepts & tools

Discussion of ClinicalApplicationPTQS Questions

Safety – for exampleQSEN Competency: Discuss impact of national safety initiatives

PD Class PD Seminar

Role Transition&

CommunityClinical Groups

PTQSMajor national safety initiatives e.g. JCAHO, NDNQI, NQF, IHI …

Students explore websites related to national initiatives with guided questions

QS Question: RT: What quality initiatives affect practice in this setting? What outcomes are being tracked? C: What population-based outcomes are relevant to what you’ve observed this week? How are outcomes from other settings relevant to community practice?

Role Transition&

CommunityClinical Groups

Teamwork – for exampleQSEN Competency: Discuss effective strategies for communicating among members of the interdisciplinary team

PD Class PD Seminar

PTQSComm. & Patient safetyTools

Pick a process: communicating a change in patient status, (hand-offs).Practice communication tools: SBAR, IPASStheBATON, etc.

T Question: RT: What forms of team communication have you seen/been part of this week? Which were effective, not… C: Same plus: how is communication the same/different in community settings? How do community members participate?

II. Faculty Development

“Quality and safety: nursing at the turning point” Jan 2008 Keynote

Marla Salmon, Dean

The Case for QualityWhy We Must Improve

Susan M. Grant, MS, RN, CNAAChief Nursing Officer, EHC

William A. Bornstein, MD, PhDChief Quality Officer, EHC

III. Clinical PartnersIII. Clinical PartnersEmory Healthcare Emory Healthcare Quality Academy Quality Academy

Office of Quality

N

IV. Student Engagement

“In your efforts to structure connections between courses, don’t overlook important clinical moments and insights.”

“It’s important to capitalize on the diversity of the background and

expertise of our class.” “You reinforce effective teamwork and leadership modeling at each opportunity.”

Comments of Student Advisory Group Members

Ferranti/White’s Fine Few

Inadequate sleep was a concern of the entire group

Group members expressed feelings of fatigue, difficulty concentration and were aware of the detrimental effects of sleep deprivation on health

After initial assessment, an inconsistent sleep duration pattern was noticed, measured in the course of a week

Sleep deprivation can lead to or be an aggravating factor in depression, heart disease, hypertension, irritability, slurred speech, slower reaction times, tremors, and weight gain (http://www.sleep-deprivation.com/articles/effects-of-sleep-deprivation/)

Most studies of partial sleep deprivation have suggested that sleeping only 5-6 hours a night can lead to impairment (Weinger & Ancoli-Israel, 2002)

The psychomotor effects of going without sleep for 24 hours are similar to that of acute alcohol intoxication (Weinger & Ancoli-Israel, 2002)

Decreased sleep duration per night

SchoolSchool

Misc.Misc.Living Living situationsituationIllnessIllness

SocialSocial Work/JobWork/Job

AssignmentsAssignments

Role TransitionRole Transition

Early class timeEarly class time

Financial stressFinancial stress

Stress r/t school workStress r/t school work

““Hanging out” lateHanging out” late

TelevisionTelevision

TelephoneTelephone

ComputerComputer

Eating/CaffeineEating/Caffeine StressStress

HoursHours

AllergiesAllergies

MedicationMedication

TemperatureTemperature InsomniaInsomnia

NoiseNoise Trouble falling asleepTrouble falling asleep

LightLight

Increase in stress level correlates to a decrease in perceived sleep quality (Daon et al., 2004)

People who use problem-based coping strategies to deal with stress have an increase in sleep (Daon et al., 2004)

Both the amount and quality of sleep should be considered when it comes to getting enough sleep (Blachowicz & Letizia, 2006)

One recommendation is to adjust the environment in a way that is favorable to sleeping (Blachowicz & Letizia, 2006)

Exposure to bright light in the evening can shift the circadian rhythm to a later time, thus increasing sleep latency (Cajochen et al., 1998)

Exposure to bright light upon waking shifts the circadian rhythm to an earlier time, which in turn improves sleep latency in the evening (Cajochen et al., 1998)

Week 1 Intervention – Limiting TV, cell phone, computer use prior to bedtime

Week 2 Intervention – Dim lights in home at least 30 minutes prior to bedtime; attain exposure to bright light within 10 minutes after awakening

Group members gained further awareness on the consequences of inconsistent sleep duration patterns

Group members became more aware of ways to improve sleep duration

Sleep consistency amongst the group members did not improve significantly

Group members were motivated to discuss methods to improve the interventions

It is important to look at the data findings from all perspectives, to avoid any misleading conclusions

It may be necessary to delete, revise or combine interventions to reach maximum effectiveness

The interventions might have been more effective if there was more control regarding certain other influences, i.e. school factors

Change is difficult, even when one has the best of intentions

QSEN Competencies in QI Project (Examples)

Safety Analyze the usefulness of national quality and safety

resources and initiatives for guiding clinical practiceTeamwork Analyze how professional and clinical team

performance affects quality of patient care and safety Identify and practice a set of effective strategies for

communication and resolving conflictQuality Improvement Design a small test of change Describe processes for identifying opportunities for

improving quality and safety. Describe processes and tools for analyzing quality and

safety problems and implementing and evaluating improvements.

Faculty Experience“ I initially thought Role Transition (clinical course) already

incorporated QSEN competencies – but once the concepts were highlighted consistently and clearly by framing them in a common language and reinforcing them between Role Transition and Professional Development, it became obvious (in group discussion and journaling) that students were noticing quality and safety indicators in clinical practice in more specific and meaningful ways.”

“Clinical preceptors involved in QI in practice settings were enthusiastic that students knew about QI and were able to engage students in meaningful dialogue about specific initiatives on their units.”

Corrine Abraham, MN, RN Coordinator, Role Transition

Lessons Students: “QI exercise was great!” Important to build awareness – what you will

see, what it means e.g. Students did not recognize PDSA and

tools in clinical practice until we brought it to their attention

Pick points of intersection carefully and efficiently

- too much intersection can get confusing especially in the beginning

Need to move some QSEN KSAs earlier in curriculum – quality & safety, teamwork

Recognize need for incremental growth, eg. Communication, conflict management

Critical Success Factors

Comprehensive ModelCurriculum Design, Student Involvement, Faculty Development, Clinical Partners

Faculty enthusiasm- willing to experiment- willing to learn along with students

Clinical course coordinators Lead coordinator role

- keep all the pieces integrated

Outcomes 100 graduates with basic competencies in

teamwork, QI and knowledge of national quality initiatives.

30+ faculty familiar with QSEN competencies; practice with many

Experience with integrated framework for teaching QSEN

Closer collaboration with Clinical Partners, shared curriculum materials, potential for IHI projects

Next StepsCurriculum Refinement Small modifications to junior year

curriculum with similar model Experiment with earlier introduction to

teamwork and quality Integration of simulation, team trainingFaculty Development and Ownership Shared strategies to embed QSEN in faculty

thinking and culture