11/3/2015. Health Professions Education

Transcription

1 Jane Barnsteiner, PhD, RN, FAAN Professor Emerita, University of Pennsylvania School of Nursing Editor, Translational Research and QI, AJN November 6, 2015 Health Professions Education 6 Core Competencies: 1. Provide patient centered care 2. Work in interdisciplinary teams 3. Employ evidence based practice 4. Safety as a system property 5. Apply quality improvement 6. Utilize informatics 1

2 IOM Competencies PCC Safety EBP Teamwork & Collaboration Quality Improvement Informatics Evidence-Based Practice Old Adhere to internal policies and procedures. New - Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. Why the focus on EBP? Leads to higher quality of care, improved patient outcomes, decreased costs, and greater nursing satisfaction. Significant gaps in care: 30 40% do not receive treatments t t proven effective, Antibiotics before and after surgery Hand hygiene 100% of the time 20 25% receive treatments that are not needed or are potentially harmful Indwelling catheters post op or in ICU 2

3 Locating and Retrieving the Evidence The World of Evidence Published Evidence Indexed and Locatable Accessible and Reviewable Use EBP Staff nurse use of research ( Yoder, AJN, 9/14) Where do you get your evidence? Personal Experience 75% Policies and Procedures 58% Peers 55% Intuition 32% Use of journals, internet 25% 36% avoid using research as they perceive they do not have authority to use even if useful. Do I hear myself saying We ve always done it this way That s not our way As soon as this change is over, we can do it I m just not comfortable with change It s just not the way it used to be I m just not a creative person 3

4 2015 National Survey Sacred Cows Practice True False Shock 51% 49% Trendelenburg Scrub the hub 81% 19% Instill NSS NTT 35% 65% Auscultate G tube Ph testing G tube Aspirate subglottic secretions to prevent VAP 31% 69% 51 49% 29% 71% Willful Blindness Conscious avoidance, not challenging the status quo 12 hour shifts lead to increased safety errors Increased staffing leads to decreased adverse events, LOS, and is cost neutral Faculty adding their name to junior faculty and student papers when not met criteria for authorship Incivility and bullying Patient/Family Centered Care Old Listen to patient and demonstrate compassion and respect. New - 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 American Association of Colleges of Nursing All Rights Reserved. 4

5 New Focus Knowledge is power. Angelina Jolie Pitt:, Diary of a Surgery, NYT Patient Centered Care is providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions (Institute of Medicine) Orthopedist goal uneventful hip replacement surgery Nursing goal discharge with no complications Patient goal be back on golf course (Need to begin to measure patient goal outcomes) It s all about the patient Not true It s about cost It s about completing the checklist It s about physician schedule It s about us being in charge as we are the most knowledgeable 5

6 Benefits of PFCC Person Outcomes Patients more involved in their care are better able to Manage complex chronic conditions Seek appropriate assistance Have reduced lengths of stay and avoidable readmissions and emergency department visits Experience increased patient satisfaction and employee engagement (Jarousse, 2011) Barriers Attitudes When physicians and nurses perceive that family members are policing them, or that unrestricted visiting by family members is not possible it speaks to a culture but not a culture of P&FCC. AJCC, 2014 Knowledge studies for past 40 years Skill HC professionals often novices with the new definition. Reason for push back on handoffs and rounds in patient rooms. Patient Engagement and Activation not anymore about handing out instructions and doing discharge teaching. Engagement Activation Patient Activation Measure (PAM)(Hibbard, et al, 2005) Plan interventions based on level of activation 6

7 Patient Engagement Evidence-based approaches that lead to patient engagement, activation and improved clinical outcomes: Medical literacy Shared decision making Goal setting Self-care skills Motivation/confidence Plans of care Patient Activation Measure (Hibbard) Lucille Packard Children s Hospital 7

8 EB Benefits of PFCC Financial Outcomes 100 Planetree healthcare institutions Increased patient satisfaction Increased staff retention Enhanced staff recruitment Decreased length of stay Decreased emergency department return visits Decreased adverse events including fewer medication errors Reduced operating costs and a lower cost per case Increased market share Improved liability claims experience Collaboration and Teamwork Old Work side by side with other HC professionals while performing nursing skills. New - Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decisionmaking to achieve quality patient care American Association of Colleges of Nursing All Rights Reserved. EB Benefits of Interprofessional Teamwork and Collaboration Improved mortality outcomes and quality of life after adjustment for patient severity Increased patient and family satisfaction with care Improved team perception of micro system conflict management, collaboration, job satisfaction and quality of care 8

9 Integrate TW&C Team STEPPS, Crucial Conversations communication Interprofessional experiences in orientation and regular discussion on work area Patient as member of team literacy and selfmanagement Incivility not tolerated Care Coordination integrator role Safety Old focus on individual performance, vigilance to keep patients safe. New - Minimize risk of harm to patients and providers through both system effectiveness and individual performance American Association of Colleges of Nursing All Rights Reserved. Technical Return to Normal van der Schaaf modified for healthcare Close Call Organizational Dangerous Situation Adequate defenses Human Factors Patient Factors Developing Errors ERROR (Inadequate Defenses) 9

10 Quality and Safety: Two Forms of Vigilance Optimal Patient Care Vigilant Individual Care (Traditional) adto a) Vigilant Systems of Care QSEN Patient Centered Care Teamwork & Collaboration Evidenced Based Practice Safety Quality Improvement Informatics Mary Dolansky 2012 QSEN National Forum 10

11 Moving Along the Continuum: In Education and Practice Continuum of Systems Thinking I will turn my patient t I will post a note above the bed to remind others I will ask other nurses about products to I will look at the ulcer rate on our I will compare our unit ulcer rate with prevent ulcers unit benchmarks End goal (Cronenwett) From: M. Dolansky & S.Moore. Systems Thinking Scale, available at: I will work with others to improve our unit s ulcer rate Quality Improvement Old Update nursing policies and procedures, chart audits of documentation. New - Use data to monitor outcomes of care processes and improvement methods to design and test changes to continuously improve quality and safety of health care systems American Association of Colleges of Nursing All Rights Reserved. One example: Handwashing (TJC 2012) Routine safety processes fail routinely Hand hygiene Medication d administration Patient identification Communication in transitions of care 11

12 Informatics - HIT Old timely and accurate documentation New - Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making American Association of Colleges of Nursing All Rights Reserved. Decision Support Aids "What clinicians need is decision support tools that fit into their workflow and remind them of evidence based practices S. Baacken, Columbia School of Nursing With electronic decision support aids clinicians: 7 times more likely to diagnose obesity 5 times more likely to spot issues in tobacco use 44 times more likely to identify depression in adults 4 times more likely to identify depression in children and adolescents 12

13 Headache Diary What It Is: Tracks every detail (including triggers and remedies) with recurring headaches. Why It's Cool: By keeping detailed notes of headache symptoms right down to the location, duration, and foods you snacked on before the headache flared you can help your health provider diagnose you more easily and begin treating you quickly. Cost: Free. Available for Android Health Patch MD About the size of a Band Aid and tracks heart rate, heart rate variability, respiratory rate, ECG and skin temperature continuously. Can be worn constantly for three days before it needs to be replaced. The stats it collects can be sent to physician in real time via the cloud. Nutrition Shopwell What It Is: With a quick scan of a barcode, this app can determine which foods meet your dietary needs. Why It's Cool: Shopwell personally scores each product just for you based on your age, gender, health goals, diet needs, and ingredient and nutrition preferences. Scores range from 0 100; the higher the number, the better the product is for you. Cost: Free. Available for ios 13

14 Evidence to Action 40 Institutional Barriers to EBP Lack of budget for information resources Lack of budget for training in resource use CNO belief that EBP not achievable in real world Individual Barriers to Use of Evidence Lack of time Lack of value for research in practice Lack of knowledge about research Lack of computer skills Lack of understanding di of electronic dtb databases Lack of access to computer and library Lack of search skills Lack of skills to critique or synthesize the literature Difficulty accessing research materials Difficulty understanding research articles Funk et al, 1995; Kajermo et al, 1998; Omery et al, 1999; Parahoo, 1998; Rodgers, 2000 Provikoff,

15 EBP Culture change necessary among health care providers to understand that life long learning has an equal priority as delivering care. Health care providers are incentivized for staying up to dt date. Greater efforts are needed to provide (commercial free) synthesized knowledge that is easily translated into practice briefs, guidelines and policies. These need to be regularly updated as new knowledge is generated. All too often guidelines are published but not kept current. Creating a Culture of EBP Accelerate uptake Awaken the spirit of inquiry Patients and Families Expect Competence They don t say I prefer you care for me by the standards and guidelines, policies and procedures of 10 years ago. Formal Methods of Dissemination Standards of Practice Practice Guidelines and Protocols Decision support systems Improved technology Smart pumps 15

16 Informal Methods of Dissemination Brown Bags Journal Clubs Newsletters Professional Meetings/Conferences Choosing Wisely Campaign (ABIM & AAN, 2014) Don t 1. Automatically initiate continuous electronic FHR 2. Let oldsters lay in bed or be in chair during hospitalization 3. Use physical restraints for oldsters 4. Wake for routine care 5. Place or maintain UC without specific indication The Choosing Wisely, Things Nurses and Patients Should Question, identified by ONS include ( ): Don t neglect to advise patients with cancer to get physical activity and exercise during and after treatment to manage fatigue and other symptoms. Don t use L carnitine/acetyl L carnitine supplements to prevent or treat symptoms of peripheral neuropathy in patients receiving chemotherapy for treatment of cancer. Don t use mixed medication mouthwash, commonly termed magic mouthwash, to prevent or manage cancer treatment induced oral mucositis. Don t administer supplemental oxygen to relieve dyspnea in patients with cancer who do not have hypoxia. Don t use aloe vera on skin to prevent or treat radiodermatitis. 16

17 Leadership EB Practice Set the vision Secure resources Create environment Establishing a Culture: Institutional Level CNO and Senior Leadership Support Budget allocations Technology, staff time, education Leverage Existing Programs Professional Development Practice and Quality Improvement Committees Advanced Practice Nurses Partner with School of Nursing Secure the Resources Unlimited access to online sources of evidence at all work areas Search engines, elearning such as Mosby Nursing Skills, paper and electronic journals Staffing and scheduling for release time to participate in education and practice development activities 17

18 Create the Environment Shared Governance research, practice, education counsels/committees Faculty Facultymentors asnurse scientists Tie into Compensation, Benefits and Incentives Nursing sensitive quality outcomes Establishing a Culture: Institutional Level Research behaviors in clinical advancement levels EBP/Research Champions Demonstrate use of electronic databases Journal clubs, brown bags, case reviews, poster sessions, Nursing Grand Rounds Research/EBP Committee Research Fellowships Establishing a Culture: Institutional Level EBP Toolkit What is a clinical question How to search tip sheet Resources librarian, champions How to do a synthesis Table of Evidence How to critique How to lead a journal club How to develop EB policies/procedures/ CPG 18

19 Integrate EBP at the POC Resources to easily access knowledge Position descriptions/performance appraisals incorporate requirement of EBP use Orientation i Evaluate Guidelines, Cochrane, JBI, Web eval of consumer content using CARS (credible, accurate, reasonable, supported) Annual competency for EBP Work area unit council discussions on practice evidence Next Steps P&FCC Safety EBP Teamwork & Collaboration Quality Improvement Informatics Overcoming Barriers to Use of Evidence Knowledge About research process Electronic databases Accessing research materials Understanding research articles Skills Computer skills Search skills Skills to critique or synthesize the literature Attitudes Value for research in practice If this is important I will find the time 19

20 Lesson on Leadership and Followers Vc&feature=related CHANGE THE WORLD OF HEALTH CARE Start where you are Use what you have Do what you can A. Ashe??? Questions, Comments and Discussion??? 20