Enhancing Quality and Safety Nursing Competencies In Ambulatory Care Practice

In the last issue of ViewPoint, the new Centers for Medicare and Medicaid Services (CMS) "Never Events" were presented and discussed, as well as how CMS considers these to be events that should never occur in ambulatory care settings (Haas, 2012). This ruling can have major reimbursement consequences, but also requires that nurses and other providers in ambulatory care settings become much more aware of quality and safety issues and ways to prevent never events through evidence-based practice (EBP) and use of the electronic health record (EHR). The Institute of Medicine (IOM) has provided multiple reports on the status of health care in the U.S. starting with To Error is Human in 1999, where flawed systems were identified as a major cause of error. In 2001, the IOM report Crossing the Quality Chasm delineated issues with quality and safety and recommended 6 aims for U.S. health care (see Figure 1).

There have been follow-up reports by the IOM (2003) where the need for practitioners to gain expertise in the areas of quality and safety are addressed. The Robert Wood Johnson Foundation funded work by Cronenwett and colleagues (Cronenwett et al., 2007; Cronenwett, Sherwood, & Gelmon, 2009a; Cronenwett, Sherwood, Pohl, et al., 2009b) called Quality and Safety in Education in Nursing (QSEN). The IOM's six aims are the foundation for QSEN's six competencies.

Using the Institute of Medicine (2003) competencies for nursing, QSEN faculty have defined pre-licensure and graduate quality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes (KSAs) to be developed in nursing pre-licensure and graduate programs for each competency (QSEN 2012a, 2012b):

  • 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.
  • Quality — 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.
  • Teamwork and Collaboration — Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision- making to achieve quality care.
  • Safety — Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
  • Evidence-Based Practice — Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
  • Informatics — Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making.

Figure 1. (in print)
IOM (2001) Six Aims for Improvement

  • Safe: avoiding injuries to patients from the care that is intended to help them.
  • Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.
  • Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
  • Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.
  • Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.
  • Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

Source: IOM, 2001.

These competencies, as defined above, provide the KSAs that make up each competency. The QSEN competencies are now part of accreditation standards for prelicensure and graduate education and are content tested in licensing and certification exams. Nursing students who are now graduating will have had exposure to these competencies in theory, simulation, and clinical classes. Of concern is the fact that nurses currently practicing may not be as familiar with the QSEN competencies. When and if new graduate nurses move into ambulatory care, they will expect to see EBP, Quality Councils, and EHR where nurses document care processes and outcomes. If this is not the norm for nursing in an ambulatory setting, retention of nurses could be an issue, as well as poor patient and organization outcomes.

Concern regarding competency with quality and safety extends beyond nursing. The Lucian Leape Institute issued a report in 2010 that was highly critical of the lack of quality and safety content and experience in medical student and residency programs. Prevention and management of potential never events in ambulatory settings requires competencies in all six of the areas specified in QSEN. However, this column will focus only on the EBP and Informatics QSEN competencies because they are a major focus of the health reform law. It is expected that providers, nurses, physicians, and other health care professionals will use best evidence-based practices in the provision of care and that they will track evidence-based processes and outcomes achieved. Tracking is where informatics comes into play. The Accountable Care law provides funding for equipment to support the EHR, especially in primary care practice. It is the expectation that the EHR will enhance communication within the health care team and across settings and decrease errors and costs due to duplication of testing, lost test results, etc. The EHR is also key to tracking evidence-based processes of care and outcomes.

In addition to falls and pressure ulcers discussed as potential never events in ambulatory care in our last ViewPoint issue, surgical or invasive procedure events and product or devise events in ambulatory care are also of concern. The Joint Commission requires use of the Universal Protocol in all accredited hospitals, ambulatory care, and office-based surgical practices to prevent such events and there is evidence that can be employed in EBP protocols to prevent adverse surgical or device events.

So where do ambulatory nurse leaders start? The QSEN Web site (https://qsen.org/) is a great resource. It is designed to assist in both nursing student and staff education, as well as education of the educator. You can search for teaching strategies by indicating which QSEN competency you want to work on, your learning setting, learner level, and strategy type (such as simulation). There are also yearly QSEN conferences where those who are using QSEN share strategies and methods. For the EBP competency, there are free interdisciplinary Web-based modules (https://ebbp.org/). These interactive modules were funded by a grant from the National Institutes of Health. Another great resource funded by the Agency for Healthcare Research and Quality is a text edited by Hughes (2008) titled Patient Safety and Quality: An Evidence-Based Handbook for Nurses. This 3-volume text is FREE to nurses on CD-ROM from http://www.ahrq.gov/qual/nurseshdbk/.

Knowing that there are resources available to upgrade and update ambulatory care nurses’ understanding of EBP and use the EHR, the first step for ambulatory care nurse leaders should be developing a strategic plan for prevention of never events in ambulatory care. Such a plan starts with developing an understanding among leadership and nurses and an appreciation of the issue of never events, methods to identify potential for them in ambulatory care settings, methods to develop or enhance understanding and comfort with development of EBP protocols suited to the ambulatory care setting, and knowledge and skills with use of documentation formats in EHR to track EBP processes and outcomes.

Such a project may seem overwhelming, but leaders need to look at one potential never event at a time. For example, look at historical data on falls or operating room errors so you can see where you should start. Begin with work on the event that has the highest incidence and the one that will have the greatest costs, both in poor patient outcomes as well as financial, should it occur and thus the greatest return on investments that will be made in EBP and the EHR. Much of the cost is related to education time for staff as well as development time needed for work on EBP protocols and EHR documentation formats.

While there are financial incentives to EBP and the use of EHR, there is a greater incentive that ambulatory nurses will respond to – providing higher quality and safer care to their patients.

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., … Warren, J. (2007). Improving quality and safety education. Nursing Outlook, 55(7), 122-131.

Cronenwett, L., Sherwood, G., & Gelmon, S., (2009). Improving quality and safety education: The QSEN Learning Collaborative. Nursing Outlook, 57(6), 304-312.

Cronenwett, L., Sherwood, G., Pohl, J., Barnsteiner, J., Moore, S., Sullivan, D., … Warren, J. (2009). Quality and safety education for advanced nursing practice. Nursing Outlook, 57(6), 338-348.

Haas, S.A. (2012). Prevention and early detection of “never events” within ambulatory settings to enhance quality and safety and prevent financial losses. ViewPoint, 34(1), 6-8.

Hughes, R. (Ed.) (2008). Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/ qual/nurseshdbk/

Institute of Medicine (IOM). (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press. Retrieved from http://www.iom.edu/Reports/1999/To-Err-is- Human-Building-A-Safer-Health-System.aspx

Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Retrieved from http://iom.edu/~/media/Files/ Report%20Files/2001/Crossing-the-QualityChasm/Quality %20Chasm%202001%20%20report%20brief.pdf

Institute of Medicine (IOM). (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press, Quality and Safety in Nursing Education. Retrieved from http://www.iom.edu/Reports/2003/Health-Professions- Education-A-Bridge-to-Quality.aspx

Lucian Leape Institute. (2010). Unmet needs: Teaching physicians to provide safe patient care. Retrieved from http://www. npsfstore.com/categories/publications

Quality and Safety Education for Nurses (QSEN). (2012a). Competency KSAs (graduate). Retrieved from http://www.qsen.org/ ksas_graduate.php

Quality and Safety Education for Nurses (QSEN). (2012b). Competency KSAs (pre-licensure). Retrieved from http://www.qsen.org/ ksas_prelicensure.php

Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at shaas@luc.edu