These are the instructions for my paper:
Leadership Paper
� Creatively write about a nursing leader who greatly influenced your thoughts and nursing practice. You may choose a formal, published and well-known nursing leader/theorist (ex: Patricia Benner, Florence Nightingale, Clara Barton, Jean Watson), or someone you identified during your journey through nursing school.
� No more than 4 and no less than 3 pages using APA, Version 6 are required.
� Use 2-4 references to support your choice, one must be from one of the class texts and one outside of class texts.
� Be sure to relate your choice to components of leadership from the course. This paper should link your opinions about this leader to nursing leadership concepts.
� Include a section that outlines how the nurse leader you�ve chosen will directly impact your nursing career.
Please link chapter 2 from Leading and Management book that I am attaching �.
LEADING and MANAGING in NURSING Revised Reprint FIFTH edition, Patricia S. Yoder-Wise (Last published in 2014)
As well as 2-3 more additional sources that you might find or use at the end of chapter
I copied ch2 from electronic version. Some of pages messed up because of pictures or graphs. Sorry!
LEADING and MANAGING in NURSING Revised Reprint FIFTH edition, Patricia S. Yoder-Wise (Last published in 2014)
Page # 25 in the book
In any discipline, most practitioners think of a leader as someone with positional authority. Terms such as manager, director, chief, and leader convey positional authority. In healthcare organizations, a hierarchy exists of �who is in charge.� Realistically, however, every registered nurse is seen by law as a leader�one who has the opportunity and authority to make changes for his or her patients. Even as far back as Florence Nightingale�s era, patient safety was important. She focused on changing the way health care was delivered to make a difference in the outcomes of care for those who served in the Crimean War. Yet, in the United States, it was not until the end of the twentieth century that major efforts refocused on the basic safety and quality outcomes of care for patients. This shift to being consumed with a passion for patient safety is a hallmark of today�s healthcare delivery and the target for the care of tomorrow. This chapter provides an overview of the key thoughts about patient safety as the basis for all aspects of leading and managing in nursing. Patient safety, and subsequently quality of care, is why the public entrusts us with licensure and why we use our passion for caring.
OBJECTIVES � Identify the key organizations leading patient safety movements in the United States. � Value the need for a focus on patient safety. � Apply the concepts of today�s expectations for how patient safety is implemented.
TERMS TO KNOW Agency for Healthcare Research and Quality (AHRQ) DNV (Det Norske Veritas) Institute for Healthcare Improvement (IHI)
Institute of Medicine (IOM) Magnet Recognition Program� National Quality Forum (NQF) The Joint Commission
Quality and Safety Education for Nurses (QSEN) TeamSTEPPS (an AHRQ strategy to promote patient safety)
CHAPTER 2 Patient Safety
Patricia S. Yoder-Wise
26 PART 1? Core?Concepts
INTRODUCTION
In Chapter 1, the concepts of leading and managing were presented. The question is, however, leading for what? No issue is more prominent in the literature or in healthcare organizations than the concern for patient safety. Although many other aspects of health care are discussed, they all center on patient safety. Many factors and individuals have influenced both the nursing profession�s and the public�s concerns about patient safety, but the seminal work was To Err Is Human: Building a Safer Health System (2000), produced by the Institute of Medicine (IOM). The Web site QSEN.org shows how important patient safety is to the foundation of quality. Even more popularized publications, such as How Doctors Think (Groopman, 2007) and The Best Practice: How the New Quality Movement is Transforming Medicine (Kenney, 2008), show how important the basic building block of quality�patient safety�is. This focus fits well with the basic patient advocacy role that nurses have supported over decades. Because the core of concern in any healthcare organization is safety, it also is the core for leaders and managers in nursing. Safety, and subsequently quality, should drive such aspects of leading and managing as staffing and budgeting decisions, personnel policies and change, and information technology and delegation decisions. Most professionals would agree that
Vickie S. Simpson, BA, BSN, RN, CCRN, CPN Dell Children�s Medical Center of Central Texas, Austin, Texas
Over the years, our hospital has focused on pressure ulcers. In 2002, for example, we reviewed literature on pediatric pressure ulcer risk assessment scales and prevention interventions. A couple of years later, as we were doing our pediatric pressure ulcer risk policy, we realized that pressure ulcers were not tracked. So it was impossible to determine the true incidence. Thus we instituted a tracking system. We also developed a pediatric SKIN bundle. SKIN stands for Surface selection, Keep turning, Incontinence management, and Nutrition. Many of these efforts included broad interdisciplinary teams. For example, after moving to our new facility in 2007, we noticed a trend of pressure ulcer development in nasally intubated patients.
THE CHALLENGE
When a root cause analysis was completed with members of the anesthesia and respiratory therapy departments, staff in the critical care unit, and the cardiovascular surgeon, numerous issues were identified. These issues included not purchasing arms for the new ventilators and identification of the need for a different taping process for nasally intubated children, which was developed by our respiratory therapists. Our outcome is that now we have no pressure ulcers on nasally intubated children in our facility. In 2009, we identified a new trend in our patient population. It was including more overweight teenagers. We had to decide what to do.
What do you think you would do if you were this nurse?
three major driving forces are behind the current emphasis on quality: IOM, the Agency for Healthcare Research and Quality (AHRQ), and The National Quality Forum (NQF). Also, other groups such as The Joint Commission, the new accrediting organization (the Det Norske Veritas [DNV]), the QSEN Institute, and the Magnet Recognition Program� have incorporated specific standards and expectations about safety and quality into their respective work. Additionally, specifically focused efforts such as those of the Quality and Safety Education for Nurses (QSEN), which provides expected competencies and resources for both undergraduate and graduate nursing students on the topics of safety and quality, and TeamSTEPPS initiatives have addressed patient safety issues. Also, the American Board of Quality Assurance and Utilization Review Physicians provides a certification program for physicians, nurses, and other healthcare professionals. No nurse can function today without a focus on patient safety, nor can any nurse leader or manager.
THE CLASSIC REPORTS AND EMERGING SUPPORTS
Several reports are reflective of the efforts to refocus healthcare to quality. Numerous other reports and supports exist. Table 2-1 highlights the key groups.
27CHAPTER 2 ? Patient?Safety
TABLE 2-1 MAJOR FORCES INFLUENCING PATIENT SAFETY
ELEMENT CORE RELEVANCE
IMPLICATIONS FOR LEADERS AND MANAGERS
Institute of Medicine Reports
To Err Is Human (2000): Defined the number of deaths attributed to patient safety issues.
Moved safety issues from the incident report level to an integrated patient safety report for the organization.
Crossing the Quality Chasm (2001): Identified the six major aims in providing health care (See Box 2-1)
Moved care from discipline centric foci to patient centered foci. Reinforced the disparities that occur within health care, which, in turn, led to a focus on best practices (and reinforced the need to be patient centered). Addressed issues such as healing environments, evidence-based care and transparency, which led to a more holistic environment that was build on evidence and that was transparent.
Health Professions Education: A Bridge to Quality (2003): Addressed the issue of silo education among the health professions in basic and continuing education (see Box 2-2)
Attempted to shrink the chasm between education and practice so that interprofessional teams would work more effectively together. Increased expectation for participation in lifelong learning.
Keeping Patients Safe: Transforming the Work Environment of Nurses (2004): Identified many past practices that had a negative impact on nurses and thus on patients
Focused on direct care nurses, supporting their involvement in decision making related to their practice. Supported the concept of shared governance. Provided a framework for considering how nurses could determine staffing requirements. Moved the Chief Nursing Officer into the Boardroom as a key spokesperson on safety and quality issues.
Improving the Quality of Health Care for Mental and Substance-Use Conditions (2005): Addressed issues related to this patient population, including those who can be found among a general care population
Provided a focus on mental health needs of patients who were not admitted for the primary reason of mental health issues.
Preventing Medication Errors (2006): Addressed many of the issues surrounding the use of medications
Validated the complexity of providing medications to patients.
Future of Nursing: Leading Change, Advancing Health (2010): Identified 8 recommendations based on evidence that the profession must attend to. (See Box 2-3)
Created state coalitions focused on improving nursing. Created nursing/community/business coalitions to accomplish the work. Moved the issue of nurses as leaders to a more visible level.
Agency for Healthcare Research and Quality
Federal agency devoted to improving quality, safety, efficiency, and effectiveness (2008) www.ahrq.gov
Outcomes research sections provide resources for nurses. Source of Five Steps to Safer Health Care (www.ahrq. gov/consumer/5step.htm) (See Box 2-3) Source of Stay Healthy checklists for men and women Source of TeamSTEPPS
Continued
28 PART 1? Core?Concepts
TABLE 2-1 MAJOR FORCES INFLUENCING PATIENT SAFETY�cont�d
ELEMENT CORE RELEVANCE
IMPLICATIONS FOR LEADERS AND MANAGERS
National Quality Forum
Membership-based organization related to quality measurement and reporting www.nqf.org
Source for Centers for Medicare and Medicaid�s never events Resource for Healthcare Facilities Accreditation Program (a CMS-deemed authority) (uses NQF�s Safe Practices) Source of nurse sensitive care standards
The Joint Commission Not-for-profit organization that accredits healthcare organizations internationally www.jointcommission.org
Focused on outcomes redirected accreditation processes and thus nurses� roles with the process Changed to unannounced visits and thus changed the way organizations prepared for accreditation. Issues annual patient safety goals Issues sentinel event announcements
Det Norske Veritas/ National Integrated Accreditation for Healthcare Organizations
Internationally based organization that accredits many fields, including healthcare. www.dnvaccreditation.com
Based on an internationally understood set of standards known as ISO (International Organization for Standardization) Visits annually and thus changed the way accreditation is viewed.
Quality and Safety Education for Nurses
Comprehensive resource, including references and video modules www.qsen.org
Created knowledge, skills, and attitudes for students and graduates related to safety.
Magnet Recognition Program �
A designation build on and evolving through research. Emphasizes outcomes nursecredentialing.com/Magnet/ ProgramOverview.aspx
Created unified approaches to seek this designation Redirected focus to outcomes, including data and efforts related to patient safety
Institute for Healthcare Improvement
Independent, not- for- profit Source of TCAB (Transforming Care at the Bedside)
Provides rapid cycle change projects designed to improve care rapidly (See Theory Box)
THE INSTITUTE OF MEDICINE REPORTS ON QUALITY
Although many reports about quality and safety had been issued before 2000, To Err is Human is the report credited with causing sufficient alarm about how widespread the issue of patient safety concerns was. When the number of deaths (98,000 annually) attributable to medical error was announced, the interest in safety intensified. Suddenly this issue was not related to just a few isolated instances nor was it likely to diminish without some concerted action. Probably the hallmark of this publication was the acknowledgment that errors commonly occurred because of system errors rather than individual practitioner
incompetence. This insight, that it was the system and not the practitioners that needed to be addressed, placed even more emphasis on roles such as chief medical officers and chief nursing officers. Hospital boards that once focused almost exclusively on finances suddenly wanted more of their agendas devoted to discussions about quality and patient safety. The call for a comprehensive approach to the issue of improving patient safety really spurred the release of a second IOM report. This next report, Crossing the Quality Chasm, was released the subsequent year (IOM, 2001). The intent of this second book was to improve the systems within which health care was delivered; after all, the first report identified that systems rather than
incompetent people were the major concern. The report spelled out six major aims in providing health care, as shown in Box 2-1. These aims were designed to enhance the quality of care that was delivered. Most are well documented in the literature, and two of them seem to be receiving much attention. One, patient-centered care, has lessened the past practices of disciplines (e.g., nursing and pharmacy) and services (e.g., orthopedics and urology) vying for control of the patient. Now, because care is to be rendered with the patient rather than to the patient, the emphasis of care is about what is provided�not who controls the decision about care. The second aim, equitable, has emphasized what the literature refers to as disparities and has led to thoughtful consideration of what best practices are and how they can be provided to the masses. The report went on to acknowledge elements of care that nurses commonly value. For example, the report cited the idea of a healing environment, individualized care, autonomy of the patient in making decisions, evidence-based decision making, and the need for transparency. Although those elements of a healthcare delivery system might not seem so dramatic today, they were fairly revolutionary in 2001. This report also provided substantive support for the use of information technology within health care. In addition, it provided the impetus for payment methods being based on quality outcomes and addressed the issue of preparing the future workforce. This latter recommendation formed the basis for another IOM report, Health Professions Education: A Bridge to Quality (IOM, 2003). Unlike the earlier reports, the Health Professions Education report emerged as the work of an invitational summit. In this report, one of the major concerns about safety was exposed publicly, namely that we educate disciplines in silos and then expect them to function as an integrated whole. This is true of both basic and continuing professional education. The report stated, �All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidencebased practice, quality improvement approaches, and informatics� (IOM, 2003, p. 3). Box 2-2 emphasizes those five competencies about health professional education. The idea of this report was to shrink the chasm between learning and reality so that learning was enhanced and reality was more closely aligned with that learning. A commitment to this redirection of learning is critical for �learning organizations,� a term coined by Peter Senge. Thus constant learning is a commitment every healthcare professional must have. Although it is the individual�s accountability to
Knowing the relevant literature about safe patient care guides nursing practice.
30 PART 1? Core?Concepts
maintain competence and participate in learning, the organization can hinder or enhance that individual�s need to meet this expectation. Learning organizations exhibit a positive commitment to enhance people�s learning and changing. After looking at safety, the system and core competencies of health professionals, the IOM turned its attention to the workplace itself. As a result, many nurses think of the IOM report Keeping Patients Safe: Transforming the Work Environment of Nurses (IOM, 2004) as the major impetus behind many changes that improved the working conditions for nurses. Because nurses are so inextricably linked with patients, it was logical that the importance of the role of nurses in health care emerged as an area of focus. This report identified that nurses had lost trust in the organizations in which they worked and that �flattening� the organization resulted in fewer clinical leaders being available to advocate for staff and patients and to provide resources to those delivering direct care. Further, numerous sources of unsafe equipment, supplies, and practices were discussed. Finally, so many organizations were still engaged in punitive practices related to errors rather than redirecting attention to the broader view of the system. This report focused on direct-care nurses being able to participate in decisions that affected them and their provision of care, which helped reinforce the ongoing work of shared governance. Addressing staffing issues was accomplished on a broad scale. In other words, the broad processes for determining staffing requirements and how to address those were identified. Average hours per patient day of care, staffing levels, turnover rates, public reporting about those data, support for annual and planned education, and specifics, such as handwashing and medication administration, were addressed. Also, this report
identified the importance of governing boards understanding the issues of safety and propelled the idea of the chief nursing officer participating in board meetings in organizations that had not already embraced this practice. Redesigning both the work of nurses and the workspace was acknowledged as critical to maximizing a positive workforce. The more recent report, The Future of Nursing: Leading Change, Advancing Health (IOM, 2010), also provides guidance to nursing. Although this report does not focus specifically on quality and safety, the evidence used to build the recommendations includes much that addresses safe, quality practices. For example, the evidence regarding the outcomes of advanced practice registered nurses shows both safety and quality in terms of care. Additionally, the call for more nurses holding bachelors and higher degrees relates to the outcomes evident in the literature about lowered morbidity and mortality with a better prepared workforce. Each of these reports fits within the IOM�s focus on quality and an attempt to make health care a quality endeavor. Together, these reports and others to be developed provide direction for the delivery of care and contain implications, if not outright recommendations, for nursing. These reports form the core of the work around quality in most organizations today. Further, they support many issues nurses have identified as key to quality care.
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
The Agency for Healthcare Research and Quality (AHRQ) is the primary Federal agency devoted to improving quality, safety, efficiency, and effectiveness of health care (Agency for Healthcare Research and Quality [AHRQ], 2008). As seen in numerous IOM reports, recommendations about what AHRQ could do to enhance safety were prominent. AHRQ�s website (www.ahrq.gov) is an information-rich source for providers and consumers alike. For example, several healthcare conditions are identified in the outcomes research section. Because AHRQ maintains current information, it is a readily available source, even if the number of conditions is limited. Another example of AHRQ�s work is the fairly well-known
BOX 2-2 COMPETENCIES OF HEALTH PROFESSIONALS
� Provide patient-centered care � Work in interdisciplinary teams � Employ evidence-based practice � Apply quality improvement � Utilize informatics
From Institute of Medicine (IOM). (2003). Health professions education: A bridge to quality. Washington, DC: National Academy Press.
31CHAPTER 2 ? Patient?Safety
�Five Steps to Safer Health Care,� which is available at www.ahrq.gov/consumer/5step.htm. Nurses who work in clinics will find these steps especially helpful in working with patients. This list identifies ways in which nurses can support people in assuming a more influential role in their own care. Further, supporting people in assuming a larger role helps them receive care that is patient-centered. Box 2-3 lists the five steps. If a patient does not volunteer the above information, a nurse could readily seek clarification by asking questions related to each of those items. This is an example of reinforcing work that has been judged to benefit patients. AHRQ is also the source for the stay healthy checklists for men and women. These checklists can be useful in any clinical setting in helping people assume a greater understanding of their own care.
for Medicare & Medicaid Services (CMS) formed its no-pay policy based on the growing work of NQF of �never events.� In other words, CMS will no longer pay for certain conditions that result from what might be termed poor practice or events that should never have occurred while a patient was under the care of a healthcare professional. The NQF brings together providers, insurers, patient groups, federal and state governments, and professional associations and purchasers, to name a few of the groups comprising the membership. This diversity provides a venue for open discussion about healthcare quality that does not normally happen. Having the patients� perspectives at the same time as the perspectives of the insurers and providers allows for a broad view of any issue. The Healthcare Facilities Accreditation Program, a CMSdeemed authority, has adopted the NQF�s 34 Safe Practices. NQF refers to nurses as �the principal caregivers in any healthcare system� (National Quality Forum [NQF], 2008). This acknowledgment, while welcomed, is also a challenge for nurses to perform in the best manner possible to lead organizations in their quests for quality. Through its consensus process, NQF created a list of endorsed nurse-sensitive care standards. These standards are divided among three key areas: patientcentered outcome measures, nursing-centered intervention measures, and system-centered measures. The first group includes fall and pressure ulcer prevalence; the second, smoking cessation programs with three diagnosis groups; and the third, skill mix, turnover rates, nursing care hours per patient day, and a practice environment scale. Box 2-4 lists the nursesensitive care standards from 2008. These standards create a common definition of measures so that any group can collect and report data in a manner comparable to other groups. As a result, those measures form the basis for comparison of quality.
BOX 2-3 FIVE STEPS TO SAFER HEALTH CARE
