The Quality And Safety Education As Nurses Core Competency for Quality Improvement Informatics and Documentation. The Education in Quality and Safety for Nurses (EQSEN) competencies are essential for nurses to continuously improve quality and safety in healthcare. These competencies include areas such as quality improvement, informatics, and documentation, which are crucial for patient well-being and improving healthcare systems.
The Quality Improvement Informatics and Documentation for Quality And Safety Education As Nurses Core Competency
Quality Improvement
Reports from the IOM since the 1990s document evidence of serous quality problems throughout the U.S. health-care system. In addition to substandard quality of care, the health-care industry is notorious for inefficiency and waste. Health care professionals are called to provide quality care, but what exactly is quality? The IOM (1990) defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (p. 4).
The AHRQ (2005) suggests that providing quality health care involves striking the right balance of services by avoiding underuse and overuse and by eliminating misuse. Others posit that applying quality improvement methods used in the industrial sector can mitigate errors, waste, and inefficiency (Greiner & Knebel, 2003). Regardless, nurses must work to provide high quality care to patients. Quality improvement originated in the industrial sector as a method to reduce errors in production processes, but its adoption by health-care organizations has been slow.
Constraints include lack of infrastructure and absence of leadership among health-care providers (Greiner & Knebel, 2003). The IOM has challenged the health-care system to build on the experiences of high-risk industries, such as aviation and nuclear power, that have demonstrated enhanced safety and quality by using quality improvement methods.
The IOM defines “apply quality improvement” as follows: “identify errors and hazards in care; understand and implement basic safety design principles, such as standardization and simplification; continually understand and measure quality of care in terms of structure, process, and outcomes in relation to patient and community needs; design and test interventions to change processes and systems of care, with the objective of improving quality” (Greiner & Knebel, 2003, p. 46).
The skills related to this competency identified by the IOM include the following (Greiner & Knebel, 2003, p. 59):
- Assess current practices and compare them with relevant better practices elsewhere as a means of identifying opportunities for improvement.
- Design and test interventions to change the process of care, with the objective of improving quality.
- Identify errors and hazards in care, and understand and implement basic safety design principles, such as standardization and simplification and human factors training.
- Both act as an effective member of an interdisciplinary team and improve the quality of one’s own performance through self-assessment and personal change.
Patient safety and quality care require nurses to systematically identify potential and actual problems, explore potential and actual causes, and develop strategies for improvement. Quality improvement is the responsibility of all nurses, regardless of position, in the health-care system. The nursing core competency of quality improvement is “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 healthcare systems” (Cronenwett et al., 2007, p. 127).
Quality improvement is a continuous process in which nurses collect quality data to establish standards for care delivery and monitor and evaluate those standards on an ongoing basis. The fundamental elements of quality improvement include structure or care environment, the care process, and outcomes of care.
Structure or Care Environment
The structure or care environment essentially means the setting where nursing care is provided. Examples include the physical environment (e.g., the unit, a patient room, a surgical suite, outpatient clinic, or a patient’s home), equipment, staffing (including staff mix and staffing ratios), policies and procedures, the organizational culture, and management of the organization.
Care Process
The care process focuses on how nursing care is provided. Examples of care process include models of care delivery such as primary care, Transforming Care at the Bedside (TCAB), and case management. The care process also encompasses critical pathways, standardized clinical guidelines, actual physical care of patients, assessment, intervention, patient education, timeliness of care, counseling, and leadership and management activities.
Outcomes of Care
The outcomes of care include the results of all the nursing care provided and reflect the effectiveness of nursing activities. Examples of outcomes of care include length of stay, infection rates, patients’ falls, post procedure complications, and failure to rescue. Currently, an approach is emerging that focuses on nursing-sensitive out comes, or outcomes linked directly to the quantity and quality of nursing care.
Informatics
Informatics is more than merely using information technology; rather, it includes the development and application of information technology systems to health-care problems, research, and education. Advances in technology have resulted in numerous innovations in health care including electronic health records, telehealth, remote monitoring, and education through simulation (IOM, 2011).
Successful use of informatics allows health-care professionals to manage knowledge and information, communicate more effectively, and reduce more errors than in the past. The IOM defines informatics as follows: “communicate, manage knowledge, mitigate error, and support decision making using information technology” (Greiner & Knebel, 2003, p. 46). The skills related to this competency identified by the IOM include the following (Greiner & Knebel, 2003, p. 63):
- Employ word processing, presentation, and data analysis software.
- Search, retrieve, manage, and make decisions using electronic data from internal information databases and external online databases and the Internet.
- Communicate using e-mail, instant messaging, LISTSERV, and file transfers.
- Understand security protections such as access control, data security, and data encryption, and directly address ethical and legal issues related to the use of information technology in practice.
- Enhance education and access to reliable health information for patients.
Informatics integrates data, information, and knowledge to support the interprofessional team and is linked consistently to patient safety and quality (Greiner & Knebel, 2003; Warren, 2012). Safe and quality care requires information technology to facilitate effective communication and documentation. Nurses must develop and maintain their skills in informatics to use electronic health records, examine relevant evidence to support clinical decisions, solve patient and system problems, manage quality improvement data, and share information (Sherwood & Barnsteiner, 2012).
In light of this, the nursing core competency of informatics is defined as the “use in formation and technology to communicate, manage knowledge, mitigate error, and support decision-making” (Cronenwett et al., 2007, p. 129). The incorporation of informatics in health care is inevitable, and nurses must develop the skills for entering patients’ data and retrieving information for clinical decision making and quality improvement. Informatics is actually a thread through all of the QSEN competencies (Warren, 2012). The fundamental elements of informatics are information management and documentation.
Information Management
Nurses depend upon information to provide safe and quality care. How information is organized and presented influences how effectively and efficiently nurses deliver care (Sewell, 2016). The Technology Informatics Guiding Education Reform (TIGER) was launched in 2006 to create a vision for the future of nursing in the digital age. Nine TIGER collaborative teams were formed to develop action plans related to key topic areas.
The TIGER Informatics Computer Collaboration (TICC) team was charged with defining “the minimum set of informatics competencies that all nurses need to succeed in practice or education in today’s digital era” (TIGER, 2009, p. 5). The TICC team developed a set of competencies related to information management and contended that all practicing nurses should “learn, demonstrate, and use information management competencies to carry out their fundamental clinical responsibilities in an increasingly safe, effective, and efficient manner” (TIGER, 2009, p. 11).
Information management is the process of collecting, analyzing, monitoring, summarizing, and communicating necessary information for health care (Greiner & Knebel, 2003; TIGER, 2009). Access to online databases provides nurses and other health-care professionals with the literature and knowledge needed to implement evidence-based practice (Greiner & Knebel, 2003).
Nurses manage information in a variety of ways, but “the preferred or required method is through information systems” (TIGER, 2009, p. 11). Skills in using information systems and patient care technologies that support delivery of safe patient care and a safe practice environment are essential for all nurses (AACN, 2008).
Documentation
Nurses have a professional responsibility to document care planning, actual care provided, and patient outcomes. Documentation is any written or electronically generated information about a patient that describes the care provided to that patient and offers an accurate account of what occurred and when it occurred. Nurses use documentation to communicate all interactions with patients including assessments, interventions, evaluations, and outcomes of care.
Documentation is maintained in a health record, which may include paper or electronic documents such as electronic medical records, faxes, e-mails, audio or video records, and images. Documentation is critical for effective interprofessional and interprofessional communication. “Clear, accurate and accessible documentation is an essential element of safe, quality, evidence-based nursing practice” (ANA, 2010b, p. 3).
Effective documentation provides a foundation for demonstrating nursing’s valuable contributions to patient outcomes as well as to the organizations that provide and support quality patient care (ANA, 2010b). According to the ANA (2010b), documentation is critical to the nursing profession in the following areas:
- Communication within the health-care team and with other professionals
- Credentialing, legal, regulation, and legislation
- Reimbursement
- Research, quality process, and performance improvement
Safety
Although the IOM does not identify safety as a separate competency, it is included as one of the six aims critical to improving the overall quality of health care as well as safety for patients and health-care workers. The IOM’s all-inclusive definition of safety is “freedom from accidental injury” (IOM, 2001, p. 45). IOM report, To Err is human, outlines recommendations for improving patient safety at the point of care delivery (Kohn, Corrigan, & Donaldson, 2000).
The report also encourages health-care organizations to focus on creating environments that foster patient safety, or in other words, creating a safety culture. Key organizations committed to the patient safety movement include the AHRQ, NQF, TJC, and Institute for Healthcare Improvement (IHI). Although the quest for safe and quality health care has been ongoing for more than 2 decades, health-care professionals continue to fall short.
Chassin and Loeb (2011) suggested that the health-care system is at a critical intersection at which patients in the hospital are increasingly vulnerable to harm from medical errors, and, unfortunately, the complexity of health care today increases the likelihood of medical errors. Safety does not just happen; it must be carefully orchestrated and requires all staff to be adequately educated about patient safety and error prevention. Nurses, more than any other health-care professionals, have been identified as vital players in promoting patient safety.
Nurses are able to recognize, interpret, evaluate, and correct health-care errors (AACN, 2008b). Safety is another competency that is present in all other QSEN competencies and is a common theme throughout this her. The safety core nursing competency is defined as follows: “minimize risk of harm to patients and providers through both system effectiveness and individual performance” (Cronenwett et al., 2007, p. 128). The fundamental elements of safety include human errors and human factors, standardized protocols and practice, safety culture, and high reliability organizations.
Human Errors and Factors
Given the high complexity of the health-care environment today, errors are in evitable. Human errors are acts of omission or commission leading to an undesirable outcome or the potential for an undesirable outcome (Wachter, 2012). Acts of omission involve failing to do the right thing or omitting something that results in an error, such as a nurse forgetting to give a patient a prescribed medication. Acts of commission involve doing something wrong or committing an error, such as a nurse giving a patient the wrong medication.
Human factors engineering is a science that studies human capabilities and limitations and applies knowledge gleaned to the design of safe, effective processes and systems for humans with the goal of achieving effective, efficient, and safe care (Boston-Fleischhauer, 2008a). Human factors engineering assumes that well designed processes and systems take into account human capabilities and limitations outside the control of those working with the processes and systems.
Such limitations can be
1) physical, such as noise, climate, lighting
2) cognitive, involving short-term memory capacity and fatigue
3) organizational, such as job and task design
(Boston-Fleischhauer, 2008a).
Poorly designed processes and systems can result in increased potential for errors and decreased patient safety (Boston Fleischhauer, 2008a). Nurses must monitor, evaluate, and improve processes and systems to ensure patient safety. Reliability science is “the ability of an operation to be failure or defect free over time” (Boston-Fleischhauer, 2008b, p. 84). In other words, reliability science is employing deliberate strategies that make it difficult for nurses to do the wrong thing and easy to do the right thing.
By designing simplistic processes and systems that are standardized and redundant, defy error, avoid reliance on memory, and employ continuous vigilance, the goal of safe, quality patient care can be realized. Simplicity and standardizing care can reduce the probability of errors by decreasing variability of care.
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