Reflect on the QSEN definition

1) Minimizes risk of harm to patients and providers through bothsystem effectiveness and individualperformance,knowledge,skills,attitudes.The Quality and SafetyEducation for Nurses (QSEN) project addresses the challenge ofpreparing future nurses with the knowledge, skills, and attitudes(KSAs) necessary to continuously improve the quality and safety ofthe healthcare systems within which they work.2) The goal of this chapter is to provide some fundamentaldefinitions that link patient safety with health care quality.Evidence is summarized that indicates how nurses are in a keyposition to improve the quality of health care through patientsafety interventions and strategies.Many view quality health careas the overarching umbrella under which patient safety resides. Forexample, the Institute of Medicine (IOM) considers patient safetyindistinguishable from the delivery of quality health care.Ancientphilosophers such as Aristotle and Plato contemplated quality andits attributes. In fact, quality was one of the great ideas of theWestern world.Harteloh reviewed multiple conceptualizations ofquality and concluded with a very abstract definition: Quality isan optimal balance between possibilities realised and a frameworkof norms and values.This conceptual definition reflects the factthat quality is an abstraction and does not exist as a discreteentity.Rather it is constructed based on an interaction amongrelevant actors who agree about standards (the norms and values)and components (the possibilities).Work groups such as those in theIOM have attempted to define quality of health care in terms ofstandards. Initially, the IOM defined quality as the degree towhich health services for individuals and populations increase thelikelihood of desired health outcomes and are consistent withcurrent professional knowledge.This led to a definition of qualitythat appeared to be listings of quality indicators, which areexpressions of the standards. Theses standards are not necessarilyin terms of the possibilities or conceptual clusters for theseindicators. Further, most clusters of quality indicators were andoften continue to be comprised of the 5Ds -death, disease,disability, discomfort, and dissatisfaction rather than morepositive components of quality.The work of the American Academy ofNursing Expert Panel on Quality Health focused on the followingpositive indicators of high quality care that are sensitive tonursing input: achievement of appropriate self-care, demonstrationof health-promoting behaviors, health related quality of life,perception of being well cared for, and symptom management tocriterion.Mortality, morbidity, and adverse events were considerednegative outcomes of interest that represented the integration ofmultiple provider inputs.The latter indicators were outlined morefully by the National Quality Forum.Safety is inferred, but notexplicit in the American Academy of Nursing and National QualityForum quality indicators.The most recent IOM work to identify thecomponents of quality care for the 21st century is centered on theconceptual components of quality rather than the measuredindicators: quality care is safe, effective, patient centered,timely, efficient, and equitable. Thus safety is the foundationupon which all other aspects of quality care are built.Many patient safety practices, such as use of simulators, barcoding, computerized physician order entry, and crew resourcemanagement, have been considered as possible strategies to avoidpatient safety errors and improve health care processes; researchhas been exploring these areas, but their remains innumerableopportunities for further research.Review of evidence to datecritical for the practice of nursing can be found in later chaptersof this Handbook.The National Quality Forum attempted to bringclarity and concreteness to the multiple definitions with itsreport, Standardizing a Patient Safety Taxonomy.This framework andtaxonomy defines harm as the impact and severity of a process ofcare failure: temporary or permanent impairment of physical orpsychological body functions or structure.In the past, we have often viewed nursing’s responsibility inpatient safety in narrow aspects of patient care, for example,avoiding medication errors and preventing patient falls. Whilethese dimensions of safety remain important within the nursingpurview, the breadth and depth of patient safety and qualityimprovement are far greater.The most critical contribution ofnursing to patient safety, in any setting, is the ability tocoordinate and integrate the multiple aspects of quality within thecare directly provided by nursing, and across the care delivered byothers in the setting. This integrative function is probably acomponent of the oft-repeated finding that richer staffing (greaterpercentage of registered nurses to other nursing staff) isassociated with fewer complications and lower mortality.While themechanism of this association is not evident in these correlationalstudies, many speculate it is related to the roles of professionalnurses in integrating care (which includes interception of errorsby others near misses), as well as the monitoring and surveillancethat identifies hazards and patient deterioration before theybecome errors and adverse events.Relatively few studies have hadthe wealth of process data evident in the RAND study of Medicaremortality before and after implementation of diagnosis relatedgroups. The RAND study demonstrated lower severity adjustedmortality related to better nurse and physician cognitivediagnostic and treatment decisions, more effective diagnostic andtherapeutic processes, and better nursing surveillance.3) Hand hygiene,nurse-patient ratios,drug and medical supplyshortages,quality reporting,resurgent diseases,mergers andacquisitions,physician burnout.4) safety and health management system means the part of theOrganisation’s management system which covers: the health andsafety work organisation and policy in a company.The planningprocess for accident and ill health prevention.The line managementresponsibilities and the practices, procedures and resources fordeveloping and implementing, reviewing and maintaining theoccupational safety and health policy.The system should cover theentire gambit of an employer’s occupational health and safetyorganisation.The key elements of a successful safety and healthmanagement system are:1. Policy and commitment

The workplace should prepare an occupational safety and healthpolicy programme as part of the preparation of the Safety Statementrequired by Section 20 of the Safety, Health and Welfare at WorkAct 2005. Effective safety and health policies should set a cleardirection for the organisation to follow.They will contribute toall aspects of business performance as part of a demonstrablecommitment to continuous improvement.Responsibilities to people andthe working environment will be met in a way that fulfils thespirit and letter of the law. Cost effective approaches topreserving and developing human and physical resources will reducefinancial losses and liabilities. In a wider context, stakeholdersexpectations, whether they are shareholders, employees or theirrepresentatives, customers or society at large, can be met.

2. Planning

The workplace should formulate a plan to fulfil its safety andhealth policy as set out in the Safety Statement. An effectivemanagement structure and arrangements should be put in place fordelivering the policy. Safety and health objectives and targetsshould be set for all managers and employees.

3. Implementation and operation

For effective implementation, organisations should develop thecapabilities and support mechanisms necessary to achieve the safetyand health policy, objectives and targets. All staff should bemotivated and empowered to work safely and to protect their longterm health, not simply to avoid accidents. These arrangementsshould be: underpinned by effective staff involvement andparticipation through appropriate consultation, the use of thesafety committee where it exists and the safety representationsystem and sustained by effective communication and the promotionof competence, which allows all employees and their representativesto make a responsible and informed contribution to the safety andhealth effort.There should be a planned and systematic approach toimplementing the safety and health policy through an effectivesafety and health management system. The aim is to minimise risks.Risk Assessment methods should be used to determine priorities andset objectives for eliminating hazards and reducing risks. Whereverpossible, risks should be eliminated through the selection anddesign of facilities, equipment and processes. If risks cannot beeliminated, they should be minimised by the use of physicalcontrols and safe systems of work or, as a last resort, through theprovision of PPE .Performance standards should be established andused for measuring achievement. Specific actions to promote apositive safety and health culture should be identified. Thereshould be a shared common understanding of the organisation‘svision, values and beliefs on health and safety. The visible andactive leadership of senior managers fosters a positive safety andhealth culture.

4. Measuring performance

The organisation should measure, monitor and evaluate safety andhealth performance. Performance can be measured against agreedstandards to reveal when and where improvement is needed. Activeself monitoring reveals how effectively the safety and healthmanagement system is functioning. Self-monitoring looks at bothhardware (premises, plant and substances) and software (people,procedures and systems, including individual behaviour andperformance). If controls fail, reactive monitoring should find outwhy they failed, by investigating the accidents, ill health orincidents, which could have caused harm or loss. The objectives ofactive and reactive monitoring are: to determine the immediatecauses of substandard performance to identify any underlying causesand implications for the design and operation of the safety andhealth management system.

5. Auditing and reviewing performance

The organisation should review and improve its safety and healthmanagement system continuously, so that its overall safety andhealth performance improves constantly. The organisation can learnfrom relevant experience and apply the lessons. There should be asystematic review of performance based on data from monitoring andfrom independent audits of the whole safety and health managementsystem. These form the basis of complying with the organisation’sresponsibilities under the 2005 Act and other statutory provisions.There should be a strong commitment to continuous improvementinvolving the development of policies, systems and techniques ofrisk control. Performance should be assessed by: internal referenceto key performance indicators.External comparison with theperformance of business competitors and best practice in theorganisation’s employment sector.Many companies now report on howwell they have performed on worker safety and health in theirannual reports and how they have fulfilled their responsibilitieswith regard to preparing and implementing their Safety Statements.In addition, employers have greater responsibilities under Section80 of the 2005 Act on ‘Liability of Directors and Officers ofUndertakings’ that requires them to be in a position to prove theyhave pro-actively managed the safety and health of their workers.Data from this Auditing and reviewing performance process should beused for these purposes.