Evidence-based Patient Safety &

Quality Improvement: the

Nursing Imperative
Ronda G. Hughes, PhD, MHS, RN
Senior Health Scientist Administrator
Agency for Healthcare Research and Quality
American Association of Colleges of Nursing
January 26, 2008

Overview
Background
Evidence-based practice
External drivers
Quality of Care

Building the evidence-base

Evidence that is actionable

Why Evidence?
Evidence-based Guidelines

www.guidelines.gov
Reduce inappropriate variations in practice
Promote high-quality care
Accountability

Evidence-based Practice Culture

Better decision-making, grounded in scientific knowledge

Decision-making process includes:

Research evidence
Patient preferences
Available resources
Clinical expertise

Central to the ability to deliver safe, effective, and patientcentered care

Diffusion of Knowledge
Clinical Procedure

Landmark Trial*

NHQR 2005

Flu Vaccine
Pneumococcal Vaccine

1968
1977

63%
56%

Diabetic Eye Exam

Mammography
Cholesterol Screening

1981
1982
1984

68%
70%
73%

SOURCE: Balas EA, Boren SA., Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical

Informatics 2002.

Evidence-based Clinical
Decisions
Clinical state,
Setting &
Circumstances

Patient
Preferences &
Actions

Clinical Expertise
Research
Evidence

Health Care
Resources

SOURCE: Haynes, Devereauxs, Guyatt. ACP J Club 2002: 136:A11-14.

Evidence Report:
Osteoarthritis of the Knee
Major Finding: Evidence is

lacking for many common ways of

treating osteoarthritis of the knee
Glucosamine and chondroitin,
widely used over-the-counter
dietary supplement ingredients,
appear to be no more effective
than placebos
No convincing evidence found of
any benefit from arthroscopic
surgery to clean the knee joint
Treatment of Primary and Secondary Osteoarthritis of the Knee, October 2007,
Available at www.ahrq.gov/downloads/pub/evidence/pdf/oaknee.pdf

Consumers Union
Consumers Union uses

findings from AHRQs

Effective Health Care
Program
The information helps
clinicians & patients
decide which drugs &
other medical treatments
work best for certain
health conditions
Drug class review reports
are downloaded at rate of
110,000 monthly
www.effectivehealthcare.ahrq.gov
(Source: COE 07-10)

Comparative Effectiveness
Review: Surgery Versus
Angioplasty
Major Finding: Patients with mid-

range coronary artery disease are

more likely to get relief & less
likely to have repeat procedures if
they get bypass surgery rather
than balloon angioplasty with or
without a stent
For mid-range coronary artery
disease, bypass surgery and
angioplasty patients had about
the same survival rates and
similar number of heart attacks
Bypass surgery presents a
slightly higher risk of stroke within
30 days of the procedure
Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery
Bypass Grafting for Coronary Artery Disease, Available at http://effectivehealthcare.ahrq.gov

Cornerstones of
Value-Driven Health Care
Quality Standards

Price Standards

Design systems to collect quality

of care information and define
what constitutes quality health care

Aggregate claims information to

enable cost comparisons between
specific doctors and hospitals

Incentives

Interoperability

Reward those who provide and

purchase high-quality and
competitively priced health care

Set common technical standards

for quick and secure
communication and data exchange

Driving Factors in Quality

Focused attention to the
Institute of Medicines 6
quality aims:
Effective, Efficient,
Safe, Timely, PatientCentered, Equitable
Public demand to know
Linking payment to quality
of care
Priority: Transparency

Opportunity: Quality Incentives

Growing number of incentive

programs to reward
improvement in quality and
safety performance
Incentives may provide new
revenue stream to enable
purchase of health IT systems
Without electronic records,
providers may not be able to
participate in P4P contracts

P
4
P

Government Drivers
IOM Chasm series
Ex.: 3 of 100 operations are complicated

by surgical site infection (Commonwealth Fund, 2006)

CMS rule for healthcare (e.g., hospital) acquired
infections (began 10-1-07)
Reporting healthcare (e.g., hospital) acquired
infections to the state (i.e.., DE, MN, NJ, NM, OR, TX, WA,
etc.) or CDC

Patient Safety Act of 2005

Creates Patient Safety

Organizations (PSOs)
Establishes Network of Patient
Safety Databases
Mandates Comptroller General
to study effectiveness of Act (by
2010)

Completely voluntary
Not possible without health IT

backbone

Judgments
Despite all of the quality improvement activities over the past few
years, the publics perception of the health system is in decline

U.S. adults
who view
hospitals as
generally
trustworthy
and honest

35%

34%
28%

2004
SOURCE: Harris Interactive Poll November 2006

2005

2006

Communication in Hospitals
Hospital patients who
report sometimes or
never having good
communication with
doctors, nurses,
about new
medications or
discharge
information, 2005

SOURCE: 2006 National Healthcare Quality Report, AHRQ.

AHRQ Research Study:

Errors Caused by Medical Residents

Major Finding: Physicians-in-training

are highly vulnerable to making
medical errors that stem from
teamwork breakdowns and a lack of
supervision
Focus was on four clinical categories:

Obstetrics
Surgical
Missed and delayed diagnosis
Medications

Despite a growing body of evidence

that links poor teamwork and
preventable medical errors, graduate
medical education programs continue
to pay insufficient attention to
teamwork-based training
Medical Errors Involving Trainees: A Study of Closed Malpractice Claims from 5
Insurers, Archives of Internal Medicine, October 22, 2007

IOMs Quality Chasm Series

More Medical Errors in U.S.

Any medical mistake, medical error or test error in last 2 years
50%

25%

0%

22%

UK

23%

GER

25%

NZ

27%

30%

AUS

CAN

34%

US

SOURCE: C Shoen et al, Taking the Pulse of Health Care Systems: Experience of Patients with Health Problems

in 6 Countries Commonwealth Fund International Health Policy Survey of Sicker Adults, 11/03/05.

People Are Set-Up to Make

Mistakes

Incompetent people are, at most,

1% of the problem. The other 99%
are good people trying to do a good
job who make very simple mistakes
and it's the processes that set them
up to make these mistakes.
Dr. Lucian Leape, Harvard School of Public Health

Overview
Background
Evidence-based practice
External drivers
Quality of Care

Building the evidence-base

Evidence that is actionable

AHRQs Focus
Improve health care quality for all

Americans
Transform research into practice
Improve health care outcomes
through research
Use evidence to improve health care

Challenges of Evidence-based
Practice
Accelerating progress toward the long-term
vision of a learning healthcare system, in
which evidence is applied and developed as a
natural product of patient care.
Advancing the near-term capacity to generate
the evidence for the medical care that is most
effective and produces the greatest value.
Improving public understanding about the
nature of evidence, its dynamic character and
its importance.

Ecology of Medical Care

1000 people
800 have symptoms

327 consider seeking

medical care
217 visit a physicians
office
113 visit primary care
physicians
office
65 visit
CAM provider
21 visit a hospital OPD
14 receive home health
care
13 visit an emergency
department
8 in a hospital
<1 in an academic health
center

SOURCE: NEJM 2000, Green et al.

IOM Definition of Health

Services Research
Health services research is a

multidisciplinary field of inquiry, both

basic & applied, that examines the use,
costs, quality, accessibility, delivery,
organization, financing, & outcomes of
health care services to increase
knowledge & understanding of the
structure, processes, & effects of health
services for individuals & populations.

Largest Clinical Profession

Approximately 2.9
million registered
nurses
83.2% (2.4 million)
employed in nursing
58.3% employed full
time
56.2% employed in
hospitals
46.8 average age
SOURCE: Health Resources and Services Administration, 2004.

Overview
Background
Evidence-based practice
External drivers
Quality of Care

Building the evidence-base

Evidence that is actionable

New Book on
Evidence-Based Nursing
Patient Safety & Quality: An
Evidence-Based Handbook for Nurses

Collaboration - > 90 experts

Topics range from Nurses at the Sharp End

to Pressure Ulcers to Tele-health

Co-funding - AHRQ & The Robert Wood

Johnson Foundation

Edited by Ronda G. Hughes, PhD, MHS, RN

Target Audience Nursing, broadly

(especially in schools of nursing)

Available January 2008 on the AHRQ website:

www.ahrq.gov.

Patient Safety & Quality: An

Evidence-Based Handbook for Nurses
Section I: Patient Safety and Quality

Defining Patient Safety and Quality Care -

Nurses at the Sharp End - Ronda Hughes

An Overview of To Err Is Human:
Reemphasizing The Message of Patient
Safety - Molla Sloane Donaldson
The Quality Chasm Series - Mary K. Wakefield
A Human Factors Framework - Kerm Henriksen,

Pamela Mitchell

Elizabeth Dayton, Margaret A. Keyes, Pascale Carayon, & Ronda Hughes

Clinical Reasoning, Decision-Making and

Action: Thinking Critically and Clinically -

Patricia E. Benner, Molly Sutphen, & Ronda Hughes

Patient Safety & Quality: An

Evidence-Based Handbook for Nurses
Section II: Evidence-Based Practice

Evidence for Evidence-Based Practice

Implementation - Marita Titler
Health Services Research: Scope &
Significance - Donald Steinwachs & Ronda Hughes
Synergistic Opportunities for Enhanced
Patient Safety: Connecting the Quality
Improvement and Disaster Preparedness
Dots - Lucy Savitz & Sally Phillips

Patient Safety & Quality: An

Evidence-Based Handbook for Nurses
Section III: Patient-Centered Care

Patient- & Family-Centered Care - Ronda Hughes

& C. Lynn Chevalier

Fall and Injury Prevention - Leanne Currie

Reducing Functional Decline in
Hospitalized Elderly - Ruth Kleinpell, Kathy Fletcher, &
Bonnie Jennings

Pressure Ulcers - Courtney Lyder & Elizabeth Ayello

Patient Safety and Quality In Home Care -

Carol Hall Ellenbecker, Linda Samia, Margaret Cushman, & Kristine Alster

Patient Safety & Quality: An

Evidence-Based Handbook for Nurses
Section III: Patient-Centered Care (cont)

Family Caregiving & Caregiver Assessment

Pediatric Safety & Quality -

- Susan Reinhard, Barbara Given, Nirvana Huhtula, & Ann Bemis

Karen Cox

Susan Lacey, Janis Smith, &

Prevention: Safety and Quality - Carol Loveland-

Cherry

Symptom Management The Example of

Pain - Nancy Wells, Margo McCaffery, & Chris Paseo
Medication Management of the
Community-Dwelling Older Adult - Karen Dorman

Marek & Lisa Antle

Patient Safety & Quality: An

Evidence-Based Handbook for Nurses
Section III Working Conditions and the Work
Environment for Nurses

Care Models - Bonnie Jennings

Leadership - Bonnie Jennings, Joanne Disch & Laura Senn

Vignettes
Transforming Healthcare for Patient Safety: Nurses Moral
Imperative to Lead - Diana Mason
Who should lead the patient quality/safety journey? Joane
Disch
Creation of a Patient Safety Culture: A Nurse Executive
Leadership Imperative - Victoria Rich

Creating a Safe & High Quality Health Care

Environment - Patricia Stone, Ronda Hughes & Maureen Dailey

Structural Characteristics
Enabling Factors: Leadership,
Technologies, Communication, Financial Resources

Employee/
Staff
- Workflow & workload
- Collaboration
- Occupational Safety

Patient
- Patient-centered care
- Evidence-based care

Organizational

Microclimates

- Efficiency
- Effectiveness
- Quality improvement

Employee/Staff Actions
Processes

(e.g., handwashing,
providing evidence-based
care, etc.)

Patient Actions
(e.g., adherence, collaboration)

Organizational Outcomes
Employee/
Staff

Patient

Organizational

Source: Stone P & Hughes RG. (2008). In Hughes, RG. (ed). Patient Safety & Quality: an Evidence-based Handbook for Nurses. AHRQ:
Rockville, MD

Patient Safety & Quality: An

Evidence-Based Handbook for Nurses
Section III Working Conditions and the
Work Environment for Nurses (cont)

Practice Implications of Keeping Patients

Safe - Ann Page

Patient Acuity - Bonnie Jennings

Restructuring & Mergers - Bonnie Jennings

Staffing - Sean Clarke & Nancy Donaldson

Nurses Work Stress & Burnout - Bonnie Jennings

Nurse Staffing, Quality of Care,

& Patient Outcomes
Staffing:
# of nursing personnel
relative to service volume

Administrative
practices

Staffing:
Staff qualifications
(education,
experience, etc.)

Quantity (dose) of
Nursing attention
Quality of nursing care
- Safety of acts
- Prevention -rescue

Model of care
delivery
Organizational
environment

Safety
outcomes
Care needs
of population

Clinical
outcomes

SOURCE: Clarke, S. & Donaldson, N.. Nurse staffing. (2008) Hughes, R.G., editor. In Patient Safety & Quality: an

Evidence-based Handbook for Nurses. AHRQ & RWJF.

Patient Safety & Quality: An

Evidence-Based Handbook for Nurses
Section III Working Conditions and the
Work Environment for Nurses (cont)

Temporary, Agency & Other Contingent

Workers - Ann Page

The Built Environment/Physical Design

John Reiling & Ronda Hughes

Turbulence

Workload for Nurses

Workflow

- Bonnie Jennings
- Pascal Carayon & Ayse Gurses

- Carol Cain & Saira Haque

Patient Safety & Quality: An

Evidence-Based Handbook for Nurses
Section IV: Critical Opportunities for Patient
Safety and Quality Improvement

Professional Communication - Jean Ann Seago

Team Work & Communication - Michelle ODaniel &
Alan Rosenstein

Handoffs - Mary Ann Friesen, Susan V. White & Jacqueline Byers

Error Reporting & Error Disclosure - Zane
Robinson Wolf & Ronda Hughes

Wrong Site Surgery - Deborah Mulloy & Ronda Hughes

The Role and Impact of Nurse Practitioners
- Eileen OGrady

Framework for
Success or Failure in Handoff
Organizational culture
Communication
Variance in interpersonal skills, experience,

& settings
Structure of how handoffs conducted
Access to information
Environmental design/environmental
factors
Knowledge on how to conduct handoffs

SOURCE: Friesen, M, Byers, S, & White, S. Nurse staffing. (2008) Hughes, R.G., editor. In Patient Safety &

Quality: an Evidence-based Handbook for Nurses. AHRQ & RWJF.

Patient Safety & Quality: An

Evidence-Based Handbook for Nurses
Section IV: Critical Opportunities for Patient
Safety and Quality Improvement (cont)

Medication Administration Safety - Ronda Hughes

& Mary Blegen

Medication Reconciliation - Jane Barnsteiner

Personal Safety for Nurses - Alison Trinkoff, Jeanne

Geiger-Brown, Claire Caruso, Jane Lipscomb, Meg Johantgen, Audrey Nelson,

Barbara Sattler, & Victoria Selby

Effects of Fatigue & Sleepiness on Nurse

Performance & Patient Safety - Ann Rogers
Preventing Health Care Acquired Infections
- Amy Collins

Strategies to Target Health Care Acquired

Infections - Ruth Kleinpell, Cindy Munro & Karen Giuliano

Countermeasures for
Fatigue & Insufficient Sleep
Obtain 7-8 hours of sleep per night

(especially

nurses age 20-30).

Work no more than 3 or 4 consecutive 12hour shifts.

Have at least 12-hours off between work
shifts.
Consider napping prior to starting 11pm or
midnight shift.

SOURCE: Rogers, A. The Effect of Fatigue & Sleep. (2008) Hughes, R.G., editor. In Patient Safety & Quality: an

Evidence-based Handbook for Nurses. AHRQ & RWJF.

Infection Prevention
Strategies

Hand Hygiene
Respiratory Care
Patient Positioning
Staff Education
Alternative approaches to urinary
catheterization
Use of antimicrobial urinary catheters

SOURCE: Collins, A & Kleinpell, R. Targeting Health Care Acquired Infections. (2008) Hughes, R.G., editor. In Patient

Safety & Quality: an Evidence-based Handbook for Nurses. AHRQ & RWJF.

Patient Safety & Quality: An

Evidence-Based Handbook for Nurses
Section V: Tools for Quality Improvement
and Patient Safety:

Quality Methods, Benchmarking &

Measuring Performance - Ronda Hughes
Indicators of Success - Marybeth Farquhar
Magnet Recognition Program - Vicki Lundmark
Patient Safety & Health Information
Technology - Nancy Staggers, Charlene Weir & Shobha Phansalkar
Patient Safety, Telenursing & Telehealth Loretta Schlachta-Fairchild, Victoria Elfrink & Andrea Deickman

Benefits of HIT Tools

Accessible, standardized patient records
Decrease medication administration

errors by using eMAR & CPOE

Seemless integration between CPOE &
BCMA improve workflow &
communication
Telehealth technologies can improve
patient adherence, access to care,
interdisciplinary care, & patient safety
SOURCE: Keenan et al, Staggers et al, and Schlachta-Fairchild et al. The Effect of Fatigue & Sleep. (2008) Hughes,
R.G., editor. In Patient Safety & Quality: an Evidence-based Handbook for Nurses. AHRQ & RQJF.

29 Patient Safety Indicators

Complications of anesthesia
Death - low mortality DRGs
Decubitus ulcer
Failure to rescue
Foreign body left during
procedure
Iatrogenic pneumothorax
Selected infections due to
medical care
Postoperative hemorrhage
or hematoma
Postoperative hip fracture
Postoperative physiological
and metabolic derangement
Postoperative PE or DVT

Postoperative respiratory
failure
Postoperative sepsis
Postoperative wound
dehiscence
Technical difficulty with
procedure
Transfusion reaction
Birth trauma injury to
neonate
Obstetric (OB) trauma
cesarean delivery
OB trauma vaginal delivery
with instrument
OB trauma vaginal delivery
without instrument

Patient Safety & Quality: An

Evidence-Based Handbook for Nurses
Section V: Tools for Quality Improvement
and Patient Safety:

Documentation & the Nurse Care-Planning

Process - Gail Keenan, Elizabeth Yakel & Dana Tschannen
Patient Care Technology & Safety - Gail PowellCope, Audrey Nelson & Emily S. Patterson

Enhancing Patient Safety in Nursing

Education - Carol Fowler Durham & Kathryn Alden

Health Professions Education

5 Core Competencies:
1.
2.
3.
4.
5.

Provide patient-centered care

Work in interdisciplinary teams
Employ evidence-based
practice
Apply quality improvement
Utilize informatics

Patient Safety & Quality: an

Evidence-base Handbook for Nurses

Links with curriculum on patient

safety and quality improvement

developed by UNC (funded by RWJF)
Available at: www.ahrq.gov

Opportunities
Use & develop best
available evidence for
decision making
Lead efforts in quality &
patient safety
Nurse-led, evidencebased quality & patient
safety infrastructure of
centers of excellence
across health care
settings

So What?