Aligning Healthcare Safety and Quality Competencies: Quality and Safety Education for Nurses (QSEN), The Joint Commission, and American Nurses Credentialing Center (ANCC) Magnet® Standards Crosswalk

Abstract

There is little to no improvement in the quality of patient care since the publication of To Err Is Human report in 1999 by the Institute of Medicine. Health care provider education must address quality and patient safety language in order to meet the demands of the 21st century. Academic institutions focus on the quality and safety language as outlined by the Quality and Safety Education for Nurses (QSEN). Conversely, hospitals emphasize competencies and standards as outlined in The Joint Commission accreditation standards and the American Nurses Credentialing Center Magnet® competencies. Nurse leaders need a crosswalk among all 3 standards that can help guide their practice. The crosswalk can help nurse leaders have an increased understanding of the role that QSEN plays in educating a competent and safe nursing workforce. There is little to no improvement in the quality of patient care since the publication of To Err Is Human report in 1999 by the Institute of Medicine. Health care provider education must address quality and patient safety language in order to meet the demands of the 21st century. Academic institutions focus on the quality and safety language as outlined by the Quality and Safety Education for Nurses (QSEN). Conversely, hospitals emphasize competencies and standards as outlined in The Joint Commission accreditation standards and the American Nurses Credentialing Center Magnet® competencies. Nurse leaders need a crosswalk among all 3 standards that can help guide their practice. The crosswalk can help nurse leaders have an increased understanding of the role that QSEN plays in educating a competent and safe nursing workforce. Over 400,000 Americans die each year due to health care provider errors.1The Rand Corporation Patient Safety in the Commonwealth of Massachusetts. Rand Corporation, Santa Monica, CA2014http://www.rand.org/content/dam/rand/pubs/research_reports/RR800/RR891/RAND_RR891.pdfGoogle Scholar This is a cause for concern as the number of deaths from medical errors supersedes that of acquired immunodeficiency syndrome, breast cancer, and motor vehicle accidents combined. Moreover, the financial impact of such avoidable errors both in the outpatient and acute care setting in the United States is projected to be 17.1 billion dollars.2Van Den Bos J Rustagi K Gray T Halford M Ziemkiewicz E Shreve J The $17.1 billion problem: the annual cost of measurable medical errors.Health Aff (Millwood). 2011; 30: 596-603Crossref PubMed Scopus (222) Google Scholar In 2003, the Institute of Medicine (IOM) published the report Health Professions Education: A Bridge to Quality in response to the IOM report Crossing the Quality Chasm: A New Health System for the 21st Century.3Institute of Medicine Health Professions Education: A Bridge to Quality. National Academy Press, Washington, DC2003http://www.nap.edu/openbook.php?isbn50309087236Google Scholar Health Professions Education highlighted the necessity to redesign the education of health care professionals. It also outlined the necessary competencies that need to be achieved in order to appropriately respond to the evolving needs of the health care system. The IOM competencies were adapted by nursing leaders and the Quality and Safety Education for Nurses (QSEN) competencies were developed.4Cronenwett L Sherwood G Barnsteiner J et al.Quality and safety education for nurses.Nurs Outlook. 2007; 55: 122-131Abstract Full Text Full Text PDF PubMed Scopus (789) Google Scholar Parallel to the movement to redesign education is the national movement to improve the safety and quality of health care services. This was led by the Centers for Medicare & Medicaid Services (CMS) through their implementation of the Hospital Value-Based Purchasing (VBP) program. In VBP, hospitals are reimbursed based on quality and not solely on the quantity of care.5Center for Medicare & Medicaid Services Hospital Value-Based Purchasing.https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect/hospital-value-based-purchasing/Date: 2014Google Scholar CMS requires that acute care institutions meet minimum health and safety standards in order to be eligible for reimbursement.6Center for Medicare & Medicaid Services Survey & Certification–Certification and Compliance.https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/index.html?redirect5/CertificationandComplianc/18_RHCs.aspDate: 2012Google Scholar The Joint Commission (TJC) is one of the largest and the oldest accrediting body in healthcare.7The Joint Commission Comprehensive Accreditation Manual for Hospitals. The Joint Commission, Oak Brook, IL2015Google Scholar Conversely, the American Nurses Credentialing Center (ANCC) Magnet® recognition is considered as the most prestigious credential a health care organization can obtain that signifies the achievement of the highest quality of nursing practice and the best patient outcomes.8American Nurses Credentialing Center The Magnet® Model Component and Sources of Evidence: Magnet Recognition Program. American Nurses Credentialing Center, Silver Spring, MD2014Google Scholar Achieving accreditation or certification from TJC and/or ANCC allows institutions to maximize third-party reimbursement from hospital VBP programs. While hospitals and schools of nursing aim to prepare nurses to provide effective, safe, and high quality patient care, the use of varying lexicons for patient safety and quality care in academic and practice settings can lead them to be out of sync. There is no document available, to date, that outlines the relationship and alignment between QSEN, TJC, and Magnet. Such a document can assist nurse leaders to increase their understanding of the important role that QSEN plays in teaching students about TJC standards and Magnet competencies. The original QSEN project, initially focused on academic curriculum, began at the University of North Carolina Chapel Hill School of Nursing in 2005 and was funded by the Robert Wood Johnson Foundation. Its aim was to educate the future nursing workforce to be competent on patient safety and healthcare quality principles.9QSEN Institute Press Release: Phase I.http://qsen.org/about-qsen/project-overview/project-phases/Date: November 2005Google Scholar Based on the 2003 IOM report Health Professions Education, the QSEN project identified 6 core quality and safety program competencies that are essential in closing the gap between the quality chasm. These competencies are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. In 2007, Cronenwett et al.4Cronenwett L Sherwood G Barnsteiner J et al.Quality and safety education for nurses.Nurs Outlook. 2007; 55: 122-131Abstract Full Text Full Text PDF PubMed Scopus (789) Google Scholar published a paper outlining the knowledge, skills, and attitudes (KSAs) that define key strategies for successful acquisition of each QSEN competency. Cronenwett et al. focused on system effectiveness as a way to ensure safety and the inclusion of quality improvement science in the preparation of pre-licensure students so that they are better prepared to address the demands of the evolving health care system. Finally, emphasis on acquisition of information technology skills and the ability to navigate through electronic health systems to provide and support patient care were identified as gaps that needed to be addressed to improve the quality of nursing education. Many key practice and academic leaders through the support of grant funding from institutions such as the Robert Wood Johnson Foundation and The Gordon and Betty Moore Foundation have worked tirelessly to help disseminate and adopt QSEN competencies in curriculums throughout nursing schools and ultimately, hospitals in the nation. Disch et al.10Disch J Barnsteiner J Mcguinn K Taking a “deep dive” on integrating QSEN in San Francisco Bay Area school of nursing.J Prof Nurs. 2013; 29: 75-81Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar and Barnsteiner et al.11Barnsteiner J Disch J Johnson J McGuinn K Chappell K Swartwout E Diffusing QSEN competencies across schools of nursing: the AACN/RWCF faculty development institutes.J Prof Nurs. 2012; 29: 68-74Abstract Full Text PDF Scopus (0) Google Scholar published works that highlight the effort to mobilize the nation to adopt such competencies. It is a fair generalization that nurse leaders are concerned in ensuring that the current and future health care workforce are well-equipped to respond to and provide safe and quality care. The main focus in most acute and post-acute care institutions is to ensure that policies and practice align with regulatory standards such as those enumerated by TJC. Additionally, acute care institutions that aim to demonstrate that they practice with the highest quality of nursing practice and best patient outcomes also focus in ensuring that nursing practice aligns with the standards set forth by the Magnet recognition program, whether they receive the magnet designation or are on “the Journey to Magnet ExcellenceTM.” QSEN is a framework that interweaves both The Joint Commission Accreditation Standards and the Magnet model and components. Nurse executives and nurse leaders can be reassured in knowing that a program structured around QSEN competencies is a program structured to produce a professional that can respond to the evolving needs of the healthcare industry. Early published reports of QSEN infusion into nursing curricula showed an increase in the intent of students to provide quality care through personal reflections.12Riley J Yearwood E The effect of pedagogy of curriculum infusion on nursing student well-being and intent to improve the quality of nursing care.Arch Psychiat Nurs. 2012; 26: 364-373Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Students generally do not have the opportunity to provide care to a rapidly deteriorating patient both in pediatrics and acute care areas due to regulatory and sometimes hospital constraints to ensure patient safety.13Pauly-O'Neill S Prion S Lambton J How often do BSN students participate in pediatric critical events during simulation and hospital rotations?.Clin Simul Nurs. 2011; 9: e113-e120Abstract Full Text Full Text PDF Scopus (7) Google Scholar, 14Young M Simpson V McComb S Kirkpatrick J La Lopa J Bullard K Toward creating an optimal acute care clinical learning: insights from staff, faculty, and students.J Nurs Educ. 2013; 53: S42-S45Google Scholar However, students are afforded the chance to practice and develop quality and safety competencies that they may otherwise not be able to practice in a traditional clinical setting through simulation curriculum scenarios that are aligned and integrated with QSEN competenices.15Pauly-O'Neill S Prion S Nguyen H Comparison of Quality and Safety Education for Nurses (QSEN)-related student experiences during pediatric clinical and simulation rotations.J Nurs Educ. 2013; 52: 534-538Crossref Scopus (10) Google Scholar, 16Brady D Using quality and safety education for nurses (QSEN) as a pedagogical structure for course redesign and content.Int J Nurs Educ Scholarsh. 2013; 8Google Scholar The movement to infuse QSEN into practice has gone beyond the 4 walls of academic institutions. Practice leaders have begun to integrate QSEN into their settings. A few examples of this movement include the dedicated education units at the Methodist University Hospital in Tennessee and the educational resource unit at ProMedica Health System in Ohio.17Mckeon T Mckeon L Webb S Using quality and safety education for nurses to guide clinical teaching on a new dedicated education unit.J Nurs Educ. 2011; 50: 706-710Crossref Scopus (29) Google Scholar, 18Didion J Kozy M Koffell C Oneail K Academic/clinical partnership and collaboration in quality and safety education for nurses education.J Prof Nurs. 2013; 29: 88-94Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Both programs aimed at decreasing the preparation-practice gap that existed in nursing education. They both demonstrated effective academic-practice partnership models that addressed the need to educate both the students and the nursing workforce on quality and safety principles through the QSEN framework. Finally, Patrician et al.19Patrician PA Dolansky MA Pair V et al.The Veterans Affairs National Quality Scholars program: a model for interprofessional education in quality and safety.J Nurs Care Qual. 2013; 28: 24-32Crossref Scopus (13) Google Scholar published a case report on the work of the Veterans Affairs National Quality Scholars Program. Their work focused on developing a pathway for nurses to work on health care quality and safety education and research, the second goal of the QSEN project. Patrician and her colleagues provided a thorough description of a model for interprofessional education and training. This was achieved with marginal cost by utilizing a pre-existing program structured for physicians. According to the authors, a joint program is better than anything that can be developed by one profession alone. The majority of the fellows have gone to be experts and leaders in the national arena within their respective fields QSEN, TJC, and Magnet all aim to ensure that clinicians provide high quality and safe care. As nurse leaders, we should focus on the commonalities and similarities of all 3 standards and stop thinking of each competency as independent of each other. The goal of the crosswalk is to help practice leaders understand the value of QSEN and to help academic leaders emphasize the correlation of QSEN with TJC and Magnet standards. The work to create a crosswalk began once it was established that there is a need to align QSEN, TJC, and Magnet competencies. To gain a deeper understanding of QSEN and the QSEN competencies, the authors read and reviewed all of the competency resource papers and the entire QSEN undergraduate learning module posted on www.qsen.org. A critical appraisal of all resources used as primary evidence was conducted using the Johns Hopkins nursing evidence based practice appraisal tool.20The John Hopkins Hospital/John Hopkins University Non-Research Evidence Appraisal Tool.http://www.hopkinsmedicine.org/institute_nursing/_docs/vebp/appendix_f_nonresearch_evidence_appraisal_tool.pdfDate: 2013Google Scholar, 21The John Hopkins Hospital/John Hopkins University Research Evidence Appraisal Tool.http://www.hopkinsmedicine.org/institute_nursing/_docs/ebp/appendix_e_research_evidence_appraisal_tool.pdfDate: 2013Google Scholar The entire 2015 TJC Accreditation manual was reviewed and notations made throughout the document. An Excel file was created with QSEN competencies in one column. Any TJC standard that aligned with the aforementioned competency was placed in the column next to it. The same process was completed with the ANCC Magnet accreditation manual. This process was completed twice to ensure accuracy of the crosswalk. The QSEN competency definition and the respective KSAs identified by Cronenwett et al.4Cronenwett L Sherwood G Barnsteiner J et al.Quality and safety education for nurses.Nurs Outlook. 2007; 55: 122-131Abstract Full Text Full Text PDF PubMed Scopus (789) Google Scholar were re-reviewed whenever a TJC standard or Magnet competency fell in more than 1 QSEN category. The competency that resembled the QSEN competency and KSA definition the closest was assigned to the quality standard in question. After completion of the final document, the crosswalk was sent to Judy Karshmer, PhD, RN, for expert review. (See Table 1 for the Abbreviated Crosswalk.)Table 1QSEN Competencies, TJC Accreditation Standards, and the ANCC Magnet® Competencies CrosswalkQSEN StandardsThe Joint Commission StandardsaThe numbers inside the parentheses indicate the number of healthcare quality and safety standards within each domain that align with the respective QSEN competencyMagnet StandardsPatient Centered CareLeadership (4)Structural Empowerment (3)Provision of Care, Treatment, and Services (26)Exemplary Professional Practice (4)Rights and Responsibilities of the Individual (18)Teamwork and CollaborationHuman Resources (8)Transformational Leadership (7)Leadership (11)Structural Empowerment (6)Medication Management (1)Exemplary Professional Service (5)Medical Staff (11)New Knowledge, Innovations, and Improvements (1)Nursing (5)Provision of Care, Treatment, and Services (1)Evidenced-Based PracticeLeadership (2)Exemplary Professional Service (5)Medical Staff (1)New Knowledge, Innovations, and Improvements (2)National Patient Safety Goals (5)Transplant Safety (1)Quality ImprovementAccreditation Participation Requirements (2)Transformational Leadership (1)Infection Prevention and Control (4)Exemplary Professional Practice (7)Environment of Care (1)Emergency Management (3)Leadership (5)Medication Management (2)Medical Staff (3)Performance Improvement (5)Transplant Safety (2)Waived Testing (2)SafetyAccreditation ParticipationStructural Empowerment (2)Requirements (9)Exemplary Professional Practice (2)Environment of Care (15)New Knowledge, Innovations, and Improvements (1)Emergency Management (9)Infection Prevention and Control (7)Leadership (7)Life Safety (18)Medication Management (17)Medical Staff (11)National Patient Safety Goal (8)Universal Protocol (3)Provision of Care, Treatment, and Services (23)Transplant Safety (2)Waived Testing (3)InformaticsInformation Management (7)Transformational Leadership (1)Leadership (1)New Knowledge, Innovations, and Improvements (2)Record of Care, Treatment, and Services (10)ANCC, American Nurses Credentialing Center; QSEN, Quality and Safety Education for Nurses; TJC, The Joint Commissiona The numbers inside the parentheses indicate the number of healthcare quality and safety standards within each domain that align with the respective QSEN competency Open table in a new tab ANCC, American Nurses Credentialing Center; QSEN, Quality and Safety Education for Nurses; TJC, The Joint Commission The validity of the tool was established by review of content experts. The primary content expert reviewer was Judy Karshmer, PhD, RN. Additionally, the tool was disseminated to various practice and academic leaders for comment and review. Presentation of the crosswalk during the 2015 Association of California Nurse Leader's Association annual conference and the 2015 National QSEN Forum were the main vehicles for tool dissemination. During the Association of California Nurse Leaders (ACNL) conference, a 3-item/6-item Likert-type questionnaire was given as a pre-test and post-test. Hospital administrators and educators agreed that the presentation and the crosswalk increased their understanding of QSEN's alignment with TJC and Magnet standards (mean scores of 4.52 and 4.4, respectively). Furthermore, overall knowledge of all survey respondents of the relationship between QSEN, TJC, and Magnet competencies increased after the presentation (pre-presentation mean: 2.687, post-presentation mean: 3.75, p value: 0.0004 [significant at p < 0.1]). The effect size was calculated and was noted to be significant (Cohen's d: 0.8360). (A detailed breakdown of survey results can be found in Table 2 and Table 3.)Table 2ACNL Survey Result: Relationship of QSEN, TJC, and Magnet CompetenciesQuestion 3 (Pre)-RelationshipQuestion 6 p (Post)-RelationshipMean score2.68753.75Difference1.0625p Value (p < 0.1)0.0004SD1.351.18Cohen's d0.836ACNL, Association of California Nurse Leaders; QSEN, Quality and Safety Education for Nurses; TJC, The Joint Commission Open table in a new tab Table 3ACNL Survey Mean of All ItemsQ1 (Pre)-Knowledge TJCQ2 (Pre)-Knowledge MagnetQ3 (Pre)-Relation shipQ1 (Post)-Hosp: QSEN Teaching TJC/MagnetQ2 (Post)-Hosp: QSEN Preparing TJC/MagnetQ3 (Post)-Faculty: QSEN Teaching TJC/MagnetQ4 (Post)-Knowledge TJCQ5 (Post)-Knowledge MagnetQ6 (Post)-Relation shipMean score3.93.72.774.354.52 (n = 22)4.4 (n = 10)3.883.673.79QSEN, Quality and Safety Education for Nurses; TJC, The Joint Commission Open table in a new tab ACNL, Association of California Nurse Leaders; QSEN, Quality and Safety Education for Nurses; TJC, The Joint Commission QSEN, Quality and Safety Education for Nurses; TJC, The Joint Commission As part of the first author's Doctor of Nursing Practice (DNP) project, part of the dissemination plan was to meet one-on-one with academic and practice leaders in the San Francisco Bay Area. Presentations are currently being held at various nurse leader functions, including ACNL. The crosswalk aims to change practice by increasing the understanding of key nursing leaders of the role that QSEN plays in preparing future nurses. This will be measured by drawing general themes from the answers gathered during the interview and the mean scores from the Likert-type questionnaire. The landmark reports from the IOM illuminated the need to increase safety, advance quality outcomes, improve communication, and redesign education. Nurses represent the largest group of US health care workers with almost 4 million members.22The Henry J Kaiser Family Foundation. Total Number of Professionally Active Nurses.http://kff.org/other/state-indicator/total-registered-nurses/Date: 2015Google Scholar Increased understanding and integration of QSEN competencies has the potential to make a sizeable impact in health care quality and outcomes. A crosswalk between QSEN, TJC, and Magnet can decrease confusion in patient safety and outcomes language by helping align all 3 standards. Preliminary results show that the crosswalk increased understanding of the alignment between QSEN, TJC, and Magnet standards.