ANSWER

The new Centers for Medicare and Medicaid Services (CMS) “Never Events” were presented and discussed in the most recent issue of ViewPoint, as well as how CMS considers these to be events that should never occur in ambulatory care settings (Haas, 2012). This ruling has significant reimbursement implications, but it also requires nurses and other providers in ambulatory care settings to become much more aware of quality and safety issues, as well as ways to prevent never events through evidence-based Practice (EBP) and the use of an electronic health record (EHR). The Institute of Medicine (IOM) has issued numerous reports on the state of health care in the United States, beginning with To Err is Human in 1999, which identified flawed systems as a major source of error. In 2001, the IOM report Crossing the Quality Chasm identified quality and safety issues and recommended six goals for U.S. health care (see Figure 1).

The IOM has issued follow-up reports (2003) that address the need for practitioners to gain expertise in quality and safety. Cronenwett and colleagues were funded by the Robert Wood Johnson Foundation for their work on Quality and Safety in Nursing Education (Cronenwett et al., 2007; Cronenwett, Sherwood, & Gelmon, 2009a; Cronenwett, Sherwood, Pohl, et al., 2009b) (QSEN). The six aims of the IOM serve as the foundation for QSEN’s six competencies.

QSEN faculty defined pre-licensure and graduate quality and safety competencies for nursing using the Institute of Medicine (2003) competencies for nursing and proposed targets for the knowledge, skills, and attitudes (KSAs) to be developed in nursing pre-licensure and graduate programs for each competency (QSEN 2012a, 2012b):

Patient-Centered Care entails acknowledging the patient or designee as the source of control and a full partner in providing compassionate and coordinated care based on respect for the patient’s preferences, values, and needs.
Quality: Monitor the outcomes of care processes using data, and use improvement methods to design and test changes to improve the quality and safety of healthcare systems continuously.
Teamwork and Collaboration: Work effectively within nursing and inter-professional teams to achieve quality care by fostering open communication, mutual respect, and shared decision-making.
Safety: Reduces the risk of harm to patients and providers through system effectiveness as well as individual performance.
Evidence-Based Practice combines the best current evidence with clinical expertise as well as patient/family preferences and values to provide optimal health care.
Informatics: The use of information and technology to communicate, manage knowledge, reduce error, and aid decision-making.
Figure 1. (in print)
IOM (2001) (2001) Six Improvement Goals

Safe: avoiding injuries to patients due to Care that is meant to help them.
Effectiveness is defined as providing services based on scientific knowledge to all those who could benefit while not providing services to those unlikely to benefit.
Patient-centered Care entails respecting and responding to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
Timely: reducing waits and potentially harmful delays for those receiving and providing Care.
Efficient means avoiding waste, such as waste of equipment, supplies, ideas, and energy.
Equitable Care is defined as Care of equal quality regardless of personal characteristics such as gender, ethnicity, geographic location, or socioeconomic status.
Source: IOM (2001).

The KSAs that comprise each competency are provided by these competencies, as defined above. The QSEN competencies are now part of prelicensure and graduate education accreditation standards and are content tested in licensing and certification exams. Nursing students who are about to graduate will have learned about these skills in theory, simulation, and clinical classes. The fact that current nurses may need to be more familiar with the QSEN competencies is cause for concern. If and when new graduate nurses enter ambulatory Care, they will expect to see EBP, Quality Councils, and EHR systems where nurses document care processes and outcomes. If this is different for nursing in an ambulatory setting, nurse retention may be a problem, as may poor patient and organizational outcomes.

Concerns about competency, quality, and safety extend beyond nursing. In 2010, the Lucian Leape Institute published a report on the lack of quality and safety content and experience in medical student and residency programs. Prevention and management of potential never events in ambulatory settings necessitate competencies in all six QSEN areas. However, because EBP and Informatics QSEN competencies are a major focus of the health reform law, this column will only cover them. It is expected that providers, nurses, physicians, and other healthcare professionals will use the best evidence-based practices in their care delivery and will track evidence-based processes and outcomes. Informatics comes into play during tracking. The Accountable Care Act funds equipment to support the EHR, particularly in primary care practice. It is expected that the EHR will improve communication within the healthcare team and across settings and reduce errors and costs associated with duplicate testing, lost test results, and so on. The EHR is also essential for tracking evidence-based care processes and outcomes.
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In addition to the falls and pressure ulcers discussed in our previous ViewPoint issue as potential never events in ambulatory Care, surgical or invasive procedure events and product or devise events in ambulatory Care are also of concern. The Joint Commission requires all accredited hospitals, ambulatory care centers, and office-based surgical practices to use the Universal Protocol to prevent such events. Evidence can be used in EBP protocols to prevent adverse surgical or device events.

So, where should ambulatory nurse leaders begin? The QSEN website (https://qsen.org/) is an excellent source of information. It is intended to help with both nursing student and staff education and educator education. You can look for teaching strategies by specifying the QSEN competency you want to work on, your learning environment, learner level, and strategy type (such as simulation). There are also yearly QSEN conferences where practitioners share strategies and methods. There are free interdisciplinary Web-based modules for the EBP competency (https://ebbp.org/). The National Institutes of Health provided funding for these interactive modules. A text edited by Hughes (2008) titled Patient Safety and Quality: An Evidence-Based Handbook for Nurses is another excellent resource funded by the Agency for Healthcare Research and Quality. This three-volume text is free for nurses on CD-ROM at http://www.ahrq.gov/qual/nurseshdbk/…

Knowing that there are resources available to help ambulatory care nurses improve their understanding of EBP and use of the EHR, the first step for ambulatory care nurse leaders should be to develop a strategic plan for never preventing events in ambulatory Care. This plan begins with developing an understanding and appreciation of the issue of never events among leadership and nurses, methods to identify their potential in ambulatory care settings, methods to develop or enhance understanding and comfort with the development of EBP protocols suited to the ambulatory care setting, and knowledge and skills with the use of documentation formats in EHR to track EBP processes and outcomes.

Such a project may appear daunting, but leaders must focus on one potential never event at a time. For example, examine historical data on falls or operating room errors to determine where to begin. Begin by focusing on the event with the highest incidence and the highest costs, both in terms of poor patient outcomes and financial costs, if it occurs, and thus the greatest return on investment in EBP and the EHR. Much of the cost is related to staff education and development time required for work on EBP protocols and EHR documentation formats.

While there are financial incentives for EBP and the use of EHR, ambulatory nurses will respond to a greater incentive: providing higher quality and safer care to their patients.