Domain 5: Quality and Safety

Descriptor: Employment of established and emerging principles of safety and improvement science. Quality and safety, as core values of nursing practice, enhance quality and minimize risk of harm to patients and providers through both system effectiveness and individual performance.

Contextual Statement: Provision of safe, quality care necessitates knowing and using established and emerging principles of safety science in care delivery. Quality and safety encompass provider and recipient safety and the recognition of synergy between the two. Quality or safety challenges are viewed primarily as the result of system failures, as opposed to the errors of an individual. In an environment fostering quality and safety, caregivers are empowered and encouraged to promote safety and take appropriate action to prevent and report adverse events and near misses. Fundamental to the provision of safe, quality care, providers of care adopt, integrate, and disseminate current practice guidelines and evidence-based interventions.

Safety is inclusive of attending to work environment hazards, such as violence, burnout, ergonomics, and chemical and biological agents; there is a synergistic relationship between employee safety and patient safety. A safe and just environment minimizes risk to both recipients and providers of care. It requires a shared commitment to create and maintain a physically, psychologically, secure, and just environment. Safety demands an obligation to remain non-punitive in detecting, reporting, and analyzing errors, possible exposures, and near misses when they occur.

Quality and safety are interdependent, as safety is a necessary attribute of quality care. For quality health care to exist, care must be safe, effective, timely, efficient, equitable, and personcentered. Quality care is the extent to which care services improve desired health outcomes and are consistent with patient preferences and current professional knowledge (IOM, 2001). Additionally, quality care includes collaborative engagement with the recipient of care in assuming responsibility for health promotion and illness treatment behaviors. Quality care both improves desired health outcomes, and prevents harm (IOM, 2001). Addressing contributors and barriers to quality and safety, at both individual and system levels, are necessary. Essentially, everyone in health care is responsible for quality care and patient safety. Nurses are uniquely positioned to lead or co-lead teams that address the improvement of quality and safety because of their knowledge and ethical code (ANA Code of Ethics, 2015). Increasing complexity of care has contributed to continued gaps in healthcare safety.

Implementing the Progression Indicators
One-Pager Guides & Videos

 

Progression Indicators:
An Overview

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In this video, Drs. Bimbola Akintade and Cynthia O'Neal from AACN's Assessment Expert Working Group introduce the progression indicators and how incorporating them into nursing curricula can improve competency assessment strategies.

Clarifying Expectations & Advancing Competency With PIs

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Dr. Mary Fey discusses the importance of aligning descriptive, observable behaviors with the Essentials sub-competencies for student assessment.

Clustering Competencies During Assessment

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Dr. Dana Tschannen provides an overview of how faculty can cluster Essentials competencies to ensure alignment throughout program curricula.

 

Competencies, Sub-competencies, and Progression Indicators Table by Level

Below presents sub-competencies by entry-level and advanced-level, with associated progression indicators. Select a competency from the dropdown to view its corresponding table of developing and developed competence. 

Table Legend:

Level 1: Entry-Level
Level 2: Advanced-Level

  Sub-competency Progression Indicators (Observable Behaviors)
    Developing (Developing Competence) Developed (Competent)
Level 1: Entry-Level 5.1a Recognize nursing’s essential role in improving healthcare quality and safety.

Identify key concepts of quality and safety in healthcare.

Describe nurses' responsibility in maintaining healthcare quality and safety.

Explain the nurse's role in preventing patient harm.

Identify nursing-specific quality indicators and safety initiatives to address clinical improvement needs.

Identify nursing-related system-level factors contributing to patient safety issues.

Articulate the importance of the nurse as the last line of defense.

5.1b Identify sources and applications of national safety and quality standards to guide nursing practice.

Identify key national safety and quality standards relevant to nursing practice.

Identify key organizations that set national safety and quality standards.

Select national safety and quality standards to analyze clinical situations and guide nursing practice.

Recommend opportunities to improve patient safety based on national safety and quality standards and new evidence.

5.1c Implement standardized, evidence-based processes for care delivery.

Identify standardized processes used in nursing practice.

Follow standardized processes for patient care.

Adapt standardized processes to meet the needs of individual patients.

Analyze patient situations/characteristics and act to mitigate patient risks.

5.1d Interpret benchmark and unit outcome data to inform individual and microsystem practice.

Identify key trends in unit-level data.

Recognize the relationship between unit-level data and national benchmarks.

Analyze unit- and system-level data to identify areas for improvement in patient care.

Use data to support evidence-based practice decisions.

5.1e Compare quality improvement methods in the delivery of patient care.

Describe the basic principles of various quality improvement methods.

Compare the strengths and limitations of quality improvement methods.

Select relevant quality improvement methods to support care improvement.
5.1f Identify strategies to improve outcomes of patient care in practice.

Explain the role of patient engagement in improving patient outcomes.

Use communication and collaboration strategies to improve patient outcomes.

Select evidence-based practice strategies to improve patient outcomes.

Recommend protocols essential to improve the outcomes of patient care.

  5.1g Participate in the implementation of a practice change.

Gather relevant data to support the need for a practice change initiative.

Identify potential barriers to implementing quality improvement initiatives.

Communicate the rationale for the proposed change to colleagues and patients.

Develop quality improvement projects.

Model a practice change and serve as a resource for peers.

  5.1h Develop a plan for monitoring quality improvement change.

Describe methods for collecting and analyzing data.

Analyze key data to monitor the effectiveness of a practice change.

Develop a monitoring plan.

Justify the selection of a particular quality improvement method to address a clinical issue.

       
Level 2: Advanced-Level 5.1i Establish and incorporate data driven benchmarks to monitor system performance. Determine the specific aspects of system performance that need to be monitored.

Choose methods and frequency of data collection and reporting.

Use data to inform the development and implementation of targeted interventions to improve system performance.

5.1j Use national safety resources to lead team-based change initiatives.

Use national safety resources to develop a framework for addressing a patient safety or system performance issue requiring improvement.

Consider relevant stakeholders for the proposed change.

Lead team development, implementation, and evaluation of a comprehensive safety action plan.
5.1k Integrate outcome metrics to inform change and policy recommendations.

Choose outcome, process, and efficiency metrics to provide a comprehensive strategy to assess change.

Use outcome data to propose policy recommendations.

Present findings to decision-makers to advocate for policy change.

Conduct a thorough evaluation of practice change to determine effectiveness.

5.1l Integrate outcome metrics to inform change and policy recommendations.

Analyze data for a process improvement initiative.

Identify patterns and trends in data relevant to improvement initiatives. 

Contribute relevant information and insights based on knowledge, experience, and evidence.

Collaborate in establishing a plan for monitoring and evaluating outcomes of process improvement initiatives.
5.1m Lead the development of a business plan for quality improvement initiatives.

Define the scope and objectives of the quality improvement plan.

Lead collection of relevant data to inform the improvement initiative.

Lead prioritized intervention and evaluation strategies for the quality improvement initiative.

5.1n Advocate for change related to financial policies that impact the relationship between economics and quality care delivery.

Analyze the impact of financial decisions and policy on quality care delivery and patient outcomes.

Propose cost-effective initiatives to improve quality care delivery.


Use data and evidence-based strategies to advocate for financial policy changes to improve quality care delivery.
  5.1o Advance quality improvement practices through dissemination of outcomes. Construct relevant dissemination strategies for outcome dissemination. Disseminate quality improvement process outcomes.

Table Legend:

Level 1: Entry-Level
Level 2: Advanced-Level

  Sub-competency Progression Indicators (Observable Behaviors)
    Developing (Developing Competence) Developed (Competent)
Level 1: Entry-Level 5.2a Describe the factors that create a culture of safety.

Identify key factors contributing to a culture of safety.

Explain how these factors influence patient outcomes.

Identify systemic barriers to a culture of safety.

Propose strategies to foster a culture of safety.

5.2b Articulate the nurse’s role within an interprofessional team in promoting safety and preventing errors and near misses.

Identify the nurse’s role in developing and implementing a safety plan in an interprofessional team setting.

Listen to and incorporate input from other team members regarding safety protocols.

Communicate the nurse's role effectively and respectfully within interprofessional teams regarding patient safety concerns.

Communicate patient safety concerns to other interprofessional team members.

5.2c Examine basic safety design principles to reduce risk of harm.

Identify basic safety design principles within clinical settings to reduce errors.

Articulate how standardized procedures and checklists contribute to patient safety.

Analyze outcome data to determine the effectiveness of safety design principles.
5.2d Assume accountability for reporting unsafe conditions, near misses, and errors to reduce harm.

Identify potential and actual errors and safety concerns related to patient care.

Articulate the steps for reporting potential or actual errors through authorized channels.

Report observed or suspected patient safety concerns using appropriate channels.

Accept feedback constructively and reflect on its role in patient safety.

5.2e Describe processes used in understanding causes of error. Compare the processes used to analyze the contributing factors for errors.  

Participate in discussions about the root causes of patient safety events.

Analyze root causes of patient safety incidents and identify potential contributing factors.

5.2f Use national patient safety resources, initiatives, and regulations at the point of care.
 

Reference relevant national patient safety guidelines and resources in clinical discussions.

Apply knowledge of patient safety regulations to clinical practice.

 

 

Utilize current evidence-based patient safety guidelines and regulations.

Integrate national patient safety resources into daily clinical practice.

 
       
Level 2: Advanced-Level 5.2g Evaluate the alignment of system data and comparative patient safety benchmarks.

Collect and analyze relevant patient safety data from multiple sources.

Compare local patient safety data to national and international benchmarks.

Analyze areas of significant variation and identify opportunities for improvement.

Propose evidence-based system-level solutions to address opportunities for improvement.

5.2h Lead analysis of actual errors, near misses, and potential situations that would impact safety.

Use root cause analyses of complex patient safety events.

Facilitate discussions and identify system-level factors contributing to safety incidents.

Develop and implement strategies for data collection and analysis of near misses and potential safety hazards.

Develop and implement innovative methods for identifying and analyzing latent safety threats.

Lead initiatives to improve the reporting and analysis of patient safety incidents.

5.2i Design evidence-based interventions to mitigate risk.

Propose system-level solutions to address opportunities for improvement.

Propose quality improvement projects related to patient safety.

Lead the implementation and evaluation of complex patient safety interventions.

Disseminate scholarly findings on innovative patient safety interventions through peer-reviewed publications and presentations.

5.2j Evaluate emergency preparedness system-level plans to protect safety.

Assess the effectiveness of emergency response systems in maintaining patient safety during critical events.

Identify areas for improvement in emergency preparedness and response related to patient safety.

Advocate for policy changes to improve the safety and resilience of healthcare systems during emergencies.

Table Legend:

Level 1: Entry-Level
Level 2: Advanced-Level

  Sub-competency Progression Indicators (Observable Behaviors)
    Developing (Developing Competence) Developed (Competent)
Level 1: Entry-Level 5.3a Identify actual and potential level of risks to providers within the workplace.

Demonstrate awareness of potential workplace hazards in clinical settings.

Seek information about workplace safety protocols and procedures.

Report observed safety hazards to appropriate personnel.

Conduct a thorough workplace safety assessment within a clinical setting.

Develop and implement strategies to mitigate identified workplace hazards.

Educate peers on identified workplace safety risks and preventative measures.

5.3b Recognize how to prevent workplace violence and injury.

Identify factors that may contribute to workplace violence and injury.

Describe strategies for preventing workplace violence and injury.

Demonstrate de-escalation techniques when interacting with agitated patients or colleagues.

Utilize safe patient handling techniques to prevent injury.

5.3c Promote policies for prevention of violence and risk mitigation.

Adhere to all workplace safety policies and procedures.

Participate in safety rounds and discussions related to workplace safety.

Suggest practical solutions to improve workplace safety within the clinical setting.

Advocate for improved workplace safety policies and procedures within a healthcare setting.
5.3d Recognize one’s role in sustaining a just culture reflecting civility and respect.

Treat patients, visitors, staff, and peers with respect and professionalism.

Communicate concerns and issues constructively and assertively.

Demonstrate empathy and compassion towards colleagues.

Recognize and address incivility or bullying through using professional and respectful communication, documenting, and reporting incidents per institutional policies, engaging in conflict resolution strategies, and advocating for a culture of respect in the workplace

Model professional behavior to foster a positive work environment.

       
Level 2: Advanced-Level 5.3e Advocate for structures, policies, and processes that promote a culture of safety and prevent workplace risks and injury.

Analyze evidence on effective workplace safety interventions.

Develop and advocate for policy changes to improve workplace safety within a healthcare organization.

Collaborate with interprofessional teams to design and implement system-wide safety initiatives.

Evaluate workplace safety programs.

Disseminate resources for improving safety and health in the workplace.

5.3f Foster a just culture reflecting civility and respect.

Propose interventions to address workplace incivility and bullying within healthcare organizations.

Facilitate discussions on workplace incivility and bullying and develop strategies for addressing these issues.

Mentor junior colleagues on professional communication and interpersonal skills.

Lead initiatives to promote a culture of civility and respect within a healthcare setting.

Serve as a mentor or coach to create a respectful and supportive work environment.

5.3g Create a safe and transparent culture for reporting incidents.

Evaluate the effectiveness of existing workplace safety reporting systems and recommend improvements.

Communicate findings from workplace safety investigations to relevant stakeholders.

Develop and advocate strategies to improve incident reporting, investigation techniques, and protections against retaliation in the workplace.

Develop strategies for collecting and analyzing workplace safety data.

Disseminate findings on workplace safety incident reporting and analysis to the broader healthcare community.

5.3h Role model and lead well-being and resiliency for self and team.

Demonstrate healthy coping mechanisms and self-care strategies to manage stress.

Promote and support the well-being and resiliency of self and colleagues within the healthcare team.

Implement an initiative or activity to promote the well-being and resiliency of healthcare professionals.

Advocate for policies and programs supporting healthcare professionals' mental and physical health.