{"id":574,"date":"2024-11-08T21:18:32","date_gmt":"2024-11-08T21:18:32","guid":{"rendered":"https:\/\/iims.uthscsa.edu\/isrn\/?page_id=574"},"modified":"2024-11-08T21:18:32","modified_gmt":"2024-11-08T21:18:32","slug":"uniting-frontline-leadership-capacities-to-improve-care","status":"publish","type":"page","link":"https:\/\/iims.uthscsa.edu\/isrn\/isrn-events\/web-seminars\/uniting-frontline-leadership-capacities-to-improve-care\/","title":{"rendered":"Uniting Frontline &amp; Leadership Capacities to Improve Care"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column width=&#8221;2\/3&#8243;][vc_column_text css=&#8221;&#8221;]<strong>Principal Investigator:\u00a0<\/strong>Kathleen R. Stevens, RN, EdD, ANEF, FAAN<br \/>\n<strong>Co-Principal Investigator:\u00a0<\/strong>Robert L. Ferrer, MD, MPH<\/p>\n<h3>Specific Aims:<\/h3>\n<ul type=\"square\">\n<li>To determine the types and frequency of first-first order operational failures that nurses self-detect<\/li>\n<li>To determine whether self-detected first-order operational failures made by nursing staff correlate with those failures that are observed by others<\/li>\n<li>To determine the types of factors that correlate with first order operational failures made by self-detection<\/li>\n<\/ul>\n<h3>Background and Significance:<\/h3>\n<ul type=\"square\">\n<li>Most adverse events in health care originate from small process failures that are common enough to be taken for granted.<sup>1<\/sup>\u00a0Although these process failures include both errors and &#8220;problems&#8221; \u2013 task interruptions due to something or someone not being available when needed \u2013 problems are far more common and have drawn far less attention.<sup>2<\/sup><\/li>\n<li>In frontline nursing care, workarounds are a common response to small operational failures,<sup>3<\/sup>\u00a0exposing patients to errors and creating inefficiencies in care.<\/li>\n<li>Endemic shortages of nursing staff and difficult working conditions present substantial barriers on the path to improvement.<sup>4<\/sup><\/li>\n<li>Detection of first order operational failures provides opportunities to fix underlying system failures and contributes to organizational learning.<\/li>\n<li>Failures occur about one per hour per nurse on hospital units and 95% of problems are managed through workarounds.<sup>2<\/sup><\/li>\n<li>How problems are managed, therefore, may be an important determinant of a hospital\u2019s organizational culture for quality of care.<sup>4<\/sup><\/li>\n<\/ul>\n<h3>Research Design and Methods:<\/h3>\n<ul type=\"square\">\n<li>Specially-designed\u00a0<strong>pocket cards\u00a0<\/strong>(index sized) will be used to collect data from all nurses on participating units.<\/li>\n<li>A variety of methods will be used to ensure that staff are engaged in the process and also have a clear understanding of what the process entails. Some of these strategies include utilizing key individuals from the unit to serve as champions, maximizing staff meetings as a tool for engagement and ensuring that the research team has a clear presence on the unit(s).<\/li>\n<li><strong>Checklists on cards<\/strong>\u00a0will capture small problems encountered in daily practice to track and create awareness of problems. The card will also provide a space to write in problems not on the list. The card will have a space to record the date.<\/li>\n<li>Nursing staff will record in real time the small operational failures that they encounter.<\/li>\n<li>Cards will be deposited in a box on each unit for later collection by research staff. Using the card data for a defined time interval as the numerator, and patient days on the unit for the same interval as the denominator, we can calculate a rate of small problems per patient-day.<\/li>\n<\/ul>\n<h3>References:<\/h3>\n<ol>\n<li>Reason J. Human error: models and management.\u00a0<em>BMJ\u00a0<\/em>2000;320:768-70.<\/li>\n<li>Tucker AL, Edmondson AC. Why hospitals don&#8217;t learn from failure: organizational and psychological dynamics that inhibit system change.\u00a0<em>California<\/em><em>\u00a0Management Review<\/em>\u00a02003;45:55-72.<\/li>\n<li>Hassmiller SB, Cozine M. Addressing the nursing shortage to improve the quality of patient care.\u00a0<em>Health Affairs<\/em>\u00a02006;25:268-74.<\/li>\n<li>Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers.\u00a0<em>Quality and Safety in Health Care\u00a0<\/em>2004;13:3-9.<\/li>\n<\/ol>\n<p><a href=\"https:\/\/iims.uthscsa.edu\/isrn\/wp-content\/uploads\/sites\/27\/2024\/11\/Network_Study_Prospectus-Frontline_Improvemnet.pdf\">To download the study prospectus,\u00a0click here<\/a>[\/vc_column_text][\/vc_column][vc_column width=&#8221;1\/3&#8243;]<nav id=\"subnav\" class=\"callout outline\" aria-label=\"Sub navigation for ISRN Subnav\"><ul id=\"menu-isrn-subnav\" class=\"subnav vertical menu accordion-menu\" data-accordion-menu><li id=\"menu-item-150\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-home menu-item-150\"><a href=\"https:\/\/iims.uthscsa.edu\/isrn\/\">ISRN Overview<\/a><\/li>\n<li id=\"menu-item-24\" class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-has-children menu-item-24\"><a 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Stevens, RN, EdD, ANEF, FAAN Co-Principal Investigator:\u00a0Robert L. Ferrer, MD, MPH Specific Aims: To determine the types and frequency of first-first order operational failures that nurses self-detect To determine whether self-detected first-order operational failures made by nursing staff correlate with those failures that are observed by others To determine the [&hellip;]<\/p>\n","protected":false},"author":13,"featured_media":0,"parent":90,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-574","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Uniting Frontline &amp; Leadership Capacities to Improve Care - Improvement Science Research Network<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/iims.uthscsa.edu\/isrn\/isrn-events\/web-seminars\/uniting-frontline-leadership-capacities-to-improve-care\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Uniting Frontline &amp; Leadership Capacities to Improve Care - Improvement Science Research Network\" \/>\n<meta property=\"og:description\" content=\"[vc_row][vc_column width=&#8221;2\/3&#8243;][vc_column_text css=&#8221;&#8221;]Principal Investigator:\u00a0Kathleen R. 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