Foundations of Practice Flashcards
Advanced practice nursing: Discuss ethical principals in practice (Nursing Code of Ethics).
The American Nurses Association developed the Nursing Code of Ethics. There are nine provisions, which are listed below:
- The nurse treats all individuals with respect and consideration, regardless of social circumstances or health condition.
- The nurse’s primary commitment is to the individual regardless of conflicts that may arise.
- The nurse promotes and advocates for the individual’s health, safety, and rights, maintaining privacy and confidentiality and protecting him or her from questionable practices or care.
- The nurse is r_esponsible for his or her own care practices_ and determines appropriate delegation of care.
- The nurse must retain respect for self and his or her own integrity and competence.
- The nurse participates in ensuring that the health care environment is conducive to providing good health care that is consistent with professional and ethical values.
- The nurse participates in education and knowledge development to advance the profession.
- The nurse collaborates with others to promote efforts to meet health needs.
- The nursing profession articulates values and promotes and maintains the integrity of the profession
Compare electronic medical records and electronic helath records.
Although many in healthcare use the terms electronic medical record (EMR) and electronic health record (HER) interchangeably, there are major distinctions between the two. The electronic medical record is created by a hospital or other health care delivery organization (CDO). The CDO owns the information in the EMR. The EMR consists of clinical documentation, orders, medications, treatments, and other clinical decision support, and is a legal record. The EHR includes information from EMRs, likely from multiple health care delivery organizations. The EHR relies on the information from the EMR to complete it. The EHR is owned by the patient and stakeholders, which could include the government, insurance companies, and healthcare providers among others. Important to the EMR is using controlled medical vocabulary so that information will be comparable among providers and other interested stakeholders. Currently in the United States the use of EHRs is limited, mostly due to many healthcare delivery organizations not having an established EMR using decided predetermined standards. There may soon be an increase in the number of organizations using EMRs with standardized language conducive to EHRs, as organizations now receive financial incentives to install EMR and EHR systems from healthcare reform.
Define the steps needed for workgroup formation.
A workgroup is a small number of people working together toward a common goal. An advantage of working in groups is that the environment allows for increased insight and creativity. A disadvantage is that workgroups sometimes fail because members of the group allow personal conflicts (in terms of personality and work styles) to interfere with the group’s goal. A popular concept identifies four stages in group development:
- Forming: This is where a group is formed and the members begin to get to know one another. Typically, individuals are quiet and polite to one another.
- Storming: This is the stage where conflicts normally arise. Effective communications must be occurring.
- Norming: Typically, conflicting factions make peace and come together. Less communication is necessary.
- Performing: This is the stage in which the group begins to really work well. Communication is free flowing.
Describe some of the roles that informatics nurse plays.
The following are some of the roles that the informatics nurse must play:
- Developing informatics theories: Assemble what sort of information should be captured on the system and how the data should be analyzed.
- Analyzing the information needs of the organization: Sort through the large amounts of data collected to determine the best information for the organization.
- Helping the organization choose computer systems: Assist in the system requirements, both for now and in the near future.
- Customizing purchased computer systems: Work with IT to customize the system so that it will be the most useful.
- Designing computer information systems: Assist IT in the overall design of the system.
- Testing new or upgraded computer systems: Conduct robust tests of the system when changes or upgrades are performed.
- Teaching other people to use the computer system: Set up training and education programs to encourage the most effective use of the system.
Describe the attributes that help to assure accuracy of information.
The following information attributes are important in assuring accuracy:
- Objective reporting - Information should be completely free from bias and reported accurately.
- Comprehensive - All the necessary information is available to complete reports and requests.
- Appropriateness - All users are able to access the information necessary to do their jobs.
- Unambiguous - The data is clearly defined in order to reduce errors.
- Reliability - When identical information is keyed in by different people, it should always be uniform in the system.
- Up to Date - The most recent information should be listed first.
- Convenience - It should not be difficult for users to locate the information they need.
Describe the differences between clinical nurses and those nurses who specialize in informatics.
The focus of a traditional clinical nurse revolves around taking care of patients. Their use of computerized systems is limited to the user level (i.e., enough knowledge to operate the equipment and enter data). Their concentration is on the accuracy of the information that they are interpreting or giving to other caregivers. They are trained to handle malfunctions and are used as a feedback source for the informatics developers. Their opinion of the computerized systems is key as to whether or not the system is successful.
Nurses who specialize in informatics focus on the information systems. They worry about the security and stability of the systems installed at their facility. They are also very adept at troubleshooting problems (especially at the user level). They make sure the systems are as user friendly as possible and, more importantly, reduce the number of tasks the traditional clinical nurse has to perform in their routine day. Efficiency arid enhanced productivity are the key goals of the informatics nurse.
Describe the essential elements in the practice of nursing informatics.
The essential elements within the practice of nursing informatics include traditional nursing aspects such as:
- Focus on the patient and their well-being.
- Healthcare in general. Keeping up to date on the latest state of the art in terms of nursing.
- Working environment. This includes how things are laid out (to avoid errors and make things as efficient as possible).
- Working with others. How to interact effectively with other healthcare practitioners and coworkers.
In terms of informatics, the related skills include:
- Knowledge of data structures (including metastructures)
- Knowledge of computer networking
- Knowledge of computer hardware
- Information system training skills
Formal education includes:
- A degree in nursing (Bachelor of Science)
- A minor (or second major) in a computer science program focused on computer systems in the healthcare industry
Describe the factors necessary for information quality.
Quality information is defined by the following factors:
- Timeliness: The necessary data is available (and retrievable) as needed.
- Precision: System dictionaries shall describe uniform wording and clear definitions.
- Accuracy: The data should be as error-free as possible.
- Measurability: The information should be quantifiable so that comparisons can be made.
- Independently verifiable: The integrity of the information remains constant regardless of the individual reporting it.
- Availability: The information should be accessible where it is needed. In the hospital or clinic environment, the information should usually be available at the patient’s location.
Describe the framework for nursing informatics as defined by the American Nurses Association.
The American Nurses Association (ANA) has laid out standards for the informatics nurse specialist. These standards are based on a “problem-solving framework” which includes both traditional aspects of nursing as well as those aspects more specific to the informatics nurse. The standards are:
- Assessment
- Diagnosis
- Identification of outcomes
- Planning implementation
- System planning
The ANA has also set standards for the performance that informatics nurses should attain. The performance issues include quality assurance, review of performance evaluation methods, and ensuring that the practice of nursing informatics is effective. The informatics nurse should also work to create guidelines for research, ethics, peer cooperation, allocation of resources, and effective communication. Finally, they should be willing to help other nurses who want to improve their skills in informatics and computer science.
Describe the history of the Health Insurance Portability and Accountability Act (HIPAA).
The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 to protect patient privacy rights. This is especially important given the large amount of sensitive data that is now handled electronically through large databases. Some key compliance dates for HIPAA are listed below (for large health plans):
- October 16, 2002: Electronic transactions and code sets are to be identified.
- April 14, 2003: Privacy standards are to be set.
- July 30, 2004: Standards for employer identification are to be set.
- April 21, 2005: Standards for system and data security are to set.
- May 23, 2007: Standards for provider identification are to be set.
These uniform standards will allow the data repositories of large healthcare systems to be efficiently monitored for adherence to the HIPAA regulations, thus assuring patient rights to privacy are honored.
Describe the informatics nurse responsibilities.
The following is a list of responsibilities that are required of the informatics nurse:
- Teaching the policies involved with information systems including the standard operating procedures and system security features.
- Deciding the effectiveness of the computer system based on overall performance (e.g., system response time) and how well the system design is working.
- Making sure the system works as it was designed to by verifying that the system produces results that are expected and troubleshooting problems.
- Deciding when computer systems need to be upgraded based on gauging the obsolescence of the hardware and system compatibility with modern software.
- Finding new ways to use technology in nursing by looking for new and novel applications of technolow.
- Ensuring compliance in regulations regarding patient information including the patient privacy regulations.
- Managing projects as needed.
- Conducting research into the field of nursing informatics.
Describe the International Council of Nurses (ICN) Code of Ethics for nurses in regards to patients.
The following is an outline of the ICN (International Council of Nurses) Code of Ethics for nurses in regards to patients:
- Foremost, the nurse’s responsibility is to the patient. The patient must receive the best possible care and their rights and well-being are respected and maintained.
- Respect and support patient rights, religious beliefs, values, and customs. The patient should be able to live their way of life while under care. This means that they should be allowed to follow their culture and traditions as best as possible.
- Make sure the patient gives informed consent for any treatment. The patient has the ultimate say as to whether or not they receive treatment. The right of the patient to accept or refuse a given treatment through the informed consent process is essential.
- Keep patient information confidential. The patient’s right to privacy is protected under law and should be respected.
In addition, nurses should be proponents for community health and act to promote environmentalism.
Describe the International Council of Nurses (ICN) Code of Ethics for nurses in regards to coworkers.
The International Council of Nurses (ICN) has developed a Code of Ethics for nurses in regards to coworkers. Healthcare is a team oriented process with all attention focused on the well-being of the patient. Effective interaction with other team members (coworkers) is a key to success in this environment. The following bullet points are key areas that need attention:
- Keep relationships with coworkers cooperative and professional
- Make sure that patients are safe and promptly deal with unprofessional or dangerous conduct on the part of coworkers
- Take care not to delegate more work than the individual is able to handle
- Promote continuing education in the workplace
- Keep the lines of communication open between departments, management, etc.
This is an area that needs constant monitoring by workers and management. Any drift from optimal conditions should be addressed before the patient is exposed to any negative effects of poor teamwork.
Describe the role of chief information officer, chief privacy officer, and chief e-health officer.
There are three management level positions that deal with the functioning of an organization’s information system:
- Chief Information Officer: The chief information officer (CIO) is the head of the information services department. This individual is in charge of hiring information systems staff budgeting for maintenance of the system, and designing and implementing new systems as needed. Generally, the CIO holds a masters or doctorate degree in computer science.
- Chief Privacy Officer: The chief privacy officer (CPO) is a federally mandated position at any facility that treats patients. This individual is responsible for all forms of patient information. The title of CPO is generally bestowed on an employee already working for the organization rather than being an entirely separate job.
- Chief E-health Officer: The e-health officer is a relatively new position created by the onset of interactive health websites. The e-health officer is generally in charge of promoting and enabling the use of online interactive patient services.
Describe the role of network administrator and trainer.
Network administrators and trainers are two types of support personnel needed primarily when an organization implements a new information system. They perform the following functions:
Network administrator: Network administrators are given access to all areas of the system and must be held to high standards of ethical accountability. These individuals take on the bulk of managing existing systems and planning new systems. They should also help the organization make hardware decisions and manage the lower level information systems employees such as PC specialists and programmers.
Trainer: Trainers teach the organization’s staff how to use computer systems. Trainers may be full-time employees of the organization, provided by the software vendor as part of the system contract, or temporary workers. They need to be up to date regarding healthcare information systems and the functions they support.
Describe the role of security officer for information systems.
Since there are many regulatory patient privacy requirements (e.g., HIPAA), security officers are essential members of the healthcare information system team. It is important that confidential information is not accessible to unauthorized users or abused by employees. The security officer is responsible for assigning system access codes, making sure passwords are kept secret (and updated), and monitoring the overall use of the system. They may also be in charge of the physical security of the computers and peripherals. A stolen hard drive or laptop computer could contain sensitive information and be a target for information thieves. It is important that the security officer work with the information systems department and the organization’s management to create enterprise wide policies and procedures, which describe the proper and ethical use of equipment andinformation. These standards should apply to all staff members.
Describe the roles of analysts, liaisons, and programmers.
There are three types of support personnel that are typically involved in information systems:
- Analyst: Analysts must have a background in healthcare information systems. Healthcare information system analysts usually have degrees in the medical field with certificates in computer studies. Their primary job is to define the way in which clinical data is entered into and processed by the information system.
- Liaison: Liaisons are hospital employees chosen to work with the information system team while remaining at their primary clinical post. Liaisons act as a conduit between the clinical and information systems staff.
- Programmers: Programmers may be full-time hospital employees, but are most likely contract workers or employees of the software vendor. These individuals write the machine language code necessary for system functions. They often work with the analyst and liaison in order to accomplish their tasks.
Discuss acquiring recommendations form national quality organizations: National Quality Forum.
The National Qualify Forum (NQF) has endorsed a set of safe practices that can be used to assess and develop the organization’s patient safety culture. Practices encompass creating a safe culture as well as specific steps to ensure safe practices throughout the organization. According to NQF, the four elements needed to create and sustain a patient safety culture include the following:
- Leadership must ensure structures are in place for organization-wide awareness and compliance with safety measures, including adequate resources and direct accountability.
- Measurement, analysis, and feedback must track safety and allow for interventions.
- Team-based patient care with adequate training and performance improvement activities must be organization-wide.
- Safety risk must be continuously identified and interventions taken to reduce patient risk.
Discuss acquiring recommendations from national quality organizations: Leapfrog initiatives related to safe practices.
Leapfrog has developed a number of specific initiatives related to safe practices, including:
- Implementation of a computerized physicians order entry system that includes software to detect and prevent errors with a goal of decreasing prescribing errors by more than 50%.
- Evidence-based hospital referral, requiring referral to hospitals that demonstrate the best results with high-risk conditions and surgeries; these are assessed, according to the number of procedures or treatments done each year and outcome data with a goal of reducing mortality rates by 40%.
- Intensive care unit physician staffing requiring specially trained specialists (intensivists) with a goal of reducing mortality rates by 40%.
Leapfrog Safe Practices Score, which assesses the progress a health care organization makes on thirty safe practices that Leapfrog has identified as reducing the risk of harm to patients.
Discuss acquiring recommendations from national quality organizations: Leapfrog initiatives related to preventing medical errors.
Leapfrog is a consortium of health care purchasers/employers providing benefits to millions of Americans. The focus initially was on reducing health care costs by preventing medical errors and “leaping forward” by rewarding hospitals and health care organizations that improve safety and quality of care. Leapfrog has developed a number of initiatives to improve safety. These initiatives can be valuable tools in assessing and developing a patient safety culture. Leapfrog provides an annual Hospital and Quality Safety Survey to assess progress, releases regional data, and encourages voluntary public reporting. Leapfrog has instituted the Leapfrog Hospital Rewards Program as a pay-forperformance program to reward organizations for showing improvement in key measures. One initiative includes preventing medical errors. Purchasers of health care agree to the base purchase of health care based on four principals:
- Educating enrollees about patient safety and providing comparative performance data
- Recognizing and rewarding health care organizations that demonstrate improvement in preventing errors
- Making health plans accountable for implementing these principles
- Advocating for these principles with clients by using benefits consultants
Discuss acquiring recommendations from national quality organizations: Quality indicators from the Agency for Healthcare Reasearch and Quality.
The quality indicators (QIs) from the Agency for Healthcare Research and Quality are distributed as a software tool free of charge to health care organizations to help them identify adverse events or potential adverse events that require further study. This software is an invaluable aid in assessing and developing the organization’s patient safety culture. Current quality indicators include the following:
- Prevention QIs use patient discharge data to determine conditions that require ambulatory care to prevent rehospitalization.
- Inpatient QIs measure quality of care through types of procedures, use of procedures, and mortality rates associated with procedures or conditions.
- Patient Safety QIs use data regarding adverse events and complications related to surgeries, medical procedures, and childbirth.
- Pediatric QIs use patient discharge data to screen for problems related to pediatric exposure to health care and analyze system changes that may prevent problems.
The data indicators may also be used to assess safety factors at an area (e.g., county) level per 100,000 population.
Discuss acquiring recommendations from national quality organizations: Agency for Healthcare Research and Quality and evidence-based practice centers.
The Agency for Healthcare Research and Quality promotes evidence-based practice through funding of evidence-based practice centers (EPCs) to develop evidence-based practice guidelines for dissemination and use in development of patient care plans, establishing insurance coverage, and development of educational materials. These centers issue research reports, including meta-analysis of all relevant research, on a wide range of topics, such as “Pain Management Interventions for Elderly Patients with Hip Fracture,” which include morbidity/mortality rates and cost-effectiveness associated with different treatments and procedures. Research focuses on areas of significance to people receiving Medicaid and Medicare. For example, five EPCs are engaging in research on technology for the Centers for Medicaid and Medicare, which focuses on topics related to the U.S. Preventive Services Task Force. Partners, such as insurance companies, professional associations, patient advocacy groups, and employers, nominate topics. Guides are available for both consumers and clinicians.
Discuss acquiring recommendations from national quality organizations: Institute of Medicine and National Committee for Quality Assurance safety issues.
The Institute of Medicine called for accrediting agencies to ensure organizations focus on patient safety. In response, the National Committee for Quality Assurance has addressed safety issues as part of its accreditation standards. Guidelines directed at managed care organizations provide useful information for other organizations as well. Organizations should:
- Educate staff regarding clinical safety by providing information.
- Provide collaborative training within the network related to safe clinical practice.
- Combine data within the network (organization) on adverse outcomes and polypharmacy.
- Make improving patient safety a priority for quality improvement activities.
Provide and distribute information about safe practices that includes information about computerized pharmacy order systems, physicians trained in intensive care, best practices, and research on safe clinical practices.
Discuss acquiring recommendations from national quality organizations: Institute of Medicine.
The Institute of Medicine (lOM), founded in 1970 under the charter of the National Academy of Sciences, is a nonprofit organization that serves an advisory role on health care issues to governmental and nongovernmental decision-makers. The lOM advises the government but is outside of the governmental structure to ensure lack of bias. The lOM issues guidelines based on research and evidence, conducts studies for Congress and other organizations, and conducts a number of epidemiological studies. The lOM is involved in a broad range of activities, issues regular reports, and provides workshops and forums about a health care issues (e.g., obesity]. The lOM has standing committees to focus on specific issues and provide forums for general discussion. Additionally, the lOM provides fellowships to help professionals gain experience and expertise in health-related fields.
Discuss acquiring recommendations from national quality organizations: National Quality Forum’s safe practices.
National Quality Forum’s safe practices include:
- Considering patient’s rights/responsibilities, providing informed consent, respecting advance directives, making full disclosure of medical errors, managing information and care by documenting care properly, providing prompt accurate test results, using standard procedures for labeling diagnostic studies, & providing discharge planning.
- Managing medications by implementing a computerized prescriber order entry system, standardizing abbreviations, maintaining updated medication lists for patients/pharmacists in medication management, identifying high-alert drugs, and dispensing drugs in unit doses.
- Providing adequate well-trained and well-supervised staff and resources, including critical care physicians.
- To prevent HCA infections: ventilate properly, central lines, wash hands, immunize, & surgical care procedures. Providing safe practices for surgery, i.e., informing patient of risks, taking measures to prevent errors, and using prophylactic treatments to prevent complications. Providing procedures/ongoing assessment to prevent adverse events, such as pressure ulcers, thromboembolism/DVT, allergic reactions, or anticoagulation complications.
Discuss adult learning theories: Theory of adult development developed by Robert Peck.
In his theory of adult development, Robert Peck expanded on Eric Erikson’s stages of adult development, believing that there were seven important tasks required during the last two stages of life.
In middle age:
- Mental flexibility vs. mental rigidity
- Valuing wisdom vs. physical powers
- Socializing vs. sexualizing
- Cathectic (libidinal energy) flexibility vs. cathectic impoverishment
Negative outcomes lead to weak relationships, inflexibility, and resistance to change.
Positive outcomes lead to strong relationships, flexibility in lifestyle, and adaptability to change.
In older adulthood:
- Ego differentiation vs. work role preoccupation
- Body transcendence vs. body preoccupation
- Ego transcendence vs. ego preoccupation
Negative outcomes lead to loss of identity after retirement, depression, inability to accept bodily or functional changes, and fear of death.
Positive outcomes lead to meaningful life after retirement, acceptance of bodily or functional changes, acceptance of death, and feeling that life has been good.
Discuss adult learning theories: Theory of adult development developed by Robert Havighurst.
Robert Havighurst, in his theory of adult development, stated that there were a number of tasks that needed to be accomplished during each stage of development and that remaining active is important. His adult stages reflect stereotypical roles to some degree related to the 1960s when marrying young was more typical than now.
Early adulthood: Tasks include finding a mate, marrying, having children, managing a home, getting started in an occupation or profession, assuming civic responsibility, and finding a congenial social group.
Middle age: Tasks include achieving civic & social responsibility, maintaining an economic standard of living, raising teen-agers & teaching them to be responsible adults, developing leisure activities, accepting physiological changes related to aging, & adjusting to aging of parents.
Older adulthood: Tasks include adjusting to a decrease in physical strength and health, death of a spouse, life in retirement, and reduced income. Other tasks include establishing ties with those in the same age-group (senior citizen’s groups/retirees), meeting social and civic obligations, and establishing physical living arrangements that are satisfactory.
Discuss adult learning theories: Theory of andragogy developed by Malcolm Knowles.
Malcolm Knowles developed the theory of andragogy in relation to adult learners, who are more interested in process than in information and content. Knowles outlined some principles of adult learning and typical characteristics of adult learners that an instructor should consider when planning strategies for teaching parents, families, or staff.
Practical & goal-oriented:
- Provide overviews or summaries and examples,
- Use collaborative discussions with problem-solving exercises.
- Remain organized with the goal in mind
Self-directed:
- Provide active involvement, asking for input.
- Allow different options toward achieving goals.
- Give them responsibilities
Knowledgeable:
- Show respect for their life experiences or education.
- Validate their knowledge and ask for feedback.
- Relate new material to information with which they are familiar.
Relevancy-oriented:
- Explain how information will be applied,
- Clearly identify objectives
Motivated:
• Provide certificates of achievement or some type of recognition for achievement.
Discuss adult learning theories: Bloom’s taxonomy developed by Benjamin Bloom.
Bloom’s taxonomy developed by Benjamin Bloom outlines behaviors that are necessary for learning, and this can apply to health care. The theory describes three types of learning:
Cognitive: (Learning and gaining intellectual skills are used to master six categories of effective learning.)
- Knowledge Comprehension
- Application
- Analysis
- Synthesis Evaluation
Affective: (Recognizing five categories of feelings and values from simple to complex is slower to achieve than cognitive learning.)
- Receiving phenomena: accepting the need to learn
- Responding to phenomena: taking an active part in care
Valuing: under-standing the value of becoming independent in care
- Organizing values: understanding how surgery or treatment has improved life
- Internalizing values: accepting condition as part of life; being consistent and self-reliant
Psychomotor: (Mastering six motor skills necessary for independence follows a progression from simple to complex.)
- Perception: uses sensory information to learn tasks
- Set: shows willingness to perform tasks
- Guided response: follows directions
- Mechanism: does specific tasks
- Complex overt response: displays competence in self-care
- Adaptation: modifies procedures as needed
- Origination: creatively deals with problems
Discuss adult learning theory: Theory of social learning developed by Albert Bandura.
In the 1970s, Albert Bandura proposed the theory of social learning, in which l_earning develops from observation, organizing, and rehearsing behavior that has been modeled_. Bandura believed that people were more likely to adopt the behavior if they valued the outcomes, if the outcomes had functional value, and if the person modeling had similarities to the learner and was admired because of status. Behavior is the result of observation of behavioral, environmental, and cognitive interactions. There are four conditions required for modeling:
- Attention: The degree of attention paid to modeling depends on many variables (e.g., physical, social, environmental}.
- Retention: A person’s ability to retain models depends on symbolic coding, creating mental images, organizing thoughts, and rehearsing (mentally or physically).
- Reproduction: The ability to reproduce a model depends on physical and mental capabilities.
- Motivation: Motivation may derive from past performances, rewards, or vicarious modeling.
Discuss applying current research findings to practice: Model of integration.
Integrating the results of data analysis and research into performance improvement or best practice guidelines varies from one organization to another, depending on the model of integration that the organization uses:
- Organizational: Processes for improvement are identified, and teams or individuals are selected to participate in different areas or departments, reporting to one individual, who monitors progress.
- Functional/coordinated: While staff specialties, such as risk management and quality management, are not integrated, they draw from the same data resources to determine issues related to quality of care and efficiency.
- Functional/integrated: While staff specialties remain, there is cross-training among specialties. A case management approach to individual care is used so that one person follows the progress of a patient through the system and coordinates with the various specialties, such as infection control and quality management.
Discuss benchmarking: External benchmarking and internal trending.
External benchmarking involves analyzing data from outside an institution, such as monitoring national rates of hospital-acquired infection, and comparing them to internal rates. In order for this data to be meaningful, the same definitions must be used as well as the same populations or effective risk stratification. Using national data can be informative, but each institution is different; thus, relying on external benchmarking to select indicators for infection control, for example, can be misleading. Additionally, benchmarking is a compilation of data that may vary considerably if analyzed individually; it can be further compromised by anonymity, making comparisons difficult.
Internal trending involves comparing internal rates of one area or population with another, such as infection rates in intensive care units and general surgery; while this can help to pinpoint areas of concern within an institution, making comparisons is still problematic because of inherent differences. Using a combination of external and internal data can help to identify indicators.
Discuss benchmarking: Xerox Corporation’s 10-step benchmarking model.
Benchmarking is an ongoing process of measuring practice, service, or product results against competitors or industry standards. The Xerox Corporation developed the 10-step benchmarking model. This model compares an organization’s efficiency with that of others and searches for improvements. The 10-step process moves through four phases: planning, analysis, integration, and action. The steps include the following:
- Identify benchmark targets.
- Identify organizations/units/providers with which to compare data.
- Determine and initiate methods of data collection.
- Evaluate current performance level and deficits.
- Project vision of future performance.
- Communicate findings and reach group agreement.
- Recommend changes based on benchmark data.
- Develop specific action plans for objectives.
- Implement actions and adjust as necessary based on monitoring of process.
- Update benchmarks based on latest data.
This basic benchmarking model is often modified to a 7 to 11 step process, depending on the needs of the organization. Benchmarking is often used to improve cash flow as health care becomes more competitive or to compare infection rates.
Discuss cloud computing and its implications for healthcare.
Cloud computing is using the internet to store and access files as opposed to a business network or a computer hard drive. Cloud computing has dramatically increased by healthcare organizations in the past years, likely associate with health care reform giving financial incentives for providers and organizations that use electronic medical records and electronic health records (EHR). Health care organizations are also using the cloud to store information that is not EHR related at rapidly increasing numbers. The benefits to using the cloud include multiple providers being able to access the records at the same time from many different locations, increasing collaboration and decreasing healthcare costs. The major disadvantages focus on privacy concerns, as patient’s personal health information is being stored on the internet, making it susceptible to cybercriminals. As the health care industry moves to new and alternative solutions to satisfy the “meaningful use” clause given by the Centers for Medicare and Medicaid Services, cloud providers are coming up with new agreements to protect private information, thereby becoming more attractive to healthcare organizations.
Discuss communication skills needed for leading intra- and interdisciplinary teams.
A number of communication skills are needed to lead and facilitate coordination of intra- and interdisciplinary teams, such as the following:
- Communicating openly is essential with all members encouraged to participate as valued members of a cooperative team.
- Avoiding interrupting or interpreting the point another is trying to make allows free flow of ideas.
- Avoiding jumping to conclusions as this can effectively shut off communication.
- Active listening requires paying attention and asking questions for clarification rather than challenging the ideas of others.
- Respecting the opinions and ideas of others, even when they are opposed to one’s own, is absolutely essential.
- Reacting and responding to facts rather than feelings allows one to avoid angry confrontations or diffuse anger.
- Clarifying information or opinions stated can help avoid misunderstandings.
- Keeping unsolicited advice out of the conversation shows respect for others and allows them to solicit advice without feeling pressured.
Discuss communication theories: Communication accommodation theory developed by Howard Giles and cultivation theory developed by George Gerbner.
Howard Giles developed the communication accommodation theory (CAT) to explain why people alter their communication styles. Individuals may practice convergence, modeling the communication style (i.e., accent, dialect, vocabulary) after the other if seeking approval, or may practice divergence, intentionally using differences in communication to emphasize social differences. Components of CAT include the following:
- Context (social and historical) influences communication.
- Accommodative orientation includes three factors: personality, positive or negative feelings, and understanding areas of conflict.
- Immediate communication is affected by social and political states, motivations, goals, convergence, divergence, linguistic choices, and attributions.
George Gerbner developed the cultivation theory to explain the effect media, primarily television, have on cultivating ideas and beliefs related more to the media than to the real world. Gerbner believed that media cultivate beliefs that already exist but spread these beliefs through society, thus affecting people’s belief systems and perceptions of reality.
Discuss documentation of quality indicators.
The Agency for Healthcare Research and Quality (AHRQ) provides software (current version 4.4) that allows tracking and documentation of quality indicators (QIs); this software and focus on QIs can be integrated into the information system so that data can be easily accessed. The QI software programs of AHRQ include:
- SAS, which uses SAS/STAT statistical software (which is commercially available).
- Windows, which has a GUI and uses a SQL Server (which has a free version).
MONAHRQ, which facilitates development of a website for health care reporting, including data regarding quality of care, use, preventable hospitalizations, and rates for different conditions and procedures (free to federal, state, and local organizations). MONAHRQ is especially valuable for documenting QIs and providing access to consumers and health care providers because it is easy to use by downloading, inputting the organization’s data, selecting options related to websites, and creating a website.
Discuss implications of health care reform.
Health care reform initiatives are spurring the switch from paper to electronic health records and sharing of health care information among health care providers, increasing the demand for health information technology and people with expertise in informatics. New programs have been developed to focus on wellness with an increased emphasis on cost-effective measures because of increases in health costs. Internal data analysis and research are becoming important means by which to identify waste, institute best practices, and reduce costs. Increasing numbers of people are covered by health plans, even those with preexisting conditions, placing more demand on health care providers for services. There is an increased need for health literacy so that people are better informed about the services available, especially those newly insured. Medicaid costs have increased, resulting in some cutbacks in care. Early transfer from acute care facilities to extended care or home health care is also increasing.
Discuss integrating the results of data analysis
Integrating the results of data analysis is necessary; attempting performance improvement and developing practice guidelines without data can be problematic. These data should be used not only as the basis for long-term strategic planning but also for identifying opportunities for performance-improvement activities on an ongoing basis. Integration of information includes:
- Identifying issues for tracking.
- Reviewing patterns and trends to determine how they impact care.
- Establishing action plans and desired outcomes based on the need for improvement.
- Providing information to process improvement teams to facilitate change.
- Evaluating systems and processes for follow-up.
- Monitoring specific cases, criteria, critical pathways, and outcomes. The integration of information should assist with case management, decision-making about individual care, improvement of critical pathways related to clinical performance, staff performance evaluations, credentialing, and privileging.
Discuss integration of key quality concepts within the organization.
There are a number of key concepts related to quality that must be communicated to ail members of an organization through inservice, workshops, newsletters, fact sheets, and team meetings. Quality care/performance should be:
- Appropriate to needs and in keeping with best practices.
- Accessible to the individual despite financial, cultural, or other barriers.
- Competent, with practitioners well-trained and adhering to standards.
- Coordinated among all healthcare providers.
- Effective in achieving outcomes based on the current state of knowledge.
- Efficient in methods of achieving the desired outcomes.
- Preventive, allowing for early detection and prevention of problems.
- Respectful and caring with consideration of the individual needs given primary importance.
- Safe so that the organization is free of hazards or dangers that may put patients or others at risk.
Discuss interpersonal communication skills: Team building.
Leading, facilitating, and participating in performance improvement teams require a thorough understanding of the dynamics of team building:
- Initial interactions: This is the time when members define their roles and develop relationships, determining if they are comfortable in the group.
- Power issues: The members observe the leader and determine who controls the meeting and how control is exercised; alliances begin to form.
- Organizing: Methods to achieve work are clarified, and team members begin to work together, gaining respect for each other’s contributions and working toward a common goal.
- Team identification: Interactions often become less formal as members develop rapport, and members are more willing to help and support each other to achieve goals.
- Excellence: This develops through a combination of good leadership, committed team members, clear goals, high standards, external recognition, spirit of collaboration, and a shared commitment to the process.
Discuss issues related to the fair distribution of health information access.
The fair distribution of health information access information specific to the individual (e.g., electronic health records), data (both aggregate and comparative), and knowledge-based information (e.g., journals, websites). While people should have access to health information, considerations must include the right to privacy, regulations regarding intellectual property, and equitable access to information. One problem with access is that many people are unaware of their rights or lack the training or tools to access information, so an important element of fair distribution must include providing public means of access, such as in libraries and through public health agencies and education (e.g., posters, handouts, videos) to educate the general public. People in rural or isolated areas may lack access to basic care and health information but may be served by telehealth services, using telecommunications to provide information and Internet health resources.
Discuss legal implications: Malpractice and negligence.
Risk management must attempt to determine the burden of proof for acts of negligence, including compliance with duty, breaches in procedures, degree of harm, and cause as a finding of negligence can lead to a malpractice suit. Negligence indicates that proper care, based on established standards, has not been provided. State regulations regarding negligence may vary, but all have some statutes of limitation. There are a number of different types of negligence.
- Negligent conduct indicates that an individual failed to provide reasonable care or to protect/assist another, based on standards and expertise.
- Gross negligence is willfully providing inadequate care while disregarding the safety and security of another.
- Contributory negligence involves the injured parties contributing to the harm done .
- Comparative negligence attempts to determine what percentage of negligence is attributed to each individual involved.
Discuss legal implications: Liability.
With the marked increase in use of electronic health records (EHRs) has come increased concern regarding liability because the EHR documents all actions in real time. For example, if there is a delay between the time a patient event occurs and when the health care provider responds, the duration of time is documented in the record and cannot be altered. This can give the appearance of negligence even if the delay was unavoidable. Additionally, errors tend to increase with any major change, and there is a learning curve in adjusting to new technology, so information may be entered into EHRs incorrectly and a facility may be liable if it did not provide adequate staff education. Providers used to reports on paper may not access electronic reports in a timely manner. Hardware or software incompatibilities may cause information, such as medicine orders, to be altered or deleted. If health care providers provide patients access to them via e-mail or messaging and do not respond promptly to those messages, then they may be liable for malpractice.
Discuss legal implications: Patient data misuse.
Patient data misuse is an increasing problem with the rapid proliferation of electronic health records (EHRs). Types of misuse include:
- Identity theft: Health records often contain identifying information, such as Social Security numbers, credit card numbers, birthdates, and addresses, making patients vulnerable.
- Unauthorized access: Although EHRs and computerized documentation systems are password protected, providers sometimes share passwords or unwittingly expose their passwords when logging in, inadvertently allowing access to information about patients.
- Privacy violations: Even professionals authorized to access a patient’s record may share private information with others, such as family or friends.
- Security breaches: Data are vulnerable to security breaches because of careless, inadequate security, especially when various business associates, such as billing companies, have access to private information.
Discuss methods to maximize reimbursement : Do-not-pay list.
As a means to control quality of care and to cut costs. Medicare instituted a do-not-pay list for serious, preventable, hospital-acquired conditions and complications for which Medicare will not reimburse hospitals; thus, avoiding these complications is a critical element in maximizing reimbursement and requires ongoing monitoring of quality care and staff education. Additionally, some insurance companies are following suit, so this has the potential to impact reimbursement seriously. For example, if surgery is done on the wrong side or botched. Medicare will not pay the costs. If a blood clot occurs after hip replacement surgery. Medicare will not pay for treatment. There are currently over forty categories on the do-not-pay list, including the following:
- Fall or other trauma that causes serious injury
- Stages III and IV pressure ulcers
- Vascular catheter-associated infections
- Catheter-associated urinary tract infections
- Transfusion reaction from blood incompatibility
- Postoperative dehiscence
- Surgical deaths associated with treatable serious complications
Discuss methods to maximize reimbursement: Overiview.
Methods to maximize reimbursement include:
- Recording of information and sending of claims in a timely manner.
- Using care managers to determine the most cost-effective care plan.
- Using standardized billing codes (Current Procedural Terminology, International Classification of Diseases [ICD]).
- Ensuring that the health care provider’s National Provider Identifier is present on all claims.
- Updating systems promptly when new coding (e.g., ICD-10) and billing regulations (e.g., pay-for-performance) are issued rather than waiting for the end of the grace period so that problems can be identified and corrected early.
- Ensuring that the presentation on admission (Medicare severity diagnosis-related group code) diagnosis is correct to avoid a different discharge diagnosis.
- Monitoring quality of care to prevent complications and reduce costs related to the do-not-pay list.
- Sending claims in the correct form and to the correct address for different entities: insurance companies. Medicaid, and Medicare.
Discuss methods to maximize reimbursement: Pay-for-performance or value-based purchasing.
A reimbursement system called pay-for-performance (P4P) or value-based purchasing, one element of the Affordable Care Act of 2010, is an alternative to standard pay-for-care reimbursement. Some states, such as California, have P4P plans in effect, and Medicare also has a number of P4P initiatives and demonstration projects. The primary objective of P4P programs is to reward health care providers when patients have good results (e.g., discharge within a defined period without complications), although there remains some controversy regarding measuring quality performance. Payment is related to quality rather than quantity of service, so ongoing quality improvement processes must be in place to maximize reimbursement. In some cases, bonus incentives may be provided. Disincentives, such as reduced payment for never events (inexcusable outcomes), are also considered. There are both hospital-based P4P plans and physician-based P4P plans.
Discuss methods to maximize reimbursement: Present-on-admission Medicare severity diagnosis-related group.
On admission to acute hospitals under the Medicare Inpatient Prospective Payment System (IPPS), patients must be given a present-on-admission (POA) Medicare severity diagnosis-related group (MS-DRG) diagnosis. The MS-DRG should include primary and secondary diagnoses present during the admission process. This is a concern regarding maximizing reimbursement because hospital acquired conditions may not be covered if there is a change at discharge from the POA diagnosis. A POA indicator must be on all claims:
- Y: Medicare pays for a condition if a hospital-acquired condition (HAC) is present on admission.
- N: Medicare will not pay for condition if a HAC is present on discharge but not on admission.
- U: Medicare will not pay for condition if a HAC is present and documentation is not adequate to determine if the condition was present on admission.
- W: Medicare will pay for condition if a HAC is present and if the health care provider cannot determine if the condition was present on admission.
Discuss methods to promote an environment for ethical decision-making and patient advocacy.
An environment for ethical decision, making and patient advocacy does not appear when it is needed; it requires planning and preparation. The expectation for the institution should clearly communicate that nurses are legally and morally responsible for assuring competent care and respecting the rights of patients and other stakeholders, Decisions regarding ethical issues often must be made quickly with little time for contemplation; therefore, ethical issues that may arise should be identified and discussed, Clearly defined procedures and policies for dealing with conflicts, including an active ethics committee, in•seflice training, and staff meetings, must be established, Patients and families need to be part of the ethical environment, which means empowering them by providing patient/family information (e.g., print form, video, audio) that outlines patient’s rights and procedures for expressing their wishes and dealing with ethical conflicts. Respect for privacy and confidentiality and a nonpunitive atmosphere are essential.
Discuss organization accreditation standards: Centers for Medicare and Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) maintain a list of approved accreditation organizations for health care providers, as providers and suppliers who have been accredited by one of these national accrediting agencies are exempt from state surveys in determining if they are in compliance with Medicare-mandated conditions. Approved organizations include the Joint Commission, Community Health Association Program, and the Accreditation Commission for Health Care. The CMS has established an incentive program for adoption, upgrade, or use of electronic health records (EHRs). Those applying for incentive programs must use certified EHR systems that demonstrate that they can store and share patient data securely. Health care providers who are eligible for incentive pay from Medicare or Medicaid can receive up to $44,000 over a 5-year period, while eligible hospitals and critical access hospitals can receive a beginning base payment of $2 million. Medicare eligibility guidelines and Medicaid eligibility guidelines vary for both eligible professionals and eligible hospitals.
Discuss team buildlng.
Leading, facilitating, and participating in performance improvement teams requires a thorough understanding of the dynamics of team building:
- Initial interactions: This is the time when members begin to define their roles and develop relationships, determining if they are comfortable in the group.
- Power issues: The members observe the leader and determine who controls the meeting and how control is exercised, beginning to form alliances.
- Organizing: Methods to achieve work are clarified and team members begin to work together, gaining respect for each other’s contributions and working toward a common goal.
- Team identification: Interactions often become less formal as members develop rapport, and members are more willing to help and support each other to achieve goals.
- Excellence: This develops through a combination of goodleadership, committed team members, clear goals, high standards, external recognition, spirit of collaboration, and a shared commitment to the process.
Discuss the American Nurses Association definition, scope, and functional areas of the informatics nurse specialist.
The informatics nurse is one who works in informatics because experience or interest in the field but has not received formal training; an informatics nurse specialist (INS) has completed graduate studies in informatics and may also have certification. According to the American Nurses Association, nursing informatics is a nursing specialty integrating nursing, computer sciences, and information sciences, which support professionals and patients in decision-making through information processes and technology. INS functions include:
- Providing tools for standardized documentation.
- Managing information and analyzing data.
- Re-engineering information processes and promoting standardization.
- Participating in research and collection of data.
- Providing nursing management and administration.
- Serving as a consultant in the field of informatics.
- Promoting and providing professional development activities, including training of human-computer interaction systems.
- Advocating for changes in policies.
- Serving as advocate for staff and patients.
- Ensuring implementation of electronic health records and computerized physician order entry systems.
- Providing support to clinical applications.
Discuss the International Medical Informatics Association Code of Ethics
The International Medical Informatics Association Code of Ethics was developed in 2002 and recently revised. Part 1, the introduction, includes the six primary ethical principles: autonomy (selfdetermination), equality and justice (equal treatment), beneficence (promoting good), nonmalfeasance (preventing harm), impossibility (predicated on possibility), and integrity (honesty and diligence).
General principles in the introduction include the following:
- The right to privacy, regarding sharing of personal information and control of collection, methods of collection, and storage
- Open process of data collection with patient informed
- Security of all data collection and protection from data manipulation
- Right to access of personal data
- Legitimate infringement or the consideration for greater good of society in regard to individual’s right to privacy
- Infringement of right to privacy with minimum interference
- Accountability for infringement
Part II, rules of ethical conduct, includes subject-centered duties, duties toward health care professionals, duties toward institutions and employers, duties toward society, self-regarding duties, and professional duties.
Discuss the synergy model: Advocacy and moral agency.
Nurse competencies under the synergy model include advocacy and moral agency. Advocacy is working for the best interests of the patient/stakeholders despite personal values in conflict and assisting patients to have access to appropriate resources. Agency is openness and recognition of issues and a willingness to act. Moral agency is the ability to recognize needs and take action to influence the outcome of a conflict or decision. The levels of advocacy and moral agency include:
- Level 1: The nurse works on behalf of the patient/stakeholders, assesses personal values, has awareness of patient’s rights and ethical conflicts, and advocates for the patient/stakeholders when consistent with the nurse’s personal values.
- Level 2: The nurse advocates for the patient/stakeholders, incorporates their values into the care plan even when they differ from the nurse’s, and can use internal resources to assist patient/stakeholders with complex decisions.
- Level 3: The nurse advocates for patient/stakeholders despite differences in values and is able to use both internal and external resources to help empower patients and their families to make decisions.
Discuss cognitive science: Psychosocial development model developed by Eric Erikson.
Eric Erikson’s psychosocial development model covers the life span, focusing on conflicts at each stage and the virtue that is the outcome of finding a balance in the conflict. The first five stages relate to infancy and childhood and the last three stages to adult-hood, but childhood development affects later adult development:
