Robert Wood Johnson Foundation funds UT Health Science Center nursing project to improve quality of care

SAN ANTONIO (Oct. 16, 2008) — We’ve all heard the saying that it’s not worth it to “sweat the small stuff.”

Three faculty members at the UT Health Science Center San Antonio, however, are out to prove that the opposite may be truer — at least in health care. They are investigating whether educating teams of nurses in new methods of solving small, everyday problems in patient care can improve larger-scale quality and safety issues.

The Small Troubles, Adaptive Responses (STAR) Project is being conducted at two hospitals in San Antonio and Austin by the interdisciplinary team of Health Science Center faculty members including:

• Kathleen Stevens, Ed.D., R.N., professor in the Department of Acute Nursing Care and director of the Academic Center for Evidence-Based Practice (ACE), who will serve as the study’s principal investigator and the nursing scholar.
• Robert Ferrer, M.D., M.P.H., associate professor, deputy chair and director of research in the Department of Family and Community Medicine, who will serve as the collaborative discipline scholar.
• Nedal Arar, Ph.D., associate research professor in the Department of Medicine’s division of renal diseases, who is a co-investigator on this project and experienced in conducting qualitative research.

The two-year study, funded by a $300,000 grant from the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative (INQRI) is one of eight awarded to interdisciplinary teams of researchers at institutions throughout the U.S.

The projects are part of a $19 million program to generate and disseminate research showing a link between what nurses do and the contributions they make to advancing better and safer care for patients.

Nurses account for more than half of all health care providers in the U.S., but little research exists to demonstrate the link between what nurses do and the effect of those interventions on patient care and safety. INQRI seeks to fill the information gap by applying rigorous science to bolster that link.

In awarding the grants, the INQRI program sought projects that offer diverse perspectives and various methodologies in order to address quality and safety issues. Preference was given to teams that incorporate “perspectives and techniques of nursing scholars and scholars from non-clinical backgrounds,” the INQRI Web site states.

“As a research team, we approach quality improvement from a variety of perspectives — nursing care, medical care and anthropology,” Dr. Stevens said. “As part of a growing cadre of scientists studying complex adaptive organizations, we are pleased to add to the synergy of funded research emerging here at the Health Science Center, specifically connected with improvement science.”

Regarding the Health Science Center project, Dr. Stevens said, “We know that organizations known for excellence pay attention to small details. What we are trying to do is apply the same attention to detail to health care.” Dr. Stevens is a nationally recognized expert in evidence-based practice, a systematic method of identifying and evaluating health care innovations to improve everyday practice.

“It is not usually one big thing that happens that causes a large error; rather, it is a series of conditions that line up, like holes in Swiss cheese that result in an unfortunate event. By giving nurses methods to become proactive in identifying and addressing the ‘small stuff’ we hope to prevent major patient errors from occurring and increase job satisfaction,” she said. For instance, a small problem, such as a patient not having an identification band, could possibly lead to a nurse failing to give critical medication at the proper time.

During the study, the Health Science Center team will prepare facilitators to lead groups in resolving small quality issues and stem progression to larger ones. In this way, unit-level nurses become a valued part of the larger-system improvement.

Through this facilitation, nurses will access a “toolbox” of established problem-solving strategies and innovate new ones to resolve small problems. Strategies include the TeamSTEPPS™ teamwork system offered through the federal government’s Agency for Healthcare Research and Quality, and other proven tools, such as the evidence-based practice guidelines and knowledge resources developed by Dr. Stevens through ACE. More than 240 nurses will be involved in the project.

“We will track the number of small problems faced by the nurses before and after the project; the rate of adverse events experienced by patients, such as hospital-acquired infections and falls; and the nurses’ evaluations of how safe their units were before and after the project,” Dr. Ferrer said. “We will also evaluate whether the innovations reduced the occurrence of larger problems at each of the institutions.

“The intervention is grounded in the idea that front-line teams have the best knowledge about the problems and workarounds they confront in everyday patient care. Our goal is to capitalize on that knowledge by empowering nurses to drive the system improvements that will improve safety and quality. The ‘interdisciplinary’ part of the project is its connection with quality improvement approaches that have been developed for primary care teams,” Dr. Ferrer explained.
Dr. Arar added, “Taking it a step further, when the nurses learn the methodology of how to solve the smaller problems, they can then share this methodology and the solutions with other members of the interdisciplinary teams in hospitals, such as doctors, office staff and even the patients, who all contribute to improving the quality of overall safety and patient care.”


The University of Texas Health Science Center at San Antonio is the leading research institution in South Texas and one of the major health sciences universities in the world. With an operating budget of $668 million, the Health Science Center is the chief catalyst for the $15.3 billion biosciences and health care sector in San Antonio’s economy. The Health Science Center has had an estimated $35 billion impact on the region since inception and has expanded to six campuses in San Antonio, Laredo, Harlingen and Edinburg. More than 23,000 graduates (physicians, dentists, nurses, scientists and other health professionals) serve in their fields, including many in Texas. Health Science Center faculty are international leaders in cancer, cardiovascular disease, diabetes, aging, stroke prevention, kidney disease, orthopaedics, research imaging, transplant surgery, psychiatry and clinical neurosciences, pain management, genetics, nursing, dentistry and many other fields. For more information, visit www.uthscsa.edu.



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