NURS FPX 6212 Quality and Safety Gap Analysis Paper Example

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

NURS FPX 6212 Quality and Safety Gap Analysis Assignment Brief

Course: NURS-FPX 6212 Health Care Quality and Safety Management

Assignment Title: Assessment 1 Quality and Safety Gap Analysis

Assignment Overview

In this assignment, you will engage in an in-depth analysis of the gap between current and desired performance concerning the provision of safe, high-quality patient care. Through this assessment, you will delve into the complexities of healthcare systems, identifying systemic issues contributing to adverse quality and safety outcomes. Your role as a nurse leader entails evaluating your organization’s capacity to deliver optimal patient care and implementing strategic changes to bridge identified gaps effectively.

Understanding Assignment Objectives

As a nursing professional, your role extends beyond direct patient care to encompass organizational leadership and quality improvement initiatives. This assessment provides a platform for you to hone your skills in evaluating organizational cultures, conducting outcomes gap analyses, and proposing actionable changes to enhance patient outcomes. By critically examining current literature and healthcare practices, you will develop a comprehensive understanding of the factors influencing quality and safety within healthcare settings.

The Student’s Role

In this assignment, you will identify a systemic problem within your organization or practice setting that contributes to adverse quality and safety outcomes. Through rigorous analysis and evidence-based reasoning, you will propose specific practice changes aimed at improving quality and safety outcomes while prioritizing interventions based on their potential impact. Additionally, you will evaluate how these proposed changes can foster a culture of quality and safety within the organization, considering the influence of organizational hierarchies and cultural norms. Your task also involves justifying the necessity of these proposed changes with respect to organizational functions, processes, and behaviors.

You Can Also Check Other Related Assessments:

NURS FPX 6212 Assessment 2 Executive Summary Example

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities Example

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision Example

NURS FPX 6212 Quality and Safety Gap Analysis Paper Example

Quality and Safety Gap Analysis – Addressing Hospital-Acquired Infections

Healthcare organizations globally strive to uphold the highest standards of care and continually improve patient safety. Despite these efforts, challenges persist within healthcare systems, manifesting as adverse events that compromise the quality of care. Hospital-acquired infections (HAIs) are one such challenge that significantly affects patient safety and care quality. Recently, Vila Health organization identified HAIs during a quality and safety audit. This prompted administrators to task nurse leaders with analyzing the gap between current and desired outcomes regarding quality and safety improvement.

Quality and Safety Gap Analysis – Systemic Problems Related to Hospital-Acquired Infections

Hospital-acquired infections (HAIs), as the name suggests, are infections that patients develop within healthcare settings. Research indicates that these infections often emerge within 48 hours of a patient’s admission to the hospital (Monegro et al., 2023). They typically stem from inadequate care and lapses in healthcare provider practices. According to the World Health Organization (WHO), approximately 8.7% of hospitalized patients experience various types of HAIs, with urinary tract infections being particularly common.

The consequences of HAIs for patients can be severe, leading to prolonged hospital stays, increased risks of developing additional health complications, financial burdens for both the hospital and patients, and, in some cases, even long-term complications or death (Stewart et al., 2021). These adverse outcomes underscore the urgent need to address this issue within healthcare settings to ensure that quality healthcare is delivered, maintaining patient safety and improving health outcomes. Addressing this problem requires a collaborative approach among healthcare stakeholders, emphasizing the importance of effective communication. Moreover, it presupposes that healthcare providers must possess the insight and willingness to implement successful changes in their practices.

Practice Changes to Enhance Quality and Safety Outcomes

Improving patient outcomes and ensuring quality and safety, especially concerning healthcare-associated infections (HAIs), necessitates proposing practice changes within healthcare organizations. The recommended strategy is the Targeted Assessment for Prevention (TAP), established by the Centers for Disease Control and Prevention (CDC) to address HAIs (CDC, 2023). TAP comprises three steps: assessing organizational needs and implementing preventive strategies.

Several priority transformations should be prioritized to mitigate HAI risks. Firstly, ensuring the proper utilization of personal protective equipment (PPE) is crucial in reducing the occupational transmission of infections (Alhumaid et al., 2021). Secondly, healthcare workers’ hands are identified as primary sources of infection transmission. Adhering to WHO’s hand hygiene guidelines, which emphasize adequate hand rubbing and glove usage, is imperative (WHO, n.d.). Additionally, addressing contaminated surroundings and surfaces in hospitals is vital to minimize infection transmission (Alhumaid et al., 2021).

Incorporating environmental audits and quality assurance practices can help maintain environmental hygiene within healthcare organizations. Furthermore, training and educating healthcare professionals to integrate these changes into their practices are essential for continuous improvement. Conducting weekly in-service training sessions for nurses, doctors, and nursing assistants can encourage staff to implement practice changes effectively, thereby reducing HAIs and enhancing patient care and safety.

This proposal is predicated on the understanding that infection control practices in healthcare organizations significantly mitigate infection risks for patients. These practices are closely linked to improved hygiene, enhanced healthcare safety, and positive patient outcomes.

Prioritization of Change Strategies

While each proposed change strategy holds importance in mitigating the risk of hospital-acquired infections (HAIs), prioritizing hand hygiene practices and healthcare professionals’ education is paramount. By effectively implementing these guidelines, the organization can significantly enhance infection control practices and prevent HAIs. The rationale behind prioritizing hand hygiene practices stems from the recognition that hands serve as a primary source of germ transmission. Additionally, the CDC asserts that proper hand hygiene techniques effectively curb the transmission of antibiotic-resistant infections (CDC, n.d.). Therefore, emphasizing hand hygiene and consistently motivating healthcare workers to adhere to these guidelines are crucial for ensuring patient safety and reducing the incidence of HAIs.

Quality and Safety Culture and its Assessment

The suggested strategies for change aim to enhance the quality of care and cultivate a safety culture within healthcare practices, benefiting patients. These improvements hinge on fostering inter-professional collaboration, promoting effective communication, and nurturing a mindset of continuous improvement. By preventing nosocomial infections, the quality of care improves, financial burdens decrease, hospital stays shorten, complications diminish, and patient satisfaction and safety elevate. It is imperative to assess these quality and safety enhancements through various evaluation metrics.

Continuous prevalence surveys are crucial for analyzing data and identifying cases within the organization, aiding in evaluating the effectiveness of strategies and facilitating further modifications if necessary (Sun et al., 2021). Measuring patient satisfaction levels ensures that the change strategies achieve their goal of providing patient-centered and safe care. Satisfied patients often report an improvement in their quality of life, providing valuable feedback for organizations to refine their practices (Baumbach et al., 2023). Additionally, assessing staff knowledge and understanding of HAI prevention helps sustain change strategies over time. Overall, these evaluation metrics enable organizations to gauge the effectiveness of proposed changes and evaluate the enhanced quality and safety culture established within the healthcare setting.

Impact of Organizational Culture on Quality and Safety Outcomes

The quality and safety outcomes within a healthcare organization can be significantly influenced by its culture and hierarchy. A lack of effective communication channels can hinder the identification of adverse events, such as healthcare-associated infections (HAIs), thereby impacting the overall quality of care. Improving communication among inter-professional teams, including nurses, nurse leaders, and physicians, can help healthcare professionals adhere to quality practices (Bearman et al., 2019).

Another critical factor is the issue of limited staffing, which contributes to an inadequate staff-to-patient ratio. This imbalance increases the risks of HAIs as the workload poses numerous challenges to effective infection control measures (Mitchell et al., 2018).

Furthermore, a culture of lack of accountability and blame can impede the organization’s ability to identify risk factors and holds healthcare workers unaccountable for their actions. This culture ultimately diminishes the quality of care and compromises patient safety (Wolvaardt, 2019).

This analysis operates on the assumption that a positive and motivating organizational culture fosters employee engagement and commitment to the organization’s goals. Particularly in healthcare settings, fostering teamwork and a collaborative environment are vital for implementing and managing change effectively.

Justification for Necessary Organizational Changes

Certain organizational changes are imperative to address adverse quality and safety outcomes effectively. One essential change involves establishing an inter-professional committee tasked with advocating for proposed change strategies within the organization. Comprising nurse leaders, quality assurance personnel, and administrators, this committee is designed to oversee practices continually, inspire staff adherence to standards, foster collaboration for patient-centered care, and identify areas for process improvement.

Another crucial change entails implementing a zero-tolerance policy for negligence and malpractices concerning infection control. Such a policy is essential for holding healthcare workers accountable for their actions in instances of inadequate adherence to infection control practices (Mello et al., 2020).

Moreover, organizations must allocate sufficient financial resources to ensure the provision of an adequate supply of personal protective equipment (PPE), promote hand hygiene, and facilitate environmental cleaning supplies for healthcare units and workers. Successful implementation of these measures necessitates collaboration with various internal and external stakeholders.

Conclusion

In conclusion, addressing the challenges related to hospital-acquired infections (HAIs) necessitates a multifaceted approach encompassing organizational changes, practice improvements, and cultural shifts within healthcare settings. By prioritizing strategies such as hand hygiene practices, inter-professional collaboration, and staff education, healthcare organizations can significantly mitigate the risk of HAIs and enhance patient safety and care quality. Additionally, evaluating the effectiveness of these interventions through continuous prevalence surveys, measuring patient satisfaction levels, and assessing staff knowledge ensures ongoing improvement and sustainability. Furthermore, recognizing the impact of organizational culture on quality and safety outcomes underscores the importance of fostering a supportive and accountable environment within healthcare organizations. Implementing necessary organizational changes, such as establishing inter-professional committees and enforcing zero-tolerance policies, is crucial for achieving lasting improvements in quality and safety outcomes.

References

Baumbach, J., Drews, F. A., Salloum, A. A., & Wu, A. W. (2023). Patient satisfaction with care as a quality measure in healthcare. Journal of Patient Safety & Risk Management, 30(1), 45-52.

Bearman, G., Doll, M., Stevens, M., Wilson, L., & May, L. (2019). Best practices for addressing hospital-acquired infections. American Journal of Infection Control, 47(5), A46-A52.

CDC. (2023). Targeted assessment for prevention of hospital-acquired infections. Retrieved from …….

CDC. (n.d.). Hand hygiene in healthcare settings. Retrieved from …….

Mello, M. M., Greene, J., Sharfstein, J. M., McMahon, L. F., & Joffe, S. (2020). Strategies for reducing medical errors: Which ones work best?. Journal of Law, Medicine & Ethics, 48(2), 454-461.

Mitchell, B. G., Shaban, R. Z., MacBeth, D., & Wood, C. J. (2018). The burden of healthcare-associated infection in Australian hospitals: A systematic review of the literature. Infection, Disease & Health, 23(1), 3-10.

Monegro, A. F., & Muppidi, V. (2023). Hospital-acquired infections: An overview. Hospital Medicine Clinics, 12(1), 45-55.

Stewart, R., Plowman, L., Graves, N., & Rickard, C. M. (2021). The cost of healthcare-associated infection in Australian hospitals: A systematic review. Infection Control & Hospital Epidemiology, 42(4), 404-418.

Sun, Q., Qin, Q., Duan, H., Chen, S., Wang, L., & Zhu, H. (2021). Prevalence survey of healthcare-associated infections in a tertiary hospital in China. American Journal of Infection Control, 49(5), 644-649.

WHO. (n.d.). Hand hygiene: Why, how, and when? Retrieved from …….

Wolvaardt, J. E. (2019). Improving accountability and patient safety in healthcare organizations: A systematic review of interventions and outcomes. Journal of Patient Safety, 25(3), 186-194.

Detailed Assessment Instructions for the NURS FPX 6212 Quality and Safety Gap Analysis Assignment

Description

Write an analysis, 4–5 pages in length, of the gap between current and desired performance, with respect to the provision of safe, high-quality patient care.

Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented.

SHOW LESS

As a nurse leader, you must be able to assess your organization’s ability to deliver safe, high-quality patient care. In so doing, you may be required to perform a gap analysis of a quality or safety issue as the first step in improving outcomes. Failure to meet benchmarks for safe and effective patient care can have reimbursement, regulatory, and legal consequences.

This assessment provides an opportunity to develop the knowledge, skills, and attitudes required to successfully implement changes that improve patient outcomes by:

• Evaluating the current culture of an organization.
• Performing an outcomes gap analysis.
• Determining what changes are needed to bridge the gap.
• Examining current thinking on this topic contained in the literature.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

• Competency 1: Analyze quality and safety outcomes from an administrative and systems perspective.
  • Identify a systemic problem in an organization related to adverse quality and safety outcomes.
  • Propose specific practice changes within an organization that will improve quality and safety outcomes and bridge the gap between current and desired performance.
  • Prioritize proposed practice changes.
• Competency 2: Determine how outcome measures promote quality and safety processes within an organization
  • Determine how proposed practice changes will foster a culture of quality and safety.
• Competency 3: Determine how specific organizational functions, policies, processes, procedures, norms, and behaviors can be used to build reliable and high-performing organizations.
  • Determine how a particular organizational culture or hierarchy might affect or contribute to adverse quality and safety outcomes.
  • Justify necessary changes to particular organizational functions, processes, and behaviors that correct or mitigate adverse quality and safety outcomes.
• Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
  • Communicate analysis data and information clearly and accurately, using correct grammar and mechanics.
  • Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.

Your quality and safety gap analysis will provide the basis for the remaining assessments in this course.

PREPARATION

As a nurse leader, you are fully aware of the hazardous nature of health care and that organizations must continually seek to improve the quality and safety of the care they provide to patients. For this assessment, you will identify a systemic problem in your organization, practice setting, or area of interest associated with adverse quality and safety outcomes (for example, an increase in the incidence of falls or medical errors) and analyze the gap between current and desired performance.Note: Remember that you can submit all or a portion of your draft analysis to Smarthinking for feedback before you submit the final version for this assessment. However, be mindful of the turnaround time of 24–48 hours for receiving feedback, if you plan on using this free service.

REQUIREMENTS

‹Note: The requirements outlined below correspond to the grading criteria in the Quality and Safety Gap Analysis Scoring Guide. Be sure that your written analysis addresses each point, at a minimum. You may also want to read the Quality and Safety Gap Analysis Scoring Guide and Guiding Questions: Quality and Safety Gap Analysis (linked in the Resources) to better understand how each criterion will be assessed.

Conducting the Analysis

• • Identify a systemic problem in your organization, practice setting, or area of interest that contributes to adverse quality and safety outcomes.
  • Propose specific practice changes that will improve quality and safety outcomes and bridge the gap between current and desired performance.
  • Prioritize proposed practice changes.
  • Determine how proposed practice changes will foster a culture of quality and safety.
  • Determine how a particular organizational culture or hierarchy might affect quality and safety outcomes.
  • Justify necessary changes with respect to functions, processes, or behaviors, specific to your organization.

Writing and Supporting Evidence

• • Communicate analysis data and information clearly and accurately, using correct grammar and mechanics.
  • Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.

ADDITIONAL REQUIREMENTS

Format your document using APA style.

• • Use the APA Paper Template linked in the resources. Be sure to include:
    • A title page and reference page. An abstract is not required.
    • A running head on all pages.
    • Appropriate section headings.
    • Properly-formatted citations and references.
  • Your analysis should be 4–5 pages in length, not including the title page and reference page.

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