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NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

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    NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

    Student Name

    Capella University

    NURS-FPX 6212 Health Care Quality and Safety Management

    Prof. Name


    Quality and Safety Gap Analysis – Hospital-Acquired Infections

    Healthcare organizations globally exert substantial efforts to uphold healthcare quality standards and enhance patient safety. However, challenges may still arise during healthcare practices, often stemming from adverse events within the healthcare system. Hospital-acquired infections (HAIs) are one such adverse event that compromises the quality of care and negatively impacts patient safety. The Vila Health organization recently identified HAIs during a quality and safety assurance audit. In response to this evolving problem, nurse leaders have been tasked with conducting a gap analysis to assess the disparity between current and desired outcomes in terms of enhancing quality and safety.

    Systemic Problems Related to Quality and Safety Outcomes

    HAIs, as the name suggests, are infections acquired within healthcare settings, typically emerging 48 hours after a patient’s admission (Monegro et al., 2023). Inadequate care and malpractices by healthcare providers are common causes, with the World Health Organization (WHO) reporting that 8.7% of hospitalized patients experience various types of HAIs, including prevalent urinary tract infections.

    HAIs lead to adverse consequences for patients, such as prolonged hospital stays, increased morbidity risks, financial burdens for both hospitals and patients, and, in severe cases, long-term complications and death (Stewart et al., 2021). These outcomes underscore the necessity of addressing this issue in healthcare settings to ensure the provision of quality healthcare, maintaining patient safety, and improving health outcomes. Assumptions guiding the problem-solving process include the need for a collaborative approach to change in healthcare organizations and the importance of healthcare providers gaining insight to effect successful practice changes.

    Practice Changes to Improve Quality and Safety Outcomes

    To enhance patient outcomes, quality, and safety, particularly regarding healthcare-associated infections, implementing practice changes within healthcare organizations is crucial. The recommended strategy is Targeted Assessment for Prevention (TAP), established by the Centers for Disease Control and Prevention (CDC) to address HAIs. The TAP strategy comprises three steps targeting organizations, assessing needs, and implementing prevention strategies (CDC, 2023).

    Critical transformations to be prioritized for implementation include: 1) proper utilization of personal protective equipment (PPE) to reduce occupational transmission risks, 2) adherence to WHO’s hand hygiene guidelines, including adequate hand rubbing, following five moments of hand washing, and using hand gloves when handling patients and surroundings, 3) improving environmental hygiene to minimize HAI risks, and 4) training and educating healthcare professionals to integrate these changes into their practices.

    Prioritization of the Proposed Change Strategies

    While all proposed change strategies are essential, prioritizing hand hygiene practices and healthcare professional education is recommended. Effectively implementing these guidelines can significantly improve infection control practices, prevent HAIs, and enhance the quality and safety of patient care.

    Quality and Safety Culture and its Evaluation

    The suggested change strategies aim to improve care quality and foster a safety culture through progressive healthcare practices. Successful implementation relies on encouraging inter-professional collaboration, effective communication, and fostering a mindset of continuous improvement. Evaluating these improvements is crucial, with metrics including continuous prevalence surveys, patient satisfaction levels, and assessments of staff knowledge regarding HAI prevention.

    Organizational Culture Affecting Quality and Safety Outcomes

    Adverse outcomes in quality and safety within healthcare organizations can be influenced by organizational culture and hierarchy. Improved communication and adequate staffing ratios are crucial factors, while a lack of accountability and blaming culture diminishes the organization’s ability to identify risk factors and compromises patient safety.

    Justification of Necessary Changes in an Organization

    To mitigate adverse quality and safety outcomes, organizational changes are imperative. Establishing an inter-professional committee, implementing a zero-tolerance policy for negligence, and securing adequate resources through collaboration with stakeholders are essential measures for promoting proposed change strategies.


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