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

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

    Student Name

    Capella University

    NURS-FPX 6212 Health Care Quality and Safety Management

    Prof. Name


    Outcomes, Measures, Issues, and Opportunities

    The impact of unsafe surgical procedures on the quality of care at Alignment Healthcare is pervasive, resulting in adverse outcomes attributed to an under-skilled team, inadequate training, lax surgical and maintenance protocols, and sterilization issues. These hazards pose a threat to patient well-being, influencing life quality and functionality, increasing financial burdens, re-operative procedures, readmissions, and hospital-acquired infections due to extended stays (Balance et al., 2023). These challenges contribute significantly to organizational reputation issues, eroding trust in the healthcare system, escalating medical errors, patient complications, and overall costs. The current evaluation focuses on a comprehensive report analyzing outcomes, measures, issues, and opportunities within Alignment Healthcare for executive leadership consideration.

    Organizational Functions, Processes, and Behaviors in High-performing Organizations

    Strategic planning and effective care plan implementation are pivotal in high-performing organizations to enhance quality care by leveraging errors for practice improvement and reducing medical errors (Buljac-Samardzic et al., 2020). Alignment Healthcare requires a multi-level organizational change to address safety concerns such as unsafe surgical procedures, postoperative complications, patient readmissions, surgical site infections, and patient satisfaction. Managing unsafe surgical procedures involves developing hygiene maintenance protocols, meticulously addressing surgical site infections through operative techniques, timely administration, and appropriate preoperative preparations like antiseptic showering, surgical attire, preoperative hair removal, and skin preparation (Ariyo et al., 2019).

    Comprehensive learning and simulation-based education can aid nurses in interactive, human-based learning, helping them anticipate risks associated with unsafe surgical procedures. This approach enhances the understanding of preoperative hygiene preparations, improving patient satisfaction and reducing postoperative risks and readmissions (Koukourikos et al., 2021). The Four E’s—engage, educate, execute, and evaluate—are effective strategies that organizations employ (Ariyo et al., 2019).

    High-performing organizations design learning modules to engage, educate, and evaluate employees, fostering effective communication, coordination, and positive interactions. Alignment Healthcare must implement similar strategies, focusing on preoperative protocols, hygiene, and simulation-based learning to improve outcomes. Addressing uncertainties in patient education, healthcare disparities, and regulatory compliance is crucial, necessitating an exploration of how high-performing organizations navigate these challenges.

    Organizational Functions, Processes, and Behaviors Support and Outcome Measures

    Outcome measures for Alignment Healthcare include the frequency of unsafe surgical procedures, postoperative complications, patient readmission, surgical site infections, and patient satisfaction. These measures enable the organization to assess care quality and professional competency (Hannawa et al., 2022). Strategic management involves timely evaluation and modification of strategies, aligning with organizational goals to improve care standards, workflow, and safety protocols.

    Positive outcomes, such as streamlined processes and improved inter-professional collaboration, enhance safety protocols and overall cultural performance. Conversely, poorly developed processes contribute to unsafe surgical procedures, higher readmission rates, increased resource allocation, and compromised safety and trust (Tiwary et al., 2019). Organizational and structural changes, including hygiene safety protocols, comprehensive learning modules, regulatory standards, and open communication, can balance positive and negative outcomes. Strong leadership plays a crucial role in controlling employee stress, reducing infection risks, and empowering staff for safe procedures (Irshad et al., 2021).

    Quality and safety outcomes, particularly unsafe surgical care procedures, were identified through gap analysis. Prevention strategies include alcohol-based antibiotics, antiseptics, and preoperative protocols to enhance preoperative strategies and minimize infection risks (Ling et al., 2019). Effective home management, patient education, and discharge planning contribute to reduced readmission rates, positively impacting overall patient satisfaction (Pugh et al., 2021).

    Performance Issues or Opportunities

    Performance issues related to unsafe surgical care procedures at Alignment Healthcare stem from professional competency, unskilled staff, lack of inter-professional collaboration, and ineffective transformational leadership. Poor sterilization practices, inadequate wound care, and communication issues contribute to surgical infections and postoperative complications. Opportunities for improvement lie in continuous learning and evaluation, benchmarking against high-performing organizations, enhancing communication, and implementing checklists to prevent errors (Balance et al., 2023).

    However, uncertainties regarding checklist implementation effectiveness, human factors, and patient characteristics necessitate careful attention. Addressing these issues and capitalizing on opportunities can have significant positive effects.

    Strategy Using PDSA

    The Plan-Do-Study-Act (PDSA) model is suitable for iterative planning, implementing, evaluating, and refining changes to enhance processes. Planning involves describing the issue and planning strategies to reduce postoperative complications and surgical site infections through infection control and preoperative management protocols (Ling et al., 2019).

    Implementation includes training sessions, protocol implementation, and data collection on outcome measures. Analysis of gathered data informs improvements, and adjustments are made based on continuous monitoring and evaluation. Training and education disseminate best practices, while feedback loops and collaborative projects encourage interaction and cooperation.


    This report addresses organizational functions, processes, behaviors, and outcome measures at Alignment Healthcare to ensure patient safety and quality improvement. Implementing strict infection control protocols and preoperative strategies, coupled with effective communication and transformational leadership, can elevate care standards and foster a culture of safety and quality.


    Andersen B. M. (2018). Prevention of postoperative wound infections. Prevention and Control of Infections in Hospitals: Practice and Theory, 377–437.

    Ariyo, P., Zayed, B., Riese, V., Anton, B., Latif, A., Kilpatrick, C., Allegranzi, B., & Berenholtz, S. (2019). Implementation strategies to reduce surgical site infections: A systematic review. Infection Control & Hospital Epidemiology, 40(3), 287–300.

    Buljac-Samardzic, M., Doekhie, K. D., & van Wijngaarden, J. D. (2020). Interventions to improve team effectiveness within health care: A systematic review of the past decade. Human Resources for Health, 18(1), 1-42.

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

    Balane, J. A. L., Yap, C. D. D., Villanueva, C. A. G., Palileo-Villanueva, L. A. M., & Tamondong-Lachica, D. R. (2023). Predictors of readmission in a medical department of a tertiary university hospital in the Philippines. BMC Health Services Research, 23(1), 1-8.

    Dharap, S. B., Barbaniya, P., & Navgale, S. (2022). Incidence and risk factors of postoperative complications in general surgery patients. Cureus, 14(11), e30975.

    Hannawa, A. F., Wu, A. W., Kolyada, A., Potemkina, A., & Donaldson, L. J. (2022). The aspects of healthcare quality that are important to health professionals and patients: A qualitative study. Patient Education and Counseling, 105(6), 1561-1570.

    Irshad, M., Majeed, M., & Khattak, S. A. (2021). The combined effect of safety specific transformational leadership and safety consciousness on psychological well-being of healthcare workers. Frontiers in Psychology, 12, 688463.

    Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward. BMC Nursing, 20(1), 1-10.

    Kalaja, R. (2023). Determinants of Patient Satisfaction with Health Care: A Literature Review. European Journal of Natural Sciences and Medicine, 6(1), 41-52.

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

    Ling, M. L., Apisarnthanarak, A., Abbas, A., Morikane, K., Lee, K. Y., Warrier, A., & Yamada, K. (2019). APSIC guidelines for the prevention of surgical site infections. Antimicrobial Resistance & Infection Control, 8(1), 1-8.

    Koukourikos, K., Tsaloglidou, A., Kourkouta, L., Papathanasiou, I. V., Iliadis, C., Fratzana, A., & Panagiotou, A. (2021). Simulation in clinical nursing education Acta Informatica Medica, 29(1), 15–20.

    Pugh, J., Penney, L. S., Noël, P. H., Neller, S., Mader, M., Finley, E. P., Lanham, H. J., & Leykum, L. (2021). Evidence based processes to prevent readmissions: More is better, a ten-site observational study. BMC Health Services Research, 21(1), 189.

    Tiwary, A., Rimal, A., Paudyal, B., Sigdel, K. R., & Basnyat, B. (2019). Poor communication by health care professionals may lead to life-threatening complications: examples from two case reports. Wellcome Open Research, 4, 7.

    Seidelman, J. L., Mantyh, C. R., & Anderson, D. J. (2023). Surgical site infection prevention: A review. JAMA, 329(3), 244–252.

    Addendum Table 1a: Summary of Medical Errors

    Medical ErrorsNumber of CasesMortality RatePatient InjuriesPostoperative Complications
    Surgical Site Infections283%14
    Patient Complaints170.3%7
    No. of Readmissions252%10

    Table 1b: Outcomes and Associated Measures

    Safety ConcernOutcome & MeasurePrevention Strategies
    Unsafe Surgical CareSurgical Site Infection RateAvoiding razors for preoperative hair removal, use of alcohol-based skin preparation agents, antiseptics, and preoperative glucose control (Seidelman, et al., 2023)
    Postoperative Complication RatePreoperative protocol optimization, management of blood loss, operation time and intraoperative complications, and infection protocol management (Dharap et al., 2022)
    Patient SatisfactionPatient Surveys, Expectations, and PerceptionsImproved satisfaction is achieved through patient surveys, managing patient expectations, and enhancing perceptions toward healthcare professionals (Kalaja, 2023)
    Readmission RatesHealthcare at HomePatient education, medical record consolidation, discharge preparation, and follow-up phone calls contribute to improved healthcare at home (Pugh, et al., 2021)