Your quality and safety gap analysis will provide the basis for the remaining assessments in this course.
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.
As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
Culture and process contribute to our ability to develop and sustain quality and safety in a health care organization. By exploring these topics, you can analyze where you may have gaps in practice that affect outcomes. In addition, organizations must create benchmarks for outcomes to determine whether they are meeting quality and safety goals.RUBRIC
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.
NURS_FPX6212_WoodsAlexandra_Assessment_1_1.docx.pdf
MSN_FP_6212_Assessment_1_Attempt_2.docx.pdf
cf_u01a1_guiding_questions.docx
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Quality and Safety Gap Analysis
Alexandra Woods
Capella University
Health Care Quality and Safety Management
February 2023
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Quality and Safety Gap Analysis
Every team member on an interprofessional healthcare team is responsible for the quality
and safety of the care we provide to the patient. The care we provide is formulated from
evidence-based best practices and is constantly being updated as we learn more. This is what
makes it high-quality care. However, gaps in care can lead to poor quality and safety outcomes
for our patients, so continuous monitoring for gaps is essential.
Identification of a Systematic Problem
Hospital-acquired infections are infections that are contracted during a patient’s time in a
hospital-setting. While there are numerous types of hospital-acquired infections, one of the most
dangerous and most costly is a central line-associated bloodstream infection (CLABSI). This is
an infection of the blood stream that occurs after insertion or access of a central line during the
hospital stay (Agency for Healthcare Research and Quality, 2017). Once an infection reaches the
bloodstream, the infection can spread throughout the rest of the body, leading to high mortality
rates. CLABSIs are completely preventable by following evidence-based practices during
insertion and while maintaining the central line during the hospital stay. While this type of
infection should never take place, our organization still sees higher rates of CLABSI than
expected on a yearly basis. This systemic problem is related to adverse quality and safety
outcomes, including significant personal cost to the patient and to the hospital. The patient has
adverse outcomes in that now they are requiring additional testing, procedures, antibiotics, a
prolonged hospital stay, end up with a larger hospital bill, and in some instances end up dying
(Haynes, et al., 2022). The hospital has adverse outcomes in that the Center for Medicare and
Medicaid services no longer reimburses for many hospital-acquired infections, and a CLABSI
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incurs an additional cost of approximately $48,000 per event (Agency for Healthcare Research
and Quality, 2017). Not only this, but the hospital damages its reputation for high-quality care
with each hospital-acquired infection that occurs. This analysis assumes that CLABSIs are solely
based on deviation in care. One knowledge gap is whether an analysis has been completed on the
manufacturers of central line kits to determine if there is a deviation in sterility practices when
making the product.
Proposed Practice Changes and Prioritization
Within our organization, there are multiple practice changes that can be implemented to
reduce our rates of CLABSIs. The first and most important practice change is to implement a
CLABSI prevention “bundle” order set. This practice change is the number one priority because
it will have the largest direct effect on the safety of our patients. The bundle will include
elements from well-established scientific data and are considered the standard of care in caring
for a central line. The key elements will include standardized protocols for insertion of central
lines and maintenance of central lines that will be imbedded within the patient’s chart. These
standardized protocols will be ordered in the EMR for each patient that has a central line so that
all care for central lines is being carried out identically through our organization. This
standardization will decrease the likelihood of deviation from evidence-based best practice and
in turn, decrease the chances of a central line infection. Our current practice includes following a
protocol that is located within the hospital’s intranet and not readily available within the EMR.
This unavailability causes some team members to skip reviewing the protocol and providing care
based on memory, since it becomes too time consuming to find the protocol. We want team
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members to be able to quickly and easily retrieve the policy at the bedside as they are about to
provide central line care so they can follow the evidence-based practice of best care.
The second priority practice change within our organization is to implement an audit tool
for the insertion and care of central lines. Our current practice for insertion of central lines
includes completing a “time out” prior to insertion to ensure we have the right patient, right
procedure, etc. However, there is nothing beyond that to ensure that the line was placed
according to our protocol. Central line insertion is meant to be a sterile procedure in order to
prevent an infection. All care thereafter is meant to be sterile as well. Central line dressings must
be changed every seven days and the dressing change must be a sterile practice. The practice
change that will improve the quality and safety outcomes of for central lines will be to
implement an audit tool that is meant to be filled out by a second team member during all
insertions and dressing changes to ensure that sterile technique was used per our protocol. This
practice change will ensure that a second set of eyes was present during the completion of sterile
technique and can be a second set of hands if needed to help avoid deviating from standard
technique. This priority is the second priority because it is a secondary way of ensuring staff is
practicing standard of care for central lines to decrease the chances of CLABSI in addition to the
first priority of ensuring all team members have easy access to the standard of care protocols.
The third priority practice change for this organization will be to implement a CLABSI
Committee. We do not currently have a committee that solely focuses on the reduction of
CLABSI events. Having this committee will bridge the gap in quality and safety outcomes
because this diverse group of team members will monitor for compliance with the new practice
changes and make changes as needed to the practices as new evidence emerges in best care of
central lines. This practice change takes third priority since the other two previously stated
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changes directly affect the safety of the patient, while this change mostly effects the culture of
our organization.
Fostering a Culture of Quality and Safety
These proposed practice changes will foster a culture of quality and safety within our
organization by giving team members evidence-based standards on which to practice the best
care they can for our patients. This should instill a sense of pride amongst our team members and
drive them to always want to be better. And leadership amongst are organization are typically
utilizing a transformational leadership style. This type of leadership has a strong focus on
motivating and engaging staff, and providing an environment that empowers them to become
effective and creative team members (Alban-Metcalfe, 2018). Practicing mindfulness in how we
care for central lines and striving for perfection in this effort will help build a culture in which
small, point-of-care improvements and attention to details are celebrated by leadership (Blouin,
2013). After the proposed practice changes are implemented and have become imbedded in the
everyday practices of our team members, we would like to do an appreciate inquiry to evaluate
how these changes have affected our organization’s culture.
Effects of Culture on Quality and Safety
Healthcare cultures and hierarchies are often damaging to quality and safety outcomes.
Too often in many sectors of the working world, we see a culture amongst workers of wanting to
do the bare minimum for the most pay possible. This is catastrophic within the healthcare sector.
This type of culture can lead to poor patient outcomes since healthcare workers are often not
motivated to care for patients the way they deserve. When healthcare workers are not interested
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in following best practices when providing care to our patients, more hospital-acquired infections
and adverse events are bound to occur. And healthcare hierarchies are also a common challenge.
We too often see physicians who feel they know what is best when practicing care based on their
personal training and experience instead of on what the organization has deemed best practice. In
terms of CLABSIs, this could lead to increased rate since physicians insert central lines
regularly. If they are not following evidence-based protocols because they feel their technique is
superior, bacteria and other contaminants can be introduced to the blood stream during that
process and the patient will ultimately pay the price for the physician’s mistakes.
Necessary Organizational Changes
A necessary change to our organization will already be implemented within the
previously mentioned proposed changes will be to create a CLABSI committee. In taking this
further, we could mitigate adverse quality and safety outcomes related to hierarchy concerns by
selecting a diverse group of a team members from different realms of the organization to be on
the committee. This will allow for all aspects of our healthcare organization, from physicians to
nurses to the clinical documentation team, to have input on standardization of central line care
and will eliminate this hierarchy challenge since everyone will have an equal voice on the
committee. And as previously mentioned, continuing to utilize a transformational leadership
style throughout our organization will help mitigate any unmotivated behaviors of team members
in caring for our patients properly to help avoid adverse quality and safety outcomes.
Conclusion
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This quality and safety gap analysis revealed that our organization has opportunities for
improvement as it relates to central line-acquired blood stream infections. A few simple but
effective changes to our current practices could help in decreasing our CLABSI rates, ensuring
an improvement in quality and safety outcomes for our patients. In doing so, we can also
positively affect our organizations culture in caring for our patients, as a team, the best we can.
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References
Alban-Metcalfe, J., & Alimo-Metcalfe, B. (2018). Engaging Leadership – a better approach to
leading a team?. Nursing Times, 114, 21. http://library.capella.edu/login?qurl=https%3A %2F%2Fwww.proquest.com%2Fmagazines%2Fengaging-leadership-better-approach- leading-team%2Fdocview%2F2091249373%2Fse-2%3Faccountid%3D27965
Agency for Healthcare Research and Quality. (2017). Estimating the Additional Hospital
Inpatient Cost and Mortality Associated with Selected Hospital-Acquired Conditions.
AHRQ. https://www.ahrq.gov/hai/pfp/haccost2017.html
Blouin, A. S. (2013). High Reliability: Truly Achieving Healthcare Quality and Safety. Frontiers
of Health Services Management, 29(3), 35-40. http://library.capella.edu/login?qurl=https
%3A%2F%2Fwww.proquest.com%2Fscholarly-journals%2Fhigh-reliability-truly-
achievinghealthcare%2Fdocview%2F1352763812%2Fse-2%3Faccountid%3D27965
Haynes, M., Mosley, E., Stauffer, K. (2022). CAUTI/CLABSI Reduction. BayCare.
https://baycare1.sharepoint.com/sites/PS/SiteAssets/Forms/AllItems.aspx?id=%2Fsites%
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Running Head: SAFETY GAP ANALYSIS ON PATIENT INJURIES 1
Safety Gap Analysis on Patient Injuries
Irene Zepeda
Capella University
MSN-FP 6212 Healthcare Quality and Safety Management
Quality and Safety Gap Analysis
September 2019
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SAFETY GAP ANALYSIS ON PATIENT INJURIES 2
Safety Gap Analysis on Patient Injuries
Systematic Problem related to Adverse Quality and Safety Outcomes
Healthcare professionals who suffer from burnout syndrome provide poor quality and
unsafe care to patients some that have resulted in failure to rescue and death. “It has been noted
that 70% of physicians and 30-50% of nurses worldwide experience professional burnout during
their working life” (Anagnostopoulos, Bogiatzaki, Frengidou, 2019). Burnout syndrome is a
feeling of fatigue, physical and emotional exhaustion, low levels of empathy, and dissatisfaction
in the workplace due to poor working environment (Anagnostopoulos, Bogiatzaki, Frengidou, et
al, 2018). Burnout is a result of understaffing, nurse shortage, and unrealistic workloads (Aiken,
Clarke, Sloane, 2002). Burnout is also a result of poor working environments that include
insufficient time to complete tasks, role conflict, poor collaboration amongst healthcare
professionals (Fitzpatrick, Bloore & Blake, 2019). “The Agency for Healthcare Research and
Quality estimate that burnout affects 10-70% of nurses, 30-50% of physicians, nurse
practitioners and physician assistants” (Bridgeman, Bridgeman, & Barone, 2018).
One study was conducted to obtain research on hospital staffing and patient outcomes
after analyzing data from 210 adult general hospitals in Pennsylvania (Aiken, Clarke, Sloane, et
al., 2002). The study concluded of the 232342 patient studied 53813 experienced a major
complication not present on admission and 4535 died within 30 days of admission (Aiken,
Clarke, Sloane, et al., 2002). “The study surveyed employees finding higher emotional
exhaustion and greater job dissatisfaction in nurses were strongly associated with patient-to-
nurse rations” (Aiken, Clarke, Sloane, et al., 2002). Hospitals are required to have adequate
staffing to provide safe and effective care to the patients they serve. Burnout syndrome increases
staff absenteeism and requires for other nurses to work additional shifts causing fatigue, feeling
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SAFETY GAP ANALYSIS ON PATIENT INJURIES 3
of being overwhelmed, anxiety, depression, and the possibility of making medication errors,
failing to assess patients properly, and even failing to rescue.
Burnout may also be caused by other factors, little is known about the number of jobs
healthcare professionals hold and how many hours they work per week. Little is known about the
relationship between patient experience, quality of care, and poor working environments
(Montgomery, Panagopoulou, et al., 2013). No research results yielded for how many jobs
healthcare professionals hold and how many hours they work at each organization per week.
More research is needed to evaluate the relationship between empathy and burnout as well as
burnout amongst non-physician and non-nursing healthcare professionals (Montgomery,
Panagopoulou, et al., 2013).
Bridging Gap between current and desired Performance
A proposed practice change within organizations across the United States to improve
quality and safety outcomes for patient is to adopt California’s current legislative mandate of a
minimum hospital patient-to-nurse ratio of five to one. This has significantly improved patient
outcomes, quality care, patient safety and patient satisfaction within that respected state. This
results in reduced burnout among nursing staff and improving working environment conditions.
(Aiken, Clarke, Sloane, & 2002).
Another proposed practice change includes enforcing the Maslach Burnout Inventory
annually to evaluate staff’s feeling of burnout. This would allow management to make necessary
accommodations to the staffing or offer support to improve or reduce the feeling of being burned
out. The Maslach Burnout Inventory evaluates risk factors for the development of burnout such
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SAFETY GAP ANALYSIS ON PATIENT INJURIES 4
as workload, lack of control in the workplace, rewards, community, fairness, values and job-
person incongruity (Bridgeman, Bridgeman, & Joseph, 2018).
Another proposed practice change includes clinical ladder programs and professional
development programs. “Clinical ladder programs promote education, experience,
professionalism, leadership, teaching, and advocacy, frequently with the potential for monetary
compensation” (Fitzpatrick, Bloore, & Blake, 2019). Professional development programs for
staff include offering additional certification to enhance learning and personal accomplishment
and provide educational assistance for future healthcare professionals and for current employees
who want to pursue an advanced degree in healthcare.
Promoting a healthy working environment can improve employee morale with an end
result of safer and quality care provided to the patients they serve. Nurses in the organization can
be encouraged to participate in shared governance, to advocate for their professional (Fitzpatrick,
Bloore, & Blake, 2019).
Practice Changes
In order in importance first, is to pass legislative policy to mandate all hospitals with
medical-surgical units to not exceed a nurse-to-patient ratio of five to one. Limiting nurse to
patient ratio to five to one allows nurses to assess their patient more frequently, provide safer
medical care, and improve patient satisfaction and patient outcomes.
Second, promote staff to participate in shared governance, this will allow current
employees to have their voices heard and assist in making legislative changes that meet their
needs. Employees who actively participate in decision-making policies feel empowered and
valued and are more likely to be committed to the organization but also reduce burnout and
provide better care to their patients.
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SAFETY GAP ANALYSIS ON PATIENT INJURIES 5
Third, to promote healthcare education assistance to individuals who desire a degree in
healthcare. This would alleviate the burden on students who are interested in obtaining higher
education but do not have the means to attend. This will result in an increase in people seeking
employment opportunities and an increase in staff to reduce inadequate staffing problems.
Third, promoting advanced education within the organization. Clinical ladder
advancement programs allow management to see which employees are seeking to gain new
knowledge and commit to their organization. This will reduce employee turnover and improve
job satisfaction.
Introduce an annual evaluation of employee feelings of burnout by administering the
Maslach Burnout Inventory. By conducting this annually would bring insight to management and
Directors knowledge on how employees view their workload, feelings of being in control,
reward system, community, fairness, values and job-person incongruity (Bridgeman, Bridgeman,
& Barone, 2018).
Fostering Culture of Quality and Safety
Proposed practice changes will foster a culture of quality and safety by
improving patient safety, satisfaction and outcomes by reducing the number of patients one nurse
is assigned during their shift. Promote educational assistance by offering scholarships to
graduating students who seek a healthcare profession who meet grade point average criteria, as
well as offer employees tuition assistance if they seek to advance their education and career
within the organization.
Criteria to evaluate patient outcomes include having patients fill out a patient satisfaction survey
after being discharged from the hospital, as well as having nurses complete a job satisfaction
survey every six months to assess their views on their job. Organizations can evaluate this by
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SAFETY GAP ANALYSIS ON PATIENT INJURIES 6
assessing their staffing needs every quarter and view how many new hires took advantage of
their tuition assistance programs.
Currently organizations with patient ratios that are high than five-to-one will be impacted
either by the burden of nursing shortages or cost of care provided. If organization have a seven-
to-one nurse-to-patient ratio with four nurses working in a medical surgical unit will now have to
have six nurses on the floor per shift. Organizational administrators or executives will have to
take into consider the burden of outweighing costs of staffing over the
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