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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 considerable effort to uphold healthcare quality standards and enhance patient safety. Despite these efforts, challenges persist within healthcare practices, often stemming from adverse events in the healthcare system. One such challenge is hospital-acquired infections (HAIs), which compromise the quality of care and pose risks to patient safety. Recently identified in the Vila Health organization during a quality and safety assurance audit, HAIs prompted administrators to task nurse leaders with analyzing the gap between current and desired outcomes in terms of improving quality and safety.

    Systemic Problems Related to Quality and Safety Outcomes

    Hospital-acquired infections (HAIs) are infections occurring within healthcare settings, typically manifesting 48 hours after a patient’s admission (Monegro et al., 2023). Predominantly caused by inadequate care and healthcare provider malpractices, these infections affect approximately 8.7% of hospitalized patients, with urinary tract infections being particularly prevalent (World Health Organization [WHO], n.d.). HAIs lead to adverse consequences, 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). Addressing this issue is imperative to ensure quality healthcare, maintain patient safety, and improve health outcomes. Key assumptions guiding this endeavor include the necessity for collaborative approaches to healthcare organizational change 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, specifically addressing healthcare-associated infections, it is crucial to propose practice changes within healthcare organizations. The Targeted Assessment for Prevention (TAP) strategy, established by the Centers for Disease Control and Prevention (CDC, 2023), offers a three-step approach involving organizational targeting, needs assessment, and the implementation of prevention strategies. Priority transformations include: 1) proper utilization of personal protective equipment (PPE) to reduce occupational transmission risks (Alhumaid et al., 2021), 2) adherence to WHO’s hand hygiene guidelines by healthcare workers, including hand rubbing and glove usage (WHO, n.d.), 3) improvement of environmental hygiene through audits and quality assurance practices, and 4) training healthcare professionals to implement these changes through regular in-service sessions. This proposal assumes that infection control practices play a pivotal role in minimizing infection risks and improving healthcare outcomes.

    Prioritization of the Proposed Change Strategies

    While each proposed change strategy is vital, prioritizing hand hygiene practices and healthcare professional education is recommended. Effectively implementing these guidelines can significantly enhance infection control practices, preventing HAIs. Prioritizing hand hygiene is justified by hands being a primary source of germ transmission, and CDC asserts that proper hand hygiene inhibits the spread of antibiotic-resistant infections, emphasizing its crucial role in patient safety regarding HAIs.

    Quality and Safety Culture and its Evaluation

    The suggested change strategies contribute to improving care quality and fostering a safety culture through advancements in healthcare practices. Success hinges on encouraging interprofessional collaboration, communication, and cultivating a mindset of continuous improvement. Preventing nosocomial infections positively impacts care quality, reducing financial burdens, shortening hospital stays, minimizing complications, and enhancing patient satisfaction and safety. Evaluation metrics include continuous prevalence surveys, measuring patient satisfaction levels, and assessing staff knowledge to gauge the effectiveness of the proposed change strategies and the established quality and safety culture.

    Organizational Culture Affecting Quality and Safety Outcomes

    The culture and hierarchy of a healthcare organization significantly impact adverse outcomes in quality and safety. Inadequate communication lines impede the identification of adverse events like HAIs, negatively affecting quality and safety. Improved communication, sufficient staffing, and fostering a positive and accountable culture are crucial for effective infection control and improved patient safety. Teamwork and collaboration are deemed essential for implementing and managing change in healthcare settings.

    Justification of Necessary Changes in an Organization

    Organizational changes are essential to mitigate adverse quality and safety outcomes. Establishing an interprofessional committee, implementing a zero-tolerance policy for negligence, and ensuring adequate resources for infection control practices are crucial. The interprofessional committee, comprising nurse leaders, quality assurance personnel, and administrators, is tasked with monitoring practices, motivating staff adherence to standards, promoting patient-centered care, and identifying areas for improvement. The zero-tolerance policy holds healthcare workers accountable for inadequate infection control, and collaboration with internal and external stakeholders is essential for securing necessary resources.


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    NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

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