Quality and safety gap analysis in provision of safe, high-quality patient care

Quality and safety gap analysis in the provision of safe, high-quality patient care

Quality and Safety Gap Analysis

Healthcare providers continuously try to enhance patient safety and quality of care in their organizations. Furthermore, for these healthcare institutions to improve patient results, employees should place an incentive on safety and quality. This assessment evaluates the gap between existing and expected performance capability for inpatient fall safety. In addition, the evaluation has recognized inpatient fall safety as an organizational challenge at my facility. Also, the paper suggests particular practice modifications to enhance fall safety and quality patient results. The corporate operations, behaviors, and procedures will be elucidated.

Organizational Issue Linked to Negative Safety and Quality Results

A report by my organization’s quality and safety department discerned that patient safety and fall hindrances strategies and processes are unsuccessful, aggregating 5.1 falls per 1000 patient days. This is viewed as way above the national average, meaning the healthcare facility must strive to close this gap by adopting specific strategies. Notably, the falls are common among senior citizens. CDC (2020) asserts that falls among these group is expensive, and every year, $50 is used on medical expenses linked to non-fatal injuries, while $754 is utilized on fatal falls. Furthermore, the long-term effects of these falls on patients comprise disability, leading patients to lose work and rely on family, caregivers, and friends for mobility. This can cause a decrease in the person’s quality of life (Florence et al., 2018) Quality and safety gap analysis in provision of safe, high-quality patient care.

Moreover, several consequences exist when a healthcare organization does not tackle these falls. Some experts claim that some of these repercussions are instant and comprise pain that may be psychological or physical (Montejano-Lozoya et al., 2020). Also, increased hospital stays and loss of trust in the community in safe healthcare delivery are some of the long-term outcomes of inpatient falls. The multidisciplinary group culpable for the negative occurrence at the facility may also suffer from reduced quality of life and mental health issues like depression and anxiety. Healthcare providers may also face legal challenges, loss of confidence, and social segregation. Like the patients and healthcare providers, the healthcare institution also suffers specific repercussions because of this gap. These consequences include decreased staff morale, leading to employee turnover. Notably, patient falls have been recognized by the Centers for Medicare and Medicaid Services (CMS) as among the eight
never occurrences
for healthcare organizations (King et al., 2016). These never occurrences are high-volume and cost occurrences that evidence-based directions can avert.

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Bridging the Gap Between Existing and Projected Outcomes

Many falls and linked injuries emanate from healthcare systems procedures and frameworks (Jones et al., 2019). The recognized safety performance disparity is inpatient care dispatch. The capability of my organization to sustain and maintain policies and results in 2020 was disrupted by the coronavirus, which led to an increased nursing shortage. Further, there is a link between patient falls and nursing staffing. A healthcare facility with a nursing shortage will likely see a rise in patient falls because most nurses are tired from working long hours, causing burnout. Moreover, burnout can impair the employees’ capability to offer quality and safe care. Systemic quality prevention was not emphasized during the pandemic, even though it subjected employees to increased workloads. Presumptions can be established that healthcare professionals want to offer patients excellent care and an improved work-life balance. These professionals wish for safe and enhanced care, meaning they do not want increased patient falls in their organizations.

Moreover, the suggested transformations will reduce the gap between existing and projected performance levels and enhance safety and quality outcomes. The preventions are aligned with the facility’s strategic plan and are emphasized based on their effect on patient safety, care quality, and facility outcomes. Also, adopting a multidisciplinary perspective to safety and quality endeavors is more successful than a nurse-centred framework. Further, bundling procedures may decrease the threat of falls. Notably, because of the nursing shortage, the initial practice modification is to apply extra client care positions to enhance the facility’s general safety culture and quality of care.

Prioritization of Projected Changes

The facility I work for prioritizes patient safety, as denoted in its mission statement. EBP, team-structured settings, and patient-centred care must be emphasized when organizing practice modifications within an institution.

Video monitoring is one program that can minimize falls and enhance patient safety (Chu, 2017). Effective prevention metrics linked to this monitoring include redirecting patients, observing their conduct, and apprising the nurse utilizing the overhead paging system. This program should also include technicians offering a web of care and monitoring, relieving nursing staff from technological-related stress. Further, creating an interprofessional fall education program for patients, families, and healthcare providers is another scheme to be emphasized. Education will help these stakeholders to understand how to prevent and minimize these falls. A committee to conduct weekly checks on existing falls will be created.

Fostering a Safety and Quality Culture

The proposed transformations will promote a safety and quality culture. Positive institutional cultures are continuously linked with enhanced client results, high quality of work-life balance, reduced patient falls, and raised patient satisfaction. By using the Leapfrog hospital safety grades that assess facilities on risk-adjusted readmissions and deaths will be discerned. Further, the satisfaction of patients can be gathered via the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Nonetheless, the existing culture in my facility shows that less than 35% of employees would recommend employment, while less than 30% trust the facility management.

Impact and Contributions of Institutions on Shaping Safety and Quality Results

An institution’s culture involves shared values, behavioral patterns, and beliefs that guarantee organizations offer composite and high-quality care. All hospital stakeholders, from the hospital executives to healthcare providers must mirror the firm’s primary needs. Positive results happen when top leadership galvanizes performance that is patient-focused and positioned with healthcare providers’ priorities. On the contrary, healthcare providers’ viewpoint is focused on finances. Moreover, meeting client needs positions with the facility’s ability to offer quality and safe care Quality and safety gap analysis in provision of safe, high-quality patient care.

Justifications for Institutional Roles, Procedures, and Conduct Change

The existing fall rate for my facility is 5.1 falls per 1000 PDs, which is higher than the average. Further, patient quality and safety are inevitably related to interprofessional interventions, staffing levels, company culture, and work-life balance. Executing these transformations will help improve the ever-changing cycle of my institution’s patient safety crusade and culture. Further, video surveillance will assist in averting falls by offering another program for nurses and an extra web of monitoring offered by technicians. Also, by instituting an interprofessional fall aversion scheme, the organization can enhance the work-life balance and fall rates while raising job satisfaction and guaranteeing increased dependability. In addition, the organization’s top executives must position its culture with client projections to be effective Quality and safety gap analysis in provision of safe, high-quality patient care.

In summation, healthcare organizations must adopt programs that enhance quality and safety. Any gaps that may lead to a reduction in patient outcomes and safety quality must be addressed via evidence-based initiatives. Patient falls are common in hospital settings, and healthcare organizations must strive to develop initiatives that minimize these gaps. The facility must involve every stakeholder for optimal results.

References

CDC. (2020, July 9).
Cost of older Adult Falls
. Centers for Disease Control and Prevention. Retrieved May 4, 2023, from https://www.cdc.gov/falls/data/fall-cost.html

Chu, R. Z. (2017). Preventing inpatient falls.
Nursing
,
47
(3), 24–30. https://doi.org/10.1097/01.nurse.0000512872.83762.69

Florence, C. S., Bergen, G., Atherly, A., Burns, E., Stevens, J., & Drake, C. (2018). Medical costs of fatal and nonfatal falls in older adults.
Journal of the American Geriatrics Society
,
66
(4), 693–698.
https://doi.org/10.1111/jgs.15304

Jones, K. J., Skinner, A., Venema, D., Crowe, J., High, R., Kennel, V., Allen, J., & Reiter‐Palmon, R. (2019). Evaluating the use of multiteam systems to manage the complexity of inpatient falls in rural hospitals.
Health Services Research
,
54
(5), 994–1006. https://doi.org/10.1111/1475-6773.13186

King, B., Pecanac, K., Krupp, A., Liebzeit, D., & Mahoney, J. (2016). Impact of fall prevention on nurses and care of fall risk patients.
The Gerontologist
. https://doi.org/10.1093/geront/gnw156

Montejano-Lozoya, R., Miguel-Montoya, I., Gea-Caballero, V., Mármol-López, M. I., Ruíz-Hontangas, A., & Ortí-Lucas, R. (2020). Impact of nurses’ intervention in the prevention of falls in hospitalized patients.
International Journal of Environmental Research and Public Health
,
17
(17), 6048. https://doi.org/10.3390/ijerph17176048 Quality and safety gap analysis in provision of safe, high-quality patient care

 

Quality and safety gap analysis in provision of safe, high-quality patient care

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.

Introduction

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.

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.

Quality and safety gap analysis in provision of safe, high-quality patient care

Quality and safety are everyone’s responsibility as a team of interprofessional care delivery partners. Together we develop policies that support quality and safe care delivery. As part of the interprofessional team, nurses are leaders in care and thus are responsible and accountable for leading and providing safe quality care.

Health care delivery is structured around evidenced-based information. Quality is defined by exploring proven, evidenced-based information. After reviewing and defining evidenced-based information, the interprofessional team applies this knowledge to assess the organization’s or the practice setting’s ability to provide evidenced-based care delivery. When a gap in care is identified, it is important to propose an evidenced-based change and to execute a plan for improved care.

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: As you revise your writing, check out the resources listed on the Writing Center’s Writing Support page.

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.

What does your organization measure, related to quality and safety, and why?

Are there certain aspects of your organization’s culture and processes that support or hinder quality and safety?

Is the organization meeting outcome measurement benchmarks?

If not, how might you address those gaps in performance? What system could be developed to support a change to close a particular gap?

The following resources are required to complete the assessment.

APA Style Quality and safety gap analysis in provision of safe, high-quality patient care Paper Tutorial [DOCX]. Use this for your gap analysis.

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 [DOCX] 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 Style Paper Tutorial [DOCX]. 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.

Portfolio Prompt: You may choose to save your gap analysis to your ePortfolio.

Competencies Measured

By successfully completing this Quality and safety gap analysis in provision of safe, high-quality patient careassessment, 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 Quality and safety gap analysis in provision of safe, high-quality patient care