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NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

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 worldwide strive effortlessly to maintain the quality of healthcare according to the standards and improve patient safety within the organization. However, there are still various challenges that may arise during the healthcare practices. These challenges occur due to several adverse events taking place within the healthcare system. Hospital-acquired infections are such adverse events that impair the quality of care and impose negative impacts on patients’ safety. Hospital-acquired infections are recently found in Vila Health organization as well during the quality and safety assurance audit. Since the problem has evolved, administrators have called upon all nurse leaders to analyze the gap which is established between current and desired outcomes in terms of improving quality and safety. 

Systemic Problems Related to Quality and Safety Outcomes 

Hospital-acquired infections (HAI), as the name suggests, are infections encountered within healthcare settings. A study claims that these infections develop 48 hours later a patient is admitted to the hospital (Monegro et al., 2023). These infections are most commonly caused by inadequate care and malpractices by healthcare providers. According to the World Health Organization (WHO), 8.7% of patients admitted to hospitals encounter different types of HAIs, whereby, urinary tract infections are very common.

HAIs result in poor consequences for the patients in terms of increasing their length of stay at the hospital, enhancing the risks of developing morbidities, adding financial burden to the hospital as well as the patients, and in serious cases, may lead to long-term complications and death (Stewart et al., 2021). These poor outcomes emphasize the need for addressing this problem within healthcare settings to ensure quality healthcare is provided by maintaining patient safety and improving health outcomes. Certain underlying assumptions that must be taken into consideration for addressing the problem are that change in healthcare organizations requires a collaborative approach whereby communication among stakeholders is essential. Moreover, it is assumed that healthcare providers should develop insight to bring successful changes in their practices. 

Practice Changes to Improve the Quality and Safety Outcomes 

To improve patient outcomes, quality, and safety, specifically addressing healthcare-associated infections, it is significant to propose practice changes within healthcare organizations. The strategy that should be used within healthcare organizations is TAP, which stands for Targeted Assessment for Prevention (TAP). This is established by the Centers for Disease Control and Prevention to improve quality in terms of HAIs. The strategy constitutes of three steps targeting the organizations, assessing the needs, and bringing prevention strategies (CDC, 2023). Several transformations which should be implemented in the organization on a priority basis to minimize the risks of HAIs are 1) proper utilization of personal protective equipment (PPE) which reduces the occupational risks of transmission of infections.

Occupational risks mean infections that travel from the patients to the healthcare providers and vice versa (Alhumaid et al., 2021), 2) hands of healthcare workers are considered the foremost source of transmission of infections. Following the WHO’s established guidelines for hand hygiene which are; a) adequate hand rubbing in case of no visible contamination with alcohol-based hand rubs, b) following five moments of hand washing and c) and use of hand gloves while handling patients and their surroundings (WHO, n.d.), 3) it is claimed that contaminated surroundings and surfaces within hospitals are major sources of transmission of infections. Therefore, improving environmental hygiene is necessary to minimize the risks of HAIs in the patient population.

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Environmental audits and quality assurance practices should be incorporated to ensure environmental hygiene within the organizations, and 4) training and educating healthcare professionals to integrate these changes within their practices is essential for continuous improvements. Weekly in-service training sessions for nurses, doctors, and nursing assistants will be beneficial to encourage staff to implement the practice changes, reduce healthcare-associated infections, and improve the quality of care and safety of patients. 

This proposal is based on the assumption that infection control practices within a healthcare organization play a critical role in minimizing the risks of infections for patients. These practices are generally associated with improved hygiene, enhanced healthcare safety, and positive patient outcomes. 

Prioritization of the Proposed Change Strategies 

Although every proposed change strategy is essential for reducing the risk of HAIs, the hand hygiene practice and education of healthcare professionals should be prioritized. By effectively utilizing these guidelines, the organization can radically improve infection control practices and prevent hospital-acquired infections. The rationale behind prioritizing hand hygiene practices is that hands are considered to be the source of germ transmission. Moreover, CDC claims that proper utilization of hand hygiene techniques inhibits the transmission of antibiotic-resistant infections. Hence, prioritizing hand hygiene and constantly encouraging healthcare workers to practice the guidelines is vital for patients’ safety in terms of HAIs. 

Quality and Safety Culture and its Evaluation 

 The suggested change strategies help in improving the quality of care and developing a safety culture for the patients by progressing healthcare practices. These improvements will be successful if inter-professional collaboration and communication are encouraged and a mindset of continuous improvement is developed. Preventing nosocomial infections improves the quality of care, reduces financial burden, decreases the length of stay, minimizes the chances of complications, and ultimately enhances patient satisfaction level and safety. It is significant to evaluate these quality and safety improvements. The evaluation metrics include:

  1. A continuous prevalence survey is important to analyze the data and identify the number of cases within the organization which will help in assessing the effectiveness of the strategies and bring further modifications, if necessary (Sun et al., 2021). 
  2. Measuring patient satisfaction levels to ensure the purpose of the change strategies is achieved, which is patient-centered and safe care. Patients who are satisfied with the care always report improvement in quality of life and this feedback helps organizations to further improve their practices (Baumbach et al., 2023). 
  3. Assessing staff knowledge and understanding of the prevention of HAIs will help in keeping the change strategies sustainable for a longer period. Overall, these evaluation metrics will help an organization to access the effectiveness of the proposed change strategies and evaluate the improved quality and safety culture that is established within the healthcare organization.

Organizational Culture Affecting Quality and Safety Outcomes 

Adverse outcomes on quality and safety within a healthcare organization can be impacted by the organization’s culture and hierarchy. Lack of communication lines can impair the process of identification of these adverse events (HAIs) thus affecting the quality. Improved communication among inter-professional teams, nurses, nurse leaders, and physicians can assist healthcare professionals in showing adherence to quality practices (Bearman et al., 2019). Another important aspect is limited staffing. The inadequate staff-to-patient ratio is considered one of the factors which increases the risks of healthcare-associated infections as the workload imposes various challenges to performing effective infection control (Mitchell et al., 2018).

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Finally, a lack of accountability and blaming culture reduces the ability of the organization to identify the risk factors and also promotes healthcare workers to remain unaccountable for their actions thus, reducing the quality of care and hindering patients’ safety (Wolvaardt, 2019). The assumption on which this analysis is based is that a motivating and positive culture within any organization helps the employees to work for the betterment of the company as well as together the goals and vision of the organization are fulfilled. Particularly for healthcare stings, teamwork, and a collaborative environment is essential for the implementation and management of change.  

Justification of Necessary Changes in an Organization

Some organizational changes are required to mitigate the adverse quality and safety outcomes. These changes include the development of an inter-professional committee specifically responsible for promoting proposed change strategies within the organization. This team includes nurse leaders, quality assurance personnel, and administrators. The purpose of the committee is to constantly monitor the practices, motivate staff to perform according to the standards, promote collaboration for patient-centered care, and identify the loopholes to improvise the processes.

Another change is to establish a zero-tolerance policy for negligence and malpractices of infection control. This policy is necessary to make healthcare workers liable for their actions in case of inadequate performance of infection control practices (Mello et al., 2020). Lastly, in terms of resources, organizations should generate adequate finances to provide sufficient PPE, hand hygiene, and environmental cleaning supplies to the healthcare unit and workers so that successful implementation is performed. For this purpose, collaboration with various internal and external stakeholders is significant.


Alhumaid, S., Al Mutair, A., Al Alawi, Z., Alsuliman, M., Ahmed, G. Y., Rabaan, A. A., Al-Tawfiq, J. A., & Al-Omari, A. (2021). Knowledge of infection prevention and control among healthcare workers and Factors Influencing Compliance: A systematic review. Antimicrobial Resistance & Infection Control10(1). https://doi.org/10.1186/s13756-021-00957-0 

Baumbach, L., Frese, M., Härter, M., König, H.-H., & Hajek, A. (2023). Patients satisfied with care report better quality of life and self-rated health—cross-sectional findings based on hospital quality data. Healthcare11(5), 775. https://doi.org/10.3390/healthcare11050775 

Bearman, G., Doll, M., Cooper, K., & Stevens, M. P. (2019). Hospital infection prevention: How much can we prevent and how hard should we try? Current Infectious Disease Reports21(1). https://doi.org/10.1007/s11908-019-0660-2 

Centers for Disease Control and Prevention. (2023, April 3). The Targeted Assessment for Prevention (TAP) strategy. Centers for Disease Control and Prevention. https://www.cdc.gov/hai/prevent/tap.html 

Mello, M. M., Frakes, M. D., Blumenkranz, E., & Studdert, D. M. (2020). Malpractice liability and health care quality. JAMA323(4), 352. https://doi.org/10.1001/jama.2019.21411 

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Mitchell, B. G., Gardner, A., Stone, P. W., Hall, L., & Pogorzelska-Maziarz, M. (2018). Hospital staffing and healthcare–associated infections: A systematic review of the literature. The Joint Commission Journal on Quality and Patient Safety44(10), 613–622. https://doi.org/10.1016/j.jcjq.2018.02.002 

Monegro, A. F., Muppidi, V., & Regunath, H. (2023). Hospital-acquired infections. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK441857/ 

Stewart, S., Robertson, C., Pan, J., Kennedy, S., Haahr, L., Manoukian, S., Mason, H., Kavanagh, K., Graves, N., Dancer, S. J., Cook, B., & Reilly, J. (2021). Impact of healthcare-associated infection on length of stay. Journal of Hospital Infection114, 23–31. https://doi.org/10.1016/j.jhin.2021.02.026 

Sun, J., Qin, W., Jia, L., Sun, Z., Xu, H., Hui, Y., Gu, A., & Li, W. (2021). Analysis of continuous prevalence survey of healthcare-associated infections based on the real-time monitoring system in 2018 in Shandong in China. BioMed Research International2021, 1–7. https://doi.org/10.1155/2021/6693889 

Wolvaardt, E. (2019). Blame does not keep patients safe. Community Eye Health, 32(106), 36. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802475/

World Health Organization, (n.d.). Hand hygiene: Why, how & when? https://www.afro.who.int/sites/default/files/pdf/Health%20topics/Hand_Hygiene_Why_How_and_When_Brochure.pdf