NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities
Phillip October 4, 2023 No Comments

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

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 unsafe surgical procedure has had a system-wide impact on the quality of care provided at Alignment Healthcare, leading to adverse outcomes with an under-skilled team, insufficient training, lax surgical and maintenance protocols, and improper sterilization issues. These surgical hazards can potentially harm the patient, affecting the quality and functionality of their life, increasing the organization’s finances, re-operative procedures and readmissions, and increasing hospital-acquired infections due to more extended stays (Balance et al., 2023). These issues are one of the leading causes of bad organizational reputation, lack of trust within the healthcare system, increased medical errors, patient complications, and increased costs. The current assessment is based on analyzing and developing a comprehensive report on the outcomes, measures, issues, and opportunities within Alignment Healthcare for the executive leadership. 

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

In high-performing organizations, strategic planning and effective care plan implementation are crucial to providing quality care because they use errors to improve their practice and reduce medical errors (Buljac-Samardzic et al., 2020). This ability to forecast, strategically plan their moves and implement patient-centered care effectively helps them outperform others. Alignment Healthcare requires a multi-leveled organizational change to manage safety issues such as unsafe surgical procedures, postoperative complications, patient readmission, surgical site infections, and patient satisfaction. Strategic management of unsafe surgical procedures includes developing organizational protocols for hygiene maintenance and managing surgical site infections by meticulously using operative techniques, timely administration, and appropriate preoperative arrangements like antiseptic showering, surgical attire, preoperative hair removal, and skin preparation (Ariyo et al., 2019). 

In addition to the preoperative hygiene-based preparations, comprehensive learning, and simulation-based education can help nurses have more human-based interactive learning (Koukourikos et al., 2021), which can help them anticipate the risk of unsafe surgical procedures and help them learn the importance of preoperative hygiene preparations, improving the patient satisfaction and ultimately reducing postoperative risks and readmission. The goal is to mitigate the risk of unsafe surgical procedures. The Four E’s: engage, educate, execute, and evaluate—are effective strategies many organizations use (Ariyo et al., 2019).

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

Many high-performing organizations design their learning and training modules to engage their employees, educate them, put them into action, and then take feedback and evaluate their progress accordingly. Similarly, Alignment Healthcare must implement preoperative strategies, hygiene protocols, and stimulation-based learning to improve outcomes. However, a few areas of uncertainty need more effective involvement, such as patient education, healthcare disparities, and regulatory compliance. They are investigating and addressing how high-performing organizations address healthcare disparities and navigate complex regulatory obligations.

Organizational Functions, Processes, and Behaviors Support and Outcome Measures 

The organization’s outcome measures include the frequency of unsafe surgical procedures, postoperative complications, patient readmission, surgical site infections, and patient satisfaction. These outcome measures enable the organization to evaluate the quality of care and the competency of the professionals (Hannawa et al., 2022). Administrators and professionals must timely evaluate and modify their strategies to improve decision-making and assess performance, such as collective organizational goals that help the organization improve standards of care, streamline workflow, and enhance safety protocols that encourage task execution. 

These organizational functions and processes have various positive and negative effects on outcome measures, such as safety protocols, which can help streamline processes and reduce errors, surgical infection, and postoperative risk. At the same time, inter-professional collaboration fosters effective communication, leading to better-coordinated care and overall cultural performance improvement. Open communication, positive interaction, and evidence-based care create a supportive environment that helps enhance communication, develop trust, and increase overall engagement in care (Kwame & Petrucka, 2021).

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

The negative effect on the outcome measures is based on the influx of poorly developed processes that lead to unsafe surgical procedures, a higher readmission rate, and more resource allocation in reimbursement and readmission management. Furthermore, the communication issues and lack of empathy lead to compromised safety and erode trust, negatively affecting the patient’s satisfaction. Studies have highlighted that ineffective communication, unsupportive environments, and complex processes can lead to increased medical errors and affect patient-provider relationships (Tiwary et al., 2019). 

Organizational and structural changes such as hygiene safety protocols, implementing comprehensive learning modules to manage the staff effectively, implementing regulatory standards, and open communication across all the departments can help balance the positive and negative outcomes. Strong leadership that can control employee work stress, lower the risk of infection, and give staff members more responsibility for providing safe procedures achieves these quality improvement outcomes (Irshad et al., 2021). It is based on the assumption that practical organizational function, positive behaviors such as inter-professional collaboration, and evidence-based practices can help improve workflow, improve clinical outcomes, and create positive patient experiences. Effective processes reduce unsafe behaviors, streamline administrative processes, enhance patient satisfaction, and improve treatment adherence and overall health outcomes. 

 Quality and Safety Outcomes and Measures

Unsafe surgical care procedures were the quality and safety outcomes that the gap analysis identified. It involves recognizing the key indicators that reflect the effectiveness and safety of patient care. For improvement in the surgical site infection rate, studies have suggested using alcohol-based antibiotics, antiseptics, and other preoperative sanitized protocol measures to provide better quality preoperative strategies that can reduce the risk of infection on the surgical site as well as reduce the risk of postoperative complications (Ling et al., 2019). Similarly, other studies have suggested optimizing the preoperative strategies and diligence during surgery regarding blood loss, operating time, and other complications while being vigilant in implementing infection control practices can help reduce the postoperative risk (Dharap et al., 2022).

Effective management of health conditions at home through patient education, medical record consolidation, proper discharge planning, and adequate follow-ups can lead to minimized readmission rates (Pugh, et al., 2021), thus increasing the overall patient satisfaction rate. Furthmore, providing quality and safe care without negligence and improving patient experiences can overall impact patient satifaction levels. The data gathered about these quality and safety outcomes and measures helps in meaningful evaluation, providing a better analysis associated with detailed. The quality of the data can be assessed by its reliability and accuracy. Along with the optimization of the preoperative measures, improving the surgical site to reduce the infection rate can further lead to a decrease in readmissions and higher patient satisfaction. 

Performance Issues or Opportunities 

Unsafe surgical care procedures reflect performance issues regarding the competency of the professionals, unskilled or untrained staff, and a lack of inter-professional collaboration among different stakeholders. Moreover, a lack of effective transformational leadership adds more pressure on the organization to manage the issues associated with unsafe surgical care procedures. The organization lacks quality sterilization and training and has lax protocols when it comes to surgical units. These issues significantly increase the risk of surgical site infection and postoperative complications, leading to adverse effects on patient satisfaction, an increased number of readmissions, and financial burdens on the organization.

Poor sterilization practices, inadequate wound care, improper handling, and preoperative strategies pose a significant risk to health outcomes (Andersen, 2018), while the lack of communication between the team members may lead to errors, negligence, overlooked risks, and incorrect procedures. These issues of surgical infection and postoperative complications are associated with the lax systems and hygiene protocols of the organization, which are caused by a lack of skilled and competent teams, leading to higher admission rate and low patient satisfaction. 

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

While there are few opportunities within the organization to learn and evaluate their strategies through continuous learning and training, assessing their performance against high-performing benchmarks such as enhancing team communication, pre-surgical discussion, briefing, effective preoperative assessment and procedures, and implementing a checklist can help provide better outcomes. Strict adherence to infection control procedures can reduce the risk of unsafe surgical procedures, reduce the readmission rate, and improve overall patient satisfaction (Balance et al., 2023). These opportunities for learning and surgical collaboration among the team lead to better hygiene and safer surgical procedures.

However, there are a few uncertainties that may require more attention regarding the extent to which the checklist would be effectively implemented and prevent errors; human factors such as stress, burnout, and workload may impact the performance, and other factors such as patient medical complications, age, and other comorbidities may influence the outcomes. Addressing these issues and capitalizing on opportunities can have significant positive effects. 

Strategy Using PDSA

The Plan-Do-Study-Act model is the most suitable for this purpose as it involves an iterative cycle of planning, implementing, evaluating, and refining the changes to improve processes. Step one is to plan, which is initiated by describing the issue of unsafe surgical care procedures leading to postoperative complications, increased surgical site infection, and patient readmissions. This step aims to improve patient satisfaction while decreasing these risks. The planned strategy to reduce the postoperative complications and surgical site infection was to increase the adherence to infection control and preoperative management protocols that can mitigate the risk with proper assessment, team collaboration, discussion, and planned surgical intervention while incorporating comprehensive simulation-based training and education (Ling et al., 2019).

The second step of the model is to implement the plan strategies (Do), such as conducting training sessions, implementing infection control protocols, using the preoperative approach, and collecting data on the outcome measures. The aim is to communicate the plan to nursing staff and other stakeholders involved and educate them regarding the need. The third step is to analyze (Study) the gathered data, trends, feedback, and surveys to understand the success of the plan and the need for improvement. The last step is to Act; based on the gathered data regarding the utilization of the set protocols, the program is analyzed, and strategies are changed based on the continuous monitoring and evaluation of the plan. Training and education will disseminate information about secure implementation of best practices, while feedback loops, collaborative projects, and team training will encourage interaction and cooperation. 


The current report was designed to address the organization’s functions, processes, behaviors, and outcome measures that can provide patient safety and quality improvement while educating staff and implementing strict infection control protocols and preoperative strategies that can help to provide better collaborative care for the patient, improving the organization’s standards of care. Therefore, nurse leaders may need to encourage a culture of safety and quality through effective communication, transformational leadership, and strict adherence to protocols. 


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. 

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.

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

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

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. 

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


Table 1a: Total number of Medical Error 

Medical Errors 
Number of Cases 
Mortality Rate 
Patient Injuries 
Postoperative Complications 50 5% 25
Surgical Site Infections  28 3% 14
Patient Complaints  17 0.3% 7
No. of Readmissions  25 2% 10


Table 1b: Outcome and Associated Measures 

Safety concern 
Outcome & Measure 
Prevention Strategies 
Unsafe Surgical Care  Surgical Site Infection Rate  Avoiding razors for preoperative hair removal, use of alcohol-based skin preparation agents, antiseptics, and preoperative glucose control (Seidelman, et al., 2023)
Postoperative Complication rate  Preoperative protocol optimization, management of blood loss, operation time and intraoperative complications, and infection protocol management (Dharap et al., 2022)
Patient Satisfaction  Patient surveys, patient expectations, and patient’s perceptions toward the medical healthcare professionals provide improved satisfaction (Kalaja, 2023)
Readmission Rates Healthcare at home is improved through patient education, medical record consolidation, discharge preparation, and follow-up phone calls (Pugh, et al., 2021)