NURS FPX 6212 Assessment 4 Planning for Change: A Leader's Vision
Phillip October 4, 2023 No Comments

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

Student Name

Capella University

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name



Planning for a Change: A Leader’s Vision

Hello! Everyone, this is Ross D. Hill. First of all, I would like to welcome you all to this presentation. In today’s presentation, we will explore nurse leaders’ critical role in promoting and sustaining a culture of quality and safety within the healthcare organization. We will explain the various aspects of a nurse leader’s role in developing, maintaining, and promoting a culture of quality and safety. The presentation will start with an overview of the importance of quality and safety within the healthcare system. The difficulties alignment organizations have in achieving these goals and examining the nursing leader’s role in promoting patient safety and quality by providing a variety of opportunities for the staff to learn and decrease the likelihood of errors.


To begin, we will provide a summary of the key aspects of the plan, and then we will explain the organizational functions, processes, and behaviors that affect the quality and safety of the organization. Following that, we will talk about the current outcome measures and the potential strengths and weaknesses associated with those measures. Then, we’ll be sharing the steps to achieve the outcome plan and the future vision of the organization. In the end, a conclusion will be provided. If you have any queries, please write them down; I’ll happily get back to you in the end. 

Summarize the Key Aspects of a Plan

Postoperative complications, medical errors, surgical site infections, increased readmissions, and decreased patient satisfaction resulted from the under-skilled team’s inadequate training and lax protocols (Purba et al., 2020), significantly affecting the patient’s quality and functionality, along with increasing resource consumption, as a result of the unsafe surgical care procedures in Alignment Healthcare. The adjustment of healthcare, which seeks to provide individualized care through in-office teams, health plan designs, and technology, places a premium on resolving these issues. Also, understanding the cause of the poor surgical procedure within the organization can help identify and eliminate the risk and provide better quality care to the patients. With the help of the gap analysis, factors including patient variety, surgical staff competence, the efficacy of preventive measures, and organizational protocols were identified. 

Unsafe surgical care procedures were identified as a systemic problem within the organization that significantly contributed to negative quality and safety outcomes, necessitating a comprehensive plan premised on the assumption of standardizing surgical procedures through the introduction of preoperative care, interpersonal team collaboration, effective communication, and strict infection control procedures that can facilitate reducing postoperative complications. The plan was based on preoperative hygiene-based preparations, comprehensive learning, and simulation-based education to provide an all-in-one environment for the staff to learn and have hands-on training in reducing surgical risks. A study has highlighted that providing integrated learning to facilitate human learning, feedback loops, and timely iteration of the problem can help provide better clinical outcomes (Viswanath et al., 2019).

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

The plan is based on the Plan-Do-Study-Act (PDSA) framework, providing an improved integrated analysis of surgical care issues to manage outcomes measures and utilizing comprehensive learning to provide patient safety and quality improvement through training staff in infection control and preoperative planning. As a result, nurse managers may need to promote a culture of safety and quality through open dialogue, transformative leadership, and rigorous adherence to established procedures. The plan aims to provide a comprehensive and integrated approach to eliminate surgery-associated risks and enhance patient care. 

Organizational Functions, Processes, and Behaviors Affecting Quality and Safety

It is essential to identify the organizational function, processes, and behaviors to manage the quality and safety of the organization. Within the organizational functions, the need for more communication and interprofessional collaboration is one of the critical lagging aspects. The lack of communication and discussion of the case resulted in the unskilled professionals, inability to anticipate the infection rate or postoperative complications (Dencker et al., 2021). This lack of communication between the team leads to a lack of competence in assessing the risk of complications during and after the surgery, which affects the patient’s satisfaction with the hospital services while increasing the risk of readmission due to postoperative complications.

Similarly, the organizational processes that we identified as impeding the organization’s quality and safety were the lack of hygiene protocol adherence, which impacts healthcare outcomes as these lax protocols lead to surgical site infections and also increase the risk of hospital-acquired infections. Moreover, the lack of accountability of healthcare professionals is one of the leading causes that affects how the professionals view their medical duties and how vigilant they professionals are during their practice. Similarly, the lack of preoperative hygiene management, such as the lack of commitment to cleaning, the use of alcohol-based antiseptics, and unsterilized tools further increases the risk of complications and the infection rate. 

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

Lax protocols and casual and unskilled staff are examples of behaviors that can affect the quality of care provided to patients and their safety. These behaviors have the potential to influence the staff’s attitude toward care and quality practices, which in turn could result in unsafe surgical procedures, a lack of accountability, and a lack of treatment options. However, there are a few areas of uncertainty that call for more effective involvement, such as the training of inter-professional teams. This lack of training leads to unskilled professionals. Medical literacy and education can help improve the professional skill set, improve the treatment evaluation process, and reduce further complications and risks.

Similarly, other unknown factors include the leadership style that might work effectively, the role of the leaders in the safety enhancement and detailed information on the baseline data regarding why the organization has such lax protocols and other organizational factors that may have increased the risk of infection and a further complication in care management. Therefore, it is essential to be mindful of the change and evaluate and modify the plan per the requirements. 

Current Outcome Measures and Their Strengths and Weaknesses 

The current outcome measures within the organization were the frequency of unsafe surgical procedures, postoperative complications, patient readmission, surgical site infections, and patient satisfaction. These outcome measures are significant in driving improvement and fostering a culture of quality and safety through diligently working on patient safety indications, hospital-acquired infections, and patient satisfaction (Braun et al., 2020). These outreach measures foster inter-professional collaboration and influential culture that enhances patient safety, improves surgical expertise, and provides better quality care through ensuring adherence to hygiene protocols, taking preoperative measures seriously, encouraging team discussions such as case conferences and surgical team preoperative analysis, anticipating the possible risk and postoperative complications, and developing a plan for the complication; furthermore, providing clear guidance and wound care and management to the families to reduce surgical site infections.

Thus, utilizing these strategies and effectively monitoring and evaluating these outcome measures can foster a culture that is based on patient-centered care and quality improvement.  The outcome measures for the organization’s quality and safety have their strengths and weaknesses, such as the surgical site infection rates, which measure the effectiveness of infection control practices in operative procedures, highlighting the organizational commitment to infection prevention (Troughton et al., 2019). Furthermore, hospital-acquired infection rates can provide an incidence of infection in the hospital during and after surgery, facilitating healthcare providers’ identification of infection-prone areas and implementing protocols accordingly. However, variability in the surveillance and a few unavoidable infection risks may impact the accuracy of the measure. Similarly, the readmission rate measures the success of post-discharge care. It reflects the organization’s urge to provide continuous care and early intervention (Upadhyay et al., 2019).

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

However, it is crucial to be aware that additional factors, such as the patient’s condition, demographics, and other social factors, can affect the readmission rate. High readmission rates sometimes do not reflect the quality of care the organization provides. Another measure was the patient’s satisfaction score, which can be used to capture the patient’s perspective and experiences and offer the opportunity to incorporate a patient’s suggestion within the care practice, reflecting on the organization’s empathy, good quality of care, and patient-centeredness (Ferreira et al., 2023). Lastly, the postoperative complications help identify areas for improvement, reflect on the organization’s culture of monitoring, and modify strategies to enhance patient care. However, defining complications and preventing all the complications can be unrealistic.

These measures can easily be optimized by ensuring data consistency, which can help increase their reliability. Risk assessment and management can help in attentively providing better combating strategies. While the comparison to benchmarking organizations can help to provide valuable content that can aid in comparing the organization’s performance with high-performing organizations, These outcomes create a culture of accountability and transparency that allows the staff and leadership to stand on the same ground, be accountable for their actions, encourage them for continuous improvement within their skill set, identify their weaknesses, and improve them to provide patient-centered care.

Steps to Achieving Outcomes 

The PDSA framework was utilized to strategically implement the suggested change strategies that can help improve the patient’s overall healthcare. The PDSA is a phase-cyclic mold that allows the iteration of planning, implementing, evaluating, and refining processes.

Step 1: Plan

It is essential to plan the change to be implemented in the organization to achieve the desired outcomes. First, a need assessment and gap analysis will be conducted to assess the need for surgical changes, evaluate current practices, and identify trends, gaps, opportunities, and threats. Then, the achievable SMART goal is set to increase standardized protocols, hygiene management, and simulation-based learning. The planning step is based on a baseline assessment that allows the organization to understand the lag in practices and provides an opportunity to rectify it. The goal of the first step is to collect data and plan specific strategies that can help reduce the infection and complication risks of the surgery while developing protocols that can prevent and reduce the risk (Ling et al., 2019).

The board of directors will be responsible for supervising the plan, while the department directors and heads will be responsible for data collection, current practice analysis, and handing information to the data analyst, who will be responsible for conducting the gap analysis and highlighting the need for change. The finance head will be responsible for budgeting and resource allocation, such as how much investment is required, searching for vendors that can provide competitive packages, and hiring trainers and educators to train the staff. The administration will be responsible for supervising the plan. At the same time, end-users would be used to gather the information and their feedback The resources required for planning will be a need analysis that can help in anticipating the budget required, finance that would be used in the whole change process, and resources such as alcohol-based agents, antiseptic wash, surgical kits, equipment, and cleaning material. 

Step 2: Do

The second step of the cycle is implementing the planned strategies to overcome quality and safety issues and increase patient satisfaction. This step will provide comprehensive training and education to train the staff to become equipped for the changes. Moreover, target-based training through workshops, seminars, and other educational formats can help the team grasp the process. Then, preoperative strategies, interpersonal collaboration, case conferences, and different strategies are also implemented to reduce complications and infection risk. The aim is to communicate the plan to nursing staff and other stakeholders involved and educate them regarding the need.

This direct involvement in the learning process can quickly shift the focus from just learning to personal skills and learning trajectory and increase patient engagement (Stoffels et al., 2021). The administration would be responsible for implementation of the protocols, and the management would be responsible for setting and communicating the protocols to the end users while using educational and awareness mediums to communicate. The training lead would be solely responsible for training the staff, while the nursing staff and physicians would facilitate implementation through practice. The resources needed here would be educational pamphlets, banners, and training modules designed to train the team, as well as finances allocated from the budget for implementation and protocol licensing. 

Step 3: Study

After the plan’s implementation, constant monitoring, feedback loops, and trends can help provide a clear report on the efficacy of the protocol implementations. Monitoring his progress in tracking improvement and identifying errors that may significantly impact the change through metrics, feedback surveys, and end-user interviews allows the organization to establish performance comparison measures that help sustain continuous feedback and help constructively communicate the feedback. The end-users, such as physicians and nurses, will be responsible for handling the monitoring and feedback loops; the administration will be responsible for the implementation and evaluation of the change processes; and the resources required would be feedback survey forms, preoperative materials such as surgical kits, alcohol-based agents, and cleaning supplies. 

Step 4: Act

The last step of the process is to gather data while utilizing the protocols, analyze the program, and make timely changes to the plan. The continuous assessment of the outcome, adjustments to the implemented strategies, and sustained effects over time can help the organization refine approaches and make timely changes. The department heads will be in charge of providing feedback, and the data analyst will be responsible for evaluating the success of change within the organization. The finance head will be responsible for budgeting and resource allocation, while the administration will be in charge of hygiene protocol implementation, checking, and evaluation. The resources required for this step are feedback surveys, comparative analysis datasheets, and process evaluation protocols. 

The assumptions of the plan on which the outcome strategy is based

  • The method assumes that the collected baseline data accurately reflects the organization’s current state.
  • The plan’s success lies in the active participation of the nursing staff.
  • Effective leadership can multitask the allocation of resources and prioritize the improvement effort.
  • Patient needs, preferences, and safety hold utmost importance.

Future Vision of the Organization

It is envisioned that Alignment Healthcare successfully cultivates a robust culture of quality and safety parameters in every aspect of the surgery. It is developed through a commitment to patient safety and well-being, staff empowerment, and continuous improvement to provide practical, patient-centered, and safe care (Lu et al., 2022). The staff member’s collaboration to achieve the common goal of patient quality and safety of care can help eradicate the issues. Fostering a culture of interpersonal cooperation, preventive measures, and effective on-time management of risk factors can help increase patient satisfaction and help the organization reach its goal of optimal care (Oldland et al., 2020). As a nursing leader, I foster team building and collaboration that can help my community provide collaborative and empathic care. This allows me to set the tone of the work by molding safe and compassionate behaviors that help streamline workflow and make the staff feel safe.

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

Furthermore, I can enhance communication, share learning, and bring synergy to patient care by fostering collaboration with other healthcare professionals. Similarly, to fully conceptualize this vision, the inter-professional teams need to work together to develop a comprehensive plan, conduct a root cause analysis of the problem to identify systemic issues, design and implement corrective action, and make sure that the quality of the practices aligns with organizational goals and visions. Leadership is significant, as a nursing leader can promote collaborative problem-solving and help the teams open up and communicate their concerns. In contrast, feedback helps them to improve (Jankelova & Joniakova, 2021). Thus, the role of the nursing leader is to facilitate organic interaction and open communication mediums and allow the team to become more expressive and interactive.


In conclusion, unsafe surgical care procedures significantly threaten the organization’s reputation, affecting patient trust and reducing their satisfaction. This presentation was developed to provide information on unsafe surgical care procedures, highlighting how different organizational functions, processes, and behaviors, such as lax protocols, a lack of inter-professional collaboration and communication, unskilled staff, a lack of preoperative measures, and a lack of accountability, can lead to safety and quality concerns of postoperative complications, readmission, a lack of patient satisfaction, and a high surgical site infection rate. The outcome measures were identified, and their strengths and weaknesses were discussed to help eradicate the problems. A plan for action was also shared, along with highlighting the roles and responsibilities of different stakeholders, and a future vision of the organization was shared. If you have any questions, feel free to ask.


Braun, B. I., Chitavi, S. O., Suzuki, H., Soyemi, C. A., & Puig-Asensio, M. (2020). Culture of safety: Impact on improvement in infection prevention process and outcomes. Current Infectious Disease Reports, 22(12), 34.

Dencker, E. E., Bonde, A., Troelsen, A., Varadarajan, K. M., & Sillesen, M. (2021). Postoperative complications: An observational study of trends in the United States from 2012 to 2018. BMC Surgery, 21(1), 393. 

Ferreira, D. C., Vieira, I., Pedro, M. I., Caldas, P., & Varela, M. (2023). Patient satisfaction with healthcare services and the techniques used for its assessment: A systematic literature review and a Bibliometric Analysis. Healthcare, 11(5), 639.

Jankelová, N., & Joniaková, Z. (2021). Communication skills and transformational leadership style of first-line nurse managers in relation to job satisfaction of nurses and moderators of this relationship. Healthcare, 9(3), 346. 

Lu, L., Ko, Y. M., Chen, H. Y., Chueh, J. W., Chen, P. Y., & Cooper, C. L. (2022). Patient safety and staff well-being: Organizational culture as a resource. International Journal of Environmental Research and Public Health, 19(6), 3722.

Oldland, E., Botti, M., Hutchinson, A. M., & Redley, B. (2020). A framework of nurses’ responsibilities for quality healthcare—Exploration of content validity. Collegian, 27(2), 150-163.

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision 

Purba, A. K. R., Luz, C. F., Wulandari, R. R., van der Gun, I., Dik, J. W., Friedrich, A. W., & Postma, M. J. (2020). The impacts of deep surgical site infections on readmissions, length of stay, and costs: A matched case-control study conducted in an academic hospital in the Netherlands. Infection and Drug Resistance, 13, 3365–3374.

Stoffels, M., van der Burgt, S. M. E., Stenfors, T., Daelmans, H. E. M., Peerdeman, S. M., & Kusurkar, R. A. (2021). Conceptions of clinical learning among stakeholders involved in undergraduate nursing education: A phenomenographic study. BMC Medical Education, 21(1), 520. 

Troughton, R., Mariano, V., Campbell, A., Hettiaratchy, S., Holmes, A., & Birgand, G. (2019). Understanding determinants of infection control practices in surgery: The role of shared ownership and team hierarchy. Antimicrobial Resistance & Infection Control, 8, 1-10.

Upadhyay, S., Stephenson, A. L., & Smith, D. G. (2019). Readmission rates and their impact on hospital financial performance: A study of Washington hospitals. Inquiry: A Journal of Medical Care Organization, Provision, and Financing, 56, 46958019860386.

Viswanath, K., Synowiec, C., & Agha, S. (2019). Responsive feedback: Towards a new paradigm to enhance intervention effectiveness. Gates Open Research, 3, 781.