Quality and safety Gap Analysis

Quality and safety Gap Analysis

Overview

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. Quality and safety Gap Analysis

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.

Table of Contents

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.

Systemic problem to write about will be increase in falls.

Requirements- The paper must address the 8 bullet points below. Organize the paper sections by each bullet point.

?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 (linked in the Resources) to better understand how each criterion will be assessed.Quality and safety Gap Analysis

Conducting the Analysis

Identify a systemic problem in your organization (increase in falls), practice setting, or area of interest that contributes to adverse quality and safety outcomes and identifies knowledge gaps, unknowns, missing information, unanswered questions or areas of uncertainty.
Propose specific practice changes that will improve quality and safety outcomes and bridge the gap between current and desired performance, and identifies assumptions on which the proposal is based.
Prioritize proposed practice changes, and provides sound rationale for prioritization.
Determine how proposed practice changes will foster a culture of quality and safety, & proposes criteria that could be used to evaluate that culture.
Determine how a particular organizational culture or hierarchy might affect or contribute to adverse quality and safety outcomes, & identifies assumptions on which that analysis is based.
Justify necessary changes to particular organizational functions, processes, and behaviors that mitigate adverse quality and safety outcomes, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty.

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 Paper Template linked in the resources. 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. At least 3 credible citations.

Attached is the actual paper directions & scoring guide with suggested resources

Increase in Patient Falls in a Healthcare Organization: A Quality and Safety Gap analysis with Regard to Current and Expected Performance Quality and safety Gap Analysis

Gap analysis is the process of identifying the difference between the current healthcare service reality or practices and the expected or desired best practice. It brings out the discrepancy between current performance and the expected practice (Marvin et al., 2016; Unruh & Hofler, 2016; Arries, 2014). Considering healthcare in service terms, a gap exists when there is a difference in the perception of the service received in the healthcare institution and the expected service. Thus:

Expected service – perceived service = Service gap

The presence of a gap in the healthcare service delivered means that the quality of the service is wanting. The Institute of Medicine (IOM) has put out the six dimensions of quality that define healthcare quality. These are safety, effectiveness, efficacy, patient-centeredness, equitability, and timeliness (Prakash, 2015; Beattie et al., 2013). This paper analyzes the gap in quality and safety present between the current service performance in a healthcare institution (which reveals an increase in the number of patient falls), and the expected/ desired/ best or optimum performance. The best or desired performance in terms of quality in this case would be the occurrence of zero patient falls; or what is described in the Six Sigma quality improvement model as “zero defects” (Rastogi, 2018).

Increase in Patient Falls as an Identified Systemic Problem in the Healthcare Organization

In the period under review in this healthcare organization that shall remain anonymous for ethical and legal reasons, it was noted that the number of incidents involving patient falls spiked considerably in the last one year before the date of review. In the immediate year before review there had been a total of 106 documented falls in the organization. This translated to at least 3 reported cases of falls per week. Of these, 70 were patient falls (66%) while the rest involved visitors and employees of the hospital. These falls occurred not only to those patient who were old and frail, but also to patients and sometimes their next of kin/ visitors who were not sick in any way. This clearly meant that there were other factors contributing to these falls other than the fact that the victim falling is sick and unstable. In other words, the falls were not accidental but as a result of a major defect in the current practices in the organization. Nationally, accidental falls are the most reported with fall rates in U.S. hospitals ranging from 3.3 to 11.5 falls per 1,000 hospital stays. In comparison, therefore, this clearly shows the seriousness of the problem of falls in this organization. The negative impact on patient safety is immense and is complicated by the fact that the Centers for Medicare and Medicaid Services (CMS) does not reimburse for services given to victims of falls in hospitals (Bouldin et al., 2013). Quality and safety Gap Analysis

ORDER A FREE-PLAGIARISM PAPER NOW

Safety, patient-centeredness, and efficiency are important dimensions of healthcare service quality that clearly lacked in this issue of increasing incidents of falls (Beattie et al., 2013). In an ideal situation, there would be no falls reported in the healthcare organization. But with the rising numbers of cases of falls in the organization, it was clear that there was a quality and safety gap that needed to be addressed. If not done, this would negatively impact reimbursement which is done based on the quality of healthcare services rendered or pay-for-performance (James, 2012). Left unaddressed, this situation would also inevitably lead to lower patient ratings and litigation for staff negligence and vicarious liability on the part of the organization. The knowledge gaps or unknowns in this situation were reasons why even persons who were not sick were suffering from falls, what the nurses’ contribution to the occurrence of the falls was, and what role the other non-clinical staff played in the occurrence of the falls.

Specific Practice Changes to Improve Quality and Safety Outcomes and Bridge the Performance Gap

As has been seen in the discussion above, it is imperative to quickly bridge the glaring gap in performance with regard to the increase in patient falls. This is true because the hospital is expected by law and regulations as a matter of course to provide services that safeguard patient safety and put nobody at risk of injury. To this end, several specific practice changes aimed at improving service quality and safety outcomes would be proposed to bridge the quality gap. These are:

To have the occupational, safety, and health committee of the hospital review all the reported incidents and the facts surrounding them to see if there are internal organizational risk factors that are placing the patients, staff, and visitors at risk of injury from falls. They would then recommend appropriate action as per their findings, within a specific timeframe. This will enable the implementation of universal fall precautions such as the training of all hospital staff to address accidental falls (AHRQ, 2013).
To have the nurse managers review the individual accounts of the nurses that they entered in the incidents book for every of those fall incidents. This way they would be able to determine if the nurses are the ones who had been negligent and take the necessary action. This intervention will enable the nurses with knowledge gaps to be trained on the standardized assessment of risk factors for falls, as well as targeted care planning that seeks to solve the identified risk factors as incorporated in each patient’s care plan. This intervention targets reduction and prevention of anticipated and unanticipated physiological falls by patients (AHRQ, 2013).
To have the construction engineers who built the establishment review the appropriateness of the materials used to construct the facility’s floors, especially the tiles. If they found that those were contributing in a way to the frequent falls, they would then make the necessary changes to prevent further falls. This intervention will address accidental falls (AHRQ, 2013). Quality and safety Gap Analysis

Fall prevention is a complex undertaking. Therefore, it should adopt a multidisciplinary approach as above for better chances of success (AHRQ, 2013). The assumptions upon which the above proposals are made are that (i) nurses in the organization under review are responsible and work in an environment that is conducive and devoid of stress; (ii) there may be procedural defects in the way the housekeeping staff clean the floors in the healthcare organization, including the chemicals they use to do that; (iii) there may be structural defects in the construction of the facility’s floors; and that (iv) there may be insufficient training of housekeeping staff on the best way to clean the floors without putting people at risk of slipping and falling.

Prioritization of the Proposed Practice Changes

The proposed practice changes that are to be used to bridge the gap in performance by correcting the prevailing situation of frequent falls are three as shown above. Even though the three processes can occur concurrently and independent of one another, the reality of finite resources (in terms of materials, human resource, time, and money) dictates that there may be need to prioritize them. Doing this would mean that one process is allowed to run through and complete within the shortest time possible before commencing the next. Because of the fact that it is not only patients that are falling frequently, it is obvious that the nurses in this organization may not be to blame for this gap in quality and safety. As such, suspicion points at either procedural and structural defects or insufficient training. According to the Agency for Healthcare Research and Quality (2013), priority should go to the intervention that seeks to implement universal fall precautions (involving the training of all hospital staff). This is then followed by the intervention that aims at training nurses on the standardized assessment of risk factors to falls in the hospital (AHRQ, 2013). This is the evidence-based practice (EBP) rationale used to prioritize the strategies here below.

The first process to be given priority will therefore be the investigation by the occupational, safety, and health committee (universal fall precautions). This would be followed by the review of the construction by the engineers to see if the floor materials are to blame for the increased incidents of falls (this intervention comes second because it has a bearing on whether or not the universal fall precautions training will be necessary or not). The rationale for this is the same as for the committee above – the problem may be procedural or structural. The last process would then focus on the nurses by reviewing all their statements for each incident. They are the last point of focus because circumstantial evidence does not seem to point at their culpability. It is not only patients who have been falling, but also visitors and patients’ relatives.

How Proposed Changes Will Foster a Culture of Quality and Safety

All the above proposed actions are intended to provide long-term solutions to the problem of frequent falls within this healthcare organization. Having the occupational, safety, and health committee review the facts surrounding the fall incidents and coming up with lasting solutions is important. If it finds that falls are mostly accidental in nature (i.e. caused by an environmental hazard), it will recommend training of all organization employees whether they are directly involved with patients or not. This will inculcate a culture of quality and safety through staff education. All staff will thereafter be aware of the universal fall precautions (AHRQ, 2013). The organization will henceforth be abiding by state and federal laws and regulations. All organizations are required by law to make their premises and environments safe for both employees and visitors. A breach of these legal provisions carries with it serious legal sanctions. This intervention will therefore foster a culture of safety and quality for the long term because it has a legal rationale. Quality and safety Gap Analysis

The second intervention that involves review of the buildings and construction materials used is also designed to foster a long-term culture of quality and safety. This is because if indeed it is the building materials that are to blame, the problem will be sorted out once and for all. If construction is not the problem, more credence will be lent to the possible need for staff training (education) as the first priority intervention seeks to address. Henceforth, there will be no more cases of falls within the organization. Lastly, investigating whether the nurses had a part to play in the occurrence of the frequent falls is also important in fostering a culture of safety and quality. If knowledge gaps among nurses are identified by the nurse managers, nurse education on standardized assessment of fall risks will foster a culture of quality and safety among the nurses. This is because every nurse should understand the organizational culture at their place of work is defined by safety and quality. This is what should guide their performance and direct them to delivering quality and safe nursing care. After all is said and done, the criteria that may be used to evaluate the organizational culture defined by safety and quality will be patient reviews and the amount of reimbursement received by the hospital.

How Organizational Culture May Contribute to Poor Quality and Safety

An example of an organizational culture that may contribute to adverse quality and safety outcomes is the lack of transformational leadership. To begin with, the top leadership/ management of the organization understood that they must support the above interventions or change strategies that are aimed at improving patient safety and care quality. This is goodwill which is vital for the success of these strategies. As transformational leaders, therefore, they appreciated that they were supposed to facilitate all the three processes both morally and financially for patient safety and improved care quality. This particular organization’s leadership also appreciated the fact that management that is authoritarian and intolerant to divergent views will beget staff that are demotivated and stressed for lack of psychological safety. These healthcare employees are prone to making many errors in the course of caring for the organization’s patients. These errors include medication errors committed by nurses and that could end up in the death of a patient. As such, patient safety and quality become severely compromised. The assumptions on which this analysis made is are that employees will respond positively to appreciation, and consultative leadership will lead to employee commitment.

ORDER A FREE-PLAGIARISM PAPER NOW

Necessary Organizational Changes to Mitigate Adverse Quality and Safety Outcomes

The changes in the functions, behaviors, and processes as have been proposed above are important in mitigating the adverse quality and safety outcomes in the organization. The outcomes of all the three processes were shared with the organization’s leadership who are the policy makers. The justification of the impact that falls have on the organization’s quality and safety was also shared with the leadership. The justification is that reimbursement is dependent on quality delivered (pay-for-performance), and legal provisions and regulations oblige organizations to provide safe and quality healthcare. After a fall, the organization is forced to foot the costs of any injuries that may be sustained (as CMS does not reimburse services for fall victims) (Bouldin et al., 2013) and also faces the prospect of litigation for negligence and vicarious liability. The costs of a fall therefore include an increased length of stay (LOS), patient care costs (footed by the organization), and liability claims (Bouldin et al., 2013). Areas of uncertainty may be represented by what the perception of the public is about the institution, and what the employees’ perception is about the institution too. Quality and safety Gap Analysis

Conclusion

Hospital falls are an important systemic problem that affects the quality of care delivered to patients as well as their safety. Quality is defined by patient safety, patient-centeredness, and efficiency. Prevalence of a high rate of patient falls violates all this. There are however evidence-based strategies that can be implemented to lower this rate and improve care quality and patient safety. These include educating staff on universal fall precautions and teaching nurses standardized assessment of fall risk factors.

References

Arries, E.J. (2014). Patient safety and quality in healthcare: Nursing ethics for ethics quality. Nursing Ethics, 21(1), 3–5, doi: 10.1177/0969733013509042

Beattie, M., Shepherd, A., & Howieson, B. (2013). Do the Institute of Medicine’s (IOM’s) dimensions of quality capture the current meaning of quality in health care? – An integrative review. Journal of Research in Nursing, 18(4), 288-304, doi: 10.1177/1744987112440568.

Bouldin, E.D., Andresen, E.M., Dunton, N.E., Simon, M., Waters, T.M., Liu, M…. & Shorr, R.I. (2013). Falls among adult patients hospitalized in the United States: Prevalence and trends. Journal of Patient Safety, 9(1), 13–17, doi:10.1097/PTS.0b013e3182699b64

James, J. (2012). Pay-for-performance. Health Affairs. https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/full/

Marvin, V., Kuo, S., Poots, A.J., Woodcock, T., Vaughan, L., & Bell, D. (2016). Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital. BMJ Open, 6(6), e010230, doi: 10.1136/bmjopen-2015-010230

Prakash, G. (2015). Steering healthcare service delivery: A regulatory perspective. International Journal of Health Care Quality Assurance, 28(2), 173–192, doi: 10.1108/ijhcqa-03-2014-0036

Rastogi, A. (March 13, 2018). DMAIC – A six sigma process improvement methodology. https://www.greycampus.com/blog/quality-management/dmaic-a-six-sigma-process-improvement-methodology

Unruh, L., & Hofler, R. (2016). Predictors of gaps in patient safety and quality in U.S. hospitals. Health Services Research, 51(6), 2258-2281, doi: 10.1111/1475-6773.12468

57 – Quality and safety Gap Analysis

Quality and safety Gap Analysis