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Assessment 1: Quality and Safety Gap Analysis

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Student Name

Capella University

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Prof Name
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Nov 10, 2023
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Quality and Safety Gap Analysis – Hospital-Acquired Infections
Healthcare organizations globally exert significant efforts to uphold healthcare quality standards
and enhance patient safety. Despite these efforts, challenges may arise during healthcare
practices, often stemming from adverse events within the healthcare system. Hospital-acquired
infections (HAIs) represent such adverse events, negatively impacting care quality and patient
safety. The Vila Health organization recently identified HAIs during a quality and safety
assurance audit. In response, nurse leaders are tasked with analyzing the gap between current
and desired outcomes to improve quality and safety.

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Systemic Problems Related to Quality and Safety Outcomes

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HAIs, occurring within healthcare settings, manifest approximately 48 hours after a patient's
admission to the hospital (Monegro et al., 2023). Commonly resulting from inadequate care,

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these infections affect 8.7% of hospitalized patients, with urinary tract infections being prevalent
(World Health Organization [WHO], n.d.). HAIs contribute to prolonged hospital stays, increased
morbidity risks, financial burdens, and, in severe cases, long-term complications or death

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(Stewart et al., 2021). Addressing this issue necessitates collaborative change within healthcare
organizations, emphasizing communication among stakeholders and the development of
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healthcare providers' insights to bring about successful practice changes.

Practice Changes to Improve the Quality and Safety Outcomes

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To enhance patient outcomes, quality, and safety, particularly in the context of HAIs,
implementing practice changes within healthcare organizations is imperative. The Targeted
Assessment for Prevention (TAP) strategy, established by the Centers for Disease Control and
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Prevention (CDC, 2023), involves three steps: targeting organizations, assessing needs, and
implementing prevention strategies. Priority changes include proper utilization of personal
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protective equipment (PPE), adherence to hand hygiene guidelines, improvement of

environmental hygiene, and continuous training for healthcare professionals. This proposal
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assumes that infection control practices within healthcare organizations play a crucial role in
minimizing infection risks, leading to improved hygiene, enhanced healthcare safety, and
positive patient outcomes.
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Prioritization of the Proposed Change Strategies

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While all proposed change strategies are vital, prioritizing hand hygiene practices and
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healthcare professional education is essential. Effective implementation of these strategies

significantly improves infection control practices and prevents HAIs. Proper hand hygiene
inhibits germ transmission, and prioritizing it aligns with CDC claims about preventing
antibiotic-resistant infections (CDC, 2023). This prioritization aims to enhance patient safety
concerning HAIs.
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Quality and Safety Culture and its Evaluation
The suggested change strategies aim to improve care quality and establish a safety culture by
advancing healthcare practices. Success depends on inter-professional collaboration,
communication, and fostering a mindset of continuous improvement. Evaluation metrics include
continuous prevalence surveys, measuring patient satisfaction levels, and assessing staff
knowledge, ensuring sustained effectiveness and the establishment of an improved quality and
safety culture within healthcare organizations.

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Organizational Culture Affecting Quality and Safety Outcomes
Adverse outcomes within a healthcare organization can be influenced by its culture and

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hierarchy. Improved communication, adequate staffing, and a positive culture enhance
adherence to quality practices. The assumption underlying this analysis is that a positive

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organizational culture fosters employee motivation, aligns with organizational goals, and
promotes teamwork, critical for implementing and managing change in healthcare settings.

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Justification of Necessary Changes in an Organization
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Organizational changes, including an inter-professional committee, a zero-tolerance policy for
negligence, and adequate resource allocation, are essential to mitigate adverse quality and
safety outcomes. The inter-professional committee monitors practices, motivates staff, promotes
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collaboration, and identifies areas for improvement. The zero-tolerance policy holds healthcare
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workers accountable, and collaboration with internal and external stakeholders ensures
sufficient resources for successful implementation.
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References
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 Control, 10(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

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quality data. Healthcare, 11(5), 775. https://doi.org/10.3390/healthcare11050775

Bearman, G., Doll, M., Cooper, K., & Stevens, M. P. (2019). Hospital infection prevention: How

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much can we prevent and how hard should we try? Current Infectious Disease Reports, 21(1).
https://doi.org/10.1007/s11908-019-0660-2

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Centers for Disease Control and Prevention. (2023, April 3). The Targeted Assessment for
Prevention (TAP) strategy. Centers for Disease Control and Prevention.

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https://www.cdc.gov/hai/prevent/tap.html

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Mello, M. M., Frakes, M. D., Blumenkranz, E., & Studdert, D. M. (2020). Malpractice liability and
health care quality. JAMA, 323(4), 352. https://doi.org/10.1001/jama.2019.21411
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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
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Commission Journal on Quality and Patient Safety, 44(10), 613–622.

https://doi.org/10.1016/j.jcjq.2018.02.002
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Monegro, A. F., Muppidi, V., & Regunath, H. (2023). Hospital-acquired infections. In StatPearls.
StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK441857/
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Stewart, S., Robertson, C., Pan, J., Kennedy, S., Haahr, L., Manoukian, S., Mason, H.,
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Kavanagh, K., Graves, N., Dancer, S. J., Cook, B., & Reilly, J. (2021). Impact of
healthcare-associated infection on length of stay. Journal of Hospital Infection, 114, 23–31.
https://doi.org/10.1016/j.jhin.2021.02.026
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Sun, J., Qin, W., Jia, L., Sun, Z., Xu, H., Hui, Y., Gu, A., & Li, W. (2021). Analysis of continuous
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prevalence survey of healthcare-associated infections based on the real-time monitoring system

in 2018 in Shandong in China. BioMed Research International, 2021, 1–7.
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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/

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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

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