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Assessment 1: Quality and Safety Gap Analysis

Student Name

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Capella University

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Course Name

Prof Name
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April 10, 2024
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Hospital-Acquired Infections (HAIs) present significant challenges to healthcare quality
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and patient safety despite ongoing efforts to maintain standards. Recently, Vila Health
identified HAIs during a quality audit, prompting nurse leaders to analyze the gaps
between current and desired outcomes.

HAIs typically arise within 48 hours of hospital admission due to suboptimal care,
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affecting 8.7% of patients, notably with urinary tract infections. These infections prolong
hospital stays, heighten morbidity risks, incur financial burdens, and may lead to
long-term complications or death. Addressing HAIs requires collaborative efforts,
emphasizing communication and provider insights for effective practice changes.
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Implementing changes within healthcare organizations is pivotal for improving patient

outcomes, particularly regarding HAIs. The Targeted Assessment for Prevention (TAP)
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strategy, spearheaded by the CDC, involves assessing needs and implementing

prevention measures such as proper PPE use, hand hygiene, and environmental
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cleanliness, alongside continuous staff training.

Prioritizing hand hygiene and staff education significantly enhances infection control,
aligning with CDC recommendations for preventing antibiotic-resistant infections.
Evaluation methods include prevalence surveys, patient satisfaction assessments, and

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staff knowledge evaluations to ensure sustained effectiveness and foster a culture of
improvement.

Organizational culture profoundly influences healthcare outcomes, with improved

communication and staffing positively impacting adherence to quality practices.
Establishing an inter-professional committee, a zero-tolerance policy for negligence,
and adequate resource allocation are vital organizational changes. These initiatives
monitor practices, hold staff accountable, and ensure collaboration with stakeholders 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

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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

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care report better quality of life and self-rated health—cross-sectional findings based on hospital
quality data. Healthcare, 11(5), 775. https://doi.org/10.3390/healthcare11050775

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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 Reports, 21(1).
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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
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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

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.,
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
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.
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

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