NURS FPX 6222 Assessment 2 Quality and Safety Gap Analysis

Quality and Safety Gap Analysis

A quality and safety gap analysis is a vital step in finding the gaps between current practices and best practice standards that guarantee excellent patient outcomes. In terms of health care domains, this type of analysis is used to identify some of the underlying problems that impact the quality-of-service provision, such as communication failure, inefficient workflows, or poor training (Busch et al., 2023).

This assessment is about the deficiency of the standardised handoff communication in the practice environment, which can be described as one of the leading factors in designing adverse events and care continuity impairment.

Identifying A Systemic Problem in a Practice Setting

A systemic issue in my practice setting is that there are standardized communications between nurses during patient handoffs, especially between shifts and between care units. Such a shortage leads to miscommunication, care delays, and missing information, which leads to negative consequences such as repetitive tests, forgetting to prescribe medications, and poor care flow (Nasiri et al., 2021). The problem weakens the safety and quality results of the patients, especially of those with complications or high-risk cases.

Some of the barriers that lead to this problem include time limits, going through a busy shift, varying the use of handoff tools, a lack of leadership focus on a standardized message, and different communication styles among the providers. Also, documentation and sharing of information are lowered due to the lack of integration of electronic handoff in the EHR system (Ahn et al., 2021).

The quality measures that have been affected are the patient satisfaction scores, re-hospitalizations, care transition scores, and sentinel events caused by communication. The continuity of care in this gap can be significantly improved by the use of standardization of handoff as well as team training, thus limiting mistakes made and improving the overall safety of the patient and satisfaction.

Proposed Practice Changes

In order to improve quality and safety outcomes, the introduction of a standardized handoff protocol, such as SBAR (Situation, Background, Assessment, Recommendation), is necessary. This communication model is applied to ensure the sharing of essential information at any time during the transfer of the patient (Kim et al., 2020).

Compulsory staff exercises ought to be run with a view to inculcating the need to have a system of structured communication, and these ought to be coupled with competency-based tests to ascertain the level of comprehension. Inclusion of the electronic handoff templates in the EHR system will allow for continuation to be accomplished and reliance on memory or word of mouth to be eliminated.

• Assumptions and How to Address Them

This proposal assumes that the staff will accept and always use the new protocol; this may not occur without cultural or behavioral change. To overcome this, leadership should advocate for a culture that favors communication and accountability and highlight the importance and effectiveness of well-defined handoffs in ensuring the safety of patients (Atinga et al., 2024). The other assumption is that we shall have resources in terms of time, training personnel, and IT support to implement.

This will be handled through the involvement of the stakeholders early in the process, administrative buy-in, and aligning the change with organizational goals (Maddry et al., 2020). Another assumption is that SBAR is generalizable universally and therefore, pilot testing in local units may assist in the personalization of the approach even before broad application so that it has value and applicability in a variety of settings.

Prioritization of Proposed Practice Changes

The priority is implementation of a standardized protocol for handoff, such as SBAR, as it is a direct address to the core problem of communication that affects patient safety. Standardized communication reduces the difference. It increases the accuracy of handling information about the patients (Nasiri et al., 2021).

The second project initiative is a training of the staff and validation of competencies so that the protocol can be used constantly and successfully (Maddry et al., 2020). After the human flow is accomplished, it should be followed by the implementation of the EHR with the use of electronic handoff tools, which would provide improvement in documentation and access.

• Change Management Principles

Successful implementation demands that organizational culture and readiness for change be assessed. When the employees are convinced that the change will bring value and help the patient, there are good chances that they will accept the change. The leadership should be able to show its support of the new practices, thus developing the culture of responsibility and safety (Wallace et al., 2023).

It is essential to use transparent, open communication and ensure that leaders make clear to all the stakeholders the reason for that, the expected benefits, and responsibilities (Rhudy et al., 2022). The readiness can be realized by the early involvement of champions, a trial period in particular sections, and the resolution of the concerns through the feedback mechanism, making the resistance less and encouraging buy-in in the organization.

Fostering a Culture of Quality and Safety

The changes proposed to practice standardize handoffs, staff training, EHR integration, and performance monitoring are the direct effects of fostering a culture of quality and safety by incorporating consistent, evidence-based practices into day-to-day workflows. Synchronized communication reduces the likelihood of variations, and therefore, critical information is not misplaced when the change of shifts is experienced (Wallace et al., 2023).

Through training, the staff will have the ability and the confidence to focus on the safety of the patient at all times. Routine of the process guarantees that accountability and professional responsibility, which are the components of a high-reliability culture, are reinforced (Maddry et al., 2020). This constant Learning and improvement are supported by regular feedback and audit that further institutionalize safety and quality as the values of the organization.

• Importance of Transparency in Delivering Successful Outcomes

Transparency is essential for successful change since it creates a sense of trust, promotes honest communication, and allows for an environment that is non-punitive and where safety issues can be discussed openly. It is also essential to be clear on the rationale for the changes in the practice so that staff members will be able to understand the impact of their activities on the patient outcome and know that they have the ability to make a difference towards enhancing the care (Atinga et al., 2024).

Transparency is beneficial because when information is shared, anything is visible, and anything is correctable, and cooperative as opposed to finger-pointing. Engagement of the staff can also be delivered because of the transparency in the processes, and this creates an open avenue in which staff can give their feedback and input, hence solutions that are better designed (Ahn et al., 2021). After all, there is no transparency of quality and safety, and when it comes to being abstract, these concepts are transparent to everyone working within the care team.

Impact of Organizational Culture or Hierarchy on Quality and Safety Outcomes

In a hierarchical organizational culture in which decision-making is top-down and communication is siloed, quality and safety outcomes may suffer. The frontline staff might be reluctant to raise their voice regarding the issues and the mistakes, as they are afraid of being punished or their contribution might seem useless (Kim et al., 2020). The interaction inhibits constructive criticism that may help to avert adverse incidents.

When such a culture does not have collaboration or psychological safety, it demolishes the implementation of evidence-based practice, such as the standardized handoffs (Maddry et al., 2020). Conversely, organizations that encourage shared governance, free communication, and inter-professional respect have a good chance of achieving better patient outcomes as the staff is emboldened to share in the quality program and raise issues concerning safety without incurring any stigma.

• Assumptions Based on the Analysis

One assumption is that all staff perceive the hierarchy in the same manner, but perceptions of organizational culture differ from one unit or job. Another assumption is that there is an awareness of leadership on the effects of hierarchy on frontline communication, which again may not be true (Nasiri et al., 2021).

It can also be supposed that I can easily change culture, but in fact, it will take a long time and leadership engagement. There are assumptions regarding the conclusion of the analysis that the development of staff will help to achieve better results, but it depends only on the systems that should involve them (Rhudy et al., 2022). It is crucial to identify and refute such assumptions, so the plans towards the change are close to reality and are all-inclusive.

Justification for Necessary Changes

Implementing standardized handoff protocols such as SBAR is essential in addressing adverse outcomes secondary to inconsistent communication. Problems with miscommunication that happen frequently during shift change and interdepartmental transfers in our organization result in duplicate tests, missed medications, and delayed interventions (Wallace et al., 2023).

These concerns are the result of poorly organized handoffs, differences in communication patterns between the providers, and the lack of responsibility to provide a complete transfer of patients. The implementation of SBAR will coordinate processes in various care units and minimize differences and information transfers with greater reliability (Ahn et al., 2021).

• Knowledge Gaps and Areas of Uncertainty

There are significant gaps in knowledge about staff understanding and consistent use of handoff protocols. Most supplying parties have never heard of evidence-based communications, such as SBAR, or even do not trust themselves when coming to the implementation in changing transitions (Kim et al., 2020).

Role accountability is fuzzy, i.e., who is directing, initiating, and performing the quality of handoff. Also, the ways that break communication are already tracked, and their solutions are not provided by the leadership, which is not clear (Rhudy et al., 2022). To ensure sustainable results in terms of quality and safety gains as a result of the interventions, such unknowns should be discovered.

Conclusion

Addressing quality and safety gaps identified through this analysis is critical to better patient outcomes and a culture of accountability and reliability. Uniformity of communication during handoff, improved training of staff, and incorporation of tools in EHR are feasible, evidence-based solutions in minimizing errors and continuity of care.

Through the closing of such gaps, the organization can improve its determination and confidence in patient safety, as well as interprofessional collaboration and effective patient-related improvements.

Explore Next Assessment: NURS FPX 6222 Assessment 3

Struggling with NURS FPX 6222 Assessment 2? Tutors Academy offers step-by-step guidance to improve grades, meet rubrics, and succeed confidently.