Your quality and safety gap analysis will provide the basis for the remaining assessments in this course. As a nurse leader, you are fully aware of the hazardous nature of health care and

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Quality and Safety Gap Analysis

Alexandra Woods

Capella University

Health Care Quality and Safety Management

February 2023

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Quality and Safety Gap Analysis

Every team member on an interprofessional healthcare team is responsible for the quality

and safety of the care we provide to the patient. The care we provide is formulated from

evidence-based best practices and is constantly being updated as we learn more. This is what

makes it high-quality care. However, gaps in care can lead to poor quality and safety outcomes

for our patients, so continuous monitoring for gaps is essential.

Identification of a Systematic Problem

Hospital-acquired infections are infections that are contracted during a patient’s time in a

hospital-setting. While there are numerous types of hospital-acquired infections, one of the most

dangerous and most costly is a central line-associated bloodstream infection (CLABSI). This is

an infection of the blood stream that occurs after insertion or access of a central line during the

hospital stay (Agency for Healthcare Research and Quality, 2017). Once an infection reaches the

bloodstream, the infection can spread throughout the rest of the body, leading to high mortality

rates. CLABSIs are completely preventable by following evidence-based practices during

insertion and while maintaining the central line during the hospital stay. While this type of

infection should never take place, our organization still sees higher rates of CLABSI than

expected on a yearly basis. This systemic problem is related to adverse quality and safety

outcomes, including significant personal cost to the patient and to the hospital. The patient has

adverse outcomes in that now they are requiring additional testing, procedures, antibiotics, a

prolonged hospital stay, end up with a larger hospital bill, and in some instances end up dying

(Haynes, et al., 2022). The hospital has adverse outcomes in that the Center for Medicare and

Medicaid services no longer reimburses for many hospital-acquired infections, and a CLABSI

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incurs an additional cost of approximately $48,000 per event (Agency for Healthcare Research

and Quality, 2017). Not only this, but the hospital damages its reputation for high-quality care

with each hospital-acquired infection that occurs. This analysis assumes that CLABSIs are solely

based on deviation in care. One knowledge gap is whether an analysis has been completed on the

manufacturers of central line kits to determine if there is a deviation in sterility practices when

making the product.

Proposed Practice Changes and Prioritization

Within our organization, there are multiple practice changes that can be implemented to

reduce our rates of CLABSIs. The first and most important practice change is to implement a

CLABSI prevention “bundle” order set. This practice change is the number one priority because

it will have the largest direct effect on the safety of our patients. The bundle will include

elements from well-established scientific data and are considered the standard of care in caring

for a central line. The key elements will include standardized protocols for insertion of central

lines and maintenance of central lines that will be imbedded within the patient’s chart. These

standardized protocols will be ordered in the EMR for each patient that has a central line so that

all care for central lines is being carried out identically through our organization. This

standardization will decrease the likelihood of deviation from evidence-based best practice and

in turn, decrease the chances of a central line infection. Our current practice includes following a

protocol that is located within the hospital’s intranet and not readily available within the EMR.

This unavailability causes some team members to skip reviewing the protocol and providing care

based on memory, since it becomes too time consuming to find the protocol. We want team

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members to be able to quickly and easily retrieve the policy at the bedside as they are about to

provide central line care so they can follow the evidence-based practice of best care.

The second priority practice change within our organization is to implement an audit tool

for the insertion and care of central lines. Our current practice for insertion of central lines

includes completing a “time out” prior to insertion to ensure we have the right patient, right

procedure, etc. However, there is nothing beyond that to ensure that the line was placed

according to our protocol. Central line insertion is meant to be a sterile procedure in order to

prevent an infection. All care thereafter is meant to be sterile as well. Central line dressings must

be changed every seven days and the dressing change must be a sterile practice. The practice

change that will improve the quality and safety outcomes of for central lines will be to

implement an audit tool that is meant to be filled out by a second team member during all

insertions and dressing changes to ensure that sterile technique was used per our protocol. This

practice change will ensure that a second set of eyes was present during the completion of sterile

technique and can be a second set of hands if needed to help avoid deviating from standard

technique. This priority is the second priority because it is a secondary way of ensuring staff is

practicing standard of care for central lines to decrease the chances of CLABSI in addition to the

first priority of ensuring all team members have easy access to the standard of care protocols.

The third priority practice change for this organization will be to implement a CLABSI

Committee. We do not currently have a committee that solely focuses on the reduction of

CLABSI events. Having this committee will bridge the gap in quality and safety outcomes

because this diverse group of team members will monitor for compliance with the new practice

changes and make changes as needed to the practices as new evidence emerges in best care of

central lines. This practice change takes third priority since the other two previously stated

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changes directly affect the safety of the patient, while this change mostly effects the culture of

our organization.

Fostering a Culture of Quality and Safety

These proposed practice changes will foster a culture of quality and safety within our

organization by giving team members evidence-based standards on which to practice the best

care they can for our patients. This should instill a sense of pride amongst our team members and

drive them to always want to be better. And leadership amongst are organization are typically

utilizing a transformational leadership style. This type of leadership has a strong focus on

motivating and engaging staff, and providing an environment that empowers them to become

effective and creative team members (Alban-Metcalfe, 2018). Practicing mindfulness in how we

care for central lines and striving for perfection in this effort will help build a culture in which

small, point-of-care improvements and attention to details are celebrated by leadership (Blouin,

2013). After the proposed practice changes are implemented and have become imbedded in the

everyday practices of our team members, we would like to do an appreciate inquiry to evaluate

how these changes have affected our organization’s culture.

Effects of Culture on Quality and Safety

Healthcare cultures and hierarchies are often damaging to quality and safety outcomes.

Too often in many sectors of the working world, we see a culture amongst workers of wanting to

do the bare minimum for the most pay possible. This is catastrophic within the healthcare sector.

This type of culture can lead to poor patient outcomes since healthcare workers are often not

motivated to care for patients the way they deserve. When healthcare workers are not interested

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in following best practices when providing care to our patients, more hospital-acquired infections

and adverse events are bound to occur. And healthcare hierarchies are also a common challenge.

We too often see physicians who feel they know what is best when practicing care based on their

personal training and experience instead of on what the organization has deemed best practice. In

terms of CLABSIs, this could lead to increased rate since physicians insert central lines

regularly. If they are not following evidence-based protocols because they feel their technique is

superior, bacteria and other contaminants can be introduced to the blood stream during that

process and the patient will ultimately pay the price for the physician’s mistakes.

Necessary Organizational Changes

A necessary change to our organization will already be implemented within the

previously mentioned proposed changes will be to create a CLABSI committee. In taking this

further, we could mitigate adverse quality and safety outcomes related to hierarchy concerns by

selecting a diverse group of a team members from different realms of the organization to be on

the committee. This will allow for all aspects of our healthcare organization, from physicians to

nurses to the clinical documentation team, to have input on standardization of central line care

and will eliminate this hierarchy challenge since everyone will have an equal voice on the

committee. And as previously mentioned, continuing to utilize a transformational leadership

style throughout our organization will help mitigate any unmotivated behaviors of team members

in caring for our patients properly to help avoid adverse quality and safety outcomes.

Conclusion

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This quality and safety gap analysis revealed that our organization has opportunities for

improvement as it relates to central line-acquired blood stream infections. A few simple but

effective changes to our current practices could help in decreasing our CLABSI rates, ensuring

an improvement in quality and safety outcomes for our patients. In doing so, we can also

positively affect our organizations culture in caring for our patients, as a team, the best we can.

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References

Alban-Metcalfe, J., & Alimo-Metcalfe, B. (2018). Engaging Leadership – a better approach to

leading a team?. Nursing Times, 114, 21. http://library.capella.edu/login?qurl=https%3A %2F%2Fwww.proquest.com%2Fmagazines%2Fengaging-leadership-better-approach- leading-team%2Fdocview%2F2091249373%2Fse-2%3Faccountid%3D27965

Agency for Healthcare Research and Quality. (2017). Estimating the Additional Hospital

Inpatient Cost and Mortality Associated with Selected Hospital-Acquired Conditions.

AHRQ. https://www.ahrq.gov/hai/pfp/haccost2017.html

Blouin, A. S. (2013). High Reliability: Truly Achieving Healthcare Quality and Safety. Frontiers

of Health Services Management, 29(3), 35-40. http://library.capella.edu/login?qurl=https

%3A%2F%2Fwww.proquest.com%2Fscholarly-journals%2Fhigh-reliability-truly-

achievinghealthcare%2Fdocview%2F1352763812%2Fse-2%3Faccountid%3D27965

Haynes, M., Mosley, E., Stauffer, K. (2022). CAUTI/CLABSI Reduction. BayCare.

https://baycare1.sharepoint.com/sites/PS/SiteAssets/Forms/AllItems.aspx?id=%2Fsites%

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Running Head: SAFETY GAP ANALYSIS ON PATIENT INJURIES 1

Safety Gap Analysis on Patient Injuries

Irene Zepeda

Capella University

MSN-FP 6212 Healthcare Quality and Safety Management

Quality and Safety Gap Analysis

September 2019

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SAFETY GAP ANALYSIS ON PATIENT INJURIES 2

Safety Gap Analysis on Patient Injuries

Systematic Problem related to Adverse Quality and Safety Outcomes

Healthcare professionals who suffer from burnout syndrome provide poor quality and

unsafe care to patients some that have resulted in failure to rescue and death. “It has been noted

that 70% of physicians and 30-50% of nurses worldwide experience professional burnout during

their working life” (Anagnostopoulos, Bogiatzaki, Frengidou, 2019). Burnout syndrome is a

feeling of fatigue, physical and emotional exhaustion, low levels of empathy, and dissatisfaction

in the workplace due to poor working environment (Anagnostopoulos, Bogiatzaki, Frengidou, et

al, 2018). Burnout is a result of understaffing, nurse shortage, and unrealistic workloads (Aiken,

Clarke, Sloane, 2002). Burnout is also a result of poor working environments that include

insufficient time to complete tasks, role conflict, poor collaboration amongst healthcare

professionals (Fitzpatrick, Bloore & Blake, 2019). “The Agency for Healthcare Research and

Quality estimate that burnout affects 10-70% of nurses, 30-50% of physicians, nurse

practitioners and physician assistants” (Bridgeman, Bridgeman, & Barone, 2018).

One study was conducted to obtain research on hospital staffing and patient outcomes

after analyzing data from 210 adult general hospitals in Pennsylvania (Aiken, Clarke, Sloane, et

al., 2002). The study concluded of the 232342 patient studied 53813 experienced a major

complication not present on admission and 4535 died within 30 days of admission (Aiken,

Clarke, Sloane, et al., 2002). “The study surveyed employees finding higher emotional

exhaustion and greater job dissatisfaction in nurses were strongly associated with patient-to-

nurse rations” (Aiken, Clarke, Sloane, et al., 2002). Hospitals are required to have adequate

staffing to provide safe and effective care to the patients they serve. Burnout syndrome increases

staff absenteeism and requires for other nurses to work additional shifts causing fatigue, feeling

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SAFETY GAP ANALYSIS ON PATIENT INJURIES 3

of being overwhelmed, anxiety, depression, and the possibility of making medication errors,

failing to assess patients properly, and even failing to rescue.

Burnout may also be caused by other factors, little is known about the number of jobs

healthcare professionals hold and how many hours they work per week. Little is known about the

relationship between patient experience, quality of care, and poor working environments

(Montgomery, Panagopoulou, et al., 2013). No research results yielded for how many jobs

healthcare professionals hold and how many hours they work at each organization per week.

More research is needed to evaluate the relationship between empathy and burnout as well as

burnout amongst non-physician and non-nursing healthcare professionals (Montgomery,

Panagopoulou, et al., 2013).

Bridging Gap between current and desired Performance

A proposed practice change within organizations across the United States to improve

quality and safety outcomes for patient is to adopt California’s current legislative mandate of a

minimum hospital patient-to-nurse ratio of five to one. This has significantly improved patient

outcomes, quality care, patient safety and patient satisfaction within that respected state. This

results in reduced burnout among nursing staff and improving working environment conditions.

(Aiken, Clarke, Sloane, & 2002).

Another proposed practice change includes enforcing the Maslach Burnout Inventory

annually to evaluate staff’s feeling of burnout. This would allow management to make necessary

accommodations to the staffing or offer support to improve or reduce the feeling of being burned

out. The Maslach Burnout Inventory evaluates risk factors for the development of burnout such

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SAFETY GAP ANALYSIS ON PATIENT INJURIES 4

as workload, lack of control in the workplace, rewards, community, fairness, values and job-

person incongruity (Bridgeman, Bridgeman, & Joseph, 2018).

Another proposed practice change includes clinical ladder programs and professional

development programs. “Clinical ladder programs promote education, experience,

professionalism, leadership, teaching, and advocacy, frequently with the potential for monetary

compensation” (Fitzpatrick, Bloore, & Blake, 2019). Professional development programs for

staff include offering additional certification to enhance learning and personal accomplishment

and provide educational assistance for future healthcare professionals and for current employees

who want to pursue an advanced degree in healthcare.

Promoting a healthy working environment can improve employee morale with an end

result of safer and quality care provided to the patients they serve. Nurses in the organization can

be encouraged to participate in shared governance, to advocate for their professional (Fitzpatrick,

Bloore, & Blake, 2019).

Practice Changes

In order in importance first, is to pass legislative policy to mandate all hospitals with

medical-surgical units to not exceed a nurse-to-patient ratio of five to one. Limiting nurse to

patient ratio to five to one allows nurses to assess their patient more frequently, provide safer

medical care, and improve patient satisfaction and patient outcomes.

Second, promote staff to participate in shared governance, this will allow current

employees to have their voices heard and assist in making legislative changes that meet their

needs. Employees who actively participate in decision-making policies feel empowered and

valued and are more likely to be committed to the organization but also reduce burnout and

provide better care to their patients.

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SAFETY GAP ANALYSIS ON PATIENT INJURIES 5

Third, to promote healthcare education assistance to individuals who desire a degree in

healthcare. This would alleviate the burden on students who are interested in obtaining higher

education but do not have the means to attend. This will result in an increase in people seeking

employment opportunities and an increase in staff to reduce inadequate staffing problems.

Third, promoting advanced education within the organization. Clinical ladder

advancement programs allow management to see which employees are seeking to gain new

knowledge and commit to their organization. This will reduce employee turnover and improve

job satisfaction.

Introduce an annual evaluation of employee feelings of burnout by administering the

Maslach Burnout Inventory. By conducting this annually would bring insight to management and

Directors knowledge on how employees view their workload, feelings of being in control,

reward system, community, fairness, values and job-person incongruity (Bridgeman, Bridgeman,

& Barone, 2018).

Fostering Culture of Quality and Safety

Proposed practice changes will foster a culture of quality and safety by

improving patient safety, satisfaction and outcomes by reducing the number of patients one nurse

is assigned during their shift. Promote educational assistance by offering scholarships to

graduating students who seek a healthcare profession who meet grade point average criteria, as

well as offer employees tuition assistance if they seek to advance their education and career

within the organization.

Criteria to evaluate patient outcomes include having patients fill out a patient satisfaction survey

after being discharged from the hospital, as well as having nurses complete a job satisfaction

survey every six months to assess their views on their job. Organizations can evaluate this by

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SAFETY GAP ANALYSIS ON PATIENT INJURIES 6

assessing their staffing needs every quarter and view how many new hires took advantage of

their tuition assistance programs.

Currently organizations with patient ratios that are high than five-to-one will be impacted

either by the burden of nursing shortages or cost of care provided. If organization have a seven-

to-one nurse-to-patient ratio with four nurses working in a medical surgical unit will now have to

have six nurses on the floor per shift. Organizational administrators or executives will have to

take into consider the burden of outweighing costs of staffing over the

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