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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.
Introduction
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.
Quality and safety are everyone’s responsibility as a team of interprofessional care delivery partners. Together we develop policies that support quality and safe care delivery. As part of the interprofessional team, nurses are leaders in care and thus are responsible and accountable for leading and providing safe quality care.
Health care delivery is structured around evidenced-based information. Quality is defined by exploring proven, evidenced-based information. After reviewing and defining evidenced-based information, the interprofessional team applies this knowledge to assess the organization’s or the practice setting’s ability to provide evidenced-based care delivery. When a gap in care is identified, it is important to propose an evidenced-based change and to execute a plan for improved care.
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.
As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
Culture and process contribute to our ability to develop and sustain quality and safety in a health care organization. By exploring these topics, you can analyze where you may have gaps in practice that affect outcomes. In addition, organizations must create benchmarks for outcomes to determine whether they are meeting quality and safety goals.
What does your organization measure, related to quality and safety, and why?
Are there certain aspects of your organization’s culture and processes that support or hinder quality and safety?
Is the organization meeting outcome measurement benchmarks?
If not, how might you address those gaps in performance? What system could be developed to support a change to close a particular gap?
The following resources are required to complete the assessment.
a systemic problem in your organization, practice setting, or area of interest that contributes to adverse quality and safety outcomes.
Propose specific practice changes that will improve quality and safety outcomes and bridge the gap between current and desired performance.
Prioritize proposed practice changes.
Determine how proposed practice changes will foster a culture of quality and safety.
Determine how a particular organizational culture or hierarchy might affect quality and safety outcomes.
Justify necessary changes with respect to functions, processes, or behaviors, specific to your organization.
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.
RUBRIC:
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 1: Analyze quality and safety outcomes from an administrative and systems perspective.
Identify a systemic problem in an organization related to adverse quality and safety outcomes.
Propose specific practice changes within an organization that will improve quality and safety outcomes and bridge the gap between current and desired performance.
Prioritize proposed practice changes.
Competency 2: Determine how outcome measures promote quality and safety processes within an organization.
Determine how proposed practice changes will foster a culture of quality and safety.
Competency 3: Determine how specific organizational functions, policies, processes, procedures, norms, and behaviors can be used to build reliable and high-performing organizations.
Determine how a particular organizational culture or hierarchy might affect or contribute to adverse quality and safety outcomes.
Justify necessary changes to particular organizational functions, processes, and behaviors that correct or mitigate adverse quality and safety outcomes.
Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
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..
Running head: QUALITY AND SAFETY GAP ANALYSIS 1
Quality and Safety Gap Analysis
Kathryn Forsyth
Capella University
Healthcare Quality Safety Management
Quality and Safety Gap Analysis
July, 2020
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QUALITY AND SAFETY GAP ANALYSIS 2
Quality and Safety Gap Analysis
Medication errors continues to be one of the most important areas to address in the
healthcare setting. These near miss or adverse events increase patient harm, reduce quality of
care, and increase healthcare costs. More common than adverse events are near misses by about
70%. Among the most common causes of death are preventable near misses and adverse events
in the United States (Nambiar, Das, & Chakravarty, 2016). This paper will review interventions
to decrease near misses and adverse events which will hopefully lead to solutions.
The process of administering medication is complex and involves multiple interactions
and high-risk activities. Errors can happen at any stage of the process, one third of errors that are
harmful to patients occur during the administration phase. Nurses administer most medications
therefore any errors that occur is the nurse’s responsibility. Nurses provide a safety against
medication errors by intercepting prescriber and pharmacists errors however they potentially
place the patient at risk as well (Cloete, 2015).
Adverse events (ADE) is related to overuse of medication, under use of medication, or
using the wrong medication. Adverse events are increasing yearly and is one of the main causes
of death for hospitalized people. Nurse turnover rates and increase nurse to patient ratio have
limited the quality of care provided by nurses. There are many responsibilities placed on nurses,
to include providing quality of care, being cost efficient, monitoring patients, checking all orders,
and verifying medications are correct. With high patient caseloads, the nurse is often tired and
that is when errors are made. One of the highest adverse events on a unit is medication errors,
which is about 50% of all mistakes reported (Nambier, 2016).
On the 50 bed burn unit in the past six months there has been an increase in administering
the wrong drug by 40% as well as an increase in administering the drug with the right time by
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QUALITY AND SAFETY GAP ANALYSIS 3
35%, the wrong route by 16%. These errors can be attributed to distractions, lack of drug
knowledge, and the physician not including enough information when writing the prescription.
This is trending upwards and this plan is to address the need to implement interventions to
address the issues. This unit has also had an influx of new graduate nurses which could be
another reason for the increase in errors. “Out of 168 participants, 55% admitted to making a
medication error. They reported the errors had resulted from lack of experience, lack of time,
unclear on the technology use, lack of adequate staffing, and needs of patients. Twenty-four
percent of the respondents did not report their errors due” (Treiber & Jones, 2018, page 277).
Plan
Due to rising medication errors, many facilities have added systems such as High
Reliability and encouraging self reporting without fear of adverse events. The application of
high-reliability principles in healthcare is being used for strategic planning. “The Joint
Commission established the Center for Transforming Healthcare to work on transforming
healthcare into a high-reliability industry. The Center and healthcare organizations work together
to analyze breakdown in care, determine underlying causes, and use the finding to educate
organizations. This effort shares data on near misses, adverse events to support learning,
prevention, and improvement” (Chochrane et al, 2017, page 63).
High reliability introduces methods to reduce ADE’s by addressing the need for
electronic checks, use of second person to verify information, and encouraging questions. Use of
the interventions in medication administration can reduce and prevent errors. This increases
safety, quality, and cost effectiveness (Hughes, 2008). High Reliability was introduced in 2013
which has led to an increase in quality of care and health initiatives (Chassin & Loeb, 2013).
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QUALITY AND SAFETY GAP ANALYSIS 4
New skills and ideas learned have been turned into sustainable improvements which has made
measurable change in medication administration (Chassin, 2013).
Most healthcare facilities are using technology to improve communication. Written
orders are often hard to read and lead to greater room for error. The electronic health records
provide legible orders, is verified by the doctor, pharmacist, and nurse. The admitting nurse also
review all medications with the patient to verify everything is correct. This ensures any missed
information is addressed, verified allergies, and decrease errors. This practice is based on high
reliability use of triple check system to improve safer health care (Chassen, 2013).
Focus for healthcare facilities should be on quality and safety of patients. Interventions
should focus on areas to reduce patient harm and increase safety (Hughes, 2008). High
Reliability not only focus’ on reducing medication errors but it addresses improving leadership,
culture of safety, and encouragement of continuous learning (Chassen, 2013). The first step of
the process is to start the triple check system, this will allow the nurse to use technology with a
fellow nurse to review the information and verify it is correct which will assist with catching
errors. Improving nurse education of pharmacology is needed for a better understanding of
medication. This will help the nurse know when to question an order and improve patient safety.
Around six percent of nurse do not have proper knowledge and understanding of medications
(Aronson, 2013).
Safer medication initiatives provider better outcomes for patients. Quality improvement
projects are dependent on ability to measure goals and self-reporting. By analyzing the data,
using statistics we can identify gaps in areas to be able to address the issues. The use of
technology has been able to better track interventions, goals, and outcomes. By using technology,
we are enabling the nurse to better care for the patient, verify information, research information
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QUALITY AND SAFETY GAP ANALYSIS 5
at bedside, and improve patient satisfaction. The focus is on interventions that improve nurse
knowledge, use of time, increase safety, and reduce near miss and adverse events.
Some barriers to the plan would include communication and a resistance to change by the
staff. Communicating with an interdisciplinary team, between staff, and with patients can be
difficult at times as there is a way a person speaks which may not be what the person
understands. We must remember to consider the ability of each person to understand what is
being said, nonmedical people will not understand medical language. To address this issue and
improve communication, the facility can use the SBAR tool. SBAR stands for situation,
background, assessment, recommendations (O’Shea & Roney, 2020). Use of the SBAR can
provide the staff with a method to provide a clear, concise report which leads to better patient
care.
Providing standard reporting tool, the nurse can provide effective communication, allows
the other party to ask questions, and have a better understanding of what is needed to be done
during their shift. This will also improve communication between nurse and patient/family. The
need to remain up to date on current evidence-based practices to improve quality, safety, patient
outcomes, and improve medication safety (Hughes, 2008). Administration needs to encourage
open, honest communication without fear of retribution to improve relationship and trust
between staff. This will improve self-reporting of near misses and adverse events that can
become teaching opportunities later.
Evidence based leadership (EBL) was created in response into organizational change to
research that identified alignment and accountability. EBL aligns all functions to prioritize goals
aligned with the mission, vision, and values of the organization. EBL is adaptable,
comprehensive, flexible, and scalable. EBL incorporates aligned goals, behaviors, and processes,
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QUALITY AND SAFETY GAP ANALYSIS 6
each with a set of tools and techniques. EBL is an integral process for culture transformation and
performance improvement, various goals and initiatives can be layered into the framework to
support the goals (Chochrane, 2017).
The organization administration and leadership are supportive of the need for new
policies and procedures related to medication administration. The need to decrease adverse
events and near misses on the burn unit is needed immediately. The first steps to implement a
double check system as well as increasing education on medications have been widely accepted
by all stakeholders. The leaders have agreed there is a need for improved communication and
will have a multidisciplinary team come up with a standard reporting tool that incorporates
SBAR.
Conclusion
Change is always challenging, however providing proper education, tools, resources, and
realistic interventions and goals can improve the willingness of staff to accept change.
Medication errors will likely always be an issue as there is a human component to medication
administration and humans make mistakes. We can implement ways to reduce errors, recognize
gaps, and improve communication to decrease errors, improve patient safety, and patient
outcomes. The healthcare system can implement safer interventions with the use of technology,
SBAR for handoffs, education, communication, and evidence-based leadership to help reduce
errors, improve communication, and potentially save lives.
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QUALITY AND SAFETY GAP ANALYSIS 7
References
Aronson, J. K. (2013). Medication errors: Definitions and classification. British Journal of
Clinical Pharmacology, 67(6), 599-604. doi:10.1111/j. 1365-2125.2009.03415.x
Chassin, M. R., & Loeb, J. M. (2013). High‐reliability health care: getting there from here. The
Milbank Quarterly, 91(3), 459-490.
Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice
(2014+), 14(1), 29. DOI:10.7748/cnp.14.1.29.e1148
Cochrane, B. S., Hagins, M., Picciano, G., King, J. A., Marshall, D. A., Nelson, B., & Deao, C.
(2017). High reliability in healthcare: Creating the culture and mindset for patient safety.
Los Angeles, CA: SAGE Publications. doi:10.1177/0840470416689314
Hughes, R. G (2008). Tools and Strategies for Quality Improvement and Patient Safety. Chapter
44. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK2682/
Nambiar, B. C., Das, A. K., & Chakravarty, A. (2016). Medication error: An unfortunate reality.
Medical Journal Armed Forces India, 72(3), 297-298. doi: 10.1016/j.mjafi.2015.04.011
O’Shea, E. R. & Roney, L. N. (2020). SBAR. Nurse Educator, Publish Ahead of Print,doi:
10.1097/NNE.0000000000000887.
Treiber L., Jones J.(2018). After the Medication Error: Recent Nursing Graduates’ Reflections on
Adequacy of Education. J Nurs Educ. 57(5) 275-280. doi: 10.3928/01484834-20180420-
04
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