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NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Student Name

Capella University

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name


Quality and Safety Gap Analysis: Hospital-Acquired Infections

Healthcare organizations globally endeavor to uphold healthcare quality standards and enhance patient safety. Nonetheless, challenges persist within healthcare practices, often stemming from adverse events within the system. Hospital-acquired infections (HAIs) represent such adverse occurrences, significantly impacting care quality and patient safety. Recently identified within the Vila Health organization during a quality and safety audit, HAIs necessitate a thorough gap analysis to bridge the disparity between current and desired outcomes for enhancing quality and safety.

Systemic Problems Related to Quality and Safety Outcomes

HAIs, occurring within healthcare settings, manifest typically 48 hours after a patient’s admission (Monegro et al., 2023), often due to inadequate care practices. According to the World Health Organization (WHO), 8.7% of hospitalized patients experience HAIs, with urinary tract infections being prevalent. These infections lead to prolonged hospital stays, increased morbidity risks, financial burdens, and potentially fatal complications (Stewart et al., 2021). Addressing this issue necessitates a collaborative approach and healthcare providers’ commitment to change.

Practice Changes to Improve Quality and Safety Outcomes

Implementing targeted strategies like the Targeted Assessment for Prevention (TAP) by the Centers for Disease Control and Prevention is crucial (CDC, 2023). Prioritizing practices such as proper utilization of personal protective equipment (PPE), adherence to hand hygiene guidelines, maintaining environmental hygiene, and continuous staff training is essential for minimizing HAIs.

Prioritization of the Proposed Change Strategies

Among proposed strategies, prioritizing hand hygiene practices and healthcare professional education is paramount due to hands being significant germ transmission sources. CDC underscores the efficacy of proper hand hygiene in preventing antibiotic-resistant infections, highlighting its criticality for patient safety.

Quality and Safety Culture and its Evaluation

Enhancing quality and safety culture through inter-professional collaboration and continuous improvement efforts is imperative. Evaluation metrics including prevalence surveys, patient satisfaction levels, and staff knowledge assessments are essential for gauging the effectiveness of change strategies.

Organizational Culture Affecting Quality and Safety Outcomes

Organizational culture significantly influences quality and safety outcomes. Enhanced communication, adequate staffing, and fostering a culture of accountability are vital for improving care quality and patient safety.

Justification of Necessary Changes in an Organization

Organizational changes such as establishing inter-professional committees, implementing zero-tolerance policies for negligence, and ensuring adequate resource allocation are necessary steps to mitigate adverse quality and safety outcomes.


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NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Monegro, A. F., Muppidi, V., & Regunath, H. (2023). Hospital-acquired infections. In StatPearls. StatPearls Publishing. 

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 Infection114, 23–31. 

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NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis