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.
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Introduction
Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented.
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 outcome 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 on 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 are therefore responsible and accountable for leading and providing safe quality care.
Healthcare delivery is structured around evidence-based information. Quality is defined by exploring proven, evidence-based information. After reviewing and defining evidence-based information, the interprofessional team applies this knowledge to assess the organization’s or the practice setting’s ability to provide evidence-based care delivery. When a gap in care is identified, it is important to propose an evidence-based change and execute a plan for improved care.
Note: Your quality and safety gap analysis will provide the basis for the remaining assessments in this course.
Scenario
As a nurse leader, you are fully aware of the hazardous nature of health care and that organizations must continually work to improve the quality and safety of the care they provide to patients. For this assessment, you will identify a systemic problem in a practice setting that is associated with adverse quality and safety outcomes. For example, you could look at an increase in transition of care deficits or the lack of integrated technology to support positive health outcomes. You will then analyze the gap between current and desired performance.
Your gap analysis will provide the basis for the remaining assessments in this course.
Note: The following topics cannot be used for this assessment.
Patient falls.
Medication errors.
Instructions
Perform a quality and safety gap analysis.
The requirements outlined below correspond to the grading criteria in the Quality and Safety Gap Analysis rubric, so be sure to address each point. You may also want to review the performance level descriptions for each criterion to see how your work will be assessed.
Conducting the Gap Analysis
Identify a systemic problem in your practice setting that contributes to adverse quality and safety outcomes and should be the focus for change.
What knowledge gaps or areas of uncertainty may need to be addressed as you think about potential changes?
What are the barriers that contribute to the systemic problem? What quality measures are impacted by the identified problem?
Propose specific practice changes that will improve quality and safety outcomes and bridge the gap between current and desired performance.
Consider the assumptions on which the proposal is based, and how to address them.
Prioritize proposed practice changes.
Include change management principles, such as organizational culture, readiness, and communication.
Determine how proposed practice changes will foster a culture of quality and safety.
Discuss the importance of transparency in delivering successful outcomes.
Determine how a particular organizational culture or hierarchy might affect quality and safety outcomes.
Consider what assumptions could arise based on the analysis.
Justify necessary changes with respect to functions, processes, or behaviors specific to your organization that correct or mitigate adverse quality and safety outcomes.
Identify knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty.
Writing and 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. Use 3–4 scholarly or professional sources.
Submission Requirements
Length: 4–5 pages, typed and double-spaced, not including title and reference pages.
Resources: Use 4–6 scholarly or professional sources with APA format citations.
APA formatting: Resources and citations are formatted according to the current APA style. Be sure to include:
A title page and a reference page. An abstract is not required.
Appropriate section headings.
Properly formatted citations and references.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and rubric criteria:
Competency 1: Analyze quality and safety outcomes from an administrative and systems perspective.
Identify a systemic problem in your practice setting that contributes to adverse quality and safety outcomes and should be the focus for change.
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, and integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.
Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.
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Criterion 1
Identify a systemic problem in your practice setting that contributes to adverse quality and safety outcomes and should be the focus for change.
Distinguished
Identifies a systemic problem in an organization related to adverse quality and safety outcomes, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty.
Proficient
Identifies a systemic problem in an organization related to adverse quality and safety outcomes.
Basic
Attempts to identify a systemic problem, but fails to explain how the problem contributes to adverse quality or safety outcomes.
Non Performance
Does not identify a systemic problem in an organization related to adverse quality and safety outcomes.
Criterion 2
Propose specific practice changes within an organization that will improve quality and safety outcomes and bridge the gap between current and desired performance.
Distinguished
Proposes specific practice changes within an organization that will improve quality and safety outcomes and bridge the gap between current and desired performance, and identifies assumptions on which the proposal is based.
Proficient
Proposes specific practice changes within an organization that will improve quality and safety outcomes and bridge the gap between current and desired performance.
Basic
Proposes specific practice changes, but fails to explain how the proposed changes will result in better outcomes.
Non Performance
Does not propose specific practice changes within an organization that will improve quality and safety outcomes and bridge the gap between current and desired performance.
Criterion 3
Prioritize proposed practice changes.
Distinguished
Prioritizes proposed practice changes, and provides sound rationale for the prioritization.
Proficient
Prioritizes proposed practice changes.
Basic
Sets priorities for proposed practice changes that do not adequately reflect their relative importance.
Non Performance
Does not prioritize proposed practice changes.
Criterion 4
Determine how proposed practice changes will foster a culture of quality and safety.
Distinguished
Determines how proposed practice changes foster a culture of quality and safety, and proposes criteria that could be used to evaluate that culture.
Proficient
Determines how proposed practice changes will foster a culture of quality and safety.
Basic
Attempts to determine how proposed practice changes foster a culture of quality and safety, but fails to explain why proposed changes will positively affect attitudes or behaviors.
Non Performance
Does not determine how proposed practice changes will foster a culture of quality and safety.
Criterion 5
Determine how a particular organizational culture or hierarchy might affect or contribute to adverse quality and safety outcomes.
Distinguished
Determines how a particular organizational culture or hierarchy might affect or contribute to adverse quality and safety outcomes, and identifies assumptions on which that analysis is based.
Proficient
Determines how a particular organizational culture or hierarchy might affect or contribute to adverse quality and safety outcomes.
Basic
Describes the organizational culture or hierarchy, but fails to explain how its characteristics might affect or contribute to adverse quality and safety outcomes.
Non Performance
Does not determine how a particular organizational culture or hierarchy might affect or contribute to adverse quality and safety outcomes.
Criterion 6
Justify necessary changes to particular organizational functions, processes, and behaviors that correct or mitigate adverse quality and safety outcomes.
Distinguished
Justifies necessary changes to particular organizational functions, processes, and behaviors that correct or mitigate adverse quality and safety outcomes, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty.
Proficient
Justifies necessary changes to particular organizational functions, processes, and behaviors that correct or mitigate adverse quality and safety outcomes.
Basic
Describes proposed changes to particular organizational functions, processes, and behaviors, but does not explain how each change might correct or mitigate adverse quality and safety outcomes.
Non Performance
Does not justify necessary changes to particular organizational functions, processes, and behaviors that correct or mitigate adverse quality and safety outcomes.
Criterion 7
Communicate analysis data and information clearly and accurately, using correct grammar and mechanics, and integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.
Distinguished
Communicates analyses and information clearly and accurately. Grammar and mechanics are error-free; integrates relevant, credible, and convincing sources of evidence to support assertions. Sources are current, and citations and references are error-free.
Proficient
Communicates analysis data and information clearly and accurately, using correct grammar and mechanics, and integrates relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.
Basic
Communication is not consistently clear and accurate, or errors in grammar or mechanics inhibit effective communication; sources lack relevance or credibility, are poorly integrated, or are incorrectly formatted.
Non Performance
Does not communicate analysis data and information clearly and accurately, using correct grammar and mechanics; does not integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.