NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

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Capella university

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name

Date

Quality and Safety Gap Analysis

Hospital-acquired infections (HAIs) are a serious challenge to patient security and quality of care, impacting recovery and increasing healthcare costs. At Mayo Clinic Hospital – Rochester (MCH-R), HAIs remain a critical concern despite existing infection control protocols (Mayo Clinic, 2020). This analysis examines the gap between current and desired performance in preventing HAIs, focusing on implementing real-time infection surveillance, enhanced staff training, and regular infection control audits. 

Hospital-Acquired Infections as a Systemic Quality and Safety Issue

HAIs represent a systemic quality and safety challenge at MCH-R. Although the hospital has shown reduced HAIs across infection types, as reflected in the 2023 data, these infections continue to pose risks to patient safety and health outcomes. For instance, current rates include 0.68 Central-Line Associated Bloodstream Infections (CLABSI) per 1,000 central-line days, 0.96 Catheter-Associated Urinary Tract Infections (CAUTI) per 1,000 catheter days, and 6.58 Ventilator-Associated Events (VAE) per 1,000 ventilator days (Leapfrog, 2023). Despite a decrease of up to 16% from the previous year, these infection rates indicate areas where the potential for harm to patients remains a significant concern.

HAIs contribute to adverse quality and safety outcomes by increasing patient morbidity, lengthening hospital stays, and elevating healthcare costs (Leapfrog, 2023). For example, patients who contract infections such as CLABSI often require additional treatments and monitoring, leading to delayed recovery and heightened risk of further complications. The financial burden of HAIs is considerable, impacting both patients and the healthcare system, as resources are diverted to treat preventable infections.

Failure to address these infections could result in higher readmission rates, loss of patient trust, and potential penalties under regulatory and reimbursement frameworks. Remaining knowledge gaps and uncertainties include identifying which specific factors contribute most to HAI risk, determining the most effective interventions for sustained infection control, and addressing potential variations in staff adherence to infection control protocols (Grasselli et al., 2021). Addressing these uncertainties through targeted changes could significantly improve patient care and quality. 

Practice Changes

This performance gap in MCH-R is about further decreasing the HAIs to eliminate any preventable cases from occurring. Even though recent data shows that there are improvements in infection rates, HAIs such as CLABSI and CAUTI pose continued threats to patient care quality. This gap indicates the potential for improving the degree of compliance with the measures described above and their constant monitoring and training of personnel (Mayo Clinic, 2020). Such a new approach includes enhanced infection surveillance systems that give out alerts when there is a deviation from the set measures to enable rectification, eliminating human errors.

The second recommendation is the more frequent targeted reinforcement of infection prevention training, especially for those employees who work in high-risk zones, to make sure that they remember the principles of infection prevention and use them correctly (Haque et al., 2020). Last but not least, increasing daily infection control audits, particularly in the high-risk area bed, will assist in finding out the noncompliance with the laid down standards in real-time. These changes assume that increased vigilance and staff education will increase compliance with preventive measures to decrease HAIs. These intervention strategies are expected to reduce the infections and enhance patient outcomes by reducing HAIs (Klompas et al., 2022).

Prioritization of the Proposed Change Strategies

Therefore, the most pressing change opportunity for MCH-R is to adopt an advanced infection surveillance technology since it addresses the issue of response to infection risks most urgently. These alerts help staff avoid deviations in following protocols, and hence, the ability to fight infections makes this technology vital for achieving the hospital’s vision of zero preventable HAI cases. This intervention is congruent with the organization’s policy of Evidence-Based Practice and contributes to achieving the program’s strategic plan of improving patient safety and quality (Grasselli et al., 2021).

The second focus is expanding targeted infection prevention staff education in specific high-risk wards. It also ensures that staff is knowledgeable and capable of adhering to the correct application of infection control measures, thus minimizing the chances of human error. Continuing education promotes safety and contributes to the hospital’s strategic plan of learning (Haque et al., 2020). Finally, increasing daily infection control audits comes third on the list. Though it can be critical, it only becomes so if the staff have yet to be trained adequately or if the technology cannot respond to threats of infection (Klompas et al., 2022). These prioritized changes fit into the hospital’s strategic plan to implement evidence-based care and improvement, advancing the Mayo Clinic’s mission of safe, effective patient care.

Quality and Safety Culture and its Evaluation

The changes to cut HAIs on MCH-R are a proposal for an improved system for infection surveillance, staff training, and audits on infection control that aim at developing a responsive and responsible culture of quality and safety. These interventions also offer resources for enhancing infection control efforts and, simultaneously, change the perception of constant awareness and individual contributions in combating HAIs. For example, through the use of real-time surveillance technology supported by high-end equipment, staff is allowed to monitor and respond to risks as they occur, thus underlining the importance of prevention and quick action. This can likely create a culture that embraces more real-time, continuous appraisals as crucial to patient patient safety (Druckerman et al., 2021).

Infection prevention training for specific populations enhances a quality culture because staff achieves the knowledge and self-assurance of implementing the best infection prevention practices and subsequently demonstrates reliable infection prevention behavior. This training can help build team identity and create a common purpose in improving patient safety. Widening the options for infection control audits brings constant chances to discuss quality activities with the staff and emphasize that everyone contributes to creating and maintaining safety conditions (Okeah et al., 2021).

However, one of the main challenges in implementing these improvements is to transform the staff from having a reactive approach to having a preventive one. However, the current culture is one of continuous improvement, and to fully adopt a prevention-first culture means focusing less on incidents and more on compliance. Measures that could be used to assess the success of this culture change may include the number of staff who adhere to the implementation of infection control measures, the number of cases of HAIs after the implementation of this change, and responses from the personnel concerning their level of confidence in averting infections (Okeah et al., 2021). These indicators will show whether the organizational culture is genuinely preventive and safety-oriented.

Organizational Culture Affecting Quality and Safety Outcomes

MCH-R’s culture is committed to excellence and innovation and is grounded in evidence-based practices and collaborative patient care. However, the hospital’s structured hierarchy can create barriers to quality and safety outcomes, particularly regarding HAIs. While leadership is supportive, the complexity of layered decision-making processes can sometimes delay rapid responses to emerging infection risks, limiting the organization’s ability to prevent HAIs proactively. Infection prevention relies on a collaborative culture where staff feel empowered to identify and act on risks without needing extensive approval.

However, in a hierarchical setting, staff may hesitate to raise concerns or suggest changes, fearing they need more authority to address issues independently. This hierarchy can unintentionally foster a reactive rather than proactive approach, where issues are addressed only after they escalate (Van et al., 2020). Assuming that enhancing communication across all levels of the hierarchy can bridge this gap, the proposed changes—real-time infection surveillance and targeted training—are designed to empower all staff levels (Okeah et al., 2021).

Justification of Necessary Changes in an Organization

Advanced infection surveillance technology, targeted infection prevention training, and improved infection control audits are important modifications that MCH-R needs to make in order to combat HAIs. Research findings suggest that technology-based infection control systems lower the incidence of HAIs by promptly alerting the care staff so that they can take timely and appropriate measures to contain the HAI. This technology fosters a preventive strategy in safety management, consistent with the theoretical models that call for early interventions as fundamental to preventing safety events (Druckerman et al., 2021). Increased infection prevention training promotes change in staff behavior within and across disciplines and increases staff knowledge and adherence to measures.

Existing theories in adult education indicate that continued, focused training leads to better recall is critical for consistent infection prevention. Moreover, increasing daily infection control audits will extend routine responsibility to increase the staff’s engagement in checking and enhancing their performance. These changes are needed because they address specific processes—communication, risk management, and interprofessional relationships—related to infection control (Okeah et al., 2021). This way, the organization can control HAIs by enhancing adherence to protocols, developing a preventive culture, integrating real-time response systems, and adding meaning to Mayo Clinic’s mission of offering safe and high-quality health services (Druckerman et al., 2021).

Conclusion

To improve the infection control and safety profile of MCH-R, specific modifications must now be made. Using real-time surveillance training and auditing will make the culture within the organization more preventive than just reactive. These changes reflect best practices and relate to Mayo Clinic’s strategic plan for patient quality and safety.

References

Druckerman, D. G., Appelbaum, N., Cooper, K., Stevens, M. P., Godbout, E., Bearman, G., & Doll, M. E. (2021). Healthcare worker perceptions of hand hygiene monitoring technologies: Does technology performance matter? Infection Control & Hospital Epidemiology, 42(12), 1–2. https://doi.org/10.1017/ice.2021.286 

Grasselli, G., Scaravilli, V., Mangioni, D., Scudeller, L., Alagna, L., Bartoletti, M., Bellani, G., Biagioni, E., Bonfanti, P., Bottino, N., Coloretti, I., Cutuli, S. L., Pascale, G. D., Ferlicca, D., Fior, G., Forastieri, A., Franzetti, M., Greco, M., & Guzzardella, A. (2021). Hospital-acquired infections in critically ill patients with COVID-19. CHEST, 160(2), 454–465. https://doi.org/10.1016/j.chest.2021.04.002

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Haque, M., McKimm, J., Sartelli, M., Dhingra, S., Labricciosa, F. M., Islam, S., Jahan, D., Nusrat, T., Chowdhury, T. S., Coccolini, F., Iskandar, K., Catena, F., & Charan, J. (2020). Strategies to prevent healthcare-associated infections: A narrative overview. Risk Management and Healthcare Policy, 13(1), 1765–1780. https://doi.org/10.2147/RMHP.S269315 

Klompas, M., Branson, R., Cawcutt, K., Crist, M., Eichenwald, E. C., Greene, L. R., Lee, G., Maragakis, L. L., Powell, K., Priebe, G. P., Speck, K., Yokoe, D. S., & Berenholtz, S. M. (2022). Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 update. Infection Control & Hospital Epidemiology, 43(6), 1–27. https://doi.org/10.1017/ice.2022.88 

Leapfrog. (2023, November 3). New hospital safety grades from the leapfrog group find improved infection rates following major spike during COVID-19 pandemic. Leapfrog.gov. https://www.leapfroggroup.org/news-events/new-hospital-safety-grades-leapfrog-group-find-improved-infection-rates-following-major 

Mayo Clinic. (2020). Mayo Clinic’s campus in Minnesota. Mayoclinic.org. https://www.mayoclinic.org/patient-visitor-guide/minnesota 

Okeah, B. O., Morrison, V., & Huws, J. C. (2021). Antimicrobial stewardship and infection prevention interventions targeting healthcare-associated Clostridioides difficile and carbapenem-resistant Klebsiella pneumoniae infections: A scoping review. British Medical Journal Open, 11(8), e051983. https://doi.org/10.1136/bmjopen-2021-051983 

Van, T., Annis, A. M., Yosef, M., Robinson, C. H., Duffy, S. A., Li, Y.-F., Taylor, B. A., Krein, S., Sullivan, S. C., & Sales, A. (2020). Nurse staffing and healthcare-associated infections in a national healthcare system that implemented a nurse staffing directive: Multi-level interrupted time series analyses. International Journal of Nursing Studies, 104, 103531. https://doi.org/10.1016/j.ijnurstu.2020.103531

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis