NURS FPX 6212 Assessment 2 Executive Summary

Name

Capella university

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name

Date

Executive Summary

Hospital-Acquired Infections (HAIs) remain a significant challenge in healthcare, impacting patient safety, increasing costs, and lengthening hospital stays (Glowicz et al., 2023). Despite established infection control measures at Mayo Clinic Hospital – Rochester (MCH-R), HAIs continue to present risks to patient outcomes. This executive summary evaluates existing outcome measures related to HAIs at MCH-R, focusing on infection surveillance, targeted staff training, and infection control audits. The paper will also discuss the strategic value of these measures and the leadership support necessary for implementing these improvements. 

Quality and Safety Outcomes Measures

Primary quality and safety indicators at MCH-R for tracking HAIs include the incidence rates of Central Line-Associated Bloodstream Infections (CLABSI), Catheter-Associated Urinary Tract Infections (CAUTI), and Ventilator-Associated Events (VAE). Recent statistics show a CLABSI rate of 0.68 per 1,000 central line days, a CAUTI rate of 0.96 per 1,000 urinary catheter days, and a VAE rate of 6.58 per 1,000 ventilator days (Leapfrog, 2023). Although these rates indicate some improvement—up to a 16% reduction from the prior year—they remain areas of concern due to the potential harm and increased costs associated with HAIs (Leapfrog, 2023).

These outcomes are essential because HAIs have noteworthy risks to patient care, hospital visits, and increase healthcare charges, impacting both the patient experience and the organization’s resources. Tracking these outcomes is critical for assessing the effectiveness of infection control protocols and identifying areas where additional preventive measures are needed (Leistner et al., 2023). Failure to control HAIs can also lead to increased readmissions and potential penalties under regulatory frameworks, which directly affect MCH-R’s reputation and financial stability (Moghnieh et al., 2023).

While these outcome measures provide valuable insight, there are limitations. For example, more than HAI rates are required to fully capture the complexity of infection control challenges, such as staff adherence variability and environmental factors influencing infection risk. These measures, while informative, need to be complemented by real-time infection surveillance and staff training data to provide a more comprehensive view of MCH-R’s infection prevention efforts and identify gaps more precisely (Klompas et al., 2022). This combination of quantitative and qualitative data would strengthen the ability to drive targeted improvements in infection control.

Strategic Value of Outcome Measures

The rationale for monitoring HAI rates at MCH-R is its strategic relevance to the company’s operations and bottom line. Rates of CLABSI, CAUTI, and VAE are all outcome measures for HAIs and are important measures of patient safety and quality of care. Preventing HAIs also benefits patients by eliminating unnecessary complications, decreasing the length of hospital stay, and improving the time patients take to recover. The lower the HAI rate, the higher the standard of care, which in turn helps MCH-R maintain the patient’s trust in the evidence-based practice, which is beneficial for the organization and its credibility (Leapfrog, 2023).

HAI outcome measures also support organizational culture, which includes quality and safety. The constant check on the number of infections ensures that all the workers, from the nursing staff to top management, do not let go of the precautionary measures. Such constant vigilance creates a culture of safety, which compels staff to be more preventive rather than responsive to infection possibilities (Moghnieh et al., 2023). Identification of HAIs exposes the need for improvement, thus resulting in interventions, including real-time infection control and staff education, which are key in contributing to a safe healthcare environment.

NURS FPX 6212 Assessment 2 Executive Summary

This means that it is important to evaluate its HAI outcomes to sustain the mentioned effects and prevent such negative outcomes. Failing to capture these outcomes would mean that various infections would go unnoticed, there would be increased HAIs, and patients would be harmed unnecessarily. Moreover, there is a need to capture HAI risk penalties in regulatory and reimbursement models, which would harm the hospital’s reputation and finances.

Lack of measurement would create a major challenge in recognizing trends, making it difficult to provide interventions at the right time and consequently enhance infection prevention practices (Klompas et al., 2022). In particular, using these outcome measures for continuous analysis will help MCH-R improve its approaches to infection control and, therefore, provide more value through better patient outcomes, cost reduction, and compliance with strategic objectives for safe care.

Relationship Between Hospital-Acquired Infections and Quality and Safety Outcomes

HAIs at MCH-R pose a systemic problem, impacting patient security and care quality. The specific outcome measures related to this problem include CLABSI, CAUTI, and VAE rates. These measures are directly tied to HAIs, highlighting the frequency and severity of infections acquired during hospital stays, which reflect the effectiveness of MCH-R’s infection prevention protocols (Glowicz et al., 2023). The relationship between HAIs and these outcomes is critical: each occurrence not only extends patient recovery time but also elevates healthcare costs and increases the risk of further complications.

Data from MCH-R indicates recent improvements in infection rates, with CLABSI at 0.68 per 1,000 central-line days and CAUTI at 0.96 per 1,000 catheter days (Leapfrog, 2023). Despite these reductions, these rates remain above optimal levels, underscoring a persistent quality gap that impacts patient safety. To deepen understanding and address this issue, MCH-R could collect additional data on factors such as staff adherence to infection control protocols, patient demographics, and specific units with higher infection occurrences (Gray et al., 2023). This data could provide insights into targeted interventions, revealing patterns or compliance gaps and ultimately supporting more effective infection control strategies across the hospital. 

Outcome Measures and Strategic Initiatives

HAIs are a concern for MCH-R, and understanding CLABSI, CAUTI, and VAE rates will be helpful in its pursuit of strategic goals to enhance safety and quality. MCH-R’s strategic plan uses evidence sources, patient safety, and improving care quality. Using these outcome measures directly supports the goals of MCH-R as it evaluates the success of infection prevention measures and the potential foci for successful interventions. Low rates in these measures over time would signify good infection control that suggests avoidance of preventable complications and harm to patients, which are central to the high-quality care model (Gray et al., 2023).

Not only do these outcome measures contribute to the success of strategic initiatives, but they also actively help foster a safe culture. HAI data should be reviewed often by MCH-R so that the organization can adjust its training, technology, and infection prevention to fill any shortcomings. It makes everyone on the project team continually evaluate their work, approach, and behaviors, essential in creating a safety culture. Moreover, the importance of these activities is evident due to increased attention to the safety culture and patient results in healthcare organizations (Perez, 2020). HAIs are linked to reimbursement rates and patient confidence; therefore, strong outcome measures for HAIs enable MCH-R to conform to new healthcare benchmarks while preserving its stellar image. 

Leadership Role

The leadership team at MCH-R can play a pivotal role in supporting the proposed changes to reduce HAIs, specifically through enhanced infection surveillance, targeted staff training, and frequent audits. Nurse leaders should begin by openly endorsing these changes, emphasizing their importance in aligning with MCH-R’s mission to provide high-quality, safe patient care. They can reinforce this support by facilitating resource allocation, including funding for advanced infection surveillance technology and scheduling protected time for staff to participate in ongoing training sessions (Perez, 2020).

To foster adoption, nurse leaders could implement structured change management strategies, including holding team meetings to discuss the proposed changes, outlining each team member’s responsibilities, and providing continuous feedback. Regular updates and transparency about progress can engage and motivate staff, showing them how their efforts reduce HAIs and enhance patient safety. Leaders should also encourage interprofessional collaboration by bringing together infection prevention specialists, nurses, and support staff to share insights and ensure unified implementation. This approach would be effective because it reinforces a shared commitment to safety, enables collective problem-solving, and empowers each discipline to contribute to improved patient outcomes (Gray et al., 2023). By actively supporting these initiatives, leadership can embed a preventive, quality-focused culture across the organization.

Conclusion 

Reducing HAIs at MCH-R requires targeted interventions, including advanced infection surveillance, staff training, and regular audits. These outcome measures are strategically valuable for enhancing patient safety and supporting a culture of continuous quality improvement. Leadership support and interprofessional collaboration are essential to successfully implementing these changes. MCH-R can make substantial progress toward zero preventable HAIs and improved patient care outcomes by focusing on these initiatives.

References

Glowicz, J. B., Landon, E., Bennett, E. E., Aiello, A. E., deKay, K., Hoffmann, K. K., Maragakis, L., Olmsted, R. N., Polgreen, P. M., Trexler, P. A., VanAmringe, M. A., Wood, A. R., Yokoe, D., & Ellingson, K. D. (2023). SHEA/IDSA/APIC practice recommendation: Strategies to prevent healthcare-associated infections through hand hygiene: 2022 update. Infection Control & Hospital Epidemiology, 44(3), 1–22. https://doi.org/10.1017/ice.2022.304 

NURS FPX 6212 Assessment 2 Executive Summary

Gray, J., Rachakonda, A., & Karnon, J. (2023). Pragmatic review of interventions to prevent catheter-associated urinary tract infections (CAUTI) in adult inpatients. Journal of Hospital Infection, 136(1), 55–74. https://doi.org/10.1016/j.jhin.2023.03.020 

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 

Leistner, R., Kohlmorgen, B., Brodzinski, A., Schwab, F., Lemke, E., Gregor Zakonsky, & Gastmeier, P. (2023). Environmental cleaning to prevent hospital-acquired infections on non-intensive care units: A pragmatic, single-centre, cluster randomized controlled, crossover trial comparing soap-based, disinfection and probiotic cleaning. Clinical Medicine, 59. https://doi.org/10.1016/j.eclinm.2023.101958 

Moghnieh, R., Al-Maani, A. S., Berro, J., Ibrahim, N., Attieh, R., Abdallah, D., Al-Ajmi, J., Hamdani, D., Abdulrazzaq, N., Omar, A., Al-Khawaja, S., Al-Abadla, R., Al-Ratrout, S., Gharaibeh, M., Abdelrahim, Z., Azrag, H., Amiri, K. M., Berry, A., Hagali, B., & Kadhim, J. (2023). Mapping of infection prevention and control education and training in some countries of the World Health Organization’s Eastern Mediterranean Region: Current situation and future needs. Antimicrobial Resistance and Infection Control, 12, 90. https://doi.org/10.1186/s13756-023-01299-9 

NURS FPX 6212 Assessment 2 Executive Summary

Perez, S. (2020). Increase in hospital-acquired carbapenem-resistant Acinetobacter baumannii infection and colonization in an acute care hospital during a surge in COVID-19 admissions — New Jersey, February–July 2020. MMWR. Morbidity and Mortality Weekly Report, 69(48), 1827–1831. https://doi.org/10.15585/mmwr.mm6948e1