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 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.
Your quality and safety gap analysis will provide the basis for the remaining assessments in this course.
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.
Note: As you revise your writing, check out the resources listed on the Writing Center’s Writing Support page.
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
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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.
• APA Style Paper Tutorial [DOCX]. Use this for your gap analysis.
Note: The requirements outlined below correspond to the grading criteria in the Quality and Safety Gap Analysis Scoring Guide. Be sure that your written analysis addresses each point, at a minimum. You may also want to read the Quality and Safety Gap Analysis Scoring Guide and Guiding Questions: Quality and Safety Gap Analysis [DOCX] to better understand how each criterion will be assessed.
• Identify 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.
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.
Format your document using APA style.
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• Use the APA Style Paper Tutorial [DOCX]. Be sure to include:
o A title page and reference page. An abstract is not required. o A running head on all pages. o Appropriate section headings. o Properly-formatted citations and references.
• Your analysis should be 4-5 pages in length, not including the title page and reference page.
Portfolio Prompt: You may choose to save your gap analysis to your ePortfolio.
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.
o 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.
o 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.
o Communicate analysis data and information clearly and accurately, using correct grammar and mechanics.
o Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.
