Quality and Safety Gap Analysis

Quality and Safety Gap Analysis

Healthcare delivery is organized around evidence-based strategies. One aspect of quality improvement in health care is exploring proven, evidence-based information and applying the information/knowledge to improve quality and safety outcomes. Every healthcare organization has the potential to improve care quality and overall system performance. When a gap in the care delivery process is identified, it is critical to propose evidence-based change and implement a plan to improve care.

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A systemic issue that contributes to poor quality and safety outcomes.

Hospital-Acquired Conditions (HACs) are conditions that patients develop while in the Hospital receiving treatment for another condition. Catheter-Associated Urinary Tract Infections (CAUTIs) are the most commonly reported hospital-acquired condition. Despite advances in infection prevention and control, CAUTIs remain common and problematic. CAUTI is a major cause of mortality and morbidity and presents a significant challenge to clinicians. CAUTI complications result in longer hospital stays, pain and discomfort, and higher healthcare costs. CAUTI is a major threat to patient safety and is estimated to cost $340 to $450 million annually (Hollenbeak & Schilling, 2018).

Sanders Medical Center (SMC) has struggled to manage CAUTIs, particularly in the last two years. The Hospital’s Quality and Safety Assurance department completed an analysis of the Hospital’s dashboard for 2019-2020 and released the data to various units for further evaluation and identification of quality gaps. While there are several areas of underperformance in terms of quality and safety, CAUTI is a major concern at SMC. In 2019, the Hospital reported 1.81 infections per 1000 line days. In 2020, the figure increased to 1.85 infections per 1000 line days. The National Healthcare Safety Network (NHSN) benchmark average for CAUTIs is 1.59 infections per 1000 line days. SMC is underperforming when it comes to CAUTI management.

To determine the causes of the increasing cases of CAUTIs, a process evaluation was carried out in collaboration with the catheter vendor. According to the analysis, only 80% of patient records contained appropriate clinical indications. Furthermore, only half of the patient records indicated appropriate peri-care. There is a need to improve the evaluation of clinical conditions, medical necessity, and peri-care.

Proposed Practice Changes That Will Improve Quality and Safety Outcomes

Although CAUTI is still a problem, studies have shown that by using evidence-based practice guidelines, the incidence of CAUTI can be significantly reduced (Connor, 2018). Analysis to determine the cause of CAUTIs at SMC revealed a lack of clinical indication in most patient records, documentation, and knowledge about peri-care. The most significant opportunity for improvement revolves around appropriate urinary catheter use, proper catheter insertion technique, surveillance, maintenance, documentation, and effective peri-care. These changes are consistent with the Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines.

During the daily 15-minute safety huddle, an interdisciplinary team comprised of the nurse manager, the charge nurse, and a physician will identify patients with catheters, the duration of catheter use, and the clinical indication for catheter use. Patients with catheters who do not have a clinical indication for catheter use will have their catheters removed by the approved catheter removal guidelines. The nurse in charge will check in with the nurse on duty during each shift to ensure proper orders are available and the process is documented.

This proposal also suggests a mandatory staff training program. The program’s theme will be patient safety, particularly concerning CAUTIs. All healthcare providers will be required to complete a one-week training program. The program is designed to provide staff with the most recent evidence-based practice guidelines for catheter use. Several strategies for preventing CAUTIs in healthcare organizations have been identified through research. The most important modifiable risk is using the catheter for the shortest possible time. Catheters will be used only when necessary by nurses. Catheters should only be inserted after careful consideration and appropriate indication. Urinary catheter insertion and duration of use should be limited, particularly in patients at high risk of CAUTI, such as the elderly and those with compromised immunity.

Prioritization of Proposed Change

To achieve and sustain CAUTI reduction at SMC, a strategy addressing clinical practice and culture is required. Although the literature recommends several evidence-based practices for CAUTI prevention, studies suggest that eliminating primary risk factors for CAUTI is the most critical and effective strategy for reducing CAUTI incidences. These risk factors include unnecessary use of indwelling urinary catheters, prolonged catheter use, and incorrect indications. To effectively mitigate CAUTI at SMC and sustain the improvement, the Hospital must promote appropriate indications for catheter placement and eliminate inappropriate indications. This can be accomplished through staff training. The guide should also encourage using catheters for the shortest possible time.

Additional evidence-based strategies, such as promoting a safety culture, are required. A safety culture consists of team values, attitudes, and beliefs that influence the team’s ability to provide quality care. All stakeholders are responsible for fAll stakeholders are responsible for fosteringehensive Unit-Based Safety Program (CUSP) is essen, anor strengthening the safety culture.

How Proposed Practice Changes Will Foster a Quality and Safety Culture

Historically, healthcare organizations promoted a culture of blame when an adverse event occurred. Individual care providers were held accountable for safety failures that were sometimes caused by a system-wide failure under this strategy. The fear of reporting CAUTI cases resulted in a failure cycle. Current evidence-based clinical practices and proposed strategies for CAUTI prevention will improve quality and safety outcomes. A Comprehensive Unit-Based Safety Program fosters a safe culture. The program works by assembling a multidisciplinary team involving senior leadership, identifying flaws, and implementing teamwork.

A strong staff training program will empower and equip employees with the necessary CAUTI prevention skills. These abilities include the proper indication for catheter use, monitoring and surveillance, removal, and peri-care. A shift huddle encourages team members to share ideas and raises awareness of the consequences of CAUTI. Well-organized workflow and documentation boost productivity and accountability, allowing the team to provide quality and safe care. The proposed strategies will improve quality and safety outcomes.

The Influence of Organizational Culture on Safety and Quality

The organizational culture impacts the organization’s quality and safety outcomes. An organisation’s culture is comprised of the leadership and the team’s values, attitudes, and beliefs, which influence the team’s ability to provide quality care (Azzolini et al., 2018). For the past two years, an assessment of the organization’s culture revealed that SMC had prioritized financial aspects, such as expanding the service line over quality. The Hospital reduced support hours to reallocate resources to expansion. SMC must focus on developing a safety culture. All stakeholders are responsible for fostering a safety culture at SMC.

The leadership of an organization has the greatest influence on its culture. Senior leadership and leadership styles are critical in improving nursing and patient outcomes (Purvis et al., 2017). Certain leadership cultures produce better healthcare outcomes than others. During a consultative meeting, nurses expressed dissatisfaction with leadership, particularly at the unit level. They complained about authoritarian leadership. This could have harmed their morale. There is a need for a transformational leadership culture that will positively impact the working environment, thereby affecting the quality of care. A transformational leadership culture encourages staff participation in quality improvement initiatives.

Changes Required to Enhance Safety and Quality

According to the quality and safety gap analysis, several areas require changes to reduce CAUTI incidences. There is a need for a safe culture that encourages open communication and information sharing among team members. A safe culture recognizes flaws in the system and implements evidence-based strategies to improve performance. Open communication during safety huddles and within the organization promotes teamwork while implementing the proposed practice guidelines (Siddiqui, 2016). Collaboration enables staff to work together to achieve the common goal of preventing CAUTI in the facility.

There is a need for change in nurse education. Nurse empowerment through training is critical in the prevention of CAUTIs. Training nurses give them the skills to implement the proposed practice guidelines. Employee training is critical in preparing employees for the change process in any improvement that involves change.

The leadership culture should shift from transactional to transformational leadership. The commitment of senior leadership to the right leadership culture will improve the work environment and promote teamwork. These elements are required to improve quality and safety outcomes.

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References

Azzolini, E., Ricciardi, W., & Gray, M. (2018). Healthcare organizational performance: why changing the culture matters. Annali dell’Istituto superiore di sanita, 54(1), 6-8.

Hollenbeak, C. S., & Schilling, A. L. (2018). The attributable cost of catheter-associated urinary tract infections in the United States: A systematic review. American Journal of Infection Control, 46(7), 751-757.

Connor, B. (2018). Best practices: CAUTI prevention. American Nurses Association. Purvis, S., Kennedy, G. D., Knobloch, M. J., Marver, A., Marx, J., Rees, S., … Shirley, D. (2017). Incorporation of Leadership Rounds in CAUTI Prevention Efforts. Journal of Nursing Care Quality, 32(4), 318–323.

Siddiqui, D. (2016). The Impact of Daily Safety Huddles on Safety Culture. Grand Canyon University.

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Quality and Safety Gap Analysis

The Gap Analysis is on Policies within the Hospital Hospitalwork.

The Attachments:

-Policy Gap Analysis–the past, current, and future status of where we are

-Policy Question–A survey was given to the staff on what policies they felt were needed

-Policy Survey–Results of the survey.