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NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Quality and Safety Gap Analysis

In practically every healthcare facility, not just in the US but all throughout the world, there are systemic issues. Although some healthcare organizations encounter comparable problems, every healthcare facility deals with a unique systemic challenge (Willems, J., & Ingerfurth, S., 2018). The systemic issue in certain businesses may affect the whole building or a specific department. In terms of systemic issues, Augusta University Medical Center is not an exception. Catheter-associated urinary infections, or CAUTIs, are the present concern that is seen as a widespread issue at AUMC (Augusta University Medical Center). Over the past year, AUMC has dealt with a few CAUTI instances to the point where patients have begun moving based on the severity from one unit to the intermediate/progressive care unit as well as other healthcare facilities. 

Identification of the Systemic Problem

A urinary tube (urinary catheter) that has been implanted to drain urine from the bladder can induce infection of the urinary tract, which is referred to as a CAUTI (Ganley et al., 2022). At AUMC, CAUTIs have been a major issue. The healthcare professional and organization as a whole have also been impacted in addition to the patient. Some patients have been raising concerns about CAUTIs, which can worsen medical problems, extend hospital stays, and raise the price of medical care (Ganley et al., 2022). The problem, however, solely affects patients using improperly maintained urine catheters in the acute setting. In addition to the matters referred by the patients, the hospital has been negatively impacted by the systemic issue due to a decline in the number of patients that come to the institution, lost profits, and a high nurse retention rate (Ganley et al., 2022). As a result, several CAUTI-related topics have been covered, including the need for practice adjustments and how organizational factors impact the patient’s efficiency and reliability of the outcome. 

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

The facility is also negatively impacted because fewer patients are being seen each day, which results in lower profit. All the Augusta University Medical Center’s CAUTI patients have recovered from their illnesses as a result of multiple treatments (Augusta University Medical Center, n.d.). But in order to prevent further negative impacts, the problem needs to be treated immediately. If CAUTIs are not treated, some of the effects may include acute kidney injury, CKD (chronic kidney disease), or perhaps mortality (Ganley et al., 2022).

Changes that will improve Quality and Safety Outcomes

When bacteria invade the urinary catheter and alter the urinary tract system, a patient typically develops the start of a CAUTI (Hill et al., 2020).   That can occur in a variety of ways. The urinary bag may not be properly emptied, which can result in urine backflow, the catheter may not be inserted using sterile technique, and finally, the catheter care may not be completed successfully (Hill et al., 2020). CAUTIs can either be considerably decreased or totally averted if these factors are managed. An Aseptic approach, cleaning and sterilizing catheter tips before insertion, and making sure the urethra has been thoroughly cleaned are some of the practice modifications that should be made (Hill et al., 2020). By preventing bacteria from entering the urinary tract, these suggested adjustments help to enhance outcomes by preventing CAUTIs from arising. 

Proposed Practice Changes

The recommended modifications are essential for CAUTI prevention, but their significance varies. Although some of the suggested adjustments should be prioritized for tackling CAUTIs because they are more critical than others (Sartelli et al., 2020). Aseptic procedure should be given primary attention among the aforementioned practice adjustments. This is the approach to providing healthcare services that tries to reduce the possibility that a patient would experience different problems, such as infections. Aseptic method, also known as sterile technique, is used to prevent CAUTIs and include complete hand washing, cleaning of all instruments, and donning the protective gear as required (Sartelli et al., 2020). The sterilization of urinary catheters is the practice modification that can be regarded as coming in second place in terms of importance. This procedure reduces the likelihood of a patient getting a CAUTI by making sure the urinary catheters being used are clean (Sartelli et al., 2020). Clearing the urinary bag fully to prevent any leftover urine from backing up into the bladder would be the third practice modification in the priority hierarchy. The urinary tract is contaminated and a kidney infection, also known as a CAUTI, results when urine from the drainage bag backflows through the ureter to the kidneys. This condition is known as VUR (Vesicoureteral Reflux) (Sartelli et al., 2020). The efficiency and patient safety in preventing CAUTIs have been taken into consideration when assessing the priority of the proposed practice adjustments. These procedures support the organization’s strategic objective for lowering catheter-associated urinary tract infections (Sartelli et al., 2020). 

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Implementation of Changes that foster a Culture of Quality and Safety

A safety and quality-oriented culture can be improved in a number of ways by the suggested measures. By learning new techniques for inserting urinary catheters, the healthcare professionals who work in the inpatient unit will be capable of improving the health and wellbeing of their patients (Van Buijtene, 2019). By altering the care provider’s viewpoint of managing urinary catheters, these competencies will enhance their thoughts and actions in the coordination of healthcare. The recommended practices gradually become part of the setting’s culture as more healthcare professionals, particularly nurses, use them. As a result, the patient’s health circumstances in the inpatient unit will change, decreasing their risk of contracting CAUTIs (Van Buijtene, 2019).

However, it can be difficult for the recommended practices to become ingrained in the facility’s culture, even though the practice improvements are considerably more advantageous to the organization in terms of minimizing CAUTIs. This is in part because healthcare professionals grow wary of change when it occurs at work. The culture among facility personnel is that certain employees are under-trained or lack expertise when it comes to appreciating the significance of lowering catheter associated UTIs (Van Buijtene, 2019). 

Outcomes affected by Organizational Cultures

The personnel at Augusta University Medical Center occasionally resists change, based on the institution’s culture. Therefore, persuading the healthcare industry to accept the suggested reforms may be more difficult. The facility also employs a simulated chain of command, which requires that any changes that must be made in the environment be informed to the adjacent junior or senior level (Augusta University Medical Center, n.d.). Should any of the employees in this situation fail to release important knowledge, no change can be made. Lastly, the company practices participative approach, where the majority’s choice is implemented. The recommended methods cannot be put into practice if the majority rejects the change (Augusta University Medical Center, n.d.).

Justifying the Necessary Changes

The conceptual model will help in changing several organizational, quality-related, risk- and protection, interactions, and leadership-related activities, among others. Kurt Lewin’s Change Model or Spradley’s Theory of Change are the two theories that should be taken into consideration (Hussain et al., 2018). According to Spradley’s Theory of Change, there are eight steps: identifying the necessity for adjustment, diagnosing the issue, evaluating potential solutions, choosing the change to be implemented, planning the change, carrying it out, evaluating it, and stabilizing the change (Hussain et al., 2018). To match the problem that needs to be solved, each step needs to be precisely calculated. The Lewin’s Change Model is the next pertinent hypothesis. The three phases of unfreezing, changing, and refreezing are used in this hypothesis (Hussain et al., 2018). The goal of the unfreezing stage is to raise awareness of the ways in which the organization is hampered in some way by the status quo, or present level of acceptance. Through successful collaboration and research, the organization’s perceptions are dispelled. The change’s execution, known as “transitioning” or “moving,” characterizes the altering stage. At this point, the shift manifests. Refreezing in the third stage represents the process of bolstering, stabilizing, and consolidating the changed condition (Hussain et al., 2018). Changes to organizational procedures, objectives, structures, programs, or personnel are recognized as the new standard and refrozen. The organization’s culture has been altered by the transition. These adjustments are required because they advocate for a culture of safety and excellence (Hussain et al., 2018). As a result, the new improvements successfully prevent any potentially negative repercussions.

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis


Willems, J., & Ingerfurth, S. (2018). The quality perception gap between employees and patients in hospitals. Health Care Management Review, 43(2), 157-167. https://doi.org/10.1097/HMR.0000000000000137

Ganley, E., Coriat, A., Shenow, S., & Prosser, D. (2022). Systemic problems require systemic solutions: The need for coordination and cooperation to improve research quality. BMC Research Notes, 15(1), 51-51. https://doi.org/10.1186/s13104-022-05932-5

Hill, J. E., Stephani, A., Sapple, P., & Clegg, A. J. (2020). The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: A systematic review. Implementation Science: IS, 15(1), 23-23. https://doi.org/10.1186/s13012-020-0975-2

Van Buijtene, A., & Foster, D. (2019;2018;). Does a hospital culture influence adherence to infection prevention and control and rates of healthcare associated infection? A literature reviews. SAGE Publications. https://doi.org/10.1177/1757177418805833

Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Kurt lewin’s change model: A critical review of the role of leadership and employee involvement in organizational change. Journal of Innovation & Knowledge, 3(3), 123- 127. https://doi.org/10.1016/j.jik.2016.07.002

Sartelli, M., Pagani, L., Iannazzo, S., Moro, M. L., Viale, P., Pan, A., Ansaloni, L., Coccolini, F., D’Errico, M. M., Agreiter, I., Amadio Nespola, G., Barchiesi, F., Benigni, V., Binazzi, R., Cappanera, S., Chiodera, A., Cola, V., Corsi, D., Cortese, F., . . . Catena, F. (2020). A proposal for a comprehensive approach to infections across the surgical pathway. World Journal of Emergency Surgery, 15(1), 13- 13. https://doi.org/10.1186/s13017-020-00295-3

Augusta University Medical Center. (n.d). Statistics and Rates. Retrieved October 2022. From https://www.augusta.edu/mcg/fammed/cauti.php

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