NURS FPX 6212 Assessment 1

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NURS FPX 6212 Assessment 1

Quality and Safety Gap Analysis

The purpose of the safety gap analysis is to determine the current state of safe, high-quality patient care and the desired state. Hospital-acquired infections (HAIs) are on the rise in a manner that concerns Vila Health.

There are two types of these infections: such as catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs). It is estimated that 15% of patients in low and middle-income countries and 7% of patients in high-income countries who are admitted to acute-care hospitals will develop at least one HAI.

Systemic Issue Related to a Safety or Quality Outcome

Vila Health is currently addressing the issue of the increasing incidence of hospital-acquired infections (HAIs). These HAI rates are very high for the company in comparison to the national standards and its own targets. This is a big issue.

HAIs also affect people’s confidence in the healthcare system and they are viewed as a mark that the organization is not one of the safest and most compassionate to seek treatment from. Some aspects of the problem are not following effective infection control measures, inadequate staff training, poor environmental hygiene, and poor drug management strategies (Deryabina et al. , 202<).

Therefore, with such high rates of HAIs, Vila Health needs to act as this is the only way it can continue to fulfill its mission of delivering safe quality care and continue to put the patient first.

Consequences of Not Addressing the Problem

Failure to address the root cause of high HAI rates will have adverse effects on patients, the organization’s reputation, and Vila Health’s profitability. The health of patients will still be in danger if HAIs are not corrected.

They will also increase the cost of healthcare, result in more cases, and undermine public confidence in the system’s capacity to deliver safe and quality care (Jukola & Gadebusch Bondio, 2022). If Vila Health does not address this critical issue related to quality and safety, it may damage their reputation, lose its license, and possibly shut down its operations.

Specific Practice Changes for Improving Quality and Safety Outcomes

The performance gap at Vila Health can be identified as the significant discrepancy between the current high rates of HAIs and Vila Health’s aim to reduce or eliminate these infections. As HAIs jeopardize the patient’s life, reduce the efficacy of the treatment, and hinder the provision of effective and safe care (Gidey et al. , 2023) this gap relates to quality and safety.

Failing to close this gap allows a problem to persist that jeopardizes the welfare of patients and erodes the public’s confidence in the health facility. To fill this gap, the plan employs a combination approach that involves making changes in behavior that are evidence-based. First, the occurrence of HAIs can be reduced through educating and reminding the staff on proper infection control measures like hand hygiene, aseptic techniques, catheters and lines care (Evans et al. , 2022).

These changes have been proven to enhance the quality and safety of the delivered services, address the performance divide and safeguard the health of patients. They would also discuss the factors that lead to HAIs.

Prioritizing Specific Practice Changes

First, the staff will get to know more about the formal evidence-based infection control measure. This is in agreement with the changes that Vila Health is implementing due to the high incidences of HAIs. The purpose of this change is to prevent healthcare-associated infections (HAIs) and it is crucial to maintain the healthcare environment to be safe and clean.

Through educating the healthcare workers on the correct hand hygiene, aseptic techniques, insertion and care of catheters and lines, Vila Health can significantly reduce the incidence of HAIs and enhance patient safety, which should be Vila Health’s main goal. The next crucial step is to begin a good antibiotic management policy. This will ensure that the drugs are used appropriately and prevent the emergence of drug-resistant bacteria that can fuel the spread of HAIs.

The purpose of this change is to offer quality care, evidence-based, resource stewardship, and sustainability of the system (Stenehjem et al. , 2022).

Proposed Changes in Fostering Quality and Safety Outcomes

Vila Health said that the changes that they are going to implement in their work in order to reduce the rates of HAIs may contribute to creation of new quality and safety standards for the company. When staff members are provided with further education and training on evidence-based infection control measures, they will be able to understand the significance of their job in reducing HAIs and enhancing patients’ health.

Everyone will be more aware, accurate, and willing to follow guidelines since they are now more informed and accountable (Omori et al. , 2022). All of these are key elements of a powerful quality and safety culture. A full drug control program and better cleaning methods also reveal that the organization is committed to improving, making evidence-based decisions and patient care.

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Individuals may have become accustomed to some practices, teams might not be effective, or some managers might not be prepared to provide assistance or appropriate resources (Wang et al. , 2023), which could pose a challenge in altering the organization in such a significant manner. It will require good communication, a team of people from different departments, and commitment from the management to address these issues as strategic objectives.

Factors Affecting Organizational Culture and Hierarchy Adversely

The culture and the structure of Vila Health as an organization can greatly influence the quality and safety, including the prevention of HAIs. Culture today comprises of such things as routines, compartments, and rigidity where change is concerned.

These may hinder the implementation of the recommended ideas (Durant & Guerrazzi-Young, 2022). It will not be possible to eliminate HAIs and promote patient safety in the community if organizations are hierarchical and do not permit interdisciplinary collaboration or empower frontline workers.

However, transformational leadership can transform the culture and organization of a company, which may reduce the rate of HAIs. Vila Health transformational leaders can encourage the healthcare workers by establishing the aim of patient-centered excellence, not tolerating any avoidable harm, and ensuring that everyone is accountable, communicative, and constantly learning.

Transformational leaders can also foster conditions where people collaborate to apply evidence-based practices. This fosters shared responsibility and results in improved quality and safety results including a significant reduction in the incidence of hospital-associated infections (Chan et al. , 202·). Some of the ways that can be done include: Involving front-line staff, tearing down the walls of leadership, and empowering cross-disciplinary teams.

Justification of Necessary Changes to Organizational Culture

To determine why Vila Health has to change in order to reduce the number of HAIs it has, the company should examine all of its roles, procedures, and practices.

Transformational leadership is significant because it has the potential to alter the attitude and make it more important to focus on patient care. To ensure that change management is sustainable, the following are vital: good communication, teamwork, and the ability to empower all employees to challenge the current systems. As for how to improve things and ensure that best practices are followed, good quality processes are also required (Mohammed & AL-Abrrow, 2022).

The decisions are made based on data, and what is happening in infection control measures is monitored and assessed frequently.

Lean management concepts and the Plan-Do-Study-Act (PDSA) cycle are two theories that provide a solution to improve outcomes and eliminate non-value added activities and waste based on data. To support the suggested steps, there is a need to change the way money is managed.

As pointed out by Kazadi (2023), funds should be provided to train the employees, implement measures that will help to control the use of antibiotics and purchase new cleaning equipment. Using instruments for safety and risk assessment, such as event reporting systems and root cause analysis, may prevent potential HAIs from occurring in the future.

This is because Vila Health has high HAI rates that threaten the safety of patients, the quality of care, and the reputation of the organization. One by one the causes of HAIs are now being altered. Some of these changes are; Poor hygiene, wrong drug administration, and poor sanitation.

Vila Health can significantly reduce the adverse quality and safety impacts of HAIS by enhancing leadership, embracing the culture of improvement, optimizing workflows, and ensuring that employees adhere to the best practices that have been proven effective (Porto et al. , 2022). This will ensure the patients’ health and regain the public’s confidence in the organization.


A very high number of HAIs are occurring in Vila Health, which may be considered as a cause for concern. There are two types of these infections: Urinary tract infections that are associated with catheters (CAUTIs) and blood stream infections associated with central lines (CLABSIs).

The gap between the current state of the organization and the desired state is a significant risk to patient safety, care, and the reputation of the organization. To address this, a more comprehensive approach is recommended. This includes enhanced staff education on how to prevent infections, initiation of good drug management practices, and enhanced measures in cleaning and hygiene of the environment.

If you need complete information about class 6025, click below to view a related sample:
NURS FPX 6025 Assessment 3


Chan, R. J., Knowles, R., Hunter, S., Conroy, T., Tieu, M., & Kitson, A. (2023). From evidence-based practice to knowledge translation: What is the difference? What are the roles of nurse leaders? Seminars in Oncology Nursing39(1), 151363.

Deryabina, A., Ainur Aiypkhanova, Almat Juvashev, Kuanysh Alimbetov, Kanat Tekebayev, Getachew Mullu Kassa, & Howard, A. A. (2023). Core components of infection prevention and control programs at the facility level in Kazakhstan: key challenges and opportunities. Antimicrobial Resistance and Infection Control12(1).

Durant, D. J., & Guerrazzi-Young, C. (2022). Evaluation of a statewide collaborative focused on antibioitc usage surveillance and stewardship in New York State Hospitals. American Journal of Infection Control, 51(7).

Evans, M. E., Simbartl, L. A., Kralovic, S. M., Clifton, M., DeRoos, K., McCauley, B. P., Gauldin, N., Flarida, L. K., Gamage, S. D., Jones, M. M., & Roselle, G. A. (2022). Healthcare-associated infections in veterans affairs acute and long-term healthcare facilities during the Coronavirus Disease 2019 (COVID-19) pandemic. Infection Control & Hospital Epidemiology, 44(3), 1–24.

Gidey, K., Gidey, M. T., Hailu, B. Y., Gebreamlak, Z. B., & Niriayo, Y. L. (2023). Clinical and economic burden of healthcare-associated infections: A prospective cohort study. PLOS ONE18(2).

Gordon, J. P., Amer Al Taie, Miller, R. L., Dennis, J. W., Blaskovich, M. A. T., Iredell, J. R., Turnidge, J. D., Coombs, G. W., David Charles Grolman, & Youssef, J. (2023). Quantifying the economic and clinical value of reducing antimicrobial resistance in gram-negative pathogens causing hospital-acquired infections in Australia. Infectious Diseases and Therapy, 12.

Jukola, S., & Gadebusch Bondio, M. (2022). Not in their hands only: Hospital hygiene, evidence and collective moral responsibility. Medicine, Health Care and Philosophy26(1), 37–48.

Katyal, S., Srivastav, S., Katoch, O., Rodrigues, C., Rupali, P., Chakrabarti, A., Ray, P., Biswal, M., Tak, V., Nath, R., Mukhopadhyay, C., Bhattacharya, S., Padmaja, K., Deotale, V., Venkatesh, V., Wattal, C., Ma, T., Nag, V. L., Ray, R., & Behera, B. (2023). A self-reported survey on the implementation of infection prevention and control elements in Indian hospitals, part of a HAI surveillance network: Results from 23 hospitals conducting a standardized IPC assessment. American Journal of Infection Control51(1), 29–34.

Kazadi, S. (2023). Reducing inefficiencies in the healthcare sector by using lean principles: A South African case study.

Mohammed, A. A., & AL-Abrrow, H. (2022). The impact of empowering and transformational leadership on organizational performance and innovation: The mediating role of shared leadership and moderating role of organizational culture in the Iraqi healthcare sector. International Journal of Organizational Analysis31(7).

Omori, K., Shigemoto, N., Kitagawa, H., Nomura, T., Kaiki, Y., Miyaji, K., Akita, T., Kobayashi, T., Hattori, M., Hasunuma, N., Tanaka, J., & Ohge, H. (2022). Virtual reality as a learning tool for improving infection control procedures. American Journal of Infection Control, 51(2).

Porto, A. P. M., Borges, I. C., Buss, L., Machado, A., Bassetti, B. R., Cocentino, B., Bicalho, C. S., Carrilho, C. M. D. M., Rodrigues, C., Neto, E. A. S., Girão, E. S., Piastrelli, F., Sapienza, G., Varkulja, G., Kolbe, K., Passos, L., Esteves, P., Gitirana, P., Feijó, R. D. F., & Coutinho, R. L. (2022). Healthcare-associated infections on the intensive care unit in 21 Brazilian hospitals during the early months of the coronavirus disease 2019 (COVID-19) pandemic: An ecological study. Infection Control & Hospital Epidemiology, 44(2), 1–7.

Sharma, R., & Paul, J. (2023). Prevention of hospital acquired infections: A scoping review.

Stenehjem, E. A., Braun, B. I., Chitavi, S. O., Hyun, D. Y., Schmaltz, S. P., Fakih, M. G., Neuhauser, M. M., Davidson, L. E., Meyer, M. J., Tamma, P. D., Dodds-Ashley, E. S., & Baker, D. W. (2022). Use of leading practices in US hospital antimicrobial stewardship programs. Infection Control & Hospital Epidemiology, 44(6), 1–8.

Tangeraas Hansen, M. J., Storm, M., Syre, H., Dalen, I., & Husebø, A. M. L. (2023). Attitudes and self‐efficacy towards infection prevention and control and antibiotic stewardship among nurses: A mixed‐methods study. Journal of Clinical Nursing, 32(17).

Wang, L., Zhang, D., Liu, J., Tang, Y., Zhou, Q., Lai, X., Zheng, F., Wang, Q., Zhang, X., & Cheng, J. (2023). The mediating role of incentives in association between leadership attention and self-perceived continuous improvement in infection prevention and control among medical staff: A cross-sectional survey. Frontiers in Public Health11.

World Health Organization. (2022, May 6). WHO launches first ever global report on infection prevention and control.

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