NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

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Capella university

NURS-FPX 6212 Health Care Quality and Safety Management

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Date

 Quality and Safety Gap Analysis

Patient falls in medical settings are a major safety and quality problem, leading to adverse results, longer hospitalization, and higher clinical expenses. Patient falls cause injuries and complications, necessitating the change of practices. This assessment offers a gap analysis at Methodist University Hospital (MUH) to uncover the factors of patient falls. It will provide a research-based proposal to enhance patient safety and care standards by reducing inpatient falls.

Organizational Problems and Adverse Quality and Safety Outcomes

The recognized concern at MUH is patient falls that have serious repercussions. They put psychological, physical, and monetary stress on patients and medical facilities. According to the Centers for Medicare and Medicaid Services (CMS) data, the patient fall score of MUH hospital is 0.295 per 1000 people (Leapfrog, 2024), which fails to meet the standard score. The issue of patient falls in hospitals is persistent; the rate of inpatient falls varies between 1.7 and 16.9 for every 1000 patient visits. It adversely impacted care quality and patient safety, causing moderate (6.9 to 72.2%) and severe (0.8 to 30.1%) injuries.

In USA hospitals, 6 to 27% of all inpatient falls cause severe harm. Those who suffered injuries from falls had hospital costs of $4200 (Ghosh et al., 2022). Inpatient falls cause issues like fractures, heavy bleeding, brain trauma, and death. Patient falls are due to patients’ deteriorating health, medication, and mobility impairment. External variables entail institutional structures and physical conditions (Ghosh et al., 2022), like slippery floors, limited access to facilities, understaffing, and congestion, raising falling threats.

Failure to solve that problem negatively affects the MUH, including increased care expenses, longer hospitalizations, regulatory implications, poor patient satisfaction, and facility credibility. When patients sustain fall-related injuries, hospitals cannot get CMS compensation for care, putting enormous monetary strain on hospitals to avoid falls (Turner et al., 2020). Many information gaps and ambiguities remain, impeding preventive actions. More knowledge is necessary about the efficacy of the current fall avoidance solution, external variables, and technological innovation in fall control at MUH. 

Practice Changes

A recent internal inspection pointed out inconsistencies in implementing fall risk assessments and insufficient prevention efforts as factors that cause falls. This disparity compromises safety and quality results, as indicated by the MUH’s high rate of inpatient falls. The suggested practice shifts will help alleviate patient falls while enhancing safety and treatment quality. Firstly, establishing guidelines for measuring fall risk using risk evaluation tools at admittance and during hospitalization can assist medical staff in identifying high-risk patients and leading to preventative efforts.

Strini et al. (2021), asserted that The Joint Commission (TJC) Standards encourage hospitals to strive to lower the risk of fall injury through proper screening and risk evaluation tools. Secondly, conducting training and education for staff is a crucial practice change to reduce patient falls in MUH. Saki et al. (2023), stated that Training programs can help individuals understand controllable factors and implement fall prevention practices. It boosts nurses’ understanding of fall avoidance and improves their skills in avoiding patient falls in medical facilities. Thirdly, adopting environmental changes like adequate lighting, supportive devices, and patient tracking tools like sitters and bed alarms will aid MUH in avoiding patient fall incidents.

Lastly, an interdisciplinary fall mitigation group should be established to boost patient security.  A team of doctors, nurses, physiotherapists, and environmentalists can use their skills to devise efforts based on patient needs, eliminate threats, and boost patient results. Albertini and Peduzzi (2024), showed that cooperation and joint effort through interprofessional interaction and role clarification for preventing falls are critical to attaining favorable outcomes in fall prevention. The proposal assumes that collaborative efforts aid in analyzing patient fall threats and lowering fall incidents. Enhanced staff training avoids falls and boosts patient security. Environmental changes and risk analysis enable risk mitigation, limiting patient falls in MUH.

Prioritization of the Proposed Change Strategies

The modifications suggested in MUH are crucial to reducing fall incidents. Staff training is a crucial tool for increasing hospital patient security by educating them about fall prevention (Saki et al., 2023). This training boosts staff expertise and patient safety, which is consistent with the MUH’s goals of delivering quality healthcare. Training practice is top prioritized as competent staff can recognize fall hazards and adopt established methods to react swiftly to fall accidents. Establishing detailed fall risk assessment standards is the second priority, as discovering potential hazards depends on staff competence and guideline adherence, which is possible through training.

It will improve the standard of care practice, aiding MUH in fulfilling its mission. Integrating the transdisciplinary fall mitigation committee is prioritized as third. Through their skills, every teammate plays a role in avoiding fall incidents via thorough screening, risk analysis, and adopting measures to boost patient safety at MUH. Effective interaction and cooperation lead to fall control and better clinical results (Albertini & Peduzzi, 2024). Environmental changes are prioritized fourth, as TJC has expressed reservations regarding the excessive reliance on bed alerts as a preventive method (Turner et al., 2020). These changes help people who cannot keep their balance or have visual issues avoid falls at MUH.

Quality and Safety Culture and its Evaluation

Incorporating the suggested changes to practice would help to promote a safe and excellent culture at MUH by offering employees the expertise and abilities they need to avert falls and take charge of their conduct. Enabling medical staff via training improves medical service quality and encourages them to apply patient safety methods that lower patient fall incidents (Saki et al., 2023).

Extensive risk analysis guidelines will enable an accurate and ongoing patient analysis of fall chances and encourage an evidence-based approach to avoid hospital falls (Strini et al., 2021), boosting safety culture. A collaborative group will promote open debate and coordination among staff. It facilitate a coordinated approach to caring for patients to address fall hazards from multiple viewpoints and offers an integrated patient fall approach (Albertini & Peduzzi, 2024). Lastly, making environmental changes and patient tracking tools can assist in reducing fall risks by managing physical and environmental dangers. This proactive method boosts safety by lowering fall accidents and injuries at MUH.

The metrics for assessing the safety culture entail tracking the incidence of patient falls to know the success of the applied modifications. Fall rates will be monitored constantly from MUH’s dashboard. Lowering the fall rate reflects the efficacy of the applied strategies. Further, performing periodic inspections and input is vital to measure staff compliance with novel guidelines, participation, and staff and patient satisfaction. Employing a survey approach to evaluate the influence of training on personnel skills and compliance with threat assessment processes can aid in estimating the success of change and ensure improved care quality. These metrics deliver data and offer possibilities for further improvement to maintain a safety culture.

Organizational Culture Affecting Quality and Safety Outcomes

Culture relates to common values and procedures, while hierarchy is concerned with the dynamics of power and the framework of making choices in a corporation. These characteristics are affected by management and leadership qualities, which affect the efficacy and safety of a corporation like MUH. Traditional hierarchical structures in hospitals could hinder successful communication and event reporting. Nurses and freshly trained doctors could hesitate to disclose patient fall events or safety concerns for fear of repercussions and their jobs. Constructive institutional culture supports open dialogue and promotes patient welfare and security, reducing fall events. It also focuses on improving staff satisfaction and involvement and encourages reporting of nearly-misses and security problems.

According to Alabdullah and Karwowski (2024), prioritizing safety safeguards patients’ and staff’s well-being, mitigates inaccuracies and improves care levels within medical facilities. In contrast, a culture that values earnings over safety inhibits reporting inaccuracies, has unbending structures without collaborative decision-making settings, and faces raised security concerns, lower employee engagement, and insufficient reporting of hazardous events like patient falls, resulting in higher safety concerns. This examination implies that corporate culture and structure impact employee behavior, patient safety, and reporting issues. It also assumes that promoting a setting of open debate and collaborative responsibility and making choices positively affects care quality and safety.

Justification of Necessary Changes in an Organization

Applying vital changes at MUH to prevent poor safety and quality results due to inpatient falls needs an extensive strategy. Initially, leadership should prioritize quality and security by proactively promoting the proposal’s execution. Further, they must establish a framework where employees feel comfortable reporting fall incidences without fear. It allows leadership to promote acceptance of these practices to boost patient safety and care quality. The MUH must enhance surveillance techniques to assess the success of the suggested modifications. Frequent inspection of the measures can assist in identifying potential for enhancement, ensuring that safety efforts are accomplishing their goals, and promoting continual care improvement.

MUH must implement tools for risk management, like fall avoidance and surveillance systems. These systems aid fall management by sensing patients’ movements and rapid threat analysis through wearable and non-wearable sensors (Usmani et al., 2021). Efficient asset distribution, including investing in technology and funding staff training, is vital. Staff training helps educate them on the skills required to control patient falls and overcome deficiencies (Saki et al., 2023).  However, there are knowledge shortages concerning the optimal staff-patient ratio and the influence of the work environment on staff commitment to fall mitigation guidelines and practices.

Conclusion

The examination underlines the need for extensive reform at MUH to minimize inpatient falls and promote patient results. Inpatient falls harm patients and raises medical costs. Through staff education, environmental changes, and established practices, MUH can decrease patient injuries due to falls. These measures boost the patient experience while fostering an atmosphere of security and care quality.

References

Alabdullah, H., & Karwowski, W. (2024). Patient safety culture in hospital settings across continents: A systematic review. Applied Sciences, 14(18), 8496–8496. https://doi.org/10.3390/app14188496

Albertini, A. C. D. S., & Peduzzi, M. (2024). Interprofessional approach to fall prevention in hospital care. Revista da Escola de Enfermagem da USP, 58, e20230239. https://doi.org/10.1590/1980-220x-reeusp-2023-0239en

Ghosh, M., O’Connell, B., Yamoah, E. A., Kitchen, S., & Coventry, L. (2022). A retrospective cohort study of factors associated with severity of falls in hospital patients. Scientific Reports, 12(1), 12266. https://doi.org/10.1038/s41598-022-16403-z

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Leapfrog. (2024). Methodist University Hospital. Leapfrog Hospital safety grade.org. https://www.hospitalsafetygrade.org/table-details/methodist-university-hospital

Saki, M., Ariaienezhad, B., Ebrahimzadeh, F., Almasian, M., & Heydari, H. (2023). The effect of nurses’ training on the implementation of preventive measures for falls in hospitalized elderly patients. International Archives of Health Sciences, 10(4), 144-149. https://doi.org/10.48307/iahsj.2023.183008

Strini, V., Schiavolin, R., & Prendin, A. (2021). Fall risk assessment scales: A systematic literature review. Nursing Reports, 11(2), 430–443. https://doi.org/10.3390/nursrep11020041

Turner, K., Staggs, V. S., Potter, C., Cramer, E., Shorr, R. I., & Mion, L. C. (2020). Fall prevention practices and implementation strategies: Examining consistency across hospital units. Journal of Patient Safety, 18(1), e236–e242. https://doi.org/10.1097/pts.0000000000000758

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Usmani, S., Saboor, A., Haris, M., Khan, M. A., & Park, H. (2021). Latest research trends in fall detection and prevention using machine learning: A systematic review. Sensors, 21(15), 5134–5134. https://doi.org/10.3390/s21155134

 

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