Quality and Safety Gap Analysis


Quality and safety are important in healthcare settings; the professionals ensure that they enhance quality and safety in service delivery. Failure to maintain care standards compromises the treatment the patients are offered and renders both healthcare workers and patients susceptible to diseases. Hospital-acquired infections are a significant problem arising from the gap in quality and safety in diverse healthcare settings. The healthcare problem has been analyzed, and the proposed practice changes to help reduce hospital-acquired infections as a result of the gap in quality and safety were implemented. Therefore, it is necessary to measure the outcomes of the implemented solution to determine whether it is effective and efficient in solving the selected healthcare problem.

Essential Quality and Safety Outcomes

Several interventions have been put in place to improve quality and safety outcomes by reducing hospital-acquired infections. The gap analysis identified nosocomial infections in the organization to be caused majorly by; lack of patients and staff education (Jeihooni et al., 2018). Also, increased workload, distraction, and frivolous attitudes by the nurses on the proper use of personal protective equipment were a great contributor. Healthcare professionals have an obligation to prevent infection; it is their golden target while caring for in-patient population.

The establishment of policies and changes within the organization could fill the identified gap. These changes include education among the staff and the patients on how to avoid hospital-acquired infections. The nurses should be trained on proper wound management, catheterization, and other aseptic techniques to handle patients. The patients were taught on environmental hygiene including sanitization and sterilization of equipment within the settings to reduce invasion of microbes. The hospital administration also provided the necessary personal protective equipment for the staff, including gloves, face shields, and disinfectants. The hospital also set out rules guiding the disposal of waste and infection control.

All these changes have a significant impact on the quality and safety outcomes. The provision of personal protective equipment to the staff dramatically reduces the incidences of hospital-acquired infections. This is because; the nurses could protect themselves better and protect the health of their patients by carrying out safe healthcare practices like changing gloves between patients (Kollef et al., 2021). Education to patients and the health care provider also significantly impacted the reduction of nosocomial infections. Improved hygiene was noted as the staff and the patients put into practice the hygiene education taught; this enhanced safety in a huge way. Adherence to the rules and policies on infection prevention and control enhanced safety and quality in healthcare services.

These quality and safety outcomes have been shown to impact the organization positively. This is because there were more improved healthcare services and satisfactory to the patients. They also minimized the costs of medications among patients, and the prolonged hospital stays that result from hospital-acquired infections. The weaknesses of the quality and safety outcomes are that: a lot of money was spent by the organization in educating the staff and the patients in infection prevention and control, developing policies, and purchasing the necessary personal protective equipment. Implementation of these changes also posed challenges to the organization.

Organization’s Strategic Value

The hospital gained enormously as a result of the quality and safety outcomes. Increased patient satisfaction was one significant achievement. The patients were satisfied with the kind of healthcare services delivered to them. The hospital environment was hygienic, and the nurses adhered to the set-out policies on infection control. This ensures the safety of the patients. Patients are often diminished by low-quality health care services and those that do not guarantee their safety (Kollef et al., 2021).

The outcomes, therefore, made the hospital a preferable health care facility. The outcomes also helped the organization is an excellent way of reducing employee turnover. Many health professionals quit their job due to increased workload that overwhelms them and consequently affects the quality of healthcare services provided (Magill et al., 2018). Reduction in hospital-acquired infections eliminates the need for prolonged hospital stays, and hence the nurses can comfortably manage their tasks.

Analysis of the Relationship Between a Systemic Problem in the Organization and the Specific Quality and Safety Outcome

Hospital-acquired infection was the central problem in the health care facility. This problem impacted negatively on the patient’s safety and the quality of healthcare services rendered. Hospital-acquired infections lead to prolonged hospital stays, increased treatment costs, increased cases of drug resistant infections, and reduced patient satisfaction. All these translate to low healthcare quality (Fatima et al., 2018). The patients’ safety was also not guaranteed as most often, they would end up with a nosocomial infection. Practice changes, however, have reduced the cases of nosocomial infections and therefore improved safety and quality. Interviewing the patients and the staff on the outcome measures could help gain information on how much the problem has been solved and suggest further interventions.

How Specific Outcome Measures Support Strategic Initiatives Related to Quality and Safety Culture

The quality and safety outcome measures have broadly supported the continued adoption of the initiatives related to quality and safety culture. The health care facility’s initiatives to reduce the number of hospital-acquired infections include education on infection prevention and control among the staff and the patients. Besides, provision of personal protective equipment by the hospital administration, and development of infection prevention policies aid in prevention of nosocomial infections (Magill et al., 2018). The outcomes of these interventions included increased patient satisfaction and safety.

These specific outcome measures support and motivate the health care providers to adhere to the policy to prevent infections and the proper use of personal protective equipment. The patients are also motivated to adhere to hygiene practices, which have generally enhanced safety and quality healthcare.

How Leadership Team Would Support the Implementation and Adoption of Proposed Practice Changes

Leaders play an essential role in influencing their subordinates, the hospital management team assists in adopting proposed practice changes by providing the infection prevention resources required while educating the staff and patients in infection prevention policy development. Leaders can also motivate their employees by rewarding them when the quality and safety gap is filled by reducing hospital-acquired infection cases. This impacts a positive employees’ attitude and motivates them to work harder towards achieving the set objectives according to World Health Organization (2017). Interprofessional collaboration also enhances patients’ safety and quality of healthcare service as the healthcare providers communicate effectively and collaboratively decide the best way a patient can be managed.


In conclusion, hospital-acquired infections have been a menace in many health care facilities. This has negatively impacted patient’s safety and lowered the quality of healthcare services needed. Therefore, causes of such gaps in health care settings need to be analyzed and the necessary interventions put in place. The outcomes of the interventions also have to be evaluated to determine the effectiveness of the interventions applied.


Fatima, T., Malik, S. A., & Shabbir, A. (2018). Hospital healthcare service quality, patient satisfaction, and loyalty. International Journal of Quality & Reliability Management. Web.

Jeihooni, A. K., Kashfi, S. H., Bahmandost, M., & Harsini, P. A. (2018). Promoting preventive behaviors of nosocomial infections in nurses: The effect of an educational program based on health belief model. Investigacion Y Educacion En Enfermeria, 36(1). Web.

Kollef, M. H., Torres, A., Shorr, A. F., Martin-Loeches, I., & Micek, S. T. (2021). Nosocomial infection. Critical Care Medicine, 49(2), 169-187. Web.

Magill, S. S., O’Leary, E., Janelle, S. J., Thompson, D. L., Dumyati, G., Nadle, J.,… & Edwards, J. R. (2018). Changes in prevalence of health care–associated infections in US hospitals. New England Journal of Medicine, 379(18), 1732-1744. Web.

World Health Organization. (2017). Patient safety: Making health care safer. World Health Organization. Web.

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NursingBird. (2023, September 19). Quality and Safety Gap Analysis. Retrieved from https://nursingbird.com/quality-and-safety-gap-analysis/


NursingBird. (2023, September 19). Quality and Safety Gap Analysis. https://nursingbird.com/quality-and-safety-gap-analysis/

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"Quality and Safety Gap Analysis." NursingBird, 19 Sept. 2023, nursingbird.com/quality-and-safety-gap-analysis/.


NursingBird. (2023) 'Quality and Safety Gap Analysis'. 19 September.


NursingBird. 2023. "Quality and Safety Gap Analysis." September 19, 2023. https://nursingbird.com/quality-and-safety-gap-analysis/.

1. NursingBird. "Quality and Safety Gap Analysis." September 19, 2023. https://nursingbird.com/quality-and-safety-gap-analysis/.


NursingBird. "Quality and Safety Gap Analysis." September 19, 2023. https://nursingbird.com/quality-and-safety-gap-analysis/.