NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis

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NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis

The field of healthcare strives for quality and safety for all clients and patients.  There is a continuous need for quality staff as well as improvements in the quality of care provided to all clients.  The promotion of a culture of quality services and safety in providing the services through nurse leaders is a must for all health care related businesses.  As nurse leaders, a top priority is to influence others positively and directly participate in in a leadership role to ensure the outcomes promote the quality of care reflected in the mission or vision of the business.  Policies and procedures must be continually monitored and reviewed to remain current with state and federal rules and regulations.  Facilities that do not receive Medicare funds do not have to report readmission rates, but records are maintained.  The 30-day readmission rate is a constantly fluctuating number, and many facilities try to reduce this rate as much as possible.  The readmission rate effects services that patients receive in the home care setting, therefore effecting businesses who provide these services.  This analysis will provide information on current average as well as the desired average for readmissions for a home care agency.  The goal is to identify common concerns in the home care setting and propose improvements in client safety and care that will produce positive outcomes, therefore narrowing the gap between the current level and desired level of services.

Adverse Quality and Safety Outcomes

NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Among patients who receive in home care services, many have the diagnoses of congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD).  Patients with the diagnosis of CHF have a 26.9% readmission rate (Nair et al., 2020), whereas patients with the diagnosis of COPD have a readmission rate of 22.6% (Portillo et al., 2018).

NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis  

There are many contributing factors to early readmission to the hospital.   In the home care setting, this can mainly be the result of noncompliance with discharge instructions.  Noncompliance can be related to the client’s ability to understand the instructions which can result in an unnecessary readmission to the hospital.  According to DeSai et al (2021), there is a decrease in treatment compliance and safety in patients who do not have sufficient information regarding their discharge plans.  Patient education during discharge from a facility can be confusing for the elderly patients, leaving them to determine what the instructions are after they return home.  Written discharge instructions are viewed as tedious and long with the important information hard to find (DeSai et al, 2021).  Many do not have family members available to assist with explaining the discharge instructions presented to them.  As an in-home care provider, the task of explaining discharge instructions can slip through the cracks if the paperwork is not available for staff to refer to for patient education.  

Proposed Changes to Improve Quality and Safety Outcomes

NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Improvements in the in-home care provider’s procedures for clients returning to the home after discharge from the hospital will be an effort on the part of the in-home aides and the nursing staff.  In-home aides will receive instructions on contacting the office to speak to an available nurse when a client returns home.  The nurse will request the discharge instructions to review to explain all information to the client and the in-home aide.  This will be conveyed in easy-to-understand terms that is on the client’s level of understanding.  Both the client and the in-home aide will verbalize their understanding of the discharge instructions and provide their own version of the information if necessary.  This method, know as the teach-back method, has been shown to be an effective educational method where the patient repeats the instructions back in their own words (Yen, 2019). 

NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis 

Documentation will be recorded per agency policy and for future readmission rates.  The nurse will follow up with the client and the in-home aide the following day and in one week to ensure understanding and compliance.  The client and the in-home aide will be instructed to contact the office immediately if there is a readmission to the hospital.  The nurse will review documentation and contact the client and in-home aide for information on potential reasons for the readmission. 

Prioritization of Proposed Practice Changes

NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis

The goal of the in-home care provider is to implement changes that will decrease the 30-day readmission rate into the hospital for home care clients.  Top priority will be increasing the client’s understanding of their discharge instructions.  The second step will include selecting members of the administrative staff that will combine with the nurses to review the new procedures for the in-home aides and training them on the procedures necessary to assist with the client’s understanding of the discharge instructions.  After the team is selected, the team members will meet daily for one week to develop strategies for conducting the training with the in-home aides.  This will include brainstorming for ideas and developing a tool for effective training.  The in-home aides will be educated on the new procedures by select administrative staff and the nurses to ensure understanding.

NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis       

The new procedures will positively impact the in-home care provider.  The clients will receive support from both the nurse and the in-home aide, increasing the chance of understanding the discharge instructions as well as compliance.  This increase in understanding and compliance should decrease the readmissions to the hospital and keep the clients healthier and safe at home.  

Organizational Support and Effects on Quality and Safety Outcomes

NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Organizational support is imperative for the success of changes in facilities.  Leadership support is needed as well to implement the positive changes into the daily practices of all involved in the organization.  A strong support system from the leadership team of the facility inspires staff to work together to achieve the set goals.  For a program to be successful in a healthcare workplace, team leaders that communicate effectively on all levels are necessary (Leadership Support, 2019).  Reducing the rate of 30-day readmissions is challenging but possible with a positive organizational support system.

Fostering a Culture of Quality and Safety

NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Quality healthcare and safety for all clients is a top priority for healthcare facilities.  The roles of both nurses and in-home aides must be clearly defined and outlined for all staff to understand.  This clear understanding will help positively impact all newly discharged clients, giving them a higher comfort level and promoting safety and independence.  Nurses will review all discharge information with clients to ensure understanding.  The in-home aides will be available to keep the clients on track with achieving the goal of correctly following discharge instructions.  Clients will be able to contact the office for any questions or concerns.  Nurse follow-ups as well as the in-home aides’ availability will greatly increase the success of this program.   


NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis

The introduction of a new program involving both nurses and in-home aides assisting clients with discharge instructions will immediately impact the rate of readmissions to the hospital.  Increasing the amount of time the nurses and in-home aides spend with discharge instructions and patient education will increase the client’s compliance and safety.  In turn, this will lead to healthier clients and a reduction in readmissions due to the client not correctly following the discharge instructions.  Clients will remain safely in their homes with the support of the nurses and in-home aides therefore increasing their level of independence and knowledge.

NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis


DeSai, C., Janowiak, K., Secheli, B., Phelps, E., McDonald, S., Reed, G., Blomkalns, A. (2021).

Empowering Patients: Simplifying Discharge Instructions. BMJ Journals,

Leadership Support. (2019). Centers for Disease Control and Prevention,

NUR FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Nair, R., Lak, H., Seba, H., Gunasekaran, D., Babar, A., Gopalakrshna, K.V.. (2020). Reducing

All-cause 30-day Hospital Readmissions for Patients Presenting with Acute Heart Failure

Exacerbations: A Quality Improvement Initiative. National Library of Medicine,

Portillo, E.C., Wilcox, A., Seckel, E., Margolis, A., Montgomery, J., Balasubramanian, P.,

Abshire, G., Lewis, J., Hildebrand, C., Mathur, S., Bridges, A., Kakumanu, S. (2018).

Reducing COPD Readmission Rates: Using a COPD Care Service During Transitions.

National Library of Medicine,

Yen, P.H., Leasure, A.R. (2019). Use and Effectiveness of the Teach-Back Method in Patient

Education and Health Outcomes. National Library of Medicine,