Description
Assessment 1 Instructions: Quality and
Safety Gap Analysis
Write an analysis, 4-5 pages in length, of the gap between current and desired
performance, with respect to the provision of safe, high-quality patient care.
Introduction
Note: Each assessment in this course builds on the work you completed in the
previous assessment. Therefore, you must complete the assessments in this
course in the order in which they are presented.
As a nurse leader, you must be able to assess your organization’s ability to
deliver safe, high-quality patient care. In so doing, you may be required to
perform a gap analysis of a quality or safety issue as the first step in improving
outcomes. Failure to meet benchmarks for safe and effective patient care can
have reimbursement, regulatory, and legal consequences.
This assessment provides an opportunity to develop the knowledge, skills, and
attitudes required to successfully implement changes that improve patient
outcomes by:
?
?
?
?
Evaluating the current culture of an organization.
Performing an outcomes gap analysis.
Determining what changes are needed to bridge the gap.
Examining current thinking on this topic contained in the literature.
Quality and safety are everyone’s responsibility as a team of interprofessional
care delivery partners. Together we develop policies that support quality and
safe care delivery. As part of the interprofessional team, nurses are leaders in
care and thus are responsible and accountable for leading and providing safe
quality care.
Health care delivery is structured around evidenced-based information. Quality
is defined by exploring proven, evidenced-based information. After reviewing
and defining evidenced-based information, the interprofessional team applies
this knowledge to assess the organization’s or the practice setting’s ability to
provide evidenced-based care delivery. When a gap in care is identified, it is
important to propose an evidenced-based change and to execute a plan for
improved care.
Your quality and safety gap analysis will provide the basis for the remaining
assessments in this course.
Preparation
As a nurse leader, you are fully aware of the hazardous nature of health care and
that organizations must continually seek to improve the quality and safety of the
care they provide to patients. For this assessment, you will identify a systemic
problem in your organization, practice setting, or area of interest associated with
adverse quality and safety outcomes (for example, an increase in the incidence of
falls or medical errors) and analyze the gap between current and desired
performance.
Note: Remember that you can submit all or a portion of your draft analysis to
Smarthinking for feedback before you submit the final version for this
assessment. However, be mindful of the turnaround time of 24?48 hours for
receiving feedback, if you plan on using this free service.
As you prepare to complete this assessment, you may want to think about other
related issues to deepen your understanding or broaden your viewpoint. You are
encouraged to consider the questions below and discuss them with a fellow
learner, a work associate, an interested friend, or a member of your professional
community. Note that these questions are for your own development and
exploration and do not need to be completed or submitted as part of your
assessment.
Culture and process contribute to our ability to develop and sustain quality and
safety in a health care organization. By exploring these topics, you can analyze
where you may have gaps in practice that affect outcomes. In addition,
organizations must create benchmarks for outcomes to determine whether they
are meeting quality and safety goals.
?
?
?
?
What does your organization measure, related to quality and safety, and
why?
Are there certain aspects of your organization’s culture and processes that
support or hinder quality and safety?
Is the organization meeting outcome measurement benchmarks?
If not, how might you address those gaps in performance? What system
could be developed to support a change to close a particular gap?
The following resources are required to complete the assessment.
?
APA Style Paper Template [DOCX]. Use this template for your gap analysis.
Requirements
Note: The requirements outlined below correspond to the grading criteria in the
Quality and Safety Gap Analysis Scoring Guide. Be sure that your written analysis
addresses each point, at a minimum. You may also want to read the Quality and
Safety Gap Analysis Scoring Guide and Guiding Questions: Quality and Safety Gap
Analysis [DOCX] to better understand how each criterion will be assessed.
Conducting the Analysis
?
?
?
?
?
?
Identify a systemic problem in your organization, practice setting, or area
of interest that contributes to adverse quality and safety outcomes.
Propose specific practice changes that will improve quality and safety
outcomes and bridge the gap between current and desired performance.
Prioritize proposed practice changes.
Determine how proposed practice changes will foster a culture of quality
and safety.
Determine how a particular organizational culture or hierarchy might
affect quality and safety outcomes.
Justify necessary changes with respect to functions, processes, or
behaviors, specific to your organization.
Writing and Supporting Evidence
?
?
Communicate analysis data and information clearly and accurately, using
correct grammar and mechanics.
Integrate relevant and credible sources of evidence to support assertions,
correctly formatting citations and references using APA style.
Additional Requirements
Format your document using APA style.
?
?
Use the APA Paper Template linked above. Be sure to include:
o A title page and reference page. An abstract is not required.
o A running head on all pages.
o Appropriate section headings.
o Properly-formatted citations and references.
Your analysis should be 4?5 pages in length, not including the title page
and reference page.
Portfolio Prompt: You may choose to save your gap analysis to your ePortfolio.
Competencies Measured
By successfully completing this assessment, you will demonstrate your
proficiency in the following course competencies and assessment criteria:
?
?
?
?
Competency 1: Analyze quality and safety outcomes from an
administrative and systems perspective.
o Identify a systemic problem in an organization related to adverse
quality and safety outcomes.
o Propose specific practice changes within an organization that will
improve quality and safety outcomes and bridge the gap between
current and desired performance.
o Prioritize proposed practice changes.
Competency 2: Determine how outcome measures promote quality and
safety processes within an organization
o Determine how proposed practice changes will foster a culture of
quality and safety.
Competency 3: Determine how specific organizational functions, policies,
processes, procedures, norms, and behaviors can be used to build reliable
and high-performing organizations.
o Determine how a particular organizational culture or hierarchy
might affect or contribute to adverse quality and safety outcomes.
o Justify necessary changes to particular organizational functions,
processes, and behaviors that correct or mitigate adverse quality
and safety outcomes.
Competency 5: Communicate effectively with diverse audiences, in an
appropriate form and style, consistent with applicable organizational,
professional, and scholarly standards.
o Communicate analysis data and information clearly and accurately,
using correct grammar and mechanics.
o Integrate relevant and credible sources of evidence to support
assertions, correctly formatting citations and references using APA
style.
Use the scoring guide to understand how your assessment will be evaluated.
Guiding Questions
Quality and Safety Gap Analysis
This document is designed to give you questions to consider and additional guidance to help
you successfully complete the Quality and Safety Gap Analysis assessment. You may find it
useful to use this document as a pre-writing exercise, an outlining tool, or as a final check to
ensure that you have sufficiently addressed all the grading criteria for this assessment. This
document is a resource to help you complete the assessment. Do not turn in this document as
your assessment submission.
Conducting the Gap Analysis
Criterion.
Identify a systemic problem in your organization, practice setting, or area of interest that
contributes to adverse quality and safety outcomes.
?
What is the nature and extent of the problem?
?
How does this problem contribute to adverse quality and safety outcomes?
?
What are the consequences of not addressing the problem?
Propose specific practice changes that will improve quality and safety outcomes and
bridge the gap between current and desired performance.
?
What is the performance gap? How does it relate to quality and a safety concerns?
?
Why will your proposed changes result in improved outcomes?
Prioritize proposed practice changes.
?
Which changes are most important in relation to quality and safety and organizational
outcomes?
?
What are your reasons or criteria for determining the order of priority? How does your
rationale relate organization?s strategic plan?
Determine how proposed practice changes will foster a culture of quality and safety.
?
What effects will your proposed changes have on attitudes and behaviors within your
practice setting?
?
As you think about the current culture in the organization, what is most complex about
initiating a change?
Determine how a particular organizational culture and hierarchy might affect quality and
safety outcomes.
?
What are the defining characteristics of the culture, hierarchy and leadership?
?
How might the culture or hierarchy shape either positive or negative outcomes?
Justify necessary changes with respect to functions, processes, or behaviors, specific to
your organization.
1
Assessment 1 Guiding Questions
?
For example, consider such functions, processes, and behaviors as leadership
practices, communications, quality processes, financial management, safety and risk
management, interprofessional collaboration, strategic planning, using the best available
evidence, and questioning the status quo on all levels.
?
What is theoretical or evidenced-based information supports the proposed changes?
?
Why are these changes necessary?
?
How will each change correct or mitigate adverse quality and safety outcomes?
Writing, Supporting Evidence, and APA Style
Communicate analysis data and information clearly and accurately, using correct
grammar and mechanics.
?
Be clear and concise in your analysis.
?
Express your main points and conclusions coherently.
?
Proofread your writing to minimize errors that could distract readers and make it more
difficult to focus on the substance of your analysis.
Integrate relevant and credible sources of evidence to support your assertions, correctly
formatting citations and references using APA style.
?
Integrate relevant evidence from 3?4 scholarly or professional sources.
Submission Reminders
?
Have you adequately addressed a systemic problem that adversely affects quality and
safety outcomes?
?
Have you proposed specific practice changes that will effectively close performance
gaps?
?
Have you prioritized proposed practice changes nd justified the order of priority?
?
Have you determined how your proposed changes will affect attitudes and behaviors
within your practice setting?
?
Are you confident in your rationale for proposing necessary changes in organizational
functions, processes, or behaviors?
?
Are your claims and conclusions well supported by 3?4 sources of credible evidence?
?
Is your analysis properly formatted and 4?5 pages in length, including the title page and
reference page?
?
Have you proofread your writing to minimize errors that could distract the audience and
make it more difficult to focus on the substance of your presentation?
2
1
Document Format: Margins are 1 in. (2.54 cm) on all sides.
All text in the document should be double-spaced.
The font is 12-point Times New Roman. Other choices are 11-point Arial and 11-point Calibri.
The title page is page 1.
There is no running head for learner assignments. (See Academic Writer: Publication Manual ?? 2.1?2.24
for paper requirements.)
Full Title of Your Paper
Learner?s Full Name (no credentials)
School of Nursing and Health Sciences, Capella University
Course Number: Course Name
Instructor?s Name
Month, Year
2
Abstract
An abstract is useful in professional papers, but not always in learner assignments. In fact,
unless you are instructed by your faculty or in the course syllabus, do not expect to use
abstracts very often at Capella. If you are submitting for publication, remember to check
with the journal or professional organization about their criteria for an abstract. The
abstract tells your reader about the article, is brief, and stands alone, so no citations are included.
The format for an abstract is a single paragraph (not indented on the first line) that follows the
title page and is less than 250 words in length. A structured abstract will have a single paragraph
without indentation but having labels (e.g., Objective, Method, Results, and Conclusions) on the
same line as the text and bold. For published works, the publishing organization will give you
guidance on these. However, for student papers, no abstract is needed unless the faculty request
one or the assignment requires it. Remember, no citations.
Keywords: include keywords in the abstract?they should be labeled like this, with the
words all in lowercase and separated by commas. Only the first line is indented, like a regular
paragraph. No period at the end.
3
APA Style Seventh Edition Paper Template: A Resource for Academic Writing
American Psychological Association (APA) style is one of the most popular methods
used to cite sources in the social sciences, but it is not the only one. When writing papers in the
programs offered at Capella University, you will likely use APA style. This document serves as
an APA style resource for the seventh edition guidelines, containing valuable information that
you can use when writing academic papers. For more information on APA style, refer to the
Publication Manual of the American Psychological Association, also referred to as the APA
manual (American Psychological Association, 2020b).
The first section of this paper shows how an introduction effectively introduces the reader
to the topic of the paper. In APA style, an introduction never gets a heading. For example, this
section did not begin with a heading titled ?Introduction,? unlike the following section, which is
titled ?Writing an Effective Introduction.? The following section will explain in greater detail a
model that can be used to effectively write an introduction in an academic paper. The remaining
sections of the paper will continue to address APA style and effective writing concepts,
including section headings, organizing information, the conclusion, and the reference list.
Writing an Effective Introduction
An effective introduction often consists of four main components, including (a) the
position statement, thesis, or hypothesis, which describes the author?s main position; (b) the
purpose, which outlines the objective of the paper; (c) the background, which is general
information needed to understand the content of the paper; and (d) the approach, which is the
process or methodology the author uses to achieve the purpose of the paper. This information
will help readers understand what will be discussed in the paper. It can also serve as a tool to
grab the reader?s attention. Authors may choose to briefly reference sources that will be
4
identified later in the paper as in this example (American Psychological Association, 2020a;
American Psychological Association, 2020b). The Writing Center has developed the acronym
POETS to help describe the proper writing style for submissions. POETS is the acronym for
purpose, organization, evidence, tone, and sentence structure (Capella Writing Center, n.d.).
There will be more on this later.
In an introduction, the writer will often present something of interest to capture the
reader?s attention and introduce the issue. Adding an obvious statement of purpose helps the
reader know what to expect, while helping the writer to focus and stay on task. For example, this
paper will address several components necessary to effectively write an academic paper,
including how to write an introduction, how to write effective paragraphs, and how to effectively
use APA style.
Level 1 Section Heading Is Centered, Bold, and Title Case
Using section headings can be an effective method of organizing an academic paper.
Section headings are not required according to APA style; however, they can significantly
improve the quality of a paper by helping both the reader and the author, as will soon be
discussed.
Level 2 Section Heading Is Aligned Left, Bold, and Title Case
The heading style recommended by APA consists of five levels (APA, 2020b, pp. 47?
48). This document contains multiple levels to demonstrate how headings are structured
according to APA style. Immediately before the previous paragraph, a Level 1 section heading
was used. That section heading describes how a Level 1 heading should be written, which is
centered, bold, and using uppercase and lowercase letters (also referred to as title case). For
another example, see the section heading ?Writing an Effective Introduction? on page 3 of this
5
document. The heading is centered and bold and uses uppercase and lowercase letters. If used
properly, section headings can significantly contribute to the quality of a paper by helping the
reader, who wants to understand the information in the document, and the author, who desires to
effectively describe it.
Section Heading Purposes
Section Headings Help the Reader. Section headings serve multiple purposes, including
helping the reader understand what is being addressed in each section, maintain an interest in the
paper, and choose what they want to read. For example, if the reader of this document wants to
learn more about writing an effective introduction, the previous section heading clearly states
that is where information can be found. When subtopics are needed to explain concepts in greater
detail, different levels of headings are used according to APA style.
Section Headings Help the Author. Section headings not only help the reader; they also
help the author organize the document during the writing process. Section headings can be used
to arrange topics in a logical order, and they can help an author manage the length of the paper.
In addition to an effective introduction and the use of section headings, each paragraph of an
academic paper can be written in a manner that helps the reader stay engaged.
Section Headings Can Demonstrate Fine Detail. Short papers and assignments may not
require or need a Level 5 heading, but these will be indented, bold, italic, and title case and end
with a period. Note the text starts on the line at the end of the heading following the period.
How to Write Effective Paragraphs
Capella University?s Writing Center (n.d.) has adopted a new set of writing standards to
assist learners in their goals to improve their scholarly writing. It is based on five skills known by
the mnemonic POETS. In other words, a well-developed Capella paper will demonstrate the
6
following standards. The paper will have a clear purpose statement, be logically organized,
utilize current and appropriate evidence that is properly cited, maintain a scholarly tone, and
demonstrate proper grammar and writing mechanics in the sentence structure (Capella Writing
Center, n.d.). Academic writing is sometimes considered dry and boring. A learning experience
may need that formula to encourage learning in different ways as the learner moves from passive
learner to active scholar. This growth, according to Gilmore et al. (2019), requires the writer to
not only think but also to write differently.
Bias-Free Language
In the seventh edition of the APA manual, another focus is on eliminating bias in
language in order to provide a more inclusive tone in scholarly writing. While long considered a
grammar issue, it is acceptable in APA to utilize they as a singular pronoun (APA, 2020b). In
fact, there is an entire chapter of the manual dedicated to ways to reduce bias in scholarly
writing. It is important to use an appropriate level of specificity in descriptions and use
sensitivity with the use of labels. Other sections include guidelines on age, disability, gender,
race and ethnicity, sexual orientation, socioeconomic status, and participation in research. Be
aware of intersectionality, a term used to describe a person based on their identified multiple
identities, interconnectivity, social context, power relations, complexity, social justice, and
inequalities that can result in oppression (Cole, 2019; Hopkins, 2017).
Considering Direct Quotations
Another important point to consider is the use of direct quotations in papers. While
plagiarism is considered an academic integrity issue, many learners are concerned with issues
such as self-plagiarism and unintentional plagiarism, and there are others who may go as far as
purchasing papers for submission (Colella & Alahmadi, 2019). As a learner travels along their
7
chosen academic pathway, their writing skills and mechanics are expected to improve. It is
imperative that the learner transition from finding information and quoting the author word for
word to using the information to support an idea, paraphrase, and then synthesize and express the
findings in one?s own words. Having said that, there are situations in which quotations may be
appropriate, so it is important to cite them properly. According to the seventh edition of the APA
manual, ?When quoting directly, always provide the author, year, and page number of the
quotation in the in-text citation in either parenthetical or narrative format? (APA, 2020b, p. 270).
If there are not page numbers, identify the location in another manner (such as a paragraph
number).
Notice that the above quote contains fewer than 40 words. There is a different style for
quotes containing 40 words or more. These longer quotes use a block quotation format:
Do not use quotation marks to enclose a block quotation. Start a block quotation on a new
line and indent the whole block 0.5 in. from the left margin. If there are additional
paragraphs within the quotation, indent the first line of each subsequent paragraph an
additional 0.5 in. Double-space the entire block quotation; do not add extra space before
or after it. Either (a) cite the source in parentheses after the quotation?s final punctuation
or (b) cite the author and year in the narrative before the quotation and place only the
page number in parentheses after the quotation?s final punctuation. Do not add a period
after the closing parenthesis in either case. (APA, 2020b, p. 272)
Conclusion
A summary and conclusion section, which can also be the discussion section of an APA
style paper, is the final opportunity for the author to make a lasting impression on the reader. The
author can begin by restating opinions or positions and summarizing the most important points
8
that have been presented in the paper. For example, this paper was written to demonstrate to
readers how to effectively use APA style when writing academic papers. Various components of
an APA style paper that were discussed or displayed in the form of examples include a title page,
introduction section, levels of section headings and their use, the POETS format, bias-free
language, in-text citations, a conclusion, and the reference list.
9
References
American Psychological Association. (2020a). Ethical principles of psychologists and code of
conduct (2002, amended effective June 1, 2010, and January 1, 2017).
https://doi.org.apa.org/ethics/code/index.aspx
American Psychological Association. (2020b). Publication manual of the American
Psychological Association (7th ed.).
Capella University. (n.d.). Writing Center. https://campus.capella.edu/writing-center/home
Cole, N. L. (2019, October 13). Definition of intersectionality: On the intersecting nature of
privileges and oppression. ThoughtCo. https://www.thoughtco.com/intersectionalitydefinition-3026353
Colella, J., & Alahmadi, H. (2019). Combating plagiarism from a transformation viewpoint.
Journal of Transformative Learning, 6(1), 59?67.
https://jotl.uco.edu/index.php/jotl/article/view/184
Gilmore, S., Harding, N., Helin, J., & Pullen, A. (2019). Writing differently. Management
Learning, 50(1), 3?10. https://doi.org/10.1177/1350507618811027
Hopkins, P. (2017). Social geography I: Intersectionality. Progress in Human Geography, 43(5),
937?947. https://doi.org/10.1177/0309132517743677
10
Appendix
Tips for the Reference List
?
Always begin a reference list on a new page. It should be placed before any appendices, figures,
or tables and titled References.
?
Set a hanging indent that starts with the second line and is double-spaced. You can look in the
Paragraph menu of Microsoft Word for formatting the hanging indent so that you will not have to
tab the indent. It gives the text a smoother look that remains consistent, even if you make edits.
?
The reference list is in alphabetical order by the first author?s last name. A reference list only
contains sources that are cited in the body of the paper, and all sources cited in the body of the
paper must be included in the reference list. If you did not cite it, do not list it.
?
The reference list above contains an example of how to cite a source when two documents are
written in the same year by the same author.
?
?
o
The lowercase letters are used after the date to differentiate the sources. The ?a? reflects
the alphabetical order in the reference list?not whether it appeared first in the text.
o
The year is also displayed using this method for the corresponding in-text citations, as in
the following sentence: The author of the first citation (American Psychological
Association, 2020b) is also the publisher; therefore, the word Author is no longer used in
the seventh edition.
DOI is the digital object identifier.
o
It can be found on the first page of an article, on the copyright page of a book, in the
database record of a work, or by searching Crossref.
o
Even if the book is in print, if there is a DOI, use it.
o
Always use the hyperlink format for a DOI?it will always start with https://doi.org/ and will
be followed by a number. If the DOI is not in this format, convert it. Do not alter this
format, and do not add a final period.
o
There is a short DOI service at http://shortdoi.org/.
URL is the uniform resource locator.
o
If there is no DOI, the URL should be used in the reference.
o
Copy and paste the URL directly into your list.
o
Do not add a period at the end.
o
Do use ?Retrieved from? before a URL.
?
The Colella and Alahmadi reference is an example of how to cite a source using a URL. Please
note that you will not use the Capella link that is often provided in the courseroom. If the URL
contains a database title, such as EBSCO or ProQuest, or the name Capella, do not use that in
your citation as it will only work for Capella learners and faculty.
?
For examples and further information on references go to:
o
Academic Writer: Sample References.
o
Academic Writer: Reference List.
Purchase answer to see full
attachment
