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. 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. 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. Identify a systemic problem in an organization related to adverse quality and safety outcomes. Propose specific practice changes within an organization that will improve quality and safety outcomes and bridge the gap between current and desired performance. Prioritize proposed practice changes. Competency 2: Determine how outcome measures promote quality and safety processes within an organization 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. Determine how a particular organizational culture or hierarchy might affect or contribute to adverse quality and safety outcomes. 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. 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. Context 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.

1. 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.
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.
By successfully completing this assessment, you will

2. demonstrate your proficiency in the following course
competencies and assessment criteria:
Competency 1: Analyze quality and safety outcomes from an
administrative and systems perspective.
Identify a systemic problem in an organization related to
adverse quality and safety outcomes.
Propose specific practice changes within an organization that
will improve quality and safety outcomes and bridge the gap
between current and desired performance.
Prioritize proposed practice changes.
Competency 2: Determine how outcome measures promote
quality and safety processes within an organization
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.
Determine how a particular organizational culture or hierarchy
might affect or contribute to adverse quality and safety
outcomes.

3. 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.
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.
Context
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

4. 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.
Questions to Consider
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.
Assessment Instructions
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

5. 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.
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 (linked in the Resources) 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,

6. 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 in the resources. Be sure to
include:
A title page and reference page. An abstract is not required.
A running head on all pages.
Appropriate section headings.
Properly-formatted citations and references.
Your analysis should be 4–5 pages in length,
not including
the title page and reference page.

7. GRADING RUBRIC:
1-
Identify a systemic problem in an organization related to
adverse quality and safety outcomes.
Passing Grade: Identifies a systemic problem in an organization
related to adverse quality and safety outcomes, and identifies
knowledge gaps, unknowns, missing information, unanswered
questions, or areas of uncertainty.
2-
Propose specific practice changes within an organization that
will improve quality and safety outcomes and bridge the gap
between current and desired performance.
Passing Grade: Proposes specific practice changes within an
organization that will improve quality and safety outcomes and
bridge the gap between current and desired performance, and
identifies assumptions on which the proposal is based.
3-
Prioritize proposed practice changes.
Passing Grade: Prioritizes proposed practice changes, and
provides sound rationale for the prioritization.
4-
Determine how proposed practice changes will foster a culture
of quality and safety.

8. Passing Grade: Determines how proposed practice changes
foster a culture of quality and safety, and proposes criteria that
could be used to evaluate that culture.
5-
Determine how a particular organizational culture or hierarchy
might affect or contribute to adverse quality and safety
outcomes.
Passing Grade: Determines how a particular organizational
culture or hierarchy might affect or contribute to adverse
quality and safety outcomes, and identifies assumptions on
which that analysis is based.
6-
Justify necessary changes to particular organizational functions,
processes, and behaviors that correct or mitigate adverse quality
and safety outcomes.
Passing Grade: Justifies necessary changes to particular
organizational functions, processes, and behaviors that correct
or mitigate adverse quality and safety outcomes, and identifies
knowledge gaps, unknowns, missing information, unanswered
questions, or areas of uncertainty.
7-
Communicate analysis data and information clearly and
accurately, using correct grammar and mechanics.
Passing Grade: Communicates analyses and information clearly
and accurately. Grammar and mechanics are error-free.

9. 8-
Integrate relevant and credible sources of evidence to support
assertions, correctly formatting citations and references using
APA style.
Passing Grade: Integrates relevant, credible, and convincing
sources of evidence to support assertions. Sources are current,
and citations and references are error-free.