Executive Summary

Introduction

This executive summary outlines the key findings of a gap analysis conducted to identify and address a performance issue related to quality and safety within a healthcare organization. The gap analysis revealed that the organization’s current outcome measures are not adequately capturing the true impact of safety issues on patients, staff, and the organization as a whole. Additionally, the organization’s current policies and procedures do not adequately support a culture of safety.

Key Findings

• The organization’s current outcome measures are not adequately capturing the true impact of safety issues on patients, staff, and the organization as a whole. For example, the organization does not track the rate of healthcare-associated infections (HAIs), which is a significant safety concern.
• The organization’s current policies and procedures do not adequately support a culture of safety. For example, there is no clear process for reporting safety concerns, and there is no accountability for safety performance.

Proposed Actions

Based on the findings of the gap analysis, the following actions are proposed:

• Develop a new set of outcome measures that will provide a more accurate picture of the organization’s safety performance. These outcome measures should include, at a minimum, the rate of HAIs, the rate of medication errors, and the rate of patient safety events.
• Develop a new policy on safety reporting that will encourage staff to report safety concerns without fear of reprisal. This policy should include a clear process for reporting concerns, and it should also provide protection for whistleblowers.
• Develop a new procedure for holding staff accountable for safety performance. This procedure should include clear expectations for safety performance, and it should also outline the consequences of failing to meet those expectations.

Implementation Plan

The following is a proposed implementation plan for the proposed actions:

• Develop a new set of outcome measures: This will involve working with a team of experts to identify the most appropriate outcome measures for the organization. The new outcome measures will then be piloted in a select number of areas before being rolled out to the entire organization.
• Develop a new policy on safety reporting: This will involve working with a team of stakeholders to develop a policy that is clear, concise, and easy to understand. The new policy will then be disseminated to all staff and will be regularly reviewed and updated as needed.
• Develop a new procedure for holding staff accountable for safety performance: This will involve working with a team of stakeholders to develop a procedure that is fair, consistent, and effective. The new procedure will then be disseminated to all staff and will be regularly reviewed and updated as needed.

Evaluation Plan

The following is a proposed evaluation plan for the proposed actions:

• Track the new outcome measures: The new outcome measures will be tracked on a regular basis to assess the organization’s progress towards its safety goals.
• Survey staff on their satisfaction with the new safety reporting policy: Staff will be surveyed on their satisfaction with the new safety reporting policy on a regular basis to identify areas for improvement.
• Track the number of disciplinary actions taken for safety violations: The number of disciplinary actions taken for safety violations will be tracked to assess the effectiveness of the new procedure for holding staff accountable for safety performance.

Conclusion

The proposed actions will help to address the performance issue related to quality and safety within the healthcare organization. By implementing these actions, the organization will be able to create a safer and more effective healthcare system for everyone.