NURS 8302 Discussion: Identifying Practice Gaps for Quality Improvement ANSWER

NURS 8302 Discussion: Identifying Practice Gaps for Quality Improvement ANSWER

NURS 8302 Discussion: Identifying Practice Gaps for Quality Improvement

By Day 3 of Week 3

Post a brief explanation of how you would identify a quality improvement practice gap in your practice or organization. Describe a potential quality improvement practice gap you might use for your DNP project, and explain why. Then, explain at least two types of tools and/or methods you might use to address this quality improvement practice gap, and explain why. Be specific and provide examples.

Quality Improvement Practice Gap

Quality practice gaps in an outpatient setting can be identified from a variety of sources.  Much of the data utilized for quality improvement practice purpose in my organization comes from EHR software, quality measurement tools such as Tableau, patient satisfaction surveys, and from the annual employee engagement surveys.  In the ambulatory setting, many quality indicators like patient falls, depression and violence screenings, pain assessments, risk assessments (BMI & hypertension) can be assessed through the EHR.  This retrospective data collection is utilized by many data collection projects including several national quality improvement database projects (Nash et al., 2019).  As a nurse manager, I have access to reporting analytics that determine the percent of compliance to these quality indicators.  Additionally, my organization utilizes a program called Tableau that also analyzes date from each clinical site in comparison with the organizational standards to produce a weekly report identifying strengths and weaknesses in the organizational quality indicators.  Another resource for identifying quality practice gaps in with our annual employee engagement survey which includes questions about culture of safety, morale, and work-life balance.  Utilizing the data from the various tools provided by my organization allows for in-depth data analysis for identifying practice gaps.

Potential Quality Improvement Gap

A quality improvement gap that has been identified at my organization is access to care.  Access to care is a critical component in providing quality care in that lack of access delays care and preventable services, excessive financial burdens, and increased hospitalizations or length of stays (“Measures Management System”, 2021).  My organization focuses on a 14-day access new patients quality measure, in which all new patient referrals should be scheduled with an appointment within 14 days. This quality indicator has been attainable for all but one provider in our clinic, with current new patient access running about 16-20 days. Provider clinic schedule changes could be made to help alleviate this burden with results tracked using a run chart to help identify improvement or setbacks, as well as the ability to annotate changes along the way

Access of care is also currently affecting my organization in another way.  Due to our extensive Covid surge taking place in our state currently, my organization’s children’s hospital is at 110% capacity with backup in the pediatric emergency department, which has led to several diverting emergency patients at several different instances.  Being one of just a few children’s hospitals in the state and the only one taking care of most of the central and eastern areas of the state, this has been a critical emergent crisis for our area.  The lack of pediatric inpatient beds affects many patients who require frequently scheduled hospitalizations, such as our scheduled admits for pediatric chemotherapy patients.  To help offset this crisis, I have been asked to assist in leading the creation of a new monoclonal antibody infusion clinic for pediatrics age 12-17 years.  This emergency request for assistance to relieve inpatient volumes was announced two days ago with a one-week deadline to open to the new clinic and is hopeful to help alleviate the strain currently being faced by the overwhelming number of pediatric Covid patients.  This will be the only pediatric monoclonal antibody infusion site in the state of Kentucky. This quality improvement gap was identified quickly, and data will be analyzed throughout the development process.


Measures Management System. (2021). Retrieved 17 September 2021, from

Nash, D., Joshi, M., Ransom, E., & Ransom, S. (2019). The Healthcare Quality Book: Vision, Strategy, and Tools (4th ed.). Healthcare Administration Press.

The methodology I would utilize to identify a quality improvement gap in my current organization is the hospitals’ scorecard on Hospital Compare.  “The Centers for Medicare & Medicaid Services (CMS), the federal agency that runs the Medicare program, created this tool in collaboration with organizations representing people with Medicare, hospice organizations, other stakeholders, and other federal agencies”. (Center for Medicare and Medicaid Services, n. d.).  CMS’s website, hospital compare, is a website that allows participants/caregivers/others, to identify providers based on the criteria most relevant to them.  In reviewing my current organizations’ scorecard via hospital compare, the hospitals’ rate for 30- day inpatient psychiatric readmissions is 21.1%, while the national average is 20.1, which is not statistically significant.  However, the percentage of patients included in this data (Medicare only), are minimal, compared to the total number of patients discharged from the inpatient psychiatric unit.

To be sure that this data was accurate, I compared this data to the same statistics reported by some of our other payors via the Value-Based Purchasing (VBP) program. This is a method of provider payments, directly related to the providers’ performance.  More specifically, providers are held accountable for the quality of care they provide, which is directly related to the organizations’ reimbursement (, n. d.).  My organization currently has VBP agreements with two payors.  As reported by these payors, our 30-day readmission rate for the inpatient psych unit is significantly higher than the local/state/national average.  Thus, this is an opportunity for our department to address.

The method I would choose to address this gap in practice is a retrospective chart review. This is a review of a medical record after a patient has been discharged from the hospital.  It is the most comprehensive method of data collection related to patient care.  Additionally, a retrospective chart review “is the primary tool for answering the “why” of a given situation” (Nash, Joshi, Ransom, E. & Ransom, S., 2019, pg. 114).  Following a patients’ discharge, a thorough review of a patients’ chart could help to provide some detail regarding the patients’ discharge plan, wrap-around services in the community and other factors, or lack thereof, that may have contributed to the patients’ readmission.

After a thorough review of a sampling of patients’ charts, collecting data, I would use a fishbone diagram to assist in sorting the data, identifying potential causes for patients’ readmissions.  The fishbone diagram organizes possible causes, in a format that’s visual for ease in understanding (Nash et al., 2019).  Although the reasons for readmission may be very individualized, my goal would be to ensure that, as an organization, we provided patients with all of the tools required to be successfully discharged to the community. Overall, in a review of this data, the focus would be on psychiatric readmissions, but would also consider patient outcomes.  “Management strategies to reduce readmissions may influence indicators of well-being such as psychiatric symptomatology, functional status, quality of life, social adjustment, self-efficacy, service satisfaction, life skills, medication adherence, and ability to live independently” (RTI-UNC Evidence-based Practice Center, 2015, pg. 25).  Improved quality of life is a goal for patients with severe and persistent mental illness.


Center for Medicare and Medicaid Services (n. d.).  Hospital Compare. (n. d.).  Value-Based Purchasing.

Nash, D. B., Joshi, M. S., Ransom, E. R., & Ransom, S. B. (Eds.), (2019).  The healthcare quality book: Vision, strategy, and tools (4th ed.). Health Administration Press.

RTI-UNC Evidence-based Practice Center (2015). Effective health care program: Management strategies to reduce psychiatric readmissions. Technical Brief Number 21.

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This is an outstanding work Andretta. The methodologies of identifying quality improvement gap in health care organization have been clearly identified. I concur with your post. Ideally, identification of quality improvement gap should be followed by addressing the gap and determination of quality of the service. However, evaluating the perceptions and expectations of patients concerning health care delivery and areas that need improvement remains a great challenge (Javed & Ilyas, 2018). Usually, surveys have been used to understand quality improvement gaps from the perspective of the patients and other stakeholders. However, another important methodology that organizations and providers can use is to compare the perceived and the expected quality of service and identify the gaps between them, utilize the feedback from the stakeholders to enhance quality, and evaluate the real experiences of health care (Lu et al., 2020). As service quality is increasingly becoming a critical aspect of corporate strategy in health care system, an approach of measuring the perception and understanding the gap between perception and expectation can be important in quality improvement initiatives (Dopeykar et al., 2018).


Dopeykar, N., Bahadori, M., Mehdizadeh, P., Ravangard, R., Salesi, M., & Hosseini, S. M. (2018). Assessing the quality of dental services using SERVQUAL model. Dental Research Journal, 15(6), 430.

Javed, S. A., & Ilyas, F. (2018). Service quality and satisfaction in healthcare sector of Pakistan—the patients’ expectations. International journal of health care quality assurance.

Lu, S. J., Kao, H. O., Chang, B. L., Gong, S. I., Liu, S. M., Ku, S. C., & Jerng, J. S. (2020). Identification of quality gaps in healthcare services using the SERVQUAL instrument and importance-performance analysis in medical intensive care: a prospective study at a medical center in Taiwan. BMC Health Services Research, 20(1), 1-11.


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A standard quality improvement tool used to identify gaps in services or within a program of services is the gap analysis.  The gap analysis incorporates a visual of what is desired versus the current status by answering the question of where we are now. Where do we want to be, and what do we propose to close the gap? I have chosen the gap analysis to identify a quality improvement gap within our organization of the lack of palliative and hospice service use early in the disease process.

Research has established a connection with palliative care early intervention to produce a better quality of life for those facing advanced disease processes. However, barriers to earlier access to palliative care remain, which might be attributable to the global lack of awareness of palliative care and the prevalence of negative perceptions and attitudes (Collins et al., 2018). Early palliative care is purported to improve quality of life, avoid unnecessary acute care use, and thus reduce health system costs(Seow et al., 2021). Palliative care may be helpful at any point in the disease trajectory and could be especially valuable soon after a person is diagnosed with a severe illness (IOM, 2015; NASEM, 2022; National Consensus Project for Quality Palliative Care, 2018).

I have identified two tools to address this quality improvement project: the Plan-Do-Check-Act (PDCA) Plan and the Matrix. The PDCA delivers guidelines for an action plan to test by first placing the theory into action by collecting data, checking the data strengths and weaknesses based on objective criteria, and acting by adopting, adapting, or abandoning the improvement theory. The Matrix shows a relation between categories (barriers) and can be used to identify themes such as workforce Core Competencies and prioritize workforce development needs to fill competency gaps(CMS, 2021). The measurable efforts of quality improvement should characterize change in the desired direction, contribute to various parts of the system, and progress toward acceptable outcomes.  Quality Improvement should reflect good-quality practice through research.

CMS Innovation Center 2021 strategy refresh, strategic direction: to an external site.

Seow H, Sutradhar R, Burge F, et al., (2021). End-of-life outcomes with or without early palliative care: a propensity score-matched, population-based cancer cohort study

BMJ Open ;11:e041432. doi: 10.1136/bmjopen-2020-041432


Allemang, B., Patton, M., Greer, K. et al,(2023). Development of the Strengths, Skills, and Goals Matrix: a tool for facilitating strengths-based adolescent and young adult engagement in research. Res Involv Engagem 9, 89.

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Jonathan, the comprehensive examination of the healthcare sector’s deficiency in implementing quality enhancement measures, particularly about effective communication during patient handovers, is evident and persuasive. The rationale for selecting this specific gap for your DNP project becomes more substantial when you draw a connection between real-world circumstances, recent data patterns, and feedback from the team. The project’s focus on communication breakdowns during handovers is highly justified, as evidenced by a specific incident that highlights the criticality of patient outcomes and safety.

It is important to exercise discernment while choosing tools such as EHR systems and handover communication sheets (Francis, 2023). An effective approach to address the observed gap is demonstrated through the use of these instruments, which leverage their ability to enhance communication efficiency. Empirical research supports the use of strategies to improve healthcare communication, which aligns with the current emphasis on simulated training and standardized protocols as effective interventions (Gasteiger et al., 2021). Overall, your ideas exhibit a cogent and intentional approach to improving healthcare quality.


Francis, L. (2023). Increasing Nurse-Provider Communication and Decreasing Hospital Admission of Patients From a Skilled Nursing Facility: A Quality Improvement Project (Doctoral dissertation, Jacksonville University).

Gasteiger, N., van der Veer, S. N., Wilson, P., & Dowding, D. (2021). Upskilling health and care workers with augmented and virtual reality: protocol for a realist review to develop an evidence-informed programme theory. BMJ open, 11(7), e050033.