NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

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Assessment 3: Outcome Measures, Issues, and Opportunities
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Student Name
Capella University
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Prof Name
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Nov 10, 2023
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Outcomes, Measures, Issues, and Opportunities
The impact of an unsafe surgical procedure at Alignment Healthcare has resulted in
system-wide consequences affecting the quality of care. Adverse outcomes, stemming from an
under-skilled team, insufficient training, lax surgical and maintenance protocols, and sterilization
issues, pose potential harm to patients. These issues contribute to organizational challenges
such as financial burdens, re-operative procedures, increased readmissions, and higher rates of
hospital-acquired infections (Balance et al., 2023). Addressing these issues is crucial for
improving organizational reputation, building trust within the healthcare system, reducing
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medical errors, managing patient complications, and controlling costs. This assessment
analyzes and develops a comprehensive report on outcomes, measures, issues, and
opportunities within Alignment Healthcare for executive leadership.
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Organizational Functions, Processes, and Behaviors in
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High-performing Organizations
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In high-performing organizations, strategic planning and effective care plan implementation are
essential for providing quality care. These organizations leverage errors as learning
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opportunities to enhance their practices and minimize medical errors (Buljac-Samardzic et al.,
2020). To address safety issues like unsafe surgical procedures, postoperative complications,
patient readmission, surgical site infections, and patient satisfaction, Alignment Healthcare
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requires multi-leveled organizational changes. Managing unsafe surgical procedures involves
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developing protocols for hygiene maintenance and handling surgical site infections through
meticulous operative techniques, timely administration, and appropriate preoperative
arrangements (Ariyo et al., 2019).
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In addition to preoperative hygiene-based preparations, comprehensive learning and

simulation-based education for nurses promote interactive learning, enabling them to anticipate
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risks associated with unsafe surgical procedures. This approach enhances patient satisfaction
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and reduces postoperative risks and readmissions. The "Four E’s" strategy—engage, educate,
execute, and evaluate—is effective in achieving organizational goals (Ariyo et al., 2019).
Alignment Healthcare must design learning and training modules that engage employees,
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educate them, encourage action, and evaluate progress.

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Organizational Functions, Processes, and Behaviors Support and

Outcome Measures
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Outcome measures at Alignment Healthcare include the frequency of unsafe surgical

procedures, postoperative complications, patient readmission, surgical site infections, and
patient satisfaction. These measures enable the organization to assess the quality of care and
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the competency of professionals (Hannawa et al., 2022). Timely evaluation and modification of
strategies are crucial for improving decision-making, achieving organizational goals,
streamlining workflow, and enhancing safety protocols.
Positive effects on outcome measures include safety protocols that streamline processes and
reduce errors, surgical infections, and postoperative risks. Inter-professional collaboration
fosters effective communication, leading to better-coordinated care and overall cultural
performance improvement. Conversely, poorly developed processes contribute to unsafe
surgical procedures, higher readmission rates, and increased resource allocation in
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reimbursement and readmission management. Communication issues and lack of empathy
negatively impact patient satisfaction and compromise safety (Tiwary et al., 2019).
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Organizational and structural changes, including hygiene safety protocols, comprehensive
learning modules, regulatory compliance, and open communication, are essential for balancing
positive and negative outcomes. Strong leadership is crucial for controlling employee work
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stress, lowering infection risks, and empowering staff to provide safe procedures, ultimately
achieving quality improvement outcomes (Irshad et al., 2021).
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Quality and Safety Outcomes and Measures
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Unsafe surgical care procedures, identified through a gap analysis, are critical quality and safety
outcomes. Implementing alcohol-based antibiotics, antiseptics, and preoperative sanitized
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protocols can improve preoperative strategies and reduce the risk of surgical site infections.
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Optimizing preoperative strategies and diligence during surgery can also reduce postoperative
risks (Ling et al., 2019).
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Effective management of health conditions at home, patient education, medical record

consolidation, proper discharge planning, and follow-ups contribute to minimized readmission
rates and increased patient satisfaction. Addressing quality and safety outcomes requires
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reliable and accurate data, and optimizing preoperative measures can lead to improved
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outcomes, reduced readmissions, and higher patient satisfaction.
Performance Issues or Opportunities

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Performance issues related to unsafe surgical care procedures include competency concerns,
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unskilled or untrained staff, and a lack of inter-professional collaboration. Inadequate

sterilization practices, improper wound care, and preoperative strategies contribute to health
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risks. Opportunities for improvement include continuous learning and training, benchmarking
against high-performing organizations, enhancing team communication, and implementing
checklists to provide better outcomes.
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However, uncertainties, such as the effective implementation of checklists, the impact of human
factors on performance, and patient-specific variables, require attention. Addressing these
issues and capitalizing on opportunities can have significant positive effects on organizational
performance.
Strategy Using PDSA

The Plan-Do-Study-Act (PDSA) model is suitable for iterative cycles of planning, implementing,
evaluating, and refining changes to improve processes. Planning involves identifying issues
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related to unsafe surgical care procedures and implementing strategies to reduce complications.
Implementation includes training sessions, protocol implementation, and data collection. The
study phase analyzes data to understand the plan's success, and the act phase refines
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strategies based on continuous monitoring and evaluation.
Training and education, along with feedback loops and collaborative projects, can disseminate
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information and encourage interaction and cooperation among the healthcare team.
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Conclusion
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This report addresses organizational functions, processes, behaviors, and outcome measures
at Alignment Healthcare, emphasizing patient safety and quality improvement. Implementing
strict infection control protocols, and preoperative strategies, and promoting a culture of safety
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through effective communication and leadership are essential for enhancing standards of care.
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References
Andersen B. M. (2018). Prevention of postoperative wound infections. Prevention and Control of
Infections in Hospitals: Practice and Theory, 377–437.
https://doi.org/10.1007/978-3-319-99921-0_33
Ariyo, P., Zayed, B., Riese, V., Anton, B., Latif, A., Kilpatrick, C., Allegranzi, B., & Berenholtz, S.
(2019). Implementation strategies to reduce surgical site infections: A systematic review.
Infection Control & Hospital Epidemiology, 40(3), 287–300. https://doi.org/10.1017/ice.2018.355
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Buljac-Samardzic, M., Doekhie, K. D., & van Wijngaarden, J. D. (2020). Interventions to improve
team effectiveness within health care: A systematic review of the past decade. Human
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Resources for Health, 18(1), 1-42. https://doi.org/10.1186/s12960-019-0411-3
Balane, J. A. L., Yap, C. D. D., Villanueva, C. A. G., Palileo-Villanueva, L. A. M., &
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Tamondong-Lachica, D. R. (2023). Predictors of readmission in a medical department of a
tertiary university hospital in the Philippines. BMC Health Services Research, 23(1), 1-8.
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https://doi.org/10.1186/s12913-023-09608-z
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Dharap, S. B., Barbaniya, P., & Navgale, S. (2022). Incidence and risk factors of postoperative
complications in general surgery patients. Cureus, 14(11), e30975.
https://doi.org/10.7759/cureus.30975
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Hannawa, A. F., Wu, A. W., Kolyada, A., Potemkina, A., & Donaldson, L. J. (2022). The aspects
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of healthcare quality important to health professionals and patients: A qualitative study. Patient
Education and Counseling, 105(6), 1561-1570. https://doi.org/10.1016/j.pec.2021.10.016
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Irshad, M., Majeed, M., & Khattak, S. A. (2021). The combined effect of safety-specific
transformational leadership and safety consciousness on the psychological well-being of
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healthcare workers. Frontiers in Psychology, 12, 688463.

https://doi.org/10.3389/fpsyg.2021.688463
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Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and
communication in nurse-patient interactions: barriers, facilitators, and the way forward. BMC
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Nursing, 20(1), 1-10. https://doi.org/10.1186/s12912-021-00684-2

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Kalaja, R. (2023). Determinants of Patient Satisfaction with Health Care: A Literature Review.
European Journal of Natural Sciences and Medicine, 6(1), 41-52.
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https://revistia.org/files/articles/ejnm_v6_i1_23/Kalaja.pdf
Ling, M. L., Apisarnthanarak, A., Abbas, A., Morikane, K., Lee, K. Y., Warrier, A., & Yamada, K.
(2019). APSIC guidelines for the prevention of surgical site infections. Antimicrobial Resistance
& Infection Control, 8(1), 1-8. https://doi.org/10.1186/s13756-019-0638-8
Call Us Now (612) 234-7670
Koukourikos, K., Tsaloglidou, A., Kourkouta, L., Papathanasiou, I. V., Iliadis, C., Fratzana, A., &
Panagiotou, A. (2021). Simulation in clinical nursing education Acta Informatica Medica, 29(1),
15–20. https://doi.org/10.5455/aim.2021.29.15-20
Pugh, J., Penney, L. S., Noël, P. H., Neller, S., Mader, M., Finley, E. P., Lanham, H. J., &
Leykum, L. (2021). Evidence-based processes to prevent readmissions: More is better, a
ten-site observational study. BMC Health Services Research, 21(1), 189.
https://doi.org/10.1186/s12913-021-06193-x
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Tiwary, A., Rimal, A., Paudyal, B., Sigdel, K. R., & Basnyat, B. (2019). Poor communication by
health care professionals may lead to life-threatening complications: examples from two case
reports. Wellcome Open Research, 4, 7. https://doi.org/10.12688/wellcomeopenres.15042.1
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Seidelman, J. L., Mantyh, C. R., & Anderson, D. J. (2023). Surgical site infection prevention: A
review. JAMA, 329(3), 244–252. https://doi.org/10.1001/jama.2022.24075
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Addendum
Table 1a: Total Number of Medical Errors
Medical Errors Number of Mortality Patient Postoperative

Cases Rate Injuries Complications
Number of Cases 50 5% 25 -
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Surgical Site 28 3% 14 -
Infections
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Patient Complaints 17 0.3% 7 -
No. of 25 2% 10 -
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Readmissions
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Table 1b: Outcome and Associated Measures
Safety concern
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Unsafe Surgical Surgical Site Infection Rate Avoiding razors for preoperative
Care hair removal, use of alcohol-based
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skin preparation agents,

antiseptics, and preoperative
glucose control (Seidelman, et al.,
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2023)
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Postoperative Preoperative protocol optimization,

Complications management of blood loss, operation
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time and intraoperative

complications, and infection protocol
management (Dharap et al., 2022)
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Patient Patient surveys, patient expectations,

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Satisfaction and patient’s perceptions toward the

medical healthcare professionals
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provide improved satisfaction (Kalaja,

2023)
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Readmission Healthcare at home is improved
Rates through patient education, medical
record consolidation, discharge
preparation, and follow-up phone
calls (Pugh, et al., 2021)
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In addition to preoperative hygiene-based preparations, comprehensive learning and

educate them, encourage action, and evaluate progress.

Organizational Functions, Processes, and Behaviors Support and

Outcome measures at Alignment Healthcare include the frequency of unsafe surgical

Effective management of health conditions at home, patient education, medical record

outcomes, reduced readmissions, and higher patient satisfaction.

Performance Issues or Opportunities

unskilled or untrained staff, and a lack of inter-professional collaboration. Inadequate

Strategy Using PDSA

Balane, J. A. L., Yap, C. D. D., Villanueva, C. A. G., Palileo-Villanueva, L. A. M., &

healthcare workers. Frontiers in Psychology, 12, 688463.

Nursing, 20(1), 1-10. https://doi.org/10.1186/s12912-021-00684-2

Table 1a: Total Number of Medical Errors

Medical Errors Number of Mortality Patient Postoperative

skin preparation agents,

Postoperative Preoperative protocol optimization,

time and intraoperative

Patient Patient surveys, patient expectations,

Satisfaction and patient’s perceptions toward the

provide improved satisfaction (Kalaja,

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