Student Name

Capella University

NURS-FPX6222 Healthcare Safety and Quality Management

Professor Name

Submission Date

Quality and Safety Gap Analysis

A quality and safety gap analysis helps evaluate how an organization measures up against its expectations, based on its mission and patient safety objectives. The analysis will help pinpoint the impact of poor communication on patient safety and quality of service (Leotin, 2025), regarding the health care professionals’ communication gap. These issues that can arise are handover issues, lack of clarity, and communication delays.

Systemic Problem in an Organization

If there is no communication among the healthcare staff, the practice of primary care nursing and bedside care of complicated patients may be adversely affected. There are some communication issues in the clinic that are linked to this low-quality score. The aforementioned communication gap occurs due to some of the communication issues that exist between the healthcare crew, poor information exchange when conducting handovers, and poor working relationships between nurses and other healthcare professionals (Leotin, 2025). This is compounded by the lack of staff, communication skills training, and accountability issues discussed above, which contribute to some discrepancies in the delivery of health services to patients. Information that is important to some patients may not be transferred to other healthcare professionals in time, or not passed at all, which may pose some threats to patients’ health, such as infection from other patients while hospitalization (Alharazi et al. 2025). Furthermore, the lack of quality control and patient communication strategy involvement by leaders is likely to have a negative impact on patients’ health.

• Knowledge Gaps and Areas of Uncertainty

But, from the data presented, little can be concluded on what factors may be responsible for the lack of effective communication among nurses. In addition, no improvement plans seem to have been established about improving practitioners’ communication skills or whether there are any information gaps among the team members (Alharazi et al., 2025). Furthermore, no information has been stated that would suggest that there is anything problematic with patients. Also, there is no information about the organizational culture of the institution.

Proposed Practice Changes to Improve Nursing and Bedside Care Quality

But there are some changes needed to ensure that information is shared at a high level in primary care between health care practitioners, including nurses. First, it’s changing the ratio of patients to nurses by using an evidence-based staffing model so as not to overstress nurses, which in turn will not affect patient communication with the nurse or other health care staff. Second, there are a few techniques of communication (situation, background, assessment, and recommendation (SBAR), bedside rounds, competency training) which can be very useful when conveying information to others (Muir et al., 2025). In addition, dashboards should be applied in the exchange of information between people, and the continuous quality improvement strategy should be employed in this exchange. Last but not least, multi-disciplinary meetings may be very helpful in the case in question.

• Assumptions

The recommendations presented on how to improve the communication among healthcare workers are based on the following assumptions. First, it is expected that the organization will have to spend resources on setting up efficient communication mechanisms, and second, that the organization will have the finances to introduce communication mechanisms of this nature. (Muir et al., 2025) Second, it can be assumed that the nurses and other health care workers will be actively involved in the training process and cooperatively develop communication skills with no inhibitions. Third, it is assumed that health workers will remain engaged in using the communication mechanisms that are currently in place and will be involved in quality improvement. Fourth, it is hoped that multidisciplinary working and feedback on performances will help to improve patient safety and quality.

Prioritization of Proposed Practice Changes at Baptist Health Floyd

Evidence-based nurse-to-patient staffing ratios in the clinic are the most important change that should be made to improve healthcare professionals’ communication. Where nurse workload is close to safety limits, some indications of a decrease in nurse-to-patient ratios are related to poorer measures of patient-care outcomes, such as higher risk of adverse outcomes like infection, delay in treatment, and the risk of communication errors, which can be as high as about 10-30% (Kang et al., 2026). Staffing problems lead to overburden, delayed, and inadequate communications with patients and a higher risk of patient safety adverse events like infection, failure to give medications, etc. Failure to provide nurses adequate time and resources for effective communication will most likely result in an unsuccessful implementation of a communication tool or any other quality improvement initiative (Leotin, 2025). Therefore, staffing is the key element to improving communication between a healthcare provider and patient, as well as improving patient safety.

Structured communication systems (such as SBAR), hourly rounding, and competency-based communication training at the point of care need to be implemented as well, along with the improvements in staffing levels. Studies have shown that the use of structured communication tools, like SBAR, has decreased the incidence of communication errors, thus providing perfection in the exchange of information and leading to an overall decrease in the rate of adverse events within multiple healthcare facilities (Shrivastava, 2025). This is important because it will minimise inconsistencies in passing information on between shifts of the same employee and therefore maximise the opportunities for important information about a patient to be passed on to the next employee. Lastly, the use of real-time performance dashboards and interdisciplinary meetings to assess the effectiveness of current communication systems will help health care organizations work to continually improve the quality of care (Muir et al., 2025). This mixture of both methods is used to enhance cross-functional working, communication, and patient care and safety.

Practice Changes Fostering a Culture of Quality and Safety

The clinic is seeking to enhance patient safety by focusing on improving the quality of care by resolving the communication issues among the providers. The three principles of nursing will be utilized in the clinic towards this goal, namely: accountability, transparency, and evidence-based nursing practices (Fukami, 2024), as well as competency-based education will enable the nurses to build on their communication skills and to develop an effective communication standard among the staff. The SBAR tool and hourly rounding will help to create a consistent and standardized way for all nurses to communicate. Real-time safety dashboards will provide increased accountability and transparency to all members of the medical and leadership teams by visually displaying how they have progressed related to communication and patient safety metrics. This will ensure transparency of the information to all stakeholders and enable any issues with communication to be identified early (Fukami, 2024). These actions create an atmosphere at the clinic that promotes effective communication within the health care facility and ensures that all staff members take an active role in delivering high-quality health care to their complex patients.

• Criteria to Evaluate the Culture of Quality and Safety

Many of these support an affirmatively supportive safety and quality culture, but there are key things that are going wrong in the quality and safety of the culture itself, such as healthcare team communication. For example, the first measure could be the ratings of nurses’ care, which indicates that communication amongst the health care team has improved with respect to nursing care for these patients (Alharazi et al., 2025). Other measurements might involve examining how many hospital-acquired infections occur from poor communication and poor clinical practices at the right time, or the number of errors reported in quarterly reports, and whether there is an increase or decrease in the number of errors.

Additionally, bi-annual employee-engagement surveys help to measure the overall happiness of nurses in their work environment, their belief in safety within their work environment, and whether or not the individual nurse would feel comfortable raising concerns if they did not feel they had been heard by the facility. Other metrics to consider are interprofessional collaboration, completion of competency-based training in communication, the successful rate of completion of interprofessional competencies, and the rapid response of leaders to patient safety issues (Alharazi et al., 2025). The findings of all the above metrics, when analyzed together, can help to determine whether the changes in communication have had a positive effect on patient safety.

Impact of Organizational Culture and Hierarchy

A hierarchical structure within an organisation might be an issue if the bedside nurse communicates to other members of the health care team about errors, concerns for patient safety, and ineffective practice due to the potential consequences that may arise from the errors. This would make it easier for nurses to communicate their concerns with the nurse manager and would also postpone the resolution of issues and critical issues that could have an impact on the organizational process in these types of organizations with hierarchical management and communication processes (Kang et al., 2026). The communication problem stated above can cause other performance issues among health care professionals in the clinic and impact the performance of the clinic for patients with complex health issues. The other communication problem that occurs in the above is the lack of a balance of power in the organization, where nurses feel uncomfortable making a comment or recommendation for improving the organization, even if the comment or improvement is very important and impactful to preventing negative impacts and improving service quality in health care delivery. As was already mentioned above, this discussion of possible communication problems assumes that the leadership style of the clinic is hierarchical and there is no sufficient level of psychological safety.

Justification for Necessary Changes

The primary care clinic will need to make significant improvements in its organisational processes and behaviours, as these are causing issues with communication and, in turn, impacting negatively on the way nurses deliver care.s deliver care. Transformational leadership is required as it will improve communication and a shared understanding that decisions will be made as a team, so that nurses feel they can express their concern about safety issues without repercussions (Ystaas et al., 2023). Moreover, by having such a new approach, the employees will be able to communicate and collaborate better among themselves to come up with efficient communication among all stakeholders. Communication protocols will need to be standardized (e.g., through the use of SBAR), and real-time quality dashboards and accountability will help to identify and resolve problems with the quality of communication. What this means is that if the quality of communication is a problem, it’s possible to detect and resolve it promptly, because the organization is undergoing changes in structure (Ghonem & El-Husany, 2023). The changes to the organization tackle the underlying issues, creating communication challenges, and help to provide a safe and more coordinated environment for the care of patients with complex needs.

• Knowledge Gaps and Areas of Uncertainty

Some of the knowledge gaps pertaining to the leadership ability in addressing the communication gap amongst the healthcare workers in the primary care facility include uncertainty on whether the leadership is equipped with all the necessary skills and resourcefulness to enable improvements in communications between healthcare professionals sustainably (Ystaas et al., 2023). There is also doubt around the readiness for sustainable changes among staff members.

Conclusion

The communication issues the nurses were dealing with within a primary care home illustrate the types of organizational issues that need to be addressed to ensure safe, quality health care services are delivered. This will involve closing the existing knowledge gaps, changing practices, and developing into an effective leader and communicator of nurses. Communication and collaboration will be effective and will help to close performance gaps.