Leading organizations for quality improvement initiative

Leading Organizations for Quality Improvement Initiatives 

Discussion Response

 respond to  two of your colleagues on  by expanding upon your colleague’s post and suggesting alternative tools and/or methods your colleague might consider using to address the quality improvement practice gap they selected.


Laura Assanga Eyong

Identifying Practice Gaps for Quality Improvement.

Practice gaps are the differences that exist between the current state of practice and its intended state. Practice gaps are a helpful tool for identifying issues in the workplace, mainly when performance is falling short of expectations in a healthcare environment (Flodgren et al., 2019). To ensure that the current state of healthcare practice meets or surpasses the expected practice, quality improvement projects can be constructed upon evaluating practice gaps (Robinson et al., 2020). Since they support advancements in critical areas of healthcare practice, like knowledge, skills, and practice, evaluating practice gaps and the ensuing quality improvement initiatives are crucial (Joshi et al., 2018).

Explanation of  How I Would Identify Improvement Practice Gap in My Practice Organization

Practice gaps, as previously stated, represent the discrepancy between what is occurring in practice at the moment and what evidence-based practices recommend should be occurring (Flodgren et al., 2019). Finding practice gaps is a crucial first step toward improving healthcare since it serves as the basis for initiatives aimed at improving quality. Gap analysis is one method of detecting practice gaps. To determine where the deviation is, a gap analysis evaluates current processes and compares them to best practices. A gap analysis describes the discrepancy between what is occurring and what ought to occur, which helps identify a practice gap (Joshi et al., 2018). Utilizing data and research findings is another method for identifying gaps in practice. By comparing best practices with existing practices, one can better discover practice gaps by understanding best practices, which is made possible by research findings (Michel et al., 2019). Among other sources, quality improvement statistics, literature reviews on a range of subjects, national clinical recommendations, patient care audits, and current healthcare trends can all be used to identify research findings (Joshi et al., 2018). A variety of data and information sources, including expert and faculty feedback, participant feedback (including needs assessment results and past CME evaluations), and participant feedback, can also be used to guide the comparison of current practice with best practice to identify practice gaps (Robinson et al., 2020). Practice gaps can also be found through data from the several regulatory agencies that oversee different professions. Understanding how current practice differs from best practice and identifying practice gaps might result from knowledge gathered from pertinent boards and state requirements (Michel et al., 2019).

Potential Quality Improvement Practice Gap that Can Be Use for My DNP Project

Medication administration errors are one possible quality improvement practice gap I might employ for my DNP project. By guaranteeing that healthcare services are safe, effective, timely, equitable, efficient, and patient-centered, a quality improvement project to reduce pharmaceutical errors would improve patient outcomes (Hammoudi et al., 2018). The complexity of pharmaceutical safety is the rationale behind the decision to address this practice gap. Medication prescription and administration are intricate procedures with many potential for error. Medication errors are not only quite likely to occur but also harm patients’ health and general well-being. Therefore, it is imperative to develop a less error-prone system to guarantee that the appropriate drugs are administered to the appropriate patients at the appropriate time (Hammoudi et al., 2018). In addition to improving patient outcomes, this would promote patients’ safety, health, and general well-being. The five rights of medicine administration—the appropriate patient, the proper medication, the right time, the proper dosage, and the correct route—can all lead to pharmaceutical errors (Hammoudi et al., 2018). However, there are times when more than one person ensures these five rights are upheld. Various healthcare experts must be involved in prescribing and administering medications (Jember et al., 2018). System modifications are required to guarantee that the five rights are upheld during the prescription and administration of drugs. It is imperative to address systemic problems, such as system misconfiguration, diversions, lengthy processes, and inadequate training of healthcare staff, that may lead to prescription errors. The quality improvement project aims to develop a pharmaceutical error prevention, mitigation, and reduction system that improves patient safety and healthcare outcomes (Hammoudi et al., 2018).

Two Types of Tools/Methods that I Might Use to Address Quality Improvement Practice Gap

The Plan-Do-Study-Act (PDSA) paradigm can be used in quality improvement projects and research endeavors that seek to positively impact healthcare procedures to achieve desired results. The Institute for Healthcare Improvement has made extensive use of this technique for quick cycle improvement (Joshi et al., 2018). The cyclical nature of affecting and evaluating change is one of this model’s distinctive aspects results (Christoff, 2018). Quality improvement projects are thoroughly vetted to ensure that they achieve the intended goal. It is best achieved by periodic, small-scale PDSAs rather than large, slow ones before system-wide changes are implemented. Establishing a functional or causal relationship between changes in processes (more especially, behaviors and skills) and results is the goal of PDSA quality improvement initiatives. Before applying the PDSA cycles, Langley and colleagues put forward the following three questions:  What is the project’s aim?  How will it be determined if the objective was accomplished? and (3) How will the objective be attained? The first steps in the PDSA cycle are to identify the type and extent of the issue, the changes that may and should be made, the specific change that needs to be planned, the people who should be involved, the things that should be measured to gauge the change’s impact, and the target audience for the strategy. After that, facts and information are gathered and changes are put into practice. Several important metrics that show success or failure are reviewed to evaluate and interpret the implementation study’s results. Finally, the results are put into practice by either starting the process over or executing the modification.

The VA’s National Center for Patient Safety created the health failure modes and effects analysis (HFMEA) tool for risk assessment. In HFMEA, there are five steps: first, establish the topic; second, put together the team; third, create a process map for the topic, numbering each step and substep in turn; and fourth, carry out a hazard analysis (e.g., determine the reason behind failure modes, assign a score to each failure mode using the hazard scoring matrix, and go through the decision tree analysis) formulate plans of action and goals. When performing a hazard analysis, it is crucial to enumerate all probable and actual failure modes for every process, assess if the failure modes call for additional action, and enumerate all causes for each failure mode when it is decided to move forward. Following the hazard analysis, evaluating the necessary steps and result measurements is critical. This includes outlining what will be removed or regulated and assigning accountability for each new action.


Practice gaps denote a difference between what should be happening in practice and what is currently happening (Flodgren et al., 2019) The identification of practice gaps is an essential building block to advance healthcare as it helps form the foundation for quality improvement projects. One way to identify practice gaps is through gap analysis. A gap analysis includes the evaluation of current practices and compares the same to best practices where the deviation is. A gap analysis informs the identification of a practice gap by outlining the difference between what is happening and what should be happening. One potential quality improvement practice gap that I would look to address is medication errors. The prescription and subsequent administration of medication is a complex process with various points of error. In addition to the high risk for errors, the occurrence of medication errors is detrimental to the patients and adversely affects their health and well-being (Hammoudi et al., 2018) As such, it is critical to come up with a system that is less prone to errors to ensure that the right medications are given to the right patients at the right time (Jember et al., 2018).



Christoff, P. (2018). Running PDSA cycles.Current problems in pediatric and adolescent health care,48(8), 198-201.

Flodgren, G., O’Brien, M. A., Parmelli, E., & Grimshaw, J. M. (2019). Local opinion leaders:effects on professional practice and healthcare outcomes.Cochrane Database of Systematic Reviews, (6).

Hammoudi, B. M., Ismail, S., & Abu Yahya, O. (2018). Factors associated with medication administration errors and why nurses fail to report them.Scandinavian Journal of Caring Sciences,32(3), 1038-1046.

Jember, A., Hailu, M., Messele, A., Demeke, T., & Hassen, M. (2018). The proportion of medication error reporting and associated factors among nurses: a cross-sectional study.BMC Nursing,17(1), 1-8.

Joshi, M., Ransom, E. R., Nash, D. B., & Ransom, S. B. (Eds.). (2014). The healthcare quality book: vision, strategy, and Tools. Chicago, IL, USA:: Health Administration Press.

Michel, J., Chimbindi, N., Mohlakoana, N., Orgill, M., Bärnighausen, T., Obrist, B., … & Tanner, M. (2019). How and why policy-practice gaps come about: a South African Universal Health Coverage context.Journal of Global Health Reports,3, e2019069.

Robinson, T., Bailey, C., Morris, H., Burns, P., Melder, A., Croft, C., … & Teede, H. (2020).Bridging the research-practice gap in healthcare: a rapid review of research translation centers in England and Australia.Health research policy and systems,181-17.



Main Discussion Post

As mentioned in the introduction to this week’s topic, a practice gap is the difference between a desirable or achievable state of practice and current reality. One strategy to identify a quality improvement practice (QI) gap is to conduct a gap analysis. A gap analysis is used to identify gaps in services or processes and helps clarify the differences between reality and the perceptions of practices in the organization (American Medical Writers Association (AMWA), 2021). Identifying practice gaps can also help to better focus resources and energy on those identified areas in order to improve them (AMWA, 2021). Lu et al. (2020), suggest using SERVQUAL, to compare the expected and perceived service quality to identify gaps between them, apply feedback from patients to improve quality of care, assess experiences of medical care, and perceptions of quality as provided by the patients.

A potential quality improvement practice gap is the lack of medication adherence. The lack of medication adherence has long affected patients, healthcare outcomes, and the overall healthcare system. Some factors that influence medication nonadherence are inadequate understanding of medications,side effects, and the inability to afford the medications. Whatever the details are surrounding medication nonadherence, it remains as a gap in healthcare practice. Medication nonadherence directly affects 30-day hospital readmission and the increasing healthcare costs. Medication nonadherence has even extended globally with an estimated $289 billion in damages (Lloyd et al., 2019). One does not have to look far when trying to locate issues with medication nonadherence. On the medical-surgical telemetry floor where I work, we tend to see the same heart failure (HF) patients almost every month or every couple of months due to HF exacerbation. Retrum et al. (2013) states that HF is the leading cause of hospital readmission and hospitalization in older adults.

The Agency for Healthcare Research and Quality (2018), suggests using a systemic approach to address quality improvement gaps by adopting a consistent QI approach like model for improvement, lean, six sigma, root cause analysis, and plan-do-study-act (PDSA). To address the medication nonadherence gap, the PDSA tool could be implemented to determine the nature and scope of the problem, what changes can and should be made, a plan for a specific change, who should be involved, what should be measured to understand the impact of change, and where the strategy will be targeted. Change is then implemented and data and information are collected. Results from the implementation study are assessed and interpreted by reviewing several key measurements that indicate success or failure. 

Another tool that can be used to address medication nonadherence is the conduction of a root cause analysis (RCA). RCA is a technique used to identify trends and assess risk that can be used whenever human error is suspected with the understanding that system, rather than individual factors, are likely the root cause of most problems. Medication adherence is a complex behavior that is influenced by factors along the continuum of care, relating to the patient, providers, and health systems. Patient-related factors include unintentional factors, which often worsen with increasingly complex medication regimens (e.g., forgetting to take medication or obtain refills, or inadequate understanding of dose or schedules); and intentional factors (e.g., active decision to stop or modify a treatment regimen based on ability to pay, beliefs and attitudes about their disease, and medication side effects). Conducting a root cause analysis can specify the cause or causes and hopefully address the issue on the system level.


Agency for Healthcare Research and Quality. (2018). Key Driver 2. Implement a data-driven quality improvement process to integrate evidence into practice procedures. 
Links to an external site.

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), 908. 
Links to an external site.

Lloyd, J. T., Maresh, S., Powers, C. A., Shrank, W. H., & Alley, D. E. (2019). How much does medication nonadherence cost the medicare fee-for-service program? Medical Care, 57(3), 218-224. 
Links to an external site.

Retrum, J. H., Boggs, J., Hersh, A., Wright, L., Main, D. S., Magid, D. J., & Allen, L. A. (2013). Patient-identified factors related to heart failure readmissions. 
Circulation. Cardiovascular Quality and Outcomes
6(2), 171–177. 
Links to an external site.

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