Topic: Hypoglycemia management
Write an analysis, 4-5 pages in length, of the gap between current and desired performance, with respect to the provision of safe, high-quality patient care.
Introduction
Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented.

As a nurse leader, you must be able to assess your organization’s ability to deliver safe, high-quality patient care. In so doing, you may be required to perform a gap analysis of a quality or safety issue as the first step in improving outcomes. Failure to meet benchmarks for safe and effective patient care can have reimbursement, regulatory, and legal consequences.

This assessment provides an opportunity to develop the knowledge, skills, and attitudes required to successfully implement changes that improve patient outcomes by:

Evaluating the current culture of an organization.
Performing an outcomes gap analysis.
Determining what changes are needed to bridge the gap.
Examining current thinking on this topic contained in the literature.
Quality and safety are everyone’s responsibility as a team of interprofessional care delivery partners. Together we develop policies that support quality and safe care delivery. As part of the interprofessional team, nurses are leaders in care and thus are responsible and accountable for leading and providing safe quality care.

Health care delivery is structured around evidence-based information. Quality is defined by exploring proven, evidence-based information. After reviewing and defining evidenced-based information, the interprofessional team applies this knowledge to assess the organization’s or the practice setting’s ability to provide evidenced-based care delivery. When a gap in care is identified, it is important to propose an evidenced-based change and to execute a plan for improved care.

Your quality and safety gap analysis will provide the basis for the remaining assessments in this course.

Preparation
As a nurse leader, you are fully aware of the hazardous nature of health care and that organizations must continually seek to improve the quality and safety of the care they provide to patients. For this assessment, you will identify a systemic problem in your organization, practice setting, or area of interest associated with adverse quality and safety outcomes (for example, an increase in the incidence of falls or medical errors) and analyze the gap between current and desired performance.

Note: Remember that you can submit all or a portion of your draft analysis to Smarthinking for feedback before you submit the final version for this assessment. However, be mindful of the turnaround time of 24–48 hours for receiving feedback, if you plan on using this free service.

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

Culture and process contribute to our ability to develop and sustain quality and safety in a health care organization. By exploring these topics, you can analyze where you may have gaps in practice that affect outcomes. In addition, organizations must create benchmarks for outcomes to determine whether they are meeting quality and safety goals.

What does your organization measure, related to quality and safety, and why?
Are there certain aspects of your organization’s culture and processes that support or hinder quality and safety?
Is the organization meeting outcome measurement benchmarks?
If not, how might you address those gaps in performance? What system could be developed to support a change to close a particular gap?
The following resources are required to complete the assessment.

APA Style Paper Template [DOCX]. Use this template for your gap analysis.

Requirements
Note: The requirements outlined below correspond to the grading criteria in the Quality and Safety Gap Analysis Scoring Guide. Be sure that your written analysis addresses each point, at a minimum. You may also want to read the Quality and Safety Gap Analysis Scoring Guide and Guiding Questions: Quality and Safety Gap Analysis [DOCX] to better understand how each criterion will be assessed.

Conducting the Analysis
Identify a systemic problem in your organization, practice setting, or area of interest that contributes to adverse quality and safety outcomes.
Propose specific practice changes that will improve quality and safety outcomes and bridge the gap between current and desired performance.
Prioritize proposed practice changes.
Determine how proposed practice changes will foster a culture of quality and safety.
Determine how a particular organizational culture or hierarchy might affect quality and safety outcomes.
Justify necessary changes with respect to functions, processes, or behaviors, specific to your organization.
Writing and Supporting Evidence
Communicate analysis data and information clearly and accurately, using correct grammar and mechanics.
Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.
Additional Requirements
Format your document using APA style.

Use the APA Paper Template linked above. Be sure to include:
A title page and reference page. An abstract is not required.
A running head on all pages.
Appropriate section headings.
Properly-formatted citations and references.
Your analysis should be 4–5 pages in length, not including the title page and reference page.
Portfolio Prompt: You may choose to save your gap analysis to your ePortfolio.

Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

Competency 1: Analyze quality and safety outcomes from an administrative and systems perspective.
Identify a systemic problem in an organization related to adverse quality and safety outcomes.
Propose specific practice changes within an organization that will improve quality and safety outcomes and bridge the gap between current and desired performance.
Prioritize proposed practice changes.
Competency 2: Determine how outcome measures promote quality and safety processes within an organization
Determine how proposed practice changes will foster a culture of quality and safety.
Competency 3: Determine how specific organizational functions, policies, processes, procedures, norms, and behaviors can be used to build reliable and high-performing organizations.
Determine how a particular organizational culture or hierarchy might affect or contribute to adverse quality and safety outcomes.
Justify necessary changes to particular organizational functions, processes, and behaviors that correct or mitigate adverse quality and safety outcomes.
Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
Communicate analysis data and information clearly and accurately, using correct grammar and mechanics.
Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.

Paper must also include the following:
1. Identifies a systemic problem in an organization related to adverse quality and safety outcomes, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty.
2. Proposes specific practice changes within an organization that will improve quality and safety outcomes and bridge the gap between current and desired performance, and identifies assumptions on which the proposal is based.
3. Prioritizes proposed practice changes and provides sound rationale for the prioritization.
4. Determines how proposed practice changes foster a culture of quality and safety, and proposes criteria that could be used to evaluate that culture.
5. Determines how a particular organizational culture or hierarchy might affect or contribute to the adverse quality and safety outcomes, and identifies assumptions on which that analysis is based.
6. Justifies necessary changes to particular organizational functions, processes, and behaviors that correct or mitigate adverse quality and safety outcomes, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty.
7. Communicates analyses and information clearly and accurately. Grammar and mechanics are error-free
8. Integrates relevant, credible, and convincing sources of evidence to support assertions. Sources are current, and citations and references are error-free.

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Solution

Quality and Safety Gap Analysis: Inappropriate Hypoglycemia Management

            Various clinical issues compromise the quality and safety of patient care in healthcare organizations. The adverse outcomes result in negative patient experiences and job dissatisfaction among healthcare providers. Thus, clinical issues should be identified, analyzed, and resolved to prevent adverse quality and safety outcomes. This paper presents inappropriate hypoglycemia management as a systemic issue in a healthcare organization associated with negative quality and safety outcomes, proposed practice changes for boosting quality and safety outcomes, prioritization of the proposed change, promoting a culture of quality and safety through the proposed practice changes, the impact of a particular organizational hierarchy or culture on adverse quality and safety outcomes, and proposed changes to particular organizational functions, behaviors, and processes to resolve negative quality and safety outcomes.

A Systemic Issue in a Healthcare Organization Associated with Adverse Quality and Safety Outcomes

The selected systemic issue associated with adverse quality and safety outcomes in a healthcare organization is improper hypoglycemia management. Hypoglycemia is caused by excess insulin in the blood leading to low blood glucose levels. Hypoglycemia symptoms are produced by various glucose levels depending on individuals and circumstances. Insulin-treated diabetic patients can report hypoglycemia symptoms, particularly those using an insulin secretagogue. These patients can experience a slight lowering of glucose between 60 and 70 mg/dl, which is not characterized by any symptoms. On the other hand, patients can experience severe hypoglycemia characterized by very low glucose levels below 40 mg/dl, which leads to neurological impairment. Inappropriate hypoglycemia management, especially severe hypoglycemia, leads to various health complications, including acute cerebrovascular disorder, neurocognitive dysfunction, myocardial infarction, death of the retinal cell, and loss of vision (Shukla et al., 2017).

Propose Practice Changes for Improving Quality and Safety Outcomes

Hypoglycemic events can be prevented or reduced in the healthcare organization through various practice changes, prioritized based on their efficacy to manage hypoglycemia incidents.

First, the care team should focus on recognizing and preventing precipitating factors. This is the most effective practice change since hypoglycemic events won’t occur once the healthcare providers have identified and managed the triggers, such as weight loss, previous hypoglycemia incident, liver dysfunction, renal insufficiency, pituitary insufficiency, and adrenal insufficiency. According to Teixeira et al. (2017), unstable blood glucose risk factors among diabetes type 2 patients include a history of hypoglycemia, autonomic cardiovascular, cognitive deficit/dementia, weight loss, and neuropathy.

The second change involves ordering appropriate scheduled anti-diabetic oral agents or insulin. According to Chaudhury et al. (2017), pharmacotherapy therapy with two oral agents effectively prevents hypoglycemia incidents. This practice change involves scheduling basal and bolus insulin for the patient while hospitalized. This drug therapy replaces physiological insulin requirements since scheduled insulin during hospitalization caters to nutritional and basal needs. Additionally, basal and separate prandial insulin are good options in managing blood glucose levels when a patient is eating scheduled meals.

The third change is monitoring the patient’s blood glucose level before meals and at the bedside. Clinicians should monitor the patient’s capillary blood glucose a minimum of four times daily. Particularly, patients should be monitored before meals and at bedtime for diabetes patients eating. Additionally, it is recommendable to check the patient’s glucose level at 3:00 a.m. for patients with fasting hyperglycemia. Elevated glucose levels could indicate inadequate nighttime insulin dosing at this time. On the contrary, insufficient caloric intake at bedtime or an early peak in evening insulin could be characterized by a low glucose level. A reduction in insulin dosage may be required in patients with persistent hypoglycemia. Furthermore, glucose levels should be checked every six hours for diabetes patients needing continuous tube feedings. Finally, clinicians should coordinate scheduled feeding with glucose checks for patients with unusual bolus tube feeding.

The next change involves medical nutrition therapy. Clinicians should ensure that all diabetes patients receive appropriate nutrition while in hospital, irrespective of dietary control therapy. Providing a patient with a diet rich in carbohydrates consistently is equal to an insulin regimen in preventing hypoglycemia incidents. A consistent carbohydrate approach should be adhered to in the three meals. Thus, a patient should take a balanced meal with other food components, including protein, fiber, and fats, in the recommended amount.

The last change involves applying systems. Clinicians use standardized or protocol order sets for scheduled insulin dosages to lower sliding scale management reliance, maintaining glucose regulation in the healthcare facility. According to Gough et al. (2016), applying dose titration protocols or standardized pathways gives superior outcomes than individualization of care in diabetes management, preventing adverse effects, including hypoglycemia incidents.

The proposed practice changes will enhance blood glucose levels, reducing hypoglycemia incidents in the organization, thus bridging the gap between the current hypoglycemia rates of 35% of total diabetes patients to below 10% within 30 days.

Fostering Quality and Safety Culture in the Healthcare Organization through the Proposed Practice Changes

The proposed practice changes will foster a quality and safety culture in the organization. Clinicians will adhere to the proposed changes when caring for diabetes patients in the inpatient unit. Applying change initiatives in the prioritized order including, recognizing and preventing precipitating factors, ordering appropriate scheduled anti-diabetic oral agents or insulin, monitoring patient’s blood glucose level before meals and at the bedside, medical nutrition therapy, and applying systems will enable inpatient care providers to control patients’ blood glucose level. According to Kodner et al. (2017), uncontrolled blood glucose levels in a diabetes patient results in adverse incidents, including delay in wound healing, high risk of contracting hospital-acquired infection, and longer hospital stay. Hence, appropriate management of blood glucose levels will reduce adverse outcomes, including hyperglycemia and hypoglycemia events and related complications, thus fostering quality and safety culture in the organization.

The Impact of Organizational Culture on Quality and Safety Outcomes

Quality and safety outcomes might be affected by organizational culture. According to Mannion and Davies (2018), healthcare corporate culture constitutes less visible and softer components of health organizations, manifested in health care patterns. Healthcare organization culture impacts other aspects of patient care substantially. Therefore, a positive organizational culture that supports change will embrace the proposed change practices, enhancing control of blood glucose levels, reducing hypoglycemia incidents in the organization. On the contrary, a negative culture will be reluctant to adopt the proposed changes, compromising blood glucose regulation leading to a high rate of hypoglycemia events in the organization.

Required Changes concerning Organization’s Functions and Processes

The implementation of the proposed change practices will change organizational functions. Only a few nurses are currently assigned to diabetes patients in the inpatient unit. These nurses are mandated to ensure that patients are administered with insulin and given meals at the scheduled time. However, sometimes nurses fail to administer insulin at the right time due to fatigue associated with overload, caused by nurse shortage in this unit. This practice area will change following the implementation of the proposed practice changes. More nurses will be required to provide bedside monitoring to diabetes patients. Hence, a nurse will be allocated the recommended number of diabetes patients in the inpatient unit to enhance blood glucose monitoring and management of hypoglycemia events. Additionally, the proposed practice changes will alter the organization’s process. Particularly, organizational processes will change following the application of systems to enable clinicians to utilize standardized or protocol order sets for scheduled insulin dosages to maintain glucose regulation in the healthcare facility.

Conclusion

Overall, inappropriate hypoglycemia management is a significant issue facing the organization, resulting in adverse quality and safety outcomes. For this reason, practice changes should be implemented in the organization to bridge the gap between the current rate of hypoglycemia events and the target. The proposed changes include recognizing and preventing precipitating factors, ordering appropriate scheduled anti-diabetic oral agents or insulin, monitoring the patient’s blood glucose level before meals and at the bedside, medical nutrition therapy, and applying systems. These changes should be prioritized in the listed order during implementation to give the desired outcomes. Clinicians will adhere to the proposed changes when caring for diabetes patients in the inpatient unit, fostering quality and safety culture in the organization. Quality and safety outcomes might be affected by organizational culture, which determines health care services delivery in the facility.

References

Chaudhury, A., Duvoor, C., Reddy Dendi, V. S., Kraleti, S., Chada, A., Ravilla, R., … & Mirza, W. (2017). Clinical review of antidiabetic drugs: implications for type 2 diabetes mellitus management. Frontiers in endocrinology, 8 (6): 1-7.

Gough, S.C., Jain, R & Woo, V, C. (2016). Insulin degludec/liraglutide (IDegLira) for the treatment of type 2 diabetes. Expert Rev Endocrinol Metab; 11(1): 7-19.

Kodner, C., Anderson, L., & Pohlgeers, K. (2017). Glucose management in hospitalized patients. American family physician, 96(10): 648-654.

Mannion, R., & Davies, H. (2018). Understanding organizational culture for healthcare quality improvement. BMJ, 363(7): 1-4.

Shukla, V., Shakya, A. K., Perez-Pinzon, M. A., & Dave, K. R. (2017). Cerebral ischemic damage in diabetes: an inflammatory perspective. Journal of neuroinflammation, 14(1): 1-22.

Teixeira, A. M., Tsukamoto, R., Lopes, C. T., & Silva, R. D. C. G. (2017). Risk factors for unstable blood glucose level: integrative review of the risk factors related to the nursing diagnosis. Revista latino-americana de enfermagem; 3(4): 1-7.