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NURS FPX 6210 Assessment 1 Care Setting Environmental Analysis

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Capella University

NURS-FPX 6210 Leadership and Management for Nurse Executives

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Part 1: Appreciative Inquiry Discovery and Dream

Stories Synthesis of and Evidence Excellence in Quality Safety Goals

In the bustling community hospital of St. Mary’s, our dedication to quality and safety goals has yielded notable success stories that exemplify our commitment to excellence in patient care. One such memorable event unfolded during a sudden cardiac arrest incident, where our adept emergency response team at St. Mary’s sprung into action with remarkable efficiency. CPR was initiated promptly, and the defibrillator was swiftly accessed, leading to the restoration of the patient’s heart rhythm within minutes.

This decisive action, coupled with seamless coordination among staff members and strict adherence to safety protocols, resulted in a remarkable 90% survival rate for such emergencies, a testament to our unwavering commitment to patient safety and quality care (Thorén, 2023). Similarly, within the corridors of St. Mary’s, a vigilant nurse’s keen observation averted a potentially harmful medication error. During routine medication administration, the nurse detected a dosage discrepancy and immediately consulted the pharmacist and prescribing physician for validation.

NURS FPX 6210 Assessment 1 Care Setting Environmental Analysis

Through collaborative efforts and meticulous attention to detail, the team successfully prevented the error, ensuring the patient’s safety. This narrative underscores our hospital’s dedication to medication safety and error prevention. This commitment has led to a commendable 95% reduction in medication-related adverse events over the past year (Fuchshuber & Greif, 2022).Beyond these compelling stories, St. Mary’s diligently tracks and analyzes data related to patient outcomes, safety incidents, and quality indicators. The data reveals a 20% improvement in patient outcomes over the last two years, attributed to our continuous efforts to enhance care delivery and patient safety protocols.

Furthermore, our hospital boasts accreditations from prestigious healthcare organizations such as the Joint Commission and the National Committee for Quality Assurance (NCQA), underscoring our adherence to stringent quality and safety standards. These accreditations serve as external validation of our hospital’s commitment to excellence in patient care and safety (Naidoo & Arifi, 2024). However, while celebrating these achievements, St. Mary’s remains committed to ongoing improvement.

Detailed root-cause analyses of safety incidents are conducted regularly to identify systemic issues and implement targeted enhancements. Additionally, soliciting feedback from patients and their families is integral to our continuous improvement efforts, ensuring that their voices are heard and valued in shaping our care delivery practices (Hatlie et al., 2020). Moreover, comparative data benchmarking against peer hospitals enables us to benchmark our performance and identify areas for further advancement. Through collaborative teamwork, data-driven practices, and unwavering dedication to our mission, St. Mary’s Community Hospital continues to set the standard for quality and safety in patient care.

Proposal for Positive, Attainable Improvement Goals for Quality and Safety

In pursuit of enhancing quality and safety in our care setting, we propose two attainable improvement goals: firstly, implementing cultural competency training for all staff members, and secondly, enhancing patient communication strategies. By accomplishing these goals, we aim to not only elevate the ethical standards of care but also foster a culturally sensitive environment that respects and meets the diverse needs of our patient population. Cultural competency training will equip our staff with the necessary data and skills to recognize and address the exclusive cultural backgrounds, principles, and preferences of our patients.

This will lead to more inclusive and respectful care practices, aligning with our commitment to providing ethical care that upholds patient autonomy and dignity. Moreover, by reducing cultural barriers to care, we anticipate a decrease in health disparities and an improvement in patient outcomes, contributing to a more equitable healthcare system (So & Rodrigues, 2021). Enhancing patient communication strategies, such as implementing language interpretation services and providing patient education materials in multiple languages, will further support our goal of providing culturally sensitive care.

NURS FPX 6210 Assessment 1 Care Setting Environmental Analysis

Effective communication is essential for promoting patient understanding, engagement, and satisfaction, thereby enhancing safety and quality of care. Additionally, clear and culturally sensitive communication will foster trust between patients and providers, strengthening therapeutic relationships and improving the overall patient experience (Kwame & Petrucka, 2021).These proposed goals align seamlessly with our care setting’s mission, vision, and values. Our mission statement emphasizes our dedication to providing everyone, regardless of cultural background, with high-quality, patient-centered care.

Likewise, our vision of creating an inclusive healthcare environment resonates with the objectives of cultural competency training and enhanced communication strategies. Furthermore, these goals reflect our core values of integrity, compassion, and diversity by prioritizing respect for patients’ cultural identities and ensuring equitable access to quality care (Varkey, 2021). The assumptions underlying these proposed goals include the belief that investing in staff training and communication strategies will yield tangible improvements in patient outcomes. We also assume that our staff members are willing and capable of participating in training and implementing new communication approaches. Overall, these improvement goals are rooted in the conviction that enhancing cultural competency and communication will lead to meaningful advancements in quality and safety, in line with our care setting’s commitment to excellence and patient-centered care (Horváth & Molnár, 2021).

Part 2: SWOT Analysis

SWOT Analysis for Quality and Safety Goals

Conducting a thorough SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis of St. Mary’s Community Hospital, mainly focusing on quality and safety goals, was imperative to gauge our current standing and chart a path for improvement. We utilized the Baldrige Using the Excellence Framework, a reliable assessment tool in the healthcare industry, and we can thoroughly assess both our external possibilities and risks as well as our internal strengths and weaknesses. Our SWOT analysis was anchored in the Baldrige Excellence Framework, aligning seamlessly with our hospital’s mission of delivering exceptional care to our community. This tool’s emphasis on continuous improvement perfectly resonates with our commitment to quality and safety.

SWOT Analysis for St. Mary’s Community Hospital


  • Skilled professionals ensure quality care.
  • Technology enhances patient care processes.


  • Inconsistent safety protocol adherence risks patients.
  • Resource constraints limit technological advancements.


  • Telemedicine aids the underserved and offers convenience.
  • Participation in collaboration shares best practices.


  • Regulatory changes challenge compliance and adaptation.
  • Competition impacts patient volume and revenue.

NURS FPX 6210 Assessment 1 Care Setting Environmental Analysis

These findings highlight areas of concern where we excel and areas that require improvement to achieve our quality and safety goals. Strengthening adherence to safety protocols and enhancing feedback mechanisms are critical steps in improving patient safety. Embracing opportunities such as community partnerships and telemedicine services will further enhance quality and accessibility. Proactively addressing threats, such as regulatory changes and competition, ensures our continued commitment to quality and safety (Berry et al., 2020).

Throughout the analysis, conflicting data and perspectives were impartially considered, providing a balanced and unbiased assessment. Input from various stakeholders, including frontline staff, management, patients, and external partners, was solicited to capture diverse viewpoints accurately (Pletcher et al., 2024). The SWOT analysis serves as a valuable tool for St. Mary’s Community Hospital, guiding us in identifying areas for improvement and capitalizing on opportunities for growth. By leveraging our strengths, addressing weaknesses, and mitigating threats, we remain steadfast in our commitment to excellence in patient care and safety, aligning with our mission of serving our community with compassion and integrity.

Part 3: Comparison of Approaches

In evaluating St. Mary’s Community Hospital, both the AI (Appreciative Inquiry) and SWOT approaches offer distinct perspectives, reflecting unique mindsets, data-gathering methods, and communication styles. Approaching St. Mary’s from an AI perspective entails a mindset focused on positivity, growth, and innovation. It involves envisioning the best possible outcomes and identifying success stories and achievements within the hospital. Conversely, adopting a SWOT perspective involves a more analytical and critical mindset, aiming to identify internal weaknesses and external threats alongside strengths and opportunities for improvement. In utilizing an AI approach at St. Mary’s, the focus is on gathering stories and evidence of past successes and exemplary performance related to quality and safety goals.

This includes data on successful patient outcomes, effective interventions, and instances where the hospital excelled in delivering high-quality care (Merriel et al., 2022). On the other hand, a SWOT approach requires collecting quantitative and qualitative data on internal strengths, weaknesses, external opportunities, and threats. This involves analyzing metrics, patient feedback, and stakeholder perspectives to identify areas for improvement (Saragih et al., 2022). Both approaches necessitate effective communication and interaction among colleagues, albeit with differing emphases. Within an AI framework, communication at St. Mary’s emphasizes fostering open dialogue, collaboration, and creativity to envision a positive future. Colleagues are encouraged to share success stories and ideas for improvement in a supportive environment (Graas & Gobbens, 2023).

NURS FPX 6210 Assessment 1 Care Setting Environmental Analysis

In contrast, interactions within a SWOT framework may involve more structured discussions focused on analyzing data, identifying challenges, and developing strategic plans (Benzaghta et al., 2021). While both approaches involve acknowledging assumptions and biases, AI encourages reframing assumptions to focus on strengths and opportunities, whereas SWOT prompts reflection on weaknesses and threats. Integrating elements of both AI and SWOT approaches at St. Mary’s Community Hospital can provide a comprehensive understanding of organizational dynamics and facilitate strategies for achieving quality and safety goals. By leveraging the strengths of each approach, the hospital can foster a culture of continuous improvement and innovation while addressing challenges proactively.

Part 4: Analysis of Relevant Leadership Characteristics and Skills.

Both the AI and SWOT approaches provide unique but complementary insights into the leadership traits and abilities necessary for spearheading possible performance improvement projects at St. Mary’s Community Hospital. For AI-based projects, leaders must embody visionary qualities that inspire positivity and collaboration. Visionary leaders articulate a compelling direction for the project, fostering enthusiasm and innovation among team members. Positivity is crucial in maintaining morale and cultivating an environment conducive to creative problem-solving.

Collaboration skills are paramount for building solid relationships and leveraging the collective expertise of the team to identify opportunities and envision a brighter future (Abell, 2020). Conversely, SWOT-based projects demand leaders with analytical prowess, critical thinking abilities, and strategic planning acumen. Analytical skills enable leaders to interpret data effectively, while critical thinking ensures objective evaluation of internal strengths and weaknesses, external opportunities, and threats. The ability to plan strategically is essential for creating workable plans that effectively address weaknesses, build on strengths, and reduce threats (Nugraheni & Kirana., 2021).

NURS FPX 6210 Assessment 1 Care Setting Environmental Analysis

Even though the approaches are different, a few traits and abilities of a good leader apply to both AI and SWOT-based projects. Effective communication plays a pivotal role in conveying the project’s vision, engaging stakeholders, and facilitating productive discussions. Adaptability enables leaders to pivot their strategies in response to evolving circumstances and feedback from the team. Empathy fosters a deep understanding of team members’ perspectives and needs, promoting trust and collaboration. Resilience empowers leaders to navigate challenges and setbacks, maintaining focus and momentum toward achieving project objectives (Burgener, 2020).

In the context of healthcare organizations, effective leadership demands a nuanced combination of visionary, analytical, and interpersonal skills. Leaders must inspire their teams, analyze complex data, and communicate effectively with stakeholders to drive positive outcomes and enhance patient care at St. Mary’s Community Hospital (Ofei et al., 2022). While the analysis identifies vital leadership characteristics and skills, further exploration is warranted to develop specific strategies for cultivating these qualities in healthcare leaders.

Additionally, understanding the unique challenges and opportunities within the healthcare industry, such as regulatory requirements and patient-centered care, could provide valuable insights into effective leadership in performance improvement initiatives. Collaborating with experts in healthcare leadership and conducting further research would help address these knowledge gaps, ultimately enhancing leadership development efforts and driving continuous improvement at St. Mary’s Community Hospital (Olatoye et al., 2024).


In conclusion, it effectively synthesizes stories and evidence, proposing attainable improvement goals aligned with quality and safety objectives. Through a comprehensive SWOT analysis, key findings are identified, and areas for improvement are proposed, consistent with the care setting’s mission and values. The comparison of AI and SWOT approaches highlights nuanced insights, while an analysis of leadership characteristics underscores their role in facilitating successful improvement projects. Overall, it demonstrates a thorough understanding of organizational dynamics and presents actionable strategies for enhancing quality and safety outcomes.


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Benzaghta, M. A., Elwalda, A., Mousa, M., Erkan, I., & Rahman, M. (2021). SWOT analysis applications: An integrative literature review. Journal of Global Business Insights6(1), 54–72. https://doi.org/10.5038/2640-6489.6.1.1148 

Berry, J. C., Davis, J. T., Bartman, T., Hafer, C. C., Lieb, L. M., Khan, N., & Brilli, R. J. (2020). Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system. Journal of Patient Safety16(2), 1. https://doi.org/10.1097/pts.0000000000000251 

Burgener, A. M. (2020). Enhancing communication to improve patient safety and to increase patient satisfaction. The Health Care Manager39(3), 128–132. https://doi.org/10.1097/hcm.0000000000000298 

Fuchshuber, P., & Greif, W. (2022). Creating effective communication and teamwork for patient safety. The SAGES Manual of Quality, Outcomes and Patient Safety, 443–460. https://doi.org/10.1007/978-3-030-94610-4_23 

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NURS FPX 6210 Assessment 1 Care Setting Environmental Analysis

Hatlie, M. J., Nahum, A., Leonard, R., Jones, L., Nahum, V., Krevat, S. A., Mayer, D. B., & Smith, K. M. (2020). Lessons learned from a systems approach to engaging patients and families in patient safety transformation. The Joint Commission Journal on Quality and Patient Safety46(3), 158–166. https://doi.org/10.1016/j.jcjq.2019.12.001 

Horváth, Á., & Molnár, P. (2021). A review of patient safety communication in multicultural and multilingual healthcare settings with special attention to the U.S. and Canada. Developments in Health Sciences4(3). https://doi.org/10.1556/2066.2021.00041 

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 Nursing20(158), 1–10. https://doi.org/10.1186/s12912-021-00684-2 

Merriel, A., Wilson, A., Decker, E., Hussein, J., Larkin, M., Barnard, K., O’Dair, M., Costello, A., Malata, A., & Coomarasamy, A. (2022). Systematic review and narrative synthesis of the impact of appreciative inquiry in healthcare. BMJ Open Quality11(2), e001911. https://doi.org/10.1136/bmjoq-2022-001911 

Naidoo, M., & Arifi, M. (2024). Disseminating best practice equity innovations in health care: A synopsis of study groups with health care executives. M-RCBG Associate Working Paper Serieshttps://nrs.harvard.edu/URN-3:HUL.INSTREPOS:37377595 

Nugraheni, R., & Kirana, G. R. (2021). SWOT Analysis of hospital health services in DKT TK IV hospital Kediri 2019. STRADA Jurnal Ilmiah Kesehatan10(1), 756–764. https://doi.org/10.30994/sjik.v10i1.550 

Ofei, A. M. A., Barnes, T., & Paarima, Y. (2022). Strategic leadership in nursing. In www.intechopen.com. IntechOpen. https://www.intechopen.com/chapters/82308 

NURS FPX 6210 Assessment 1 Care Setting Environmental Analysis

Olatoye, N. F. O., Elufioye, N. O. A., Okoye, C., Nwankwo, E., & Olakunle, J. (2024). Leadership styles and their impact on healthcare management effectiveness: A review. International Journal of Science and Research Archive11(1), 2022–2032. https://doi.org/10.30574/ijsra.2024.11.1.0271 

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Saragih, J. F. H., Nugraheni, S. A., & Adi, M. S. (2022). Benefits of using SWOT analysis and balanced scorecard for the development of the quality of health services : Narrative review. Jurnal Aisyah : Jurnal Ilmu Kesehatan7(S1), 263–272. https://doi.org/10.30604/jika.v7iS1.1076 

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Thorén, A. (2023). Prediction and monitoring of in-hospital cardiac arrest. In openarchive.ki.se. Inst för medicin, Solna / Dept of Medicine, Solna. https://openarchive.ki.se/xmlui/handle/10616/48825 

Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice30(1), 17–28. https://doi.org/10.1159/000509119 

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