MM week 6

INSTRUCTIONS

Gap Analysis Tool Adapted from AHRQ

What is this tool? The purpose of the gap analysis is to provide project teams with a format in which to do the following:

• Compare the best practices with the processes currently in place in your organization. • Determine the “gaps” between your organization’s practices and the identified best

practices. • Select the best practices you will implement in your organization.

Who are the target audiences? The project liaison (you will serve as the liaison for this assignment) will be the primary individual to prepare this written gap analysis, but the entire improvement project team should be engaged in performing the gap analysis. How can the tool help you? Upon completion of the gap analysis, project teams will have the following:

• An understanding of the differences between current practices and best practice. • An assessment of the barriers that need to be addressed before successful implementation

of best practices.

How does this tool relate to others? Information from AHRQ’s Self-Assessment (Tool A.3) about the readiness of the hospital/practice setting to perform quality improvement for the Quality Indicators or Best/Evidence-based practices can be considered in the gap analysis as possible strengths or weaknesses (i.e., barriers) to be managed when implementing improvements. The best practice elements defined in the Selected Best Practices and Suggestions for Improvement (Tool D.4) are prefilled in the gap analysis tool. This provides the elements for the Implementation Plan (Tool D.6). Instructions

1. List the identified practice problem in Column 1. 2. In Column 2, provide a description of identified best practices (3 best practices required) to address the problem 4. In Column 3, identify barriers that may hinder successful implementation of each best practice strategy. Consider systems, procedures, policies, people (i.e. stakeholders), equipment, etc. 5. In Column 4, discuss your thoughts on whether your organization will implement that best practice strategy. If not, explain why. 6. Repeat steps 1-4 for each best practice.

Gap Analysis Tool (as adapted from AHRQ’s Tool D-5)

Improvement Project: _____________________ Quality Indicator/Practice Metric: ____________________________

Individual Completing This Form: ______________________________

Column 1 Column 2 Column 3 Column 4

How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss whether you believe the identified best practices could/would be implemented)

Best Practice #1: [insert description of best practice here]

Column 1 Column 2 Column 3 Column 4

How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss whether you believe the identified best practices could/would be implemented)

Best Practice #2: [insert description of best practice here]

Column 1 Column 2 Column 3 Column 4

How Your Practices Differ From Best Practice (describe the practice problem you have identified for this improvement process)

Best Practice Strategies (what a review of the literature indicates is a best practice approach that you could implement to address the problem)

Barriers to Best Practice Implementation (this could be actual or anticipated/potential barriers)

Will Implement Best Practice (considering the barriers you identified – discuss whether you believe the identified best practices could/would be implemented)

Best Practice #3: [insert description of best practice here]

1. Improvement Project: Fall Assessment Tool
2. Quality IndicatorPractice Metric:
3. Individual Completing This Form: Michelle Murray
4. Column 1: The facility lacks a validated tool of assessing fall risks. Informal observation and inconsistent documentation are used to determine risk. During admission or regularly, screening is not done that leads to the identification of high-risk individuals sluggishly and reactive measures instead of preventive measures. .
5. Column 2: Morse Fall Scale and CDC STEADI toolkit are tools with evidence-based applicability in offering standardized fall risk screening. STEADI model incorporates the yearly screening, drug review, gait and balance evaluations, and referral to the respective interventions . Research indicates that the use of standardized tools has a great impact on the reduction of falls in nurse-led programs
6. Column 3: Lack of staff training little time to make evaluations. Resistance to change of workflow. Insufficiency of policy that requires screening.
7. Column 4: Yes. The facility can implement STEADI where some nurse champions will spearhead training and screening process as a part of the regular intake assessment.
8. Best Practice Strategies what a review of the literature indicates is a best practice approach that you could implement to address the problem: Fall Risk Screening- Standardized (STEADI or Morse Fall Scale)
9. Column 1_2: Prevention measures are taken following a fall. It lacks a risk-based individualized prevention plan, particularly in regard to risk level, medication profile, or mobility status.
10. Column 2_2: One-on-one treatments, including the use of strength and balance exercises, medication monitoring, environmental adjustments, and eye checkups are effective to prevent falls. The STEADI model focuses on customized interventions, as opposed to universal prevention.
11. Column 3_2: little interdisciplinary cooperation. Restrained access to physical therapy. Staffing shortages Budget constraints
12. Column 4_2: Yes, by gradual introduction. Referrals will be made through nurses, with the high-risk patients taken priority first.
13. Best Practice Strategies what a review of the literature indicates is a best practice approach that you could implement to address the problem_2: Personalized Fall Prevention Care Plans.
14. Column 1_3: The training of the staff and the formal fall tracking system is not standardized. There is no trend and prevention improvement analysis of falls.
15. Column 2_3: Frequent nurse training sessions and fall-incidence monitoring systems enhance the staffs knowledge and minimize the falls. Constant quality improvement and accountability is made possible by data monitoring.
16. Column 3_3: Limited time for training Technology limitations Absence of administrative assistance.
17. Column 4_3: Yes. Monthly trainings and a basic electronic fall log will be presented to trace trends and provide directions on the quality improvement.
18. Best Practice Strategies what a review of the literature indicates is a best practice approach that you could implement to address the problem_3: Continued Education of Staff and Fall Statistics.
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