Gap Analysis

Criterion

EXEMPLARY

PROFICIENT

DEVELOPING

NEEDS IMPROVEMENT

Introduction

(Step 1)

15

Comprehensively describes all aspects of the organization, unit-based governance, perceptions of teamwork, culture of safety, and public benchmarks

12

Describes all aspects of the organization, unit-based governance, perceptions of teamwork, culture of safety, and public benchmarks

10

Describes some aspects of the organization AND/OR unit based governance, AND/OR perceptions of teamwork, AND/OR culture of safety, AND/OR public benchmarks

0-10

Does not provide a clear or logical description of the organization AND/OR unit based governance, AND/OR perceptions of teamwork, AND/OR culture of safety, AND/OR public benchmarks

Current state

(Step 2)

20

Comprehensively describe the team development, assessment of current knowledge, variabilities of performance, and classification of the event. Includes a detailed graphic depiction of the problem/event of the 5-Whys root cause determination

18

Describes the team development, assessment of current knowledge, variabilities of performance, , and classification of the event.. Includes a graphic depiction of the problem/event of the 5-Whys root cause determination

15

Minimal description of the team development, assessment of current knowledge, variabilities of performance, , and classification of the event.. Includes a basic graphic depiction of the problem/event of the 5-Whys root cause determination

0-15

Does not provide multiple points of description of the team development, assessment of current knowledge, variabilities of performance, , and classification of the event AND/OR missing a graphic depiction of the problem/event of the 5-Whys root cause determination

Literature, Policy, and Regulatory Review

(Step 3)

20

Comprehensive comparison of the current state, impact to patient safety, and key points of opportunity for quality improvement

18

Comparison of the current state, impact to patient safety, and key points of opportunity for quality improvement

15

Minimal comparison of the current state, impact to patient safety, and key points of opportunity for quality improvement

0-15

Does not provide a related AND/OR logical comparison of the current state, impact to patient safety, and key points of opportunity for quality improvement

Recommended Actions/Change

(Step 4)

20

Comprehensive description of the plan, the team who will implement the actions/change, cost/benefit analysis with staffing and financial impact, the data that will be collected and evaluated, and replication throughout the organization if applicable

18

Description of the plan, the team who will implement the actions/change, cost/benefit analysis with staffing and financial impact, the data that will be collected and evaluated, and replication throughout the organization if applicable

15

Minimal description of the plan, the team who will implement the actions/change, cost/benefit analysis with staffing and financial impact, the data that will be collected and evaluated, and replication throughout the organization if applicable

0-15

Does not provide a logical or related description of the plan, the team who will implement the actions/change, cost/benefit analysis with staffing and financial impact, the data that will be collected and evaluated, and replication throughout the organization if applicable

Summary

(Step 5)

10

Comprehensive and concise summary of the key points to advocate for change recommendations

8

Summary of the key points to advocate for change recommendations

7

Minimal summary of the key points to advocate for change recommendations

0-7

Does not provide a logical, related, AND/OR concise summary of key points to advocate for change recommendations

Appendices

(Step 6)

5

Comprehensive and detailed graphic depiction of 5-Why analysis

4

Detailed graphic depiction of 5-Why analysis

3

Minimal graphic depiction of 5-Why analysis

0

Missing graphic depiction of 5-Why analysis

Professional and scholarly writing

(Step 7)

10

All articles are peer reviewed and within 5 years of publication.

Less than 3 errors in spelling, grammar, language, APA format, readability

7.5

At least 2 articles are peer reviewed and within 5 years of publication.

3-5 errors in spelling, grammar, language, APA format, readability

5

Articles utilized are not peer reviewed AND/OR are not within 5 years of publication.

5-7 errors in spelling, grammar, language, APA format, readability

0-5

Articles are not peer reviewed AND are more than 5 years from publication.

More than 7 errors in spelling, grammar, language, APA format, readability