NSG/516AD v4 Gap Analysis Tool NSG/516AD v4 Page 2 of 3 Gap

NSG/516AD v4
Gap Analysis Tool
NSG/516AD v4
Page 2 of 3
Gap Analysis Tool
Purpose
The purpose of the gap analysis tool 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.
Upon completion of the gap analysis, project teams will have the following:
An understanding of the differences between current practices and best practices.
An assessment of the barriers that need to be addressed before successful implementation of best practices.
Instructions
Use the tables on the following page to complete these steps:
List the expected evidence-based best practice above each table, replacing the bracketed text with the description of your best practice(s).
In column 1, list all the steps associated with the best practice process.
In column 2, document your organization’s practices and describe how they differ from each best practice element. Be specific and include information like policies, protocols, guidelines, and staffing.
In column 3, identify barriers that may hinder successful implementation of each best practice strategy. Consider systems, procedures, policies, people, equipment, etc.
In column 4, indicate whether your organization will implement the best practice strategy. If not, explain why.
Repeat steps 1-5 for each best practice, adding rows as needed.
Gap Analysis Tool
Patient teach back method
Montefiore Medical Center Outpatient Clinic
Best Practice #1: [Chunk and check practice]
Best Practice Process Steps
How Your Current Practices Differ from Best Practices
Barriers to Best Practice Implementation
Implementation – Yes/No? Why Not?
Subdivide heavy information into segments
Information is provided in chunks without segmentation
Resistance among healthcare staff on the process of chunk and check
Yes
Inform the patient or the family of the various segments of information
Little to no information is shared with families
Limited time between patients and providers
Yes
The client teaches back the information given
The client teaches back sometimes, although not compulsory
Patient literacy
Yes
Best Practice #2: [consistent teach-back method]
Best practice process steps
How your current practices differ from best practices
Barriers to best practice implementation
Implementation – yes/no? Why not?
Use teach-back with every patient
Nursing staff only use aspect of teach-back with unlearned patients
Lack of buy-in of maintaining consistency with all patients
Yes
Use teach-back every time
The times of long wait times between patients, the nurses do not use the teach-back methods
Limited time for nurses to work with all patients
Yes
Best Practice #3: [Use of show-me method and handouts as an accompaniment]
Best practice process steps
How your current practices differ from best practices
Barriers to best practice implementation
Implementation – yes/no? Why not?
Demonstrate the processes of home care like medication regimens and dieting, among others
Little to no demonstration of the process about home-care
Limited time
Yes
Use of handouts to accompany the patients back home
Few handouts are given to patients
Limited resources
Yes
Best Practice #4: [Using questions to attract teach-back from the patients]
Best practice process steps
How your current practices differ from best practices
Barriers to best practice implementation
Implementation – yes/no? Why not?
Formulating indirect questions that can attract proper teach-back (e.g., “I know we talked about how to take this medication; if asked by your family at home, what will you tell them?)
No questions are used to attract teach-back from the patients
Limited time and untrained personnel
Yes
Use of direct questions to attract teach-back (e.g., “I know we have a talked about how to take this medication, would you mind explaining it to me so that I can know if I got everything right?)
Sometimes direct questions are used to attract teach-back from the patients
Limited time and untrained personnel
Yes
SMART Objectives
To initiate and achieve the Patient teach-back method at the institution by all the nursing staff and providers within the Montefiore medical center outpatient clinic from 30% to 100% within three months
To improve patient satisfaction scores on home-care practices within the community and those that visit the institution from 60% to 95%
To improve the healthcare providers’ awareness of the use and importance of the patient teach-back method by 70%
This material was reprinted and reformatted with permission from the U.S. Department of Health and Human Service’s Agency for Healthcare Research and Quality, www.ahrq.gov.
This material was reprinted and reformatted with permission from the U.S. Department of Health and Human Service’s Agency for Healthcare Research and Quality, www.ahrq.gov.