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 (aka stakeholders), equipment, etc. 5. In Column 4, discuss your thoughts whether your organization will implement that best practice strategy. If not, explain why. 6. Repeat steps 1-4 for each best practice.
https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a3_combo_selfassessment.pdf
https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d6_combo_implementationplan.pdf
Gap Analysis Tool (as adapted from AHRQ’s Tool D-5)
Improvement Project: Quality Indicator/Practice Metric:
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