Mind the Gap

by: Clayton Wheat, RN

You have been tasked with conducting a Gap Analysis for a process at your site. What are the next steps?

A Gap Analysis is the method used to review the status of each site’s current processes to determine if they meet Corizon Health’s standards-based Core Processes. Issues are identified that may be interfering with optimal performance of the site in terms of patient safety and efficiency for providing care.

A Gap Analysis also reveals processes that are working well and do not require revision.

The Gap Analysis is not exclusive to site management. Current trends in leadership research suggest that increased ownership in a process invites more responsibility and “buy-in.” Plus, team members who perform tasks on a day-to-day basis know the processes the best. The Gap Analysis can be a great tool to engage and empower staff when the entire site is involved.

The Gap Analysis consists of several steps that are listed in the Operations Checklists in the Core Processes program, which include:

Identify the Future State

First, identify the objectives that are desired using the Operations Checklists as a blueprint. The Operations Checklists provide the future state – the “place” where the operation should be when a review of the process has been completed.

Analyze the Current Situation

For each of the objectives, analyze the current situation within the operation. To do this, consider the following questions:

  • Who has the knowledge needed? Which member of the team can provide clear insight into the current situation? For example, when conducting a Gap Analysis of the medication room, the inventory control manager or medication manager would be good team members to include.
  • Is the information in “people’s heads,” or is it documented somewhere? Have team members write down, step-by-step, the process as they know it (current state). Identify team members to complete this task on different shifts (i.e., to compare what day shift is doing compared to night shift). Then ask: should the process be different?

Identify How to Bridge the Gap

Once the current state is known, explore what is required to bridge the gap and reach objectives established at the site using the Operations Checklists as the “future state.” Steps to do this include:

  • Create an action plan using the Operations Checklists and input from the team members.
  • Assign the action plan to someone for completion. Remember, managers should not do it all. Various team members should be entrusted with the responsibility for competing action plan items. The manager’s responsibility is to verify that assigned tasks are completed. An empowered team can change the work environment through responsibility and ownership of environment in which they work.

Finally, a Gap Analysis is not just about checking off items on a list. Rather, is a tool for managers to utilize that ensures processes are being completed in the most efficient and timely manner possible. The Gap Analysis also is a tool that fosters team engagement and ownership, and further supports the development of a team that is knowledgeable and dependable.