Gap Analysis

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Practice Gap Analysis and Recommended Improvement with RCA²

 

Your Practice Gap Analysis and Recommended Improvement with RCA² will be determined by the clinical practice gap that you have identified in your practicum setting.  This document will include an overview of the problem, how you determined the root cause of the gap, policy, regulatory, and literature review, evidence-based practice recommendation, impact to nursing care, staffing, and finances, identification of data that will measure progress, and proposed outcome evaluation.  The written report is provided using APA document guidelines, minimum 10 pages and maximum 12 pages in length (excluding title page, abstract, graphics, and references).  Peer-reviewed, evidence-based literature support is required and is not to be older than 5 years.

 

  1. Introduction –Describe the organization, its structure and table of organization, leadership culture and governance model, model of nursing care, and position of the nursing department within the organization  Describe the department and/or unit, leadership structure, staffing, unit-based governance model, communication styles, and perception of teamwork.   Describe the culture of safety within the organization and any public benchmarks of performance or ratings.
  2. Current State– Describe how you organized your stakeholder team and their relation to the problem/event (how they know the details of the problem/event).  Assess and clarify the current knowledge of the policy or practice. Identify and understand any variabilities or reasons for performance deviance (practice drift).   Develop your fishbone or timeline to visualize the 5-Whys of the root cause determination. Classify the event.
  3. Literature, Policy, and Regulatory Review – Describe the current state of practice as compared to the practices identified in the literature, policy, and regulatory review. How does this impact patient safety?  Provide key points on why this is an opportunity for quality improvement (this is where you include discussion points on how the policy or practice needs to be changed in order to improve the outcomes of patient care, efficiency, and/or staff or patient safety
  4. Recommended Actions/Change – Describe the plan and the team (staff) that is responsible for implementing the changes to the policy or practice and how they will be educated to make the changes. Include best practice citations from the literature to support recommendations. Describe how the plan will be carried out and which data will be collected to measure change in practice.  Describe how the outcomes will be evaluated and acted on from what is learned. How will this change be replicated, if needed, throughout the organization? If replication is not indicated, describe why.

    1. Staffing and Financial Impact – Describe the cost-benefit analysis and include information in this section that informs the leadership team of what the return on investment and financial considerations will be in order to successfully implement the change in the policy or practice. When you discuss the cost-benefit analysis include answers to the following questions:

      1. What changes to staffing are required (if any?) and/or changes to the method of delivery of nursing care.
      2. What is the impact if these changes are not incorporated?
      3. What are the possible costs of pursuing the recommendations for change? Consider equipment, technology, and any and all other resources needed
      4. How will the costs compare with the benefits? (Cost/Benefit analysis)
      5. Is there a financial impact if the policy or practice is not changed?
      6. Is there more than one option to achieve the implementations of the changes to achieve the desired goals, and if so, what are those options and how do they compare in cost?
  5. Summary – Summarize the key points that you want the leadership team to consider so that they will adopt your recommendations for change of the policy or practice.  This is a concise section that is your opportunity to advocate for your change recommendations.
  6. Appendices – Include the graphic depiction of the 5-Why Analysis
  7. Professional and scholarly writing – This will be the last page of your report and you need to provide all of the evidence-based practice literature that you referenced in support of your recommendations.  The reference page begins on a separate page and follows APA format. The written report is provided using APA document guidelines, minimum 10 pages and maximum 12 pages in length (excluding title page, abstract, graphics, and references).  Peer-reviewed, evidence-based literature support is required and is not to be older than 5 years.

 

Helpful tips and resources for writing a contrast and comparison analysis essay.

  • Write in APA format
  • Provide a cover page with the title of the assignment, your name, the course name, your professor’s name, and the date
  • Use evidence based and peer reviewed best practice literature published within the last 5 years to support your viewpoints
  • Provide a reference page on your paper in APA format
  • Check for spelling or grammar errors before submitting the paper (read out loud) or use the Writing Fellows for assistance
  • Websites with helpful tips on writing essays- https://writingcenter.unc.edu/tips-and-tools/comparing-and-contrasting/  or https://writingcenter.fas.harvard.edu/pages/strategies-essay-writing
  • Make sure each paragraph is constructed with a topic sentence, supporting details, and a concluding sentence.  Each paragraph should have a minimum of 3 sentences and no more than 5-6 sentences.
  • This assignment should be 5-7 pages- excluding title page, diagram page, and references

 

Peer reviewed articles to support this assignment:

Dash, S., Shakyawar, S., Sharma, M. & Kaushik, S. (2019). Big data in healthcare: Management , analysis, and future prospects. Journal of Big Data 6(54:1-25. https://doi.org/10.1186/s40537-019-0217-0 

Groot, W. (2021). Root cause analysis – what do we know? MAB (’s-Gravenhage. Online), 95(1/2), 87–93. https://doi.org/10.5117/mab.95.60778

National Patient Safety Foundation (2016). RCA² Improving Root Cause Analyses and Actions to Prevent Harm, Version 2. Boston, MA. https://www.ihi.org/resources/Pages/Tools/RCA2-Improving-Root-Cause-Analyses-and-Actions-to-Prevent-Harm.aspx

Niraula, S. R. (2019). A review of research process, data collection and analysis. Insights in Biology and Medicine 3: 001-006. https://www.heighpubs.org/hjbm/ibm-aid1014.php

Volden, G. H. (2019). Assessing public projects’ value for money: An empirical study of the usefulness of cost–benefit analyses in decision-making. International Journal of Project Management, 37(4), 549–564. https://doi.org/10.1016/j.ijproman.2019.02.007