Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
Gap Analysis
What is the purpose of 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 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 the Self-Assessment (Tool A.3) about the readiness of the hospital to perform quality improvement for the Quality Indicators 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
List the expected evidence-based best practice in the header row (shaded in light gray).
Replace the red 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 such as 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 2-4 for each best practice, adding rows as needed.
Current Practice
There were 4 cases of retained foreign body in 2021. This led to the introduction of a new wanding policy in January 2022. This new organizational policy requires the Circulator Nurse to wand the patient once dressing has been applied in the operating room. The nurse is then required to document in the electronic medical record (EMR), the time of wanding and the time of dressing. Compliant cases will always have dressing time precede the wanding time. This sequence is not always achieved. Of the 311 surgical cases in January of 2023, 279 (89%) were noted to be compliant, 32 (11%) were noted to be noncompliant. This increases the risk for foreign body retainment, identifies opportunity to evaluate practice and need for reeducation.
On February 23rd 2023, I had the opportunity to go to the Montefiore Weiler Campus and observe several wandings in the operating room. Of the 8 surgical cases I observed, 6 (75%) were wanded accordingly, 2 (25%) were not.
Best Practice:
According to the Organizational surgical count policy, radiofrequency (RF) wanding should be performed on all patients at the end of surgery after dressing is on and before the patient leaves the operating room by the circulator nurse.
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
References
Peng, J., Ang, S. Y., Zhou, H., & Nair, A. (2022). The effectiveness of radiofrequency scanning technology in preventing retained surgical items: An integrative review. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.16447
Primiano, M., Sparks, D., Murphy, J., Glaser, K., & McNett, M. (2020). Using radiofrequency technology to prevent retained sponges and improve patient outcomes. AORN journal, 112(4), 345-352. https://doi.org/10.1002/aorn.13171