The optimal use of time, money, materials, and human resources is perhaps more important in healthcare than in any other industry. With a myriad of fast-changing regulatory requirements and a high-stakes mission of saving lives, healthcare organizations must constantly strive to deliver the highest quality service while controlling costs and managing resources as efficiently as possible. To do this, many are adopting methodologies used by for-profit businesses to help analyze their performance and make targeted process improvements.

One of those methodologies is a gap analysis. A gap analysis in healthcare is intended to identify gaps in services or processes—instances in which what is happening is falling short of what should be happening—and shine a light on why these gaps exist. Such an analysis is crucial for improving care delivery and outcomes.

In this article, we’ll delve into the importance of a healthcare gap analysis and offer a step-by-step guide on how to perform one.

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Chapter 1: What is a gap analysis in healthcare?

A gap analysis is an examination and assessment of your performance for the purpose of identifying the differences between your current state of operation and where you’d like to be. It helps clarify the difference between reality and the ideal for your organization—for instance, on measures where you’re falling short of a target—so you can better focus your resources and energy on those identified areas in order to improve them.

For each process or business unit being examined, a gap analysis can be boiled down into three questions:

• Where are we now?
• Where do we want to be?
• What can we do to close the gap in performance?

For example, you might have this organizational objective:

Offer industry-best medical treatments that lead to measurable improvement in patient well-being.

A measure and target for this objective might be:

Reduce the percentage of hospital readmission rates, with a target of 15% reduction over the course of a year.

If your organization is not on track to meet this target halfway through the year, a gap analysis will help uncover organizational practices and/or processes that may be preventing you from achieving it. Such an analysis can be done within a department, for an entire business, or even just for a single process.

The gap analysis is not new; for-profit businesses have long used it to explain deficits between actual and real performance. And even though the concept of performance analysis is becoming a more common practice among healthcare organizations, many still don’t use it intentionally, nor do they have a consistent process they follow for carrying it out. It’s beneficial to perform gap analyses regularly (depending on the size of your organization, annually is a good guideline) so you can stay on top of performance, particularly if you’re pursuing PHAB accreditation or something similar. But it’s also an excellent problem-solving tool to apply whenever problems crop up, like:

• Patient complaints
• Underperformance on a specific metric or on the part of a certain department
• Issues meeting healthcare compliance requirements
• Noticeable differences in the current vs. desired states

Identifying process and service gaps can also be helpful during your annual strategic planning activities. Knowing the specific issues that need to be solved in order to meet your targets may inform the projects you choose to take on in the year ahead. Are there projects or actions you could implement to help you change course and close a gap? Being strategic about the allocation of your time and resources on projects that will move the dial one way or the other is key to improving performance. Using strategic planning software like ClearPoint, you can easily align all your activities to goals and evaluate performance simply.

Note that gaps in care are different than gaps in processes and services. What are gaps in care? They refer to gaps between the recommended best practices for medical care and the care that’s actually provided—for instance, if patients aren’t utilizing annual screenings that would be considered a gap in care. Performance improvement in this area requires a different strategy.

Chapter 2: A 5-step Gap Analysis

Below are the steps to perform a typical gap analysis in healthcare. For organizations that have many divisions, facilities, programs, etc., these may be performed on a smaller scale, as processes/services differ across these categories.

1. Identify the current state of the program or process.

The first step is identifying or realizing the gap. Look at your measures (an example would be the one noted above) and their RAG statuses—are they yellow, red, or green? Also look at the trend over time—has it been red for a while, or just the past few months? The answer will likely inform the factors that may be influencing it as well as the cause.

2. Identify and define the desired state as well as the best practice needed to reach the desired state.

If you are doing a gap analysis within the context of your strategic plan, take a look at the targets on your plan. These targets may be three to five years out, which is ideal. Where are you with them? To answer that, go back to your current state areas of focus. You likely have an idea about best practices around how to reach the desired state—document those for further analysis.

3. Figure out the nature of the gap.

If you’re concerned with low patient satisfaction rates, for example, what’s the difference between where they are and what you would like them to be? Whether it’s large or small, this is the gap. This is also a good time to figure out why there is a gap. To do that, ask questions—and question the answers to those questions—of everyone involved in the process, at all levels. This may involve in-person, facilitated focus groups or discussions with key stakeholders (clinicians, administration, execs, etc.). What are people (both leaders and workers) noticing day to day surrounding this issue? Also, review your documentation around organizational policies and procedures, which may be a contributing factor. You’ll have to dig deep to find these answers.

4. Develop and implement a plan to achieve the desired results.

Now that you’ve discovered why the gap is taking place, it’s time to figure out the proper course of action to close it. As you’re doing so, take into consideration the cost of implementation for each solution—do you have enough resources to allocate to it? If it’s a main contributor to realizing an organizational objective, you may need to rethink existing projects and their allocated resources to accommodate the new action plan.

5. Monitor.

Once you’ve read through this gap analysis template and created your own, be sure to follow up on the improvements. Otherwise, there’s a risk that the solutions you’ve so carefully engineered will fall through the cracks. Periodically review the results of your gap analysis and continue to define next steps in the implementation process.

Chapter 3: Gap Analysis Examples In Healthcare

A Hospital Gap Analysis: Patient Safety

Patient safety is of prime concern to hospitals. Falls that occur on hospital grounds are particularly troublesome because they impact patients’ quality of life and are extremely costly for organizations. So when one medical care center was experiencing fall rates that exceeded national benchmarks by more than 40%, it initiated a gap analysis to assess current practices and improve.

The medical center’s analysis of current practices as compared to industry best practices shed light on gaps in its current level of care. Among other things, it noticed that nurses were not consistently proactive with patient check-ins, and there was a lack of readily available fall prevention equipment. To address these issues, the center implemented the following:

• Educational sessions for nurses around check-ins, including how best to provide mobilization assistance and address patient needs. Unit leaders also began doing daily rounds to evaluate critical factors in fall prevention for patients.
• Additional fall prevention equipment, and provided staff education on the correct use and transfer of mobility equipment.

Once these and other corrective actions were taken to address all the identified gaps, the medical center began tracking the change to falls and injury rates, and regularly reviewed the results. Since the project began, the center has seen a steady decrease in falls.

Albany Medical Center Hospital: A Workforce Gap Analysis

After the introduction of New York State’s Medicaid redesign program, Albany Medical Center Hospital (AMCH) anticipated a change in demand for healthcare workers within its provider network. To prepare for the impact, AMCH conducted a gap analysis to identify discrepancies between the state of the current and target workforce.

The analysis projected an increase in the need for primary care providers, medical assistants and administrative support staff, nurses, and the care management workforce; it also anticipated a significant increase in demand for patient navigators, community health workers, and care coordinators. Findings from the gap analysis were used to develop a workforce transition roadmap that would help reach the target workforce state. The gap analysis also helped identify challenges in managing the workforce impacts, including redeploying, retraining, and hiring for positions as needed.

Chapter 4: Gap Analysis As Part Of Performance Management

For healthcare organizations, gap analysis is a key part of performance management, which is vital for delivering the highest quality care and outcomes. Performance management software like ClearPoint helps ensure you are continually improving processes to achieve organizational objectives.

ClearPoint allows you to house all information relevant to your gap analysis in one place, and see the results in relation to your overall organizational strategy. It allows you to:

• Examine and assess current performance using measures. You can track different areas of performance, whether it’s patient care, provider reviews, or anything else. Our RAG status feature makes it easy to see how you’re doing with all your healthcare metrics (using visual red, amber/yellow, or green indicators), and you can quickly view trends over time.

• Link process improvements to relevant goals and objectives. Our software allows you to link any proposed improvements to organizational goals, so you can see the impact your gap plan is having; it also helps inform what you may want to do going forward. Our clients frequently use summary reports for gap analyses data related to current and desired states.

• Define initiatives and action items for improvement. Our software allows you to track action items and link them to goals or measures. You can track who is accountable, and they can give regular updates on their progress. Depending on the project, users can even attach files and images to help provide context for the work they are doing.

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