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Gap Analysis: Governance
Posted By admin On October 7, 2011 @ 11:09 am In | No Comments
A governance level gap analysis should be conducted to focus the Board on the current state versus future state. A Board of Director(s) is often comprised of community and/or industry leaders and patients, who may or may not be familiar with all of the patient safety indicators, processes and measures. Utilizing this gap analysis template to discuss key issues will keep the Board focused and current on the organization’s key patient safety activities. It further creates an opportunity for each of them to participate in the improvement activities. A confluence of process, provider practice and product application are imperative for creating optimal standards of safe care.
EXAMPLE: Number of Patient Falls with Injury |
|
| Current State | We had 3 falls with injury in one week. The root cause showed that the patient’s did not follow direction and one of the bed alarms was not implemented per policy. |
| Future/Ideal State | Decrease falls with injury by 50%. |
| Gap Y/N | Y |
| Governance Oversight Steps to Close Gap |
|
| Responsible Person/Team | Executive Team and Board |
| Completion Date | Q3 2010 |
| Comments / Notes |
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