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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.

 

Patient Safety Performance Measure Reviewed
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
  • Hourly rounding implemented in high risk units
  • Executive will conduct observation to validate implementation and demonstrate support
Responsible Person/Team Executive Team and Board
Completion Date Q3 2010
Comments / Notes

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