documenting gap analysis: a thorough assessment of the ......gap analysis the nurse planner starts...
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Documenting Gap Analysis:
A Thorough Assessment of the Education Need
Amy L. Charette, MS, RN
WMSD Nurse Peer Review Leader
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Gap Analysis
Why must we do this?
Why do we do this?
Why should we do this?
How do we do this?
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Part of the “Education Design Process”
outlines the process of developing and/or evaluating
individual educational activities according to ANCC
Accreditation Program criteria,
which ensure that individual educational activities are
effectively planned, implemented, and evaluated
according to educational standards and adult learning
principles.
Chapter 3 -- ANCC 2015 Accreditation Program Manual
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Starts with identifying a “problem”
Feedback on previous individual activity evaluations.
Learner requests, leadership requests.
Clinical data trends – patient outcomes
Quality/Risk Management data
Discussions with health care professionals including interdisciplinary feedback (as appropriate or available).
Colleagues and content experts.
Conducting assessment surveys, assessing changing trends in healthcare policy and the healthcare workplace.
References to standards, consensus statements, and published guidelines.
U. S. government statistics and websites (such as the Centers for Disease Control and Prevention).
Trends in literature: Review of various journals and websites providing information on clinical data, trends in quality management, health care literature, law, social issues, healthcare delivery and health care policy
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When “gap” is not yet a problem
At this step in the process, the Nurse Planner is determining what are the problems creating practice gaps.
There are times when the problem/learner need is for reinforcing knowledge, skills, or practices that are already satisfactory. There is not a “gap” in the form of a deficit, instead the need is to prevent a gap from occurring.
Or there may be opportunities for improvement – there is not a current problem in practice, but new data is available to support a modification of current practice to improve performance or patient outcomes.
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Selected the problem
What is:
35-50%
screenedWhat should
be: annual
dilated exams
Traditional
continuing
education
“Measure twice, cut once”
Problem in practice or opportunity for improvement
(professional practice gap)
How do you know it is a problem?
What data do you have to validate the problem?
What is the reason that the problem exists?
Is the problem a “professional practice gap”?
Gap Analysis
The Nurse Planner starts by analyzing data that validate the need for the educational activity.
This analysis forms the basis of a professional practice gap, or the difference between the current state of practice and the desired state of practice.
It is important to note that a professional practice gap may exist for registered nurses or health care teams, regardless of the practice setting.
Professional practice gaps are not limited to clinical practice and may also exist in areas of professional work such as administration, education, and research.
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Gap Analysis
• Every gap analysis starts with
introspection.
• ‘Current State’ you list out all the
attributes you’d like to see improved.
• Your focus can be wide (ex: the whole
facility) or narrow (ex: a dept. or shift)
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Gap Analysis
• The analysis can be quantitative (‘30 falls
per year; 2% nosocomial infections; 10%
faculty turnover)
• Can be Qualitative or both.
• The key thing is to be specific and factual
with an emphasis on identifying
weaknesses – “gaps”.
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Professional Practice Gap
Gap is the difference between the
current state of “what is” and the
desirable or achievable state “what
should be or desired”
Gap Analysis
Assessing Education Merit
The merit assessment has two parts:
1) does educational intervention have potential to
address the gap
2) does your organization agree the problem in practice
or opportunity for improvement is a priority for the
education resources to advance professional
development outcomes?
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Gap analysis worksheet
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Determining the underlying reason
➢Gap due to knowledge – doesn’t know
➢Gap due to skills – doesn’t know how
➢Gap due to practices – not able to show or
do in practice
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Miller’s Model of Clinical Competence
Knows: learner has knowledge about the topic/subject
Knows how: learner is capable of applying the knowledge
Shows how/does: learner is able to apply knowledge and skills in a
simulated setting (shows how) or the practice environment (does)
Miller’s
Model of
Clinical
Competence
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Assess knowledge (knows):
Simple knowledge tests (multiple choice or similar)
Assess skill (knows how):
Case studies/extended matching multiple choice
Case presentations
Essay questions
Assess practice (shows/does):
Simulation (Objective Structured Clinical Examination)
Observation in the practice setting
* ACCME uses the analogous terms knowledge, competence and performance
Educational Design Process
25Type of Gap Learning Techniques Evaluation Methods
Knowledge
(knows)
▪ Didactic
▪ Discussion
▪ Pre/post test
▪ Case studies
▪ Games
▪ Discussion/debriefing at the end
of the program
▪ Pre/post test
▪ Case study with group
discussion
Skills
(knows how)
▪ Case studies with group
discussion
▪ Demonstration/return
demonstration
▪ Simulation
▪ Case studies with group
discussion
▪ Return demonstration
▪ Simulation
Practice
(shows/does)
▪ Review of current practice
▪ Return demonstration
▪ Simulation
▪ Supervised practice
▪ Follow-up survey
▪ Interviews
▪ Return
demonstration/simulation
▪ Observation of practice
▪ Record audits
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Let’s practiceCurrent
state
Desired
state
Identified
gap
Evidence to
validate gap
Gap due to
knowledge, skill
and/or practice
Learning
outcome
Method of
evaluation
New
monitors
have been
purchased
for the ICU
Nurses
know how
to set up
and use
the
monitors
accurately
and safely
Nurses
currently
do not
know how
to use the
new
monitors
The majority
of nurses in
the ICU have
no experience
with the new
monitors; new
technology
Knowledge – have
not had exposure to
new monitor; do
not know basic
features of monitor
system
Skill – don’t know
how to use the new
monitor
Practice – have not
used the new
monitor in patient
care
Nurses will
successfully
demonstrate
knowledge
related to use
of new
monitoring
system
Nurses will pass
post-test with
score of 90% or
greater with
content focused
on safe use of
new monitoring
system.
28Learning Outcome
Describe Current State
Describe Desired State
Describe Identified State
Education Plan to Address Gap
Example: The Emergency Nurse will successfully pass a certification exam in emergency nursing.
Only 10% of our emergency department staff nurses are certified in emergency nursing.
Nurses will be able to successfully pass the CEN exam after completing an exam preparation course and engaging in appropriate study based on their individual learning needs.
Nurses lack the knowledge and skills to pursue emergency nurse certification.
Provide an emergency nursing certification review course, including an individualized self-assessment to help the nurse identify areas for additional study.
Example: The Nurse will be able to implement non-pharmacologic pain management strategies for patients experiencing arthritis pain.
The nurses on our unit have identified that they are not comfortable with recommending non-pharmacologic pain management strategies for patients with arthritis.
Nurses will be able to suggest at least two non-pharmacologic pain management techniques for patients with arthritis.
RNs may not be knowledgeable of, or feel empowered to suggest or provide alternative methods for pain management.
Review of basic principles of pain management, along with a skills lab for hands-on practice of pain management techniques. Including cold, heat, relaxation, and deep breathing.
Example: The Nurse will be able to describe the state nurse practice act as it relates to their current practice.
A recent discussion at our shared governance committee revealed that nurses were unfamiliar with the Nurse Practice Act in our state and could not identify rules and regulations pertinent to registered nurse practice.
Nurses will be able to access and explain the nurse practice act and relevant rules and regulations.
RNs are aware of the existence of the Nurse Practice Act, but my not be completely familiar with specific rules and regulations.
Nurses will participate in a facilitated review of the Nurse Practice Act led by a member of the nursing leadership, and will engage in roundtable discussions about specific rules and regulations related to nursing practice in our state.
Let’s practiceCurrent
state
Desired
state
Identified
gap
Evidence to
validate gap
Gap due to
knowledge, skill
and/or practice
Learning
outcome
Method of
evaluation
Pediatric
patients in
respiratory
distress are
placed on a
non-
rebreather
facemask
within 5
minutes of
presentation
to the
Emergency
Department
100% of the
time but
frequently the
facemask is
not applied
correctly
Pediatric
patients in
respiratory
distress are
placed on a
non-
rebreather
facemask
applied
correctly
within 5
minutes of
presentation
to the
Emergency
Department
100% of the
time
Frequent
inappropriate
non-
rebreather
facemask
application for
pediatric
patients in
respiratory
distress
Direct observation
by Clinical Nurse
Specialist;
comments from
respiratory
therapist in ED;
comments from
ED medical staff
Lack of skill in correctly
applying facemask to
pediatric patients in
respiratory distress
Registered nurses
in the Emergency
Department will
apply a non-
rebreather
facemask
correctly to all
pediatric patients
in respiratory
distress
Successful return
demonstration of
application of a non-
rebreather facemask
for pediatric patients
in respiratory distress
Let’s practiceCurrent
state
Desired
state
Identified
gap
Evidence to
validate gap
Gap due to
knowledge, skill
and/or practice
Learning
outcome
Method of
evaluation
40% of
patients 65
and older in
our
community
health clinic
are receiving
the
pneumococc
al vaccine
consistent
with national
guideline
100% of
patients 65
and older in
our
community
health clinic
receive the
pneumococc
al vaccine
consistent
with national
guideline
60% of
patients 65
and older in
our
community
health clinic
are not
receiving the
pneumococc
al vaccine
consistent
with national
guideline
Chart audit of
patient files;
interviews with
nurses; 75% of
nurses report
they are not
familiar with
updated national
guideline and
therefore were
not providing
information
about the vaccine
Knowledge – unaware
of updated guidelines
Registered
nurses will
demonstrate
they know the
updated vaccine
recommendatio
ns for all
patients 65 and
older
Complete post-test
with passing rate of
80% or greater
WMSD Resources
• WMSD Website
• http://www.westernmsd.org/MainMenu/CE
• WMSD Resources – Individual Activity Applications or
Approved Providers• Gap Analysis Worksheet and Examples
• WMSD Website FAQs
• http://westernmsd.org/MainMenu/CE/Frequently-
Asked-CNE-Questions
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