Gap Analysis Facilitator's Guide

AHRQ Communication and Optimal Resolution Toolkit

Purpose: To evaluate the extent to which current processes align with the Communication and Optimal Resolution (CANDOR) process and includes:

  • Identifying the existing process.
  • Identifying the existing outcome(s).
  • Identifying the desired outcome(s).
  • Identifying and documenting the gap(s).

Who should use this tool? The CANDOR Implementation Team.

How to use this tool: Conduct a gap analysis prior to implementing the CANDOR process. In addition, periodic gap analyses can be conducted as part of an ongoing plan-do-study-act process to monitor progress toward its goal of fully implementing the CANDOR process.


Gap Analysis Process
   Obtain documents to review prior to conducting the gap analysis
   Conduct the Gap Analysis focus group sessions
     Identify the current process stakeholders
     Session Preparation
     Tips for the Facilitator
     Review results and determine priorities
     Summary Report
Appendix A—CANDOR Gap Analysis Document Review Checklist
Appendix B—Gap Analysis Structured Interview Questions
Appendix C—Gap Analysis Structured Interview Guide
Appendix D—Anonymous Reporting Tool
Appendix E—Gap Analysis Report Template

Gap Analysis Process

The gap analysis is comprised of three steps:

  1. Review of documentation of organizational practices, policies, and procedures.
  2. In-person, facilitated focus groups with key stakeholders focused on CANDOR practices.
  3. Review results of the gap analysis, and define next steps in the implementation process.

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Obtain Documents To Review Prior to Conducting the Gap Analysis

Pertinent documents should be collected and reviewed as part of the gap analysis process. This activity will allow for verification and clarification of the existing processes. Documents to include are:

  • Administrative and departmental policies and procedures.
  • Bylaws for medical staff and/or hospital.
  • Organizational safety and/or quality plan.
  • Organizational structure.
  • Safety survey or other quality survey, such as patient satisfaction results.
  • Board minutes or reports related to quality and safety.

Go to Appendix A, CANDOR Gap Analysis Document Review Checklist, to use when collecting documents.

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Conduct the Gap Analysis Focus Group Sessions

Identify the current process stakeholders

Key stakeholders may include hospital leadership, operational department leads, medical staff, frontline staff, support staff, and patients and families. This stakeholder list is intended to be a guide and may include others as determined by your organization.

Stakeholder category Job types
Medical Staff—Frontline Medical staff
C-Suite Leadership C-Suite executives

  • Chief executive officer
  • Chief operating officer
  • Chief finance officer
  • Chief medical officer
  • Chief nursing officer
  • Chief human resources officer
  • Chief information officer (HIM)
  • Marketing and communications
  • Others as appropriate
Board Members Members of the hospital or system board
Quality, Safety, and Risk Management Selected leaders from these areas:

  • Quality
  • Safety
  • Risk management
  • Patient relations
  • Compliance
  • Performance improvement
Legal and Claims Selected leaders from these areas
Medical Staff—Leadership Selected members of the medical staff including:

  • President of medical staff
  • Department heads
    • Radiology
    • Emergency medicine
    • Anesthesia
    • Hospitalist medicine

A sample of program directors if there are residency programs

Resident Physicians Selected physicians from various residency programs


Stakeholder category Job types
  • Emergency department
  • Operating room
  • Surgery
  • Obstetrics
  • Other high-risk or representative areas, as appropriate
  • Emergency department
  • Operating room
  • Surgery
  • Obstetrics
  • Other high-risk or representative areas, as appropriate
Unit-Level Staff
  • Emergency department
  • Radiology
  • Surgery
  • Obstetrics
  • Pharmacy
  • Other high-risk and/or representative areas, as appropriate
Frontline Staff
  • Nurses
  • Respiratory therapists
  • Case managers
  • Social work
  • Diagnostic frontline providers
Support Staff
  • Housekeeping
  • Dietary
  • Transportation
  • Materials management
  • Biomedical engineering
Patients and Families Representative(s) from the Patient and Family Advisory Council

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Session Preparation

The purpose of the focus group sessions is to learn what is occurring at the organization from the stakeholders, so that next steps can be identified to support implementation of the CANDOR process. A focus group is intended to be a group of six to 10 people led through the questioning and discussion by a facilitator.

The group should be comprised of individuals from the same key stakeholder group, to facilitate open and honest communication. In addition, a facilitator, timekeeper, and notetaker should be assigned to conduct/support the meeting. This will necessitate convening multiple focus groups over the course of 1–3 days.

To prepare for the meeting:

  • Assign a neutral person without authority over the participants to lead each gap analysis focus group, in an effort to encourage those attending to volunteer their views without concern about repercussions. (If it is impractical to find a neutral individual, ensure that at the beginning of each session, the focus group leader makes a statement letting the group know the purpose of the meeting.) Specific mechanisms to achieve this objective include:
    • Schedule groups of individuals to meet together by functional responsibilities (e.g., C-suite, frontline staff, medical staff), but avoid scheduling supervisors and subordinates in the same group. If this can't be avoided, seek to determine the relationship of the staff member(s) and supervisor, and determine whether it will allow for open and honest communication.
    • Discussion about who should participate in each gap analysis focus group should occur early (at least 4–6 weeks prior to the actual assessment) to allow time for adjustments and permit participants to arrange their schedules.
    • Schedule groups at times and locations that are convenient for the members of the group. This may increase the likelihood of their participation. If possible, schedule all groups over 1–3 consecutive days to reduce the chance of participants discussing the proceedings, which has the potential to affect individual responses and discussion.
  • Other preparation for the meeting includes the following:
    • Prior to conducting the focus group, set an agenda. The agenda may include a participant welcome, review of goals of the session, introductions, questions and answers, and next steps.
    • Designate a timekeeper to help ensure that the meeting length does not exceed 1–1.5 hours.
    • Arrange for the assessments to be conducted in a room large enough to accommodate all invited attendees. Structure the seating so that all people participating can see each other, which helps foster open dialogue.

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Tips for the Facilitator

  • Begin each session with very brief introductions, and remind everyone that these sessions are confidential and what is shared during the process will not be shared with others. This applies to all of the participants including the facilitator, notetaker, and timekeeper.
  • Advise participants that the focus is on learning about what is occurring at the institution as stated by those stakeholders. To produce more consistently useful results, the facilitator should use structured interview questions, rather than solely relying on his/her intuition. Go to Appendix B for Gap Analysis Structured Interview Questions.
    • The Guide is structured to allow the facilitator to lead participants through a set of questions designed to elicit participant views on a variety of key policies and practices. The questions should be asked of each focus group with the goal of comparing variations in perceptions and identifying potential "gaps" that could impede implementation of the CANDOR process. Appendix C is the structured interview guide, formatted for notetaking during the session.
  • It is important to minimize cross-sharing of interview responses from one group to another. If the facilitator is asked to share information on how another group answered, it is recommended that the facilitator respond in generalities.
  • Ensure that the Anonymous Reporting Tool (Appendix D) is sent out to participants in all groups to allow them to provide feedback they may not have given during the focus group assessment.

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Review Results and Determine Priorities

Upon the conclusion of each individual focus group, discussion summaries and notes should be compiled to ensure pertinent details are captured. If the session is recorded, tapes should be transcribed. A coding system can be used to tally the responses to the questions. For instance, the number 2 can be used for "yes" responses, the number 1 can be used for inconsistent/unsure responses, and a zero can be used for "no" responses.

Coded responses can be tallied and aggregated into a numeric value for each question. Questions can then be ranked from lowest to highest. This will allow the facilitator and improvement team to determine the areas where a gap exists and serve as the basis for the implementation plan.

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Summary Report

The purpose of the Gap Analysis report is to call attention to common themes among the groups, as well as variations among the groups in their perceptions and degree of commitment to the CANDOR process principles. Findings should be used for targeted education, consensus building, and operational planning. These reports should be completed without associating individual participants with their reported remarks or findings. A report template is included as Appendix E.

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Proceed to Appendix A

Return to CANDOR Contents

Page last reviewed February 2017
Page originally created April 2016
Internet Citation: Gap Analysis Facilitator's Guide. Content last reviewed February 2017. Agency for Healthcare Research and Quality, Rockville, MD.
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