Gap Analysis Facilitator's Guide: Appendix A

CANDOR Gap Analysis Document Review Checklist

Instructions: At least 1 month prior to the onsite gap analysis, collect and provide the following documents for analysis by the Gap Analysis Team.

Documents for Submission to Reviewers Is the document available?
Policies and procedures

  1. Reporting of incidents, occurrences, or complaints
  2. Complaint/grievance management
  3. Disruptive behavior and/or code of conduct
  4. Investigation of occurrences (i.e., sentinel events or other triggers for RCA)
  5. Other peer review policies
  6. Informed consent or shared decisionmaking
  7. Disclosure
  8. Care for the caregiver, employee assistance, physician wellness
  9. Ethics consult triggers

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Bylaws for medical staff and/or hospital

  1. Peer review process
  2. Oversight/management of adverse or "harm" events

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Organizational safety and/or quality plan

  1. FMEAs or other proactive process
  2. RCA policies/procedures/processes

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Organizational Structure

  1. Organizational chart showing connections among safety, risk, quality, credentialing, ethics, legal, and claims

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  1. Patient and family advisory council: membership and bylaws
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Safety survey or other quality survey, such as patient satisfaction results

  1. Safety attitudes questionnaire
  2. AHRQ Hospital Survey on Patient Safety Culture
  3. Hospital patient satisfaction survey
  4. Employee engagement surveys

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Board minutes or reports related to quality and safety

  1. Reports related to demographic and descriptive data of vulnerable populations
  2. Quality and safety outcomes based on race, ethnicity, and language

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Proceed to Appendix B

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Page last reviewed April 2016
Page originally created April 2016
Internet Citation: Gap Analysis Facilitator's Guide: Appendix A. Content last reviewed April 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3-facguide-apa.html