Gap Analysis Facilitator's Guide: Appendix B
Gap Analysis Structured Interview Questions
The Gap Analysis Structured Interview Questions allow the facilitator to lead participants through a set of questions designed to elicit participant views on a variety of key policies and practices.
- Leadership and Culture:
- Are governance/senior leaders regularly and thoroughly briefed on risks and hazards?
- Has a safety culture survey been completed?
- Is there a system in place for patients to give feedback about the organization's performance?
- Do patients and families serve on committees and give input to leadership?
- Are patient safety risks, hazards, and opportunities discussed and documented at board meetings?
- Is a patient safety program in place?
- Are patient safety improvement committees interdisciplinary?
- Does a "just culture"—in which frontline personnel feel comfortable with reporting and "disclosure"—exist?
- Do board members receive basic teamwork, communication, and patient safety training?
- Does leadership designate resources to patient safety activities?
- Is the safety and quality culture assessed annually?
- Culture Measurement and Feedback:
- Were the results of the most recent safety and culture surveys distributed?
- Is there a clear process for communication among staff in response to adverse events?
- Are survey findings used to guide process improvement interventions?
- Is there a process in place for rapid dissemination of critical process improvements?
- Identification and Analysis of Actual and Potential Adverse Events:
- Is there a process in place for identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions?
- Do staff have access to a system for reporting adverse events?
- Do staff have access to a system for reporting disruptive behaviors?
- Is a root cause analysis conducted after serious reportable and sentinel events?
- Is a root cause analysis conducted after near miss events?
- Does the organization perform at least one prospective analysis per year using a method approved by the organization?
- Is the root cause analysis committee inter-professional?
- Are the number and category of patient safety events tracked in a searchable database?
- Are the costs associated with inappropriate care-related harm events tracked and trended?
- Are claims and lawsuits tracked and analyzed for lessons learned?
- Are the lawsuits associated with individual physicians tracked within the organization?
- Is a risk manager available at all times to respond to patient safety incidents?
- Is the investigatory process for harm events designed to afford all members the protections of State statutes?
- Are patients and families encouraged to report safety concerns?
- Does the hospital collect race, ethnicity, and language (REAL) preference data from patients in a standardized way at registration?
- Does the hospital routinely use its REAL data to identify patient safety event disparities and establish disparities reduction goals?
- Informed Consent:
- Do patients "teach back" key information about treatment and procedures?
- Are informed consent documents written at or below the 5th grade level?
- Are informed consent documents available in languages other than English?
- Are interpreters or readers available 24/7 when needed?
- Does the organization embrace the concept of "shared decisionmaking?"
- Does the organization employ any methodology to assess the effectiveness of the consent process?
- Disclosure and Resolution:
- Is there a formal process for disclosing unanticipated outcomes in the organization?
- Is there a formal process for disclosing unanticipated outcomes to a patient safety organization?
- Is information related to disclosed outcomes linked to performance improvements?
- Does disclosure to patients and families include the sharing of facts not otherwise known or knowable by the family?
- Does the institution encourage expressions of empathy?
- Are patients and families updated on the results of the investigation?
- Is an attempt made to disclose within the first 24 hours following an adverse event?
- Does a licensed practitioner or administrative leader offer an apology when appropriate?
- Does disclosure include emotional support for patients and their families?
- Have all practitioners agreed to participate in the disclosure program?
- Have all of the medical malpractice insurers for the hospital and practitioners agreed to the process of response and communication after harm events?
- Is early remediation an element of the disclosure process?
- Are bills for hospital or professional fees waived if inappropriate care caused harm?
- Care for the Caregiver:
- Is there a care for the caregiver program associated with unanticipated events?
- Have the staff had training related to the vulnerabilities of caregivers involved in harm events?
- Do staff have the opportunity to participate in event investigations and process improvement initiatives?
- Has an organized process to assess behavior related to the event been established?
- Is supportive care provided to the caregiver within 24 hours of the event?
- Do individuals directly involved in events undergo a "fitness for work" assessment?
- Is followup provided for staff involved in harm events?
Page last reviewed April 2016
Page originally created April 2016
Page originally created April 2016
Internet Citation: Gap Analysis Facilitator's Guide: Appendix B. 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-apb.html