Gap Analysis Facilitator's Guide: Appendix C

Gap Analysis Structured Interview Guide

To produce more consistently useful results, use structured interview questions. The facilitator should review the questions in advance to determine which questions are appropriate for each focus group session. It may help to ask the same question of multiple groups, as the answers may reveal the perception of the particular group.

Gap Analysis Structured Interview Guide
Organization Name
Stakeholders Interviewed

Yes—This means the respondents have answered positively about this question.

Inconsistent/Unsure—This means the respondents are unsure about this question or the respondents indicate that the actions related to the question are inconsistently being done.

No—This means the respondents have answered negatively about this question.


CANDOR Policies & Processes Yes Inconsistent/
No Comments
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 time 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?        
Is the root cause analysis committee inter-professional?        
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 behavior?        
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?        
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 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 patient 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 concepts 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 organization encourage expressions of empathy?        
Do disclosures include a commitment to investigate and prevent future occurrences?        
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 an 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?        

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