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Gap analysis leads hospital to quality improvement

HCPro's Weekly Update on the ANCC Magnet Recognition Program®*, July 11, 2006

Conducting a gap analysis is like examining your organization with a magnifying glass. Susan Herrmann, RN, MSN, director of professional practice and ANCC Magnet Recognition Program® (MRP) project coordinator at Delnor-Community Hospital in Geneva, IL, a designated organization since 2004, explained that the gap assessment showed Delnor that when building an MRP environment, leaders and staff needed to incorporate structure, theory, and education into everything they built.

Delnor employees created a plan to cultivate three particular areas in their pursuit of "magnetism." One area was Force 7: Quality improvement. Prior to the gap analysis, the organization already employed a model for quality improvement that required them to "plan, do, check, and act." However, the gap analysis asked the difficult questions about whether this was always followed. "Many times, we do the plan and do [part], but we didn't check, act, and make a difference in our results," Herrmann says. To enhance quality improvement efforts, nursing adopted a model for improvement and worked with other disciplines to learn from their processes and procedures.

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