Protocol Development and Quality Improvement
current and best practices. An assessment must be made of the barriers that exist before best practice can be
implemented successfully. A Gap Analysis should be conducted using the following steps. Using a tool to
track best practices, future state, gaps, and solutions is helpful to keep all information organized and track
the progress of the change to be implemented.
Identify best practices and determine/define what the future state should be.
Shadow processes or βWalk-the-Lineβ to experience what the current state is like.
Compare ideal or future state to the current state to identify gaps.
This can be categorized as fully compliant, partially compliant, in progress, noncompliant, or
potentially not applicable, depending on the practice site.
Evaluate potential solutions to bridge the gaps to achieve the future state.
Implement change management with timeline goals for successful progress.
Monitor the progress of implemented solutions to ensure the change is sustained.
Review of the primary literature
ISMP Best Practices
ISMP Safety Alert newsletters
Published guidelines such as USP 797 or USP 800
| d. | The Joint Commission and National Patient Safety Goals |
|---|
CMS Core Measures
Survey practitioners β Feedback from practitioners (e.g., ICU pharmacists, nurses, physicians) may be
helpful when best practices have not been published or their buy-in is essential
Survey strategies
Have a single well-defined objective.
ii.
Keep the survey short.
iii.
Assure respondents that survey responses will be kept anonymous (if possible).
iv.
Survey a large-enough sample to ensure meaningful results.
Explain the purpose of the survey, and how you intend to use the results, in your invitation/
greeting page.
vi.
Spell out the time expectations in your invitation and on the greeting page.
vii.
Survey the appropriate people.
viii.
Design the survey for easily measurable results.
ix.
Evaluate one concept per question.
Avoid biasing the response.
xi.
Limit the number of required questions.
xii.
Question order matters β The first question or two should be easy and interesting.
xiii.
Create a logical flow to the questions.
xiv.
Test the survey.
xv.
Share the results and actions with the respondents.
and detection, therapeutic use, critical thinking and knowledge, and education. A gap analysis should also
include policies, procedures, protocols, guidelines, competencies, patient care models, educational methods,
and other key components to maximize efficacy and prevent medication errors and harm.