I am in need of a Gap Analysis to be put together in a power point presentation at least 10 slides with grafts in at least 2 slides. 

The Gap Analysis is on Policies within the Hospital that I work at. 

The Attachments:

-Policy Gap Analysis–the past current and future status of the where we are

-Policy Question–A survey was given to the staff on what policies they felt were needed

-Policy Survey–Results of the survey. 


Previous state

·
Policies were purged and Lippincott was implemented

·
This caused a huge dissatisfier for the staff and mostly new hires.

·
This left staff confused and feeling lost with basic standard of practices

·
Policies, Guidelines, SOPs and Lippincott are all located in different areas making it difficult for the staff to locate

·
Staff and management not understanding the difference between Policies, guideline, and SOP’s.


Current state

Below is where the hospital is currently at with policies, SOP, and guidelines.

· Steps taken to get here

· Standardization of education across the hospital and ownership of policies

· Education to the education team and leaders on the difference of Policy vs SOP vs Guideline

· Education to the education tem on how to initiate and follow up on policies via compliance 360

This was completed by the Holtz Women’s and children’s education team

·
Current Policy revisions

·
Pediatrics

· Brain Death Determination Pedi—JHS 400.087.1

· Parental or Guard Notification for Pts under 18 for Pregnancy—JHS 4000.013.1

· Organ Donation After Cardiac Death Pedi—JHS 400.018.1

· Disclosure of HIV Status to Minors—JHS 400.050

· Exchange transfusion

· Closed medication administration system

·
Women’s

· Fetal Reeducation—JHS 400.013.2

· Termination of Pregnancy—JHS 400.013

· Certificate of Fetal Death; Stillbirth Reg—JHS 400.011

· Sterilization—JHS 400.010

· Low Risk Delivery Newborn Resuscitation

· Baby Friendly breast feeding

· High risk delivery newborn resuscitation

·
Newly Established Policies

· VAD policy

· Oxytocin concentration

· PCN desensitization

· CRRT/ECHMO

· OB

· OB patient disposition

· OB patient care

· Pediatric Code Blue

· Neonatal Code Blue

·
Guidelines

· Unit Admission Guidelines

· Unit specific Documentation Guidelines

· Required task per shift (eg: IPOC)

·
Pathways

· Early onset sepsis

· Hypoglycemia

· Hyperbilirubinemia

· Code Pink

·
SOP’s

· Protocol for management of Placentas

· OB Alert Emergency Standard of Care

· MFTI

· Prioritization of the OB patient in triage

·
Quick tips

· IV site documentation

· Admission, Discharge, transfer criteria (referencing policy 401)

· Ca

Holtz Children’s & The Women’s Hospital

1 / 2

Q2 Are there any other policies (not mentioned above) that would be most
important to consider in our first phase.

Answered: 37 Skipped: 42

# RESPONSES DATE

1 Labor and delivery policies for different medications 6/29/2022 3:44 PM

2 Intra hospital ratio for our patients, because we’re always struggling. 6/16/2022 11:00 AM

3 Intra hospital transport for floor patients. 6/16/2022 10:59 AM

4 Transitional care 6/15/2022 11:26 AM

5 Labor and delivery 6/13/2022 10:46 PM

6 no 6/10/2022 5:51 PM

7 all 6/10/2022 8:27 AM

8 Misoprostol, 6/9/2022 12:39 PM

9 Staffing ratios, first priority 6/9/2022 9:32 AM

10 Staffing ratios , first priority 6/9/2022 9:31 AM

11 Precepting readiness. 6/9/2022 7:09 AM

12 Magnesium sulfate for PEC and neuro protection. Specifically how long should they stay for
recovery post delivery

6/9/2022 4:16 AM

13 Newborn Glucose management: admission to MB, mother GDM Newborn Mag exposure.
Newborn thermoregulation

6/8/2022 3:50 PM

14 Guidelines for monitoring antenatal testing resulting in transfer of care or admission effects
both antenatal testing out patient and 7B ; diabetic monitoring, orders and the
antepartum/postpartum patient

6/8/2022 7:55 AM

15 No 6/8/2022 6:14 AM

16 Vacuum assisted deliveries 6/8/2022 4:01 AM

17 Specific policies for L&D such as pitocin management 6/8/2022 2:56 AM

18 medications 6/8/2022 12:16 AM

19 Feeding protocol 6/8/2022 12:01 AM

20 Policies for magnesium, pitocin, miso for IUFD, penicillin desensitization 6/7/2022 10:19 PM

21 Every policy regarding how things needed to be done. 6/7/2022 8:28 PM

22 Appropriate Staffing for standard of care 6/7/2022 8:07 PM

23 Managing labor and delivery patients 6/7/2022 5:15 PM

24 Cooling blanket policies ECMO policies Patient acuity policy (patient to nurse ratio based on
acuity) IVH bundle policy

6/7/2022 11:48 AM

25 TOO NEW TO KNOW. EVERYTHING! 6/7/2022 10:19 AM

26 Diabetic policies 6/5/2022 1:58 AM

27 N/A 6/3/2022 1:53 PM

28 Safety 6/3/2022 1:30 PM

29 neonatal ecmo management. neonatal hypothermia management. neonatal respiratory 5/30/2022 7:08 PM

Holtz Children’s & The Women’s Hospital

2 / 2

distress, neonatal infection control. peripheral line management aseptic techniques vs sterile
technique for picc and central lines.

30 1.How often and how much to administer for cheek painting 2. Documentation in the 3 different
level of care 3. Glucose monitor frequency in the different level of care and for baby on insulin.
4. DNR policy for NICU ( currently we have no parental consent form) 5. Please please please
a policy on dos

Holtz Children’s & The Women’s Hospital

1 / 2

Q1 For the policies below, please rate them in order of priority to your
clinical care.

Answered: 79 Skipped: 0

18.99%
15

15.19%
12

8.86%
7

26.58%
21

26.58%
21

3.80%
3

79

3.62

20.51%
16

24.36%
19

29.49%
23

14.10%
11

6.41%
5

5.13%
4

78

4.23

22.78%
18

32.91%
26

20.25%
16

16.46%
13

7.59%
6

0.00%
0

79

4.47

2.53%
2

3.80%
3

12.66%
10

24.05%
19

30.38%
24

26.58%
21

79

2.44

31.58%
24

21.05%
16

28.95%
22

9.21%
7

6.58%
5

2.63%
2

76

4.54

5.13%
4

2.56%
2

0.00%
0

8.97%
7

20.51%
16

62.82%
49

78

1.74

0 1 2 3 4 5 6 7 8 9 10

Vascular
access Devic…

Unit Admission
Guidelines

Documentation
Guidelines

Thermoregulatio
n (neonatal…

Nursing
standard of…

Tracheostomy
Care

1 2 3 4 5 6 TOTAL SCORE

Vascular access Device Management/Dressing
change

Unit Admission Guidelines

Documentation Guidelines

Thermoregulation (neonatal standard of
practice)

Nursing standard of practice

Tracheostomy Care

Holtz Children’s & The Women’s Hospital

2 / 2

Q2 Are there any other policies (not mentioned above) that would be most
important to consider in our first phase.

Answered: 37 Skipped: 42