Gap Analysis Facilitator's Guide: Appendix A

CANDOR Gap Analysis Document Review Checklist

Instructions: At least 1 month prior to the onsite gap analysis, collect and provide the following documents for analysis by the Gap Analysis Team.

Documents for Submission to Reviewers	Is the document available?
Policies and procedures Reporting of incidents, occurrences, or complaints Complaint/grievance management Disruptive behavior and/or code of conduct Investigation of occurrences (i.e., sentinel events or other triggers for RCA) Other peer review policies Informed consent or shared decisionmaking Disclosure Care for the caregiver, employee assistance, physician wellness Ethics consult triggers	___ ___ ___ ___ ___ ___ ___ ___ ___
Bylaws for medical staff and/or hospital Peer review process Oversight/management of adverse or "harm" events	___ ___
Organizational safety and/or quality plan FMEAs or other proactive process RCA policies/procedures/processes	___ ___
Organizational Structure Organizational chart showing connections among safety, risk, quality, credentialing, ethics, legal, and claims	___
Patient and family advisory council: membership and bylaws	___
Safety survey or other quality survey, such as patient satisfaction results Safety attitudes questionnaire AHRQ Hospital Survey on Patient Safety Culture Hospital patient satisfaction survey Employee engagement surveys	___ ___ ___ ___
Board minutes or reports related to quality and safety Reports related to demographic and descriptive data of vulnerable populations Quality and safety outcomes based on race, ethnicity, and language	___ ___