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 -Polic
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)
· Care and Maintenance of Vascular Access Devices
· Medication Administration (referencing policy 400.025)
· Berlin Heart
Resource Binders
The Education team has also been a part of the following system wide policies
· Suicide Prevention policy non-behavioral Health (there are now 2)
Top 6 policies requested from the survey (see attached)
Vascular access Device/Management/Dressing change
Unit Admission Guidelines—-Making a guideline
Documentation Guidelines—Making a Guideline
Thermoregulation (neonatal standard of practice)
Nursing standard of practice—-Addressed in the Unit admission and documentation guideline
Tracheostomy Care
Future
1. things that we are working on to ensure that resources are available for staff in a central location
· Resource Binders
· front part of each binder will be standardized hospital wide (see below)
· Second half of each binder will have valid information and tools for each unit to assist with the following:
· Documentation standards per unit
· Quick tips
· Ect.
· We are working with IT to have the binders be electronic with links for easy access.
to be on the following units within Holtz and Women’s
· Pedi Clinics
· Antepartum
· GYN/GYO
· BMT
· PRU
· Pedi Hem/Onc
· Pedi Transplant
· PICU
· CICU
· PSPU
· L&D
· OB Triage
· OB OR
· OB Recovery
· OB Transition nursing
· NICU
· NICU-D
· Mother Baby
· Pedi ED
· Dialysis
· Pedi Transport
· PPEC
Each binder to consist of the following
· Holtz and Women’s
· Emergency number
· Security
· Color codes
· Web link for badge buddy
· Hospital Department numbers
· TJC handouts (race/pass/ hand hygiene)
· Map of campus
· Nursing assessment policy (health record documentation guideline)
· Quick tips
· Restraints
· Zolls
· BBraun quick tip
· POCT reference
· Unit Specific (per unit above)
· Unit phone list
· Unit chain of command ( w/ contact info & title)
· Pathways
· Map of the Unit
· Tools (humpty dumpty)
· Unit specific documentation
· FREQUENCY (Q1, Q4, etc.)
· Pre Op/ Post op/ during procedure
· Stroke/ DKA/ STEMI/ Pitocin/ Mg drip etc.
· Resource binders to be made electronic with the help of IT
KEY
In progress
Recently completed
Requested, not initiated
,
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 dose to administer nasally for Versed for procedure.(currently doctors have an agreement nurses do not have anything in writing.
5/27/2022 10:45 AM
31 PACU/Recovery 5/27/2022 7:54 AM
32 Medication administration and compatabilities. Neonatal development 5/26/2022 9:47 AM
33 N/A 5/26/2022 9:37 AM
34 No 5/26/2022 9:35 AM
35 N/a 5/26/2022 9:35 AM
36 1.Report guidelines ie history of the mother as well as the baby especially on admission. 2. Blood draw guidelines ie nurses should be trained to obtain all blood draws and not be restricted. This should include blood cultures and should be coordinated with IV insertions. 3. Noise control guidelines ie loud talking over the baby’s bed/isolette especially during admissions and parents having their phones on speaker within inches of the infant’s face.
5/26/2022 7:40 AM
37 not at this time 5/23/2022 8:46 AM
,
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
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
