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Gap Analysis Facilitator’s Guide

Purpose: To evaluate the extent to which current processes align with the Communication and Optimal Resolution (CANDOR) process and includes; Identifying the existing process Identifying the existing outcome(s) Identifying the desired outcome(s) Identifying and documenting the gap(s)Who should use this tool? The CANDOR Implementation TeamHow to use this tool: Conduct a gap Analysis prior to implementing the CANDOR process . In addition, periodic gap analyses can be conducted as part of an ongoing plan-do-study-act process to monitor progress toward its goal of fully implementing the CANDOR of ContentsGap Analysis process ..2 Obtain Documents to Review Prior to Conducting the Gap Analysis ..2 Conduct the Gap Analysis Focus Group Sessions.

a. Is there a process in place for identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions? b. Do staff have access to a system for reporting adverse events? c. Do staff have access to a system for reporting disruptive behaviors? d. Is a root cause analysis conducted after serious reportable and sentinel ...

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