Gap Analysis Approaches for the NPD Practitioner

Respond by identifying a possible process or system issue that could be at the root of the problem they have presented.

Gap Analysis Approaches for the NPD Practitioner

                For this discussion I choose a local mid-sized medical center in central Massachusetts. This medical center has two campuses with a 302-bed capacity and offers a wide variety of medical services such as women’s health, oncology, bariatric, and physical therapy services (U.S Centers for Medicare and Medicaid [CMS], n.d.).

Gap Analysis

To provide a multifaceted analysis of this health care system, a comprehensive review was conducted using the compare tool for on the website for Medicare and Medicaid national standards. According to the data, the hospital system is on target for national averages for general serious complications, complications after joint replacement, and deaths among patients with serious treatable complications with surgery (CMS, n.d.).

For Infections, the hospital system was on track with national benchmarks for central line associated infections, post-surgical infections, and MRSA infections (CMS, n.d.). Interestingly, their average for post urinary catheterization infections is 2.6% higher than the national average of one percent (CMS, n.d.). For death rates for common diagnosis such as COPD, heart failure/attack, pneumonia, stoke and CABG are all at the national standards (CMS, n.d.).

Learning Needs

With considering this data, the nurse professional development practitioner (NPD) may want to consider formulating education and protocol change for prevention of catheter associated urinary infections. The main function of the NPD is to optimize the overall care of the patients and publics health (Dickerson, 2017). The NPD will need to complete an analysis often to exam the patient outcomes form the hospital vs. national standards. This is important for quality improvement, prioritizing nursing excellence, and maintain needed reimbursement implications for CMS standards of care (Dickerson, 2017). Per the CMS (n.d.) comparison, for urinary catheter associated infections the health care system is alarming compared to the national average.

More information would need to be conducted by completed a root cause analysis to address staff, products, sanitation methods, and review of physician orders to see what improvements can be made (Harper & Maloney, 2016). Conducting staff interviews, surveys for subjective data, and collaborating with the infection control nursing will be essential to address the gap analysis (Dickerson & Graebe, 2018). Staff education on infection control practices, revising policy and procedure, and implementing a new order bundle associated with urinary catheter insertion may need to be addressed to lower the numbers of infection and improve practice. Protecting the health of the community is a vital function of the NPD.



Dickerson, P. (2017). Core curriculum for nursing professional development (5th ed.) Chicago, IL: Association for Nursing Professional Development.

Dickerson, P. S. & Graebe, J. (2018). Analyzing gaps to design educational interventions. The Journal of Continuing Education in Nursing. 49(1), 4-6.

Harper, M. G., & Maloney, P. (2016). Nursing professional development scope & standards of     practice (3rd ed.). Chicago, IL: Association for Nursing Professional Development.

U. S. Centers for Medicare and Medicaid Services. (n.d.). Hospital compare.