Chat with us, powered by LiveChat 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 | Wridemy

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


· 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


· 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


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




· Pedi Hem/Onc

· Pedi Transplant




· L&D

· OB Triage


· OB Recovery

· OB Transition nursing



· Mother Baby

· Pedi ED

· Dialysis

· Pedi Transport


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


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


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



20.51% 16

24.36% 19

29.49% 23

14.10% 11

6.41% 5

5.13% 4



22.78% 18

32.91% 26

20.25% 16

16.46% 13

7.59% 6

0.00% 0



2.53% 2

3.80% 3

12.66% 10

24.05% 19

30.38% 24

26.58% 21



31.58% 24

21.05% 16

28.95% 22

9.21% 7

6.58% 5

2.63% 2



5.13% 4

2.56% 2

0.00% 0

8.97% 7

20.51% 16

62.82% 49



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

Our website has a team of professional writers who can help you write any of your homework. They will write your papers from scratch. We also have a team of editors just to make sure all papers are of HIGH QUALITY & PLAGIARISM FREE. To make an Order you only need to click Ask A Question and we will direct you to our Order Page at WriteDemy. Then fill Our Order Form with all your assignment instructions. Select your deadline and pay for your paper. You will get it few hours before your set deadline.

Fill in all the assignment paper details that are required in the order form with the standard information being the page count, deadline, academic level and type of paper. It is advisable to have this information at hand so that you can quickly fill in the necessary information needed in the form for the essay writer to be immediately assigned to your writing project. Make payment for the custom essay order to enable us to assign a suitable writer to your order. Payments are made through Paypal on a secured billing page. Finally, sit back and relax.

Do you need an answer to this or any other questions?

About Wridemy

We are a professional paper writing website. If you have searched a question and bumped into our website just know you are in the right place to get help in your coursework. We offer HIGH QUALITY & PLAGIARISM FREE Papers.

How It Works

To make an Order you only need to click on “Order Now” and we will direct you to our Order Page. Fill Our Order Form with all your assignment instructions. Select your deadline and pay for your paper. You will get it few hours before your set deadline.

Are there Discounts?

All new clients are eligible for 20% off in their first Order. Our payment method is safe and secure.

Hire a tutor today CLICK HERE to make your first order

Related Tags

Academic APA Writing College Course Discussion Management English Finance General Graduate History Information Justify Literature MLA