Gap Analysis Tool Adapted from AHRQ

What is this tool? The purpose of the gap analysis is to provide project teams with a format in which to do the following:

• Compare the best practices with the processes currently in place in your organization.

• Determine the “gaps” between your organization’s practices and the identified best practices.

• Select the best practices you will implement in your organization. Who are the target audiences? The project liaison (you will serve as the liaison for this assignment) will be the primary individual to prepare this written gap analysis, but the entire improvement project team should be engaged in performing the gap analysis. How can the tool help you? Upon completion of the gap analysis, project teams will have the following:

• An understanding of the differences between current practices and best practice.

• An assessment of the barriers that need to be addressed before successful implementation

of best practices.

How does this tool relate to others? Information from AHRQ’s Self-Assessment (Tool A.3) about

the readiness of the hospital/practice setting to perform quality improvement for the Quality Indicators

or Best/Evidence-based practices can be considered in the gap analysis as possible strengths or

weaknesses (i.e., barriers) to be managed when implementing improvements. The best practice

elements defined in the Selected Best Practices and Suggestions for Improvement (Tool D.4) are prefilled

in the gap analysis tool. This provides the elements for the Implementation Plan (Tool D.6).

Instructions

1. List the identified practice problem in Column 1. 2. In Column 2, provide a description of identified best practices (3 best practices required) to address the problem 4. In Column 3, identify barriers that may hinder successful implementation of each best practice strategy. Consider systems, procedures, policies, people (aka stakeholders), equipment, etc. 5. In Column 4, discuss your thoughts whether your organization will implement that best practice strategy. If not, explain why. 6. Repeat steps 1-4 for each best practice.

Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!

Step-by-Step Guide to Completing the Gap Analysis Tool Successfully

Step 1: Clearly Identify the Practice Problem

In Column 1, write one specific, clearly defined practice problem observed in your organization.

✔ Strong practice problems:

Are narrow and focused
Affect patient outcomes, safety, or efficiency
Can realistically be improved

💡 Tutor tip: Avoid vague problems such as “poor care” — instead specify what is not meeting standards.

Step 2: Identify Three Evidence-Based Best Practices

In Column 2, list three best practices that directly address the identified problem.

Each best practice should:

Be supported by evidence-based guidelines or literature
Represent current gold-standard care
Be clearly explained in 2–3 sentences

✔ Cite sources if required by your course.

Step 3: Analyze Barriers to Implementation

In Column 3, think critically about what might prevent implementation.

Consider barriers related to:

Systems (workflow, EHR limitations)
Policies (organizational rules or regulations)
People (staff resistance, training needs)
Resources (time, staffing, equipment, cost)

💡 Be realistic—acknowledging barriers strengthens your analysis.

Step 4: Determine Feasibility of Implementation

In Column 4, explain whether your organization can realistically implement each best practice.

If yes:

Briefly explain why it is feasible

If no:

Clearly state why (cost, staffing, leadership support, etc.)
This will help justify alternative strategies later

✔ There is no penalty for stating a best practice cannot be implemented if your reasoning is sound.

Step 5: Repeat the Process for All Three Best Practices

Ensure:

Each best practice has its own barrier analysis
Implementation decisions are clearly justified
Columns align logically across each row

Step 6: Review for Clarity and Alignment

Before submitting:

✔ All four columns are complete
✔ Best practices clearly align with the problem
✔ Barriers are specific, not generic
✔ Implementation decisions are well explained

Helpful Academic & Professional Resources

Use these to support your gap analysis:

Agency for Healthcare Research and Quality (AHRQ):
https://www.ahrq.gov
AHRQ Quality Improvement Tools & Resources:
https://www.ahrq.gov/quality
Johns Hopkins Evidence-Based Practice Model:
https://nursing.jhu.edu/evidence-based-practice

Gap Analysis Tool Explained for Evidence-Based Practice Project