Key Point #2: Perform a Gap Analysis and Prepare an "Elevator Speech"
Gap Analysis
Performing a gap analysis is an excellent starting point for guideline implementation. A gap analysis is a performance improvement strategy, which formally compares current practice with what is recommended. One method is to start with a list of the recommendations and then review current practice (Table 2). Data concerning current practice can be obtained from rounds, case reviews, and interviews with staff and should include different shifts and different ICUs, with both novice and experienced staff. It is important not to rely on what is said in committee meetings but to go directly to the clinicians at the bedside. Here you will discover the variation in practice between people regardless of what is said in committees, policies, or standard operating procedures. It will also become clear what has worked in the past versus what processes staff members have developed as work-arounds because of missing, cumbersome, or broken processes.
The gap analysis could also be sent out as a survey where the guideline recommendations are listed as items that are evaluated in response to their frequency (e.g., always done, usually done, seldom done, never done, comment). The act of sending out a survey would help inform recipients of some of the details within the guideline, but it cannot be relied upon as the only method of data gathering. In regard to the recommendations related to medication use, data could be collected through a Medication Usage Evaluation conducted by the Department of Pharmacy. For example, this strategy would be helpful to determine total use of benzodiazepines in patients who are not at risk for alcohol withdrawal syndrome. Using a grid such as the one in Table 2, which summarizes the data obtained from all forms of data gathering (e.g., interviews, surveys, observation), will reveal the gaps between practice habits and the new recommendations.
Elevator Speech
Once a gap analysis has been performed and you have identified where the key areas of needed change are, consider making an informal three- or four-sentence "elevator speech" to summarize the fact that you are evaluating the new guidelines to see what can be done to update the current practice at your organization. Frame the elevator speech in the positive. Use the elevator speech anytime you engage anyone in the analysis or the action plan for change or during the change process. The elevator speech should be deliverable in the time it takes you to get from the lobby to your department on the elevator.
For example, The new SCCM guideline for pain, agitation, and delirium was finally published. We are looking at opportunities we might have to improve practice at our medical center. It looks like we are already doing most of what is in the guideline, but there are definitely a few surprising recommendations that we might consider in the future.
The elevator speech should stimulate a discussion. People will naturally take the conversation to where their own point of interest lies, and their response will likely provide insight needed to direct future change.
The implementation of some specific parts of the recommendations (i.e., early mobility) will require more institutional support. An elevator speech may be very useful when one is approaching administrative management to levy for resources and personnel allocation changes. It would also be imperative to engage the Department of Quality, which is responsible for overseeing performance improvements within the organization early in the process. The department may have access to an electronic project management system that will assist you in keeping track of the project progress over time and may provide support to manage the change.
In addition to using an elevator speech to introduce the idea, when soliciting support from either administration or various departments such as the Department of Quality, it would be important to quantify the rationale for change and how the change will improve patient safety and patient outcomes or reduce cost of care. For instance, it can be anticipated that reducing delirium will decrease length of stay and cost of care. Pain management is routinely monitored on patient satisfaction surveys. Reducing agitation may improve both staff safety (injuries related to violence) and patient safety. All of these indicators are keenly aligned to operating objectives overseen by hospital administrators and the Department of Quality. When a business case is made for the change, it is more likely that resources will be provided to conduct the project.