What Is a Healthcare Gap Analysis (or Gap Assessment)?

A gap analysis, or gap assessment, is a staple tool of business management that applies to all types of businesses, including healthcare organizations. The “gap” refers to the difference between business goals and actual performance. Without a gap analysis, it can be difficult to identify the specific problems that are causing your organization to fall short of a goal. Perhaps more importantly, healthcare gap analyses can help you pinpoint the areas that will yield the greatest improvement.

Forbes defines four types of gap analyses: strategic, skills, market, and profit. Here, we’ll look at the first two, which are interrelated: strategic gaps and skills gaps. An understanding of these two types of gaps is fundamental to any organization and will accelerate improvement in the other two.

Hypothetical scenario: slow pandemic recovery

Imagine the following scenario. You are a mid-level leader at “Friendly Hospital,” a large healthcare organization. Friendly’s executive team has just held an internal quarterly meeting and announced that the organization is aiming to meet pre-pandemic performance benchmarks. The reality is that the organization is struggling to regain stability in several areas, and improvement will not be easy.

At Friendly, staffing is an ongoing problem. Vacancies have led to staff burnout, turnover, and lagging performance. Your organization formerly achieved improvement year after year along with high ratings, but it has been challenging since the pandemic to maintain the top-tier service levels it has been known for. How do you proceed?

A gap analysis identifies specific problems and causes

Conducting a strategic gap analysis can reveal issues affecting performance. In our example, Friendly Hospital had previously achieved and maintained a five-star HCAHPS rating for several years, both overall and in patient surveys. These excellent ratings were a point of pride for the organization.

During the pandemic, the hospital was hit hard by regional staffing and supply shortages. The use of travel nurses cut deeply into the operating budget, leading to the elimination of some administrative positions. Ratings fell to four stars.

Now, the executive team is pressing to regain the higher ratings, but leaders lack the data and strategic insight to ascertain which areas could yield the most effective and impactful improvement.

A strategic gap analysis guides targeted performance improvement

As Friendly Hospital begins its strategic gap analysis, it starts by reporting on the status of every major organizational process and the current people, tools, and resources being used for each. The key to a successful gap analysis is to quantify both the shortfall and the improvement needed.

Goals should fulfill the S.M.A.R.T. framework (specific, measurable, achievable, relevant, and time-bound). Once each process has sufficient data to show the difference between the current state and the desired state, it is easier to see where the greatest needs are and the options for moving forward.

Questions to ask for a strategic gap analysis

For a strategic gap analysis, ask the following:

• What are the major organizational processes?
• What is the status of each vs. the targeted levels?
• What tools and resources are being used and by whom for each?
• What evidence-based best practices should be used going forward?
• What barriers exist for closing the gaps?

This systematic, data-backed approach takes guesswork and speculation out of forecasting future performance. In addition to identifying specific areas or processes that need improvement, a gap analysis can also indicate how much improvement you might realistically achieve in each area. The drivers behind a gap assessment methodology are more than economic or performance-based, however.

“Conducting gap analyses is a best practice for identifying, reducing, or mitigating risk to your organization. Results from an analysis can systematically uncover where the greatest gaps are occurring — which oftentimes can be the areas of greatest risk, whether they are in patient safety, care quality, patient satisfaction, organizational reputation, or other major pain point.” — John Harrington, CMI, Director of Clinical Solutions at Relias.

For example, one study documented how Johns Hopkins Medicine’s Armstrong Institute for Patient Safety and Quality used a gap analysis to evaluate their current state of inpatient diabetes care. Clinicians collected process data and found inconsistencies that resulted in measurable gaps. They later addressed these with new policies, improved infrastructure, education, automation, and standardization.

Using results to target improvement

In our scenario, Friendly Hospital leaders conducted a gap analysis of its major operational processes. Despite less-than-optimal staffing projections for the coming year, leaders concluded that areas such as patient safety and compliance were on track with only minor variances from targets.

However, the analysis also showed that Friendly’s goal of achieving higher patient survey ratings had previously depended on a small but well-trained team of patient care coordinators. Because of recent budget pressures, the hospital had eliminated most of these positions, resulting in longer wait times, patient processing problems, and higher numbers of patient complaints.

Based on the results, hospital leaders decided to reinstate two of their patient care coordinator roles. In doing so, they significantly improved their level of service, provided better support for the care teams, and improved continuity among the many travel nurses, new grad nurses, and other new clinicians on staff. Without examining its major operations through a gap analysis, the hospital could have overlooked this significant win with system-wide impact.

A skills gap analysis helps evaluate and improve staff competencies

A skills gap analysis for healthcare looks specifically at the skills of your workforce. It differs from a strategic gap analysis, which looks at processes and services. Analyzing the skills of your staff is a critical part of performance management because a highly competent staff enables your organization to deliver on its performance targets to ultimately ensure the best patient outcomes.

McKinsey and Company reported that using skills gap assessments can boost productivity by as much as 40% and raise employee engagement by 50%. That much improvement is possible because most organizations have a poor understanding of their existing skills base and needs.

Like a strategic gap analysis, a skills gap analysis begins with a thorough assessment of your existing state. You will assess employees’ existing skills against the competencies needed for high performance to find where gaps exist. Because employee roles can be complex, McKinsey recommends defining each role and the associated skill taxonomies that align with them. Some skills apply across roles, and some apply only to specific roles. Ideally, your organization’s learning experience platform will provide this functionality as part of a robust staff assessment solution.

By analyzing the competencies of your staff, you can both improve individual performance and identify missing skills within teams. Competency assessment is also critical for compliance with regulatory requirements from accrediting bodies such as The Joint Commission and OSHA.

Questions to ask for a skills gap analysis

For a skills gap analysis, ask the following:

• What is your organizational process for evaluating skills and competencies during recruitment and the pre-hire stage?
• How does your organization evaluate and prepare new hires to ensure readiness to practice?
• How does your organization administer and assess required training and certifications?
• How does your organization develop its staff to foster employee growth and provide opportunities for career advancement through continuing education and professional development?
• What are the current skill levels vs. desired benchmarks for the full range of staff competencies?
• What educational initiatives can close the gaps?

Having good data to assess your staff’s current competencies across skill sets is the foundation for achieving improvement in targeted areas. Assessing the knowledge, skills, and abilities of staff members — both individuals and teams — can illuminate where they are and where they need to be.

A skills gap analysis drives upskilling and reskilling

The ability to assess staff competencies thoroughly and accurately gives organizations an advantage in a difficult labor market. International business educator Emeritus suggests that optimizing your existing staff is more important than ever when finding and hiring new talent is a challenge.

In addition to knowing what may be missing from your staff members’ individual learning plans to do their jobs better, you should also identify opportunities for reskilling and upskilling.

• Reskilling is the practice of identifying and developing staff members who have the potential to take on different responsibilities where a gap may exist within your organization. Employees may already have a skill set or partial skill set that your team could leverage with additional training.
• Upskilling enables employees to advance by expanding their skill sets with competencies that fulfill needs within your organization.

Being proactive and innovative with your talent not only benefits your organization in the short term, it could also increase retention, save money, provide recruiting incentives, promote a culture of learning, and raise the quality of your teams overall. Your staff will benefit as they advance in their careers, become more versatile, and gain in confidence and morale.

Undertake a skills gap analysis on a regular basis by building it into your workforce development process and employee performance plans. By doing so, you’ll operationalize the gains from this systemic approach and optimize the most important resource you have — your people.