Demonstrate Your Commitment to Quality and Safety: A Gap Analysis Approach for Section 38 and 39 Organisations
Introduction
For Section 38 and 39 health and social care services, upholding quality and safety standards is crucial. These organisations, often supported by government funding, are obliged to meet a range of quality standards, including the National Standards for Safer Better Healthcare, ensuring that quality and safety are at the forefront of service delivery.
One powerful tool for organisations to align with these standards and demonstrate your commitment is through a gap analysis. A gap analysis not only highlights compliance gaps but also provides a roadmap for continuous improvement in quality and safety, an essential step for fostering trust among stakeholders, staff, and the community.
In this blog, we’ll explore how conducting a gap analysis can help Section 38 and 39 organisations strengthen regulatory compliance, optimise service user safety, and establish a transparent, accountable approach to quality care. We’ll break down the key steps in a successful gap analysis and discuss how addressing these gaps can lead to tangible benefits for both the organisation and those it serves.
The Role of Section 38 and 39 Organisations
Section 38 and 39 organisations play a unique and vital role in Ireland’s health and social care landscape. Section 38 organisations are funded to provide services on behalf of the Health Service Executive (HSE), whilst Section 39 organisations, partly funded by the HSE, operate independently but provide essential health and social services that complement the public healthcare system. Together, these organisations support diverse populations, making their adherence to quality and safety standards critical to Ireland’s overall healthcare goals.
Due to their publicly funded status, Section 38 and 39 organisations are required to meet strict regulatory requirements, such as HIQA National Standards and guidelines, HSE standards, and various clinical governance requirements. For these organisations, compliance is not merely a box-ticking exercise; it’s a cornerstone of their operational legitimacy and ethical duty. Consistent adherence to regulations ensures that these organisations meet service delivery expectations, protect patient and service user welfare, and maintain access to essential funding. By prioritising compliance, Section 38 and 39 organisations can reinforce their reputation as reliable care providers, demonstrating a proactive commitment to the highest standards of safety, quality, and accountability.
Why take a Gap Analysis approach?
A gap analysis is an evaluative process that helps organisations identify and bridge the difference between their current practices and the standards they are required to meet. For Section 38 and 39 organisations, a gap analysis involves comparing current policies, procedures, and practices against benchmarks such as HIQA National Standards for Safer Better Healthcare. By systematically reviewing these areas, organisations gain a clear picture of where they are in compliance, where they fall short, and the steps needed to close those gaps. This approach ensures a structured, evidence-based path toward improved quality and regulatory adherence.
Stages for an effective Gap Analysis
- Establish the Target
- Understand the Assessment Approach
- Analyse the current processes
- Detail the findings
- Rate the service’s level of compliance
- Develop a comprehensive, step by step action plan
Stage 1: Establishing the Target
The first step in any successful gap analysis is to set clear objectives and establish the regulatory or best practice standards that will serve as a benchmark. For Section 38 and 39 organisations, conducting a Gap Analysis against the National Standards for Safer Better Healthcare is an appropriate target.
It is also important, before you start to prepare a tool, such as an excel spreadsheet, to record your findings and action plans. Some of the key areas to include in the tool are the standards, the findings, a compliance rating, any action plans, responsibility, timeline and the ongoing status.
Stage 2: Understand the Assessment Approach
When you are undertaking your Gap Analysis, it is important to consider what approach to take when conducting the assessment. Regulatory bodies such as HIQA provide documentation or Assessment Judgement Frameworks that detail lines of enquiry to be explored by inspectors in order to assess compliance with the standards. HIQA recently published a Guide to Assessment-Judgment-Framework to monitor against the National Standards for Safer Better Healthcare which can be used to support a comprehensive Gap Analysis against the National Standards for Safer Better Healthcare.
Stage 3: Analyse the Current Processes
Once you have identified your target, developed the Gap Analysis tool and gained an understanding of the assessment approach required, then you can embark on the Gap Analysis process. It is important to utilise a triangulation model which incorporates interviews, observation and documentation reviews.
The first step is to schedule the Gap Analysis. To do this you need to identify who the facilitators are, the regulations covered, the agenda and timeline for the observation and interviews and who are the required attendees.
Objectivity is critical and must be reflective of a regulatory body approach. As such, it is important to review beyond the paperwork. Information may be sourced from observations, one to one discussions (with staff and residents if possible) as well as review of documentation.
When conducting observations and interviews, consider the following:
- Look for evidence of implementation
- Need to observe the processes being implemented.
- Be considerate of privacy, dignity and consent
- Speak to the staff that implement the processes on a day to day basis, not just the Managers
- Discuss with staff whether they know what to do when things go wrong not just when they go right do they know the escalation process?
Examples of documentation for review include:
Governance records
- Strategic and operational plans, Team charts, Teams terms of reference, minutes, agendas, Statement of Purpose, business continuity plan, financial records.
Service monitoring and measurement documentation
- Audit reports, KPI’s, annual review data, incident management records, risk registers, Quality Improvement Projects/Initiatives, external reporting information
HR records
- Staff files, job descriptions, training plans, induction and ongoing training records, staff rotas, agency staff records, performance reviews, supervision records.
Service user records
- Individual support plans, records of service provision, survey reports, complaint management records.
Supplier contracts and monitoring records
Stage 4: Detail the Findings
Once the onsite audit and the documentation review has been completed, compare the current evidence of compliance with the expected evidence of compliance and identify the gaps.
Stage 5: Rate Compliance
The compliance rating applied during a Gap Analysis should be reflective of the Regulatory Bodies rating model, i.e.
- Not compliant (Red): The service has not complied with a regulation and considerable action is required to come into compliance. Continued non-compliance or where the non-compliance poses a significant risk to the safety, health and welfare of service users will be risk rated red (high risk).
- Not compliant (Orange): The service has not complied with a regulation and considerable action is required to come into compliance. Where the non-compliance does not pose a risk to the safety, health and welfare of service users it is risk rated orange (moderate risk).
- Substantially compliant (Yellow): The service has generally met the requirements of the regulation, but some action is required to be fully compliant. This finding will have a risk rating of yellow which is low risk.
- Compliant (Green): The service is in compliance with the relevant regulation.
Stage 6: Develop the Improvement Plan
At this stage, you must develop a comprehensive, step by step action plan to bring the current status to where we need to be to meet the regulatory requirements. You need to ensure that individuals are provided with responsibilities not Teams. If it becomes a Teams responsibility, then it decreases the likelihood of the action being undertaken.
It is also important to set a timeline for implementation of the actions and from this review the open actions on a scheduled basis, e.g. as part of the Management Team meeting on a monthly basis. Incorporate this as part of the agenda items for the Management Team to ensure that it is monitored appropriately. Achievement or otherwise of open QIP’s should be documented in the Team Meeting minutes.
How a Gap Analysis Demonstrates Commitment to Quality and Safety
- Transparency and Accountability: Gap analysis shows a commitment to safe, reliable care by identifying and addressing non-compliance, building credibility with stakeholders and the public.
- Continuous Improvement: It fosters ongoing quality enhancements, allowing organisations to adapt to evolving standards and maintain high care levels for patients and communities.
- Trust Building: Demonstrating a proactive approach to quality and safety through gap analysis reinforces trust among service users, families, and the community, critical for publicly funded organisations.
How can HCI help?
HCI has been working with health and social care organisations for almost two decades, supporting them make intelligence driven decisions to attain, manage and improve quality, safety and regulatory compliance.
We have supported many health and social care organisations to conduct Gap Analysis against the National Standards for Safer Better Healthcare. We use our knowledge and understanding of HIQA’s approach to develop a comprehensive report that will detail areas of good practice and areas of non-compliance against the National Standards. This report can be used as a roadmap to help you implement a best practice Quality and Safety Management System to ensure your service is operating to the highest standards of care and safety.
For more information contact HCI at 01 629 2559 or info@hci.care.