Conducting gap analyses to successfully implement new clinical practices at Tilbury Manor

Tilbury Manor, a 75-resident long-term care home in Tilbury chose to focus on provincially-mandated “required programs” (fall prevention, skin and wound care, continence care, bowel management and pain management) when seeking to improve resident care.

They conducted a gap analysis to compare their current practices with the best practices outlined in related RNAO best practice guidelines. Their analysis included an assessment of clinical practices, policies and documentation systems. The results of the gap analysis helped them create specific action plans.

Tilbury Manor then formed project teams led by nurses and supported by a team of champions. These teams proceeded to educate staff, implement new clinical practices, conduct care reviews and conduct audits.

Multiple positive outcomes were reported as a result of implementing these best practices including reductions in reports of pain, less use of restraints, and less falls, pressure ulcers and urinary tract infections.