Overview: You will now complete a gap analysis and supply executive leadership with recommendations for how to address gaps identified.

Prompt: In Milestone One, you identified a specific safety issue from the given scenario and analyzed the regulations and accreditation standards associated with that issue and their impact on your organization.

For Milestone Two, you will submit a draft of your gap analysis with recommendations. Your draft should explain the process that is in place or should be in place for approaching regulatory or accrediting compliance and determine current or potential gaps related to your chosen safety issue. In addition, you should draft your recommendations for corrective action strategies, defend your strategies, and explain a compliance program and how you will track compliance.

Specifically, the following critical elements must be addressed:

II. Gap Analysis: In this section, you will conduct a gap analysis and explain the key elements of any compliance plans that are in place (or should be in place). Be sure to:

A. Explain the process that is in place or should be in place for approaching regulatory or accrediting compliance. For example, what actions has the department taken to ensure compliance? What are the procedures or strategies employed or should be employed by the department to maintain compliance?

B. Determine current or potential gaps in the regulatory or accrediting compliance of the healthcare department or system. In other words, is the department compliant with appropriate regulations or accreditation? What gaps are present regarding compliance?

III. Recommendations: In this section, imagine you are preparing recommendations for your supervisor regarding the regulatory or accreditation compliance of the department. Specifically:

A. Recommend corrective action strategies that address your described gaps and meet the compliance requirements of the regulating bodies or accrediting agencies that would apply to the department or system.

B. Defend your strategies by explaining the implications for the department or system if the previously identified gaps are not addressed. In other words, what could happen to the department if it did not follow your recommendations?

C. Explain how you would establish an accreditation or compliance program for the department or system. Be sure to relate implementing your program with previously identified gaps. In other words, explain how you would implement your recommendations regarding accreditation or a compliance program.

D. Explain how you would collect meaningful data to track compliance with your corrective action plan. Consider different ways to go about tracking this compliance.

Guidelines for Submission: This milestone should adhere to the following formatting requirements: 3–4 pages, double-spaced, all references cited in APA format.