Alignment of health organisation policies and procedures with the World Falls Guidelines: a gap analysis

Objective This study aimed to assess the degree of alignment of a large health organisation’s documented policies and procedures with the recommendations in the World Guidelines for Falls Prevention and Management for Older Adults. Methods A gap analysis to assess the alignment of documented policies and procedures with the World Falls Guidelines was conducted at a large health organisation. The gap analysis involved creating a tool to collect information from the health organisation’s documented policies and procedures. Stakeholder meetings were conducted to complete the tool, and proposed strategies to improve alignment were also documented. Results The gap analysis included 10 meetings with key stakeholder groups. Health organisation policies and procedures aligned with 45% (31 of 69) of recommendations in the World Falls Guidelines. There was misalignment of policy with some recommendations, including management of ‘falls risk increasing drugs’ and routine provision of tailored education in hospital settings. To improve alignment, changes to policies and procedures were proposed. Conclusion A structured gap analysis process revealed areas of misalignment between organisational policy and procedures and the World Falls Guidelines. This process could be replicated in other health services seeking to align their falls policy with best available evidence.