This guide is for Practice Facilitators, Primary Care Providers (PCPs), office managers, medical assistants (MAs), and quality improvement (QI) teams.

It’s a step-by-step blueprint designed to help you improve how your practice identifies and closes care gaps — whether in preventive care, chronic disease management, or behavioral health.

You’ll find:

The Care Gap Closure (CGC) improvement process begins with three essential prework steps:

Following this Pre-Work, the practice team completes a structured sequence of 12 tasks that guide them through the full cycle of quality improvement—from selecting a care gap and mapping workflows, to testing changes, training staff, evaluating results, and fully integrating the new process into the clinic’s quality infrastructure.

This guide is designed to be practical and flexible—whether you’re a Practice Facilitator supporting multiple clinics or a clinic leader (such as an office manager or lead clinician) guiding your own team.

Ways to Use This Guide:

Care gap closure refers to identifying and addressing missing clinical services — such as screenings, immunizations, or follow-up care — that patients are due for based on clinical guidelines and quality measures.

Addressing care gaps directly impacts your practice’s performance on HEDIS-like metrics and improves patient outcomes.

Practices use a variety of strategies to close care gaps. These include:

The EPT Initiative is focused on closing the following high-impact care gaps for each population of focus (POF):

Benefits of improved processes for care gap closure include:

When working to improve care gap closure, knowing what "good" looks like helps the PCP gather ideas and jump-start their own design and implementation work in these areas.

Find examples of what “good” looks like by:

An exemplar is a clinic, team, staff person or clinician that is performing at a high level on specific metrics (e.g., HEDIS-like measures) or demonstrating success with a particular care gap closure process that your practice is working to improve.

Identify exemplars through:

Exemplars do not need to be good at everything. They may be an exemplar in one specific process, and not in another. Engage them for that one process.

Arrange virtual visit to the exemplar – a video conference where the exemplar shares their process, workflows, and “top three recommendations” and you get to ask questions to inform your own care gap closure design process.

Here are some case examples from your peers that have been nominated by their peers, plan or practice facilitator as an “exemplar” in care gap closure for one or more metrics.

Table 1. Partial list of case Examples. Click here: https://www.lanetpbrn.net/caregapclosure

Access Care Gap Closure Tools shared by EPT Practices and PFs/Coaches Here: https://www.lanetpbrn.net/caregapclosure

https://www.lanetpbrn.net/caregapclosure

As a first step in care gap closure improvement, meet with practice leadership to discuss their interest in this improvement work, their goals for their care gap closure processes, and the area they would like to focus on first and why. Also identify who will be the "champion" for the CMP at the practice. This individual should have sufficient authority to ensure the implementation of the processes at the practice and a personal interest or passion for the CMP or the practice's goals for implementing it.

For the next step, identify the team that will lead care gap closure efforts. This may be an existing QI team, or a new group brought together for this purpose. Also remember, the most critical voices are not always the most obvious. Successful care gap closure depends on engaging the right people from across the workflow—those who play a hands-on role in identifying, addressing, and documenting gaps in care—make sure these roles are present on the team.

Work with the project team to review their current care gap closure processes and identify areas of strength and areas where they are experiencing challenges. Use the assessment worksheet below to get started.

Work with the project team to set their first care gap closure process improvement goal.

Use the Worksheet below to help the practice select which care gap they will focus on first. Use the worksheet below to guide the practice through this selection process.

Next work with the practice to conduct a small n chart audit to identify reasons the selected care gap is not being closed. Use a "last 10 patient" chart audit to review the records of the last 10 patients this week (or day) that should have received the indicated preventive care service and the most common reason/s they did not.

A “Last 10” Patient Chart Audit is a simple, hands-on way for practices to understand how their current workflow is (or isn’t) closing the selected care gap. It looks at what actually happened with recent patients, rather than relying only on reports or assumptions. This gives the team insight into where things are working and where they break down that they can use to design changes to their processes.

Steps to complete a Last 10 Audit on the care gap or gap closure process:

1. Pull the records for the last 10 patients seen in the practice who were eligible for that service/care process.

2. Review each record to see whether the gap was: identified, addressed, closed.

3. Document where and why the service was not delivered (e.g., no flag, patient declined, staff didn’t act).

4. Calculate your “missed opportunity” rate: the % of patients who did not receive the indicated service or associated action (e.g. referral, visit scheduled)

5. Look for patterns in the reasons for missed opportunities: were multiple patient records missing alerts? was the gap closure missed on particular types? Or with a particular care team?

Use the audit sheet below to collect and organize the data and calculate your “missed opportunity” rate. As you do improvement work, the missed opportunity rate should decline.

If you need a resource to train practice staff on how to conduct a “last 10” audit you can use this module: https://www.ahrq.gov/downloads/ncepcr/pf-modules/chart-audit/story.htm

Next examine the results of the Last 10 Audit for patterns and root causes. The practice can then use the findings to design improvements to their current processes.

Steps to complete a simple Root Cause Analysis:

1. Pick a few missed opportunities from the Last 10 Audit.

2. Look for patterns across patients that did not receive the care.

3. Use the 5 Whys technique to dig deeper into why the patients did not receive the indicated care.

4. Use the findings to inform the new workflow design and future tests.

The 5 Whys is a simple but powerful tool for identifying the root cause of a problem. It works by asking “Why?” five times—or as many times as needed—to dig beneath the surface of a missed opportunity and uncover the underlying reasons it occurred.

For a brief training on the “5 whys” and other tools for conducting root cause analysis, view this module: https://www.ahrq.gov/downloads/ncepcr/pf-modules/5-whys/story.html

It’s especially effective when used as a team activity and should be applied to both problems and successes to identify what’s working well and where improvements are needed.

PEARL: Last 10 Chart Audits and 5 Whys are not just for identifying what’s broken. ALSO use them to identify what is working well! The things that facilitate gap closure that you can scale and spread.

Using insights from the Last 10 Chart Audit and Root Cause Analysis, identify the care gap closure approach the practice would like to focus on first. Each approach involves different workflows, staff roles, and technology supports. While most practices eventually use a combination of strategies to fully address care gaps, starting with one can help your team test changes, build confidence, and learn what works best.

Choose the approach that best fits the barriers identified in earlier tasks and the resources currently available in your practice. Think about where your efforts can have the most immediate impact while staying feasible for your team.

For example:

Over time, your practice may decide to layer in additional approaches—either to focus on a high-priority gap (e.g., colorectal cancer screening) or to adopt a more comprehensive “whole-person” approach that addresses all open gaps whenever possible.

Work with the practice to inventory the health IT, human and point of care resources that can be used to enhance its care gap closure workflows; and to identify technology gaps that the practice may want to add.

Use the worksheet below to inventory resources the practice has in these areas as well as the practice’s level of expertise and current use of these tools:

Also, use the worksheet to create a “wish list” of technologies and tools the practice would like to add in the future to enhance its work in care gap closure.

Work with the practice to map the current care gap closure process, begin by identifying the starting and ending points, and creating a high-level process map. Then create a detailed swimlane maps that show the workflow for each member of the staff and care team related to the care or administrative process.

Begin with the process as it currently is, not how the practice would like it to be. Process mapping works best as a group activity, with the individual who conducts the actions, completing the mapping of their part of the process -based on actual actions – not memory.

Any steps involving HIT—such as generating care gap reports, sending automated patient reminders, updating the EHR, or triggering clinical decision support—should be labeled with the name of the tool or system used (e.g., EHR, registry, patient portal, HIE). Use specific symbols or annotations (e.g., icons, shaded boxes, or color codes) to distinguish HIT-supported steps from manual tasks.

Once the practice has mapped the current process, work with them to improve the process using information they learned from the last-10 chart audit and the root cause analysis, and also from reviewing approaches used by any exemplars they have identified.

If the practice does not have a current process for closing the care gap it is working to improve, they can use the results of the Last 10 audit and root cause analysis and review of exemplars to guide design of a new process.

For a brief review of process mapping to share with a practice go here: https://www.ahrq.gov/downloads/ncepcr/pf-modules/process-mapping/story.html

Use Plan-Do-Study-Act (PDSA) cycles to test the new or enhanced workflows. PDSAs are “small tests” of the new or redesigned process. It is an iterative process where you test your new workflows with one patient, or with one care team, or for one day, study what worked and didn’t work, refine the process based on that information, test again, until the process is ready to fully implement.

Use PCP and staff and patient feedback and modified Last 10 chart audits to study the workflows. Do as many small tests as you need to do until you are ready to scale and spread to the entire practice.

You can use this module to provide a quick training to the practice on PDSA cycles: https://www.ahrq.gov/downloads/ncepcr/pf-modules/model-pdsa/story.html

PDSA Worksheet (Option 1)

PDSA Worksheet (Option 2)

Once the PDSA testing is complete and the team feels confident in the new workflow, it’s time to prepare to implement.

For a brief training on how to create a job aid, use the module at U.S. AHRQ here: https://www.ahrq.gov/downloads/ncepcr/pf-modules/scale-improvements/story.html

PEARL: To save time, drop the process map (or list of steps) the practice made earlier in this Guide into an AI engine like Chatgpt with the prompt: “create a simple job aid” and it will generate a first draft that then you can edit and refine.

Making care gap closure part of your practice’s culture requires consistent reinforcement in daily conversations, visible tracking of progress, recognition of contributions, and meaningful rewards that make the work feel worthwhile.

Start by integrating care gap closure into the rhythm of practice operations. Talk about it often and tie it to your team’s identity. Reinforce that this is a shared goal, not just another task handed down from leadership. Motivate your team by helping them feel their progress and success.

Saying “We closed 20 gaps today” builds energy and pride—and helps replace a culture of doing the minimum with one that values excellence.

Specific strategies to operationalize this culture include:

These approaches help create momentum and signal to staff that care gap closure is a priority—one that brings real rewards and shared wins.

Once new workflows are launched, monitor how well they are being adopted by both staff and clinicians and gather feedback from them and patients to continue to refine the new workflows.

Use the following strategies:

For a brief training on audit and feedback and "elbow-support" to support new workflow adoption view this module: https://www.ahrq.gov/downloads/ncepcr/pf-modules/scale-improvements/story.html

Work with the practice to include the new care gap closure process into their QI plan and dashboard. Use the worksheet below to help the practice draft recommendations to their QI team/director or office manager on possible metrics to add to the practice's overall QI program.

Use the worksheet below to generate a guidance letter to the practice’s QI team/director/data governance team.

Also add a description of the new process/es to the practice’s:

Use the worksheets below to document additions to administrative documents.

Your insights—whether a simple workflow tweak, a training guide, or a practical workaround—can be invaluable to others trying to implement similar improvements.

Click here to share your tools and what you've learned: https://www.surveymonkey.com/r/TXB7MZG

Or email them to: [email protected]

A. Exemplar Case Studies. Click here: https://www.lanetpbrn.net/caregapclosure

B. Virtual Visits to Exemplar Practices. Click here: https://www.lanetpbrn.net/caregapclosure