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Institutional Gap Analysis Based on EFQM Criteria
CoursesEuropean Excellence Model (EFQM) Programs
Professional Training Program

Institutional Gap Analysis Based on EFQM Criteria

Professional EFQM training program: Institutional Gap Analysis Based on EFQM Criteria.

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Course Details

Overview

The "Institutional Gap Analysis Based on EFQM Criteria" course is an advanced applied training program aimed at enabling participants to conduct a systematic and comprehensive analysis of the gaps between the organization's current performance and the requirements of the EFQM excellence model, in order to accurately identify strengths and improvement opportunities and build actionable development plans to move to higher levels of institutional excellence. Gap Analysis is the cornerstone of any institutional improvement journey, as it provides the organization with a clear map of where it stands now and where it wants to reach, and what actions are needed to close the gaps.

In the context of Saudi Vision 2030, which aims to raise the efficiency of the government and private sectors and enhance global competitiveness, gap analysis according to excellence criteria has become a vital tool for organizations to assess their current performance and set improvement priorities. This course is based on the EFQM 2025 Model as a reference framework, covering all seven main criteria and 32 sub-criteria, and the RADAR methodology to assess the maturity level for each criterion (from basic to outstanding). The course takes the participant from the analysis planning stage, to data collection and the application of assessment tools (such as the Business Excellence Matrix – BEM, surveys, interviews, document review), to identifying quantitative and qualitative gaps, analyzing the root causes of the gaps, setting improvement priorities, and building a roadmap to close the gaps.

The program is designed to be 80% practical, through real case studies of Saudi organizations that conducted gap analyses (including SDAIA, SWPC, and others), practical exercises on using the BEM to assess the maturity level, identifying gaps, analyzing root causes using tools such as 5 Whys and the Ishikawa Diagram, and developing a prioritized action plan.

Program Duration: Given the complexity of the gap analysis process and the need for hands-on training on assessment and data analysis tools, the course is designed over 5 days (25 training hours).

Objectives

Program Objectives

By the end of this course, the participant will be able to:

  1. Understand the concept of institutional Gap Analysis and its importance in the excellence journey – distinguishing between gap analysis (the difference between the current and target state) and self-assessment (measuring current performance), and understanding how gap analysis guides the continuous improvement strategy and resource allocation.

  2. Apply the Business Excellence Matrix (BEM) tool or other self-assessment tools – using the BEM (or equivalent self-assessment models) to assess the organization's maturity level in each of the seven EFQM criteria and each sub-criterion, using the 5-level maturity scale (Basic, Intermediate, Advanced, Outstanding, World Class).

  3. Identify quantitative and qualitative gaps between current performance and the standard requirements – calculating the gaps between the current maturity score and the target score (for example, the gap = the target level (70%) – the current level (30%)). Classifying the gaps by their size (small, medium, large) and their strategic importance.

  4. Analyze the root causes of the gaps (Root Cause Analysis) – using tools such as (5 Whys, the Ishikawa Diagram, Fault Tree Analysis) to reach the deep causes of the gaps, rather than dealing with the symptoms only.

  5. Prioritize the gaps (Prioritization) and build an Improvement Roadmap – using prioritization matrices (such as impact × effort, or importance × urgency) to rank the gaps by priority, formulating specific improvement initiatives for each high-priority gap, and developing a time-based roadmap (12–24 months) that includes the timeline, responsibilities, budget, and performance indicators.

  6. Prepare a Gap Analysis Report – documenting the analysis results in a professional, structured report that includes: an executive summary, the analysis methodology, the assessment results (the maturity scores for each criterion), the identified gaps (for each sub-criterion), the root-cause analysis, the priorities, and the improvement roadmap.

Target Audience

Target Audience

  1. Managers and officers of institutional excellence, quality, and strategic planning.

  2. Business Analysts and process improvement officers.

  3. Members of self-assessment teams and internal reviewers.

  4. Officers of performance management, governance, and risk.

  5. Consultants specialized in organizational development and institutional excellence.

  6. Strategic planning officers and project officers.

  7. Graduates of business administration, industrial engineering, and quality management.

Competencies

Core Competencies

Conducting a full self-assessment using the Business Excellence Matrix (BEM)

Applying the BEM tool to assess the maturity level of a hypothetical organization (or part of it) across all seven EFQM criteria, calculating the maturity scores for each criterion (a percentage) and determining the level (Basic, Intermediate, Advanced, Outstanding, World Class).

Identifying the gaps between current performance and the standard requirements

Calculating the gaps for each sub-criterion (the target level – the current level), and classifying the gaps into (a small gap (0–10%), a medium gap (11–25%), a large gap (>25%)).

Root Cause Analysis (RCA) for a specific gap

Using the Ishikawa Diagram or the 5 Whys technique to analyze a specific gap (for example, "a gap in the innovation criterion: the current maturity level is 30% versus the 70% target"), and identifying at least 3 key root causes.

Prioritizing the gaps using the Impact × Effort Matrix

Creating a matrix (the gap's impact on institutional performance on the Y-axis, the effort required to close the gap on the X-axis), and classifying the gaps into four categories: (high impact / low effort – top priority, high impact / high effort – high priority, low impact / low effort – medium priority, low impact / high effort – low priority).

Formulating a specific Improvement Initiative

Writing a description of an improvement initiative to address a high-priority gap, including: the initiative name, the objective, the scope, the key activities, the timeline (3–6 months), the required resources (budget, staff, tools), the owner, and the key performance indicators to measure success.

Preparing a Gap Analysis Report

Compiling the analysis results into a structured report (10–15 pages) that includes: an executive summary, the analysis methodology, the assessment results (tables and charts), the gaps (for each criterion), the root-cause analysis (for the top 5 gaps), the priorities, and the improvement roadmap (a timeline for the initiatives).

Learning Journey

Program Outline

01

Day 1: Introduction to Gap Analysis and the Assessment Frameworks (EFQM and RADAR)

The Concept of Institutional Gap Analysis and Its Importance
Definition of gap analysis: a systematic process to identify the difference between the organization's current performance and the required or target performance (according to the criteria of an excellence model such as EFQM). The importance of gap analysis: (1) it provides a clear view of the organization's strengths and weaknesses. (2) it helps set improvement priorities based on strategic impact. (3) it guides the allocation of resources (budget, time, staff) toward the areas most in need. (4) it forms the basis for building development plans and excellence roadmaps. (5) progress can be measured over time (by conducting periodic analyses).
The Stages of the Gap Analysis Process
The four main stages: (1) Planning: defining the scope of the analysis (the entire organization or a specific unit?), forming the analysis team, selecting the assessment tool (such as the BEM), and setting the timeline. (2) Data Collection: gathering information from multiple sources (documents, interviews, surveys, observation). (3) Assessment: using the assessment tool (such as the BEM) to assess the maturity level for each criterion, and calculating the gaps between the current level and the target level. (4) Analysis & Recommendations: analyzing the root causes of the gaps, setting priorities, formulating improvement initiatives, and writing the report.
Assessment Frameworks: The EFQM 2025 Model as a Reference Framework
A quick review of the EFQM 2025 criteria (the seven) and the methodology (RADAR) as a basis for assessing performance. The criteria: (1) Purpose, Vision & Strategy, (2) Organizational Culture & Leadership, (3) Engaging Stakeholders, (4) Creating Sustainable Value, (5) Driving Performance & Transformation, (6) Stakeholder Perceptions, (7) Strategic & Operational Performance. The RADAR methodology: Results, Approach, Deployment, Assessment, Refine.
Self-Assessment Tools – The Business Excellence Matrix (BEM)
Definition of the BEM: an Excel-based assessment tool developed by EFQM to assess organizations according to the model criteria using the RADAR logic. The BEM provides a quantitative scoring system (0% to 100%) for each sub-criterion, and classifies the maturity level into 5 levels: Basic (0–30%), Intermediate (31–50%), Advanced (51–70%), Outstanding (71–90%), World Class (91–100%). The BEM structure: a worksheet for each main criterion, containing rows for each sub-criterion, and columns for each of the RADAR elements (Approach, Deployment, Assessment, Refine, Results). The assessor evaluates each cell on a scale of 0–3 (0=no evidence, 1=limited evidence, 2=good evidence, 3=comprehensive evidence). The maturity score for each sub-criterion is calculated automatically.
Practical Workshop (getting acquainted with the BEM and applying it to one criterion)
Objective: to get acquainted with the BEM interface and apply it to assess one criterion. Required (small working teams): (1) distribute a copy of the BEM file (Excel) to each team. (2) read the description of one criterion (for example, Criterion 2: Organizational Culture & Leadership) and its sub-criteria (2.1, 2.2, 2.3). (3) based on a brief case study of a hypothetical organization (describing its culture and leadership model), assess each sub-criterion by entering a score (0–3) for each of the RADAR elements (Approach, Deployment, Assessment, Refine, Results). (4) observe how Excel automatically calculates the maturity score for each sub-criterion and for the main criterion. (5) discuss: which RADAR elements had the lowest scores? What can the organization improve to raise its score?
02

Day 2: Applying the Business Excellence Matrix (BEM) for a Comprehensive Assessment

Assessment Guidelines – The Assessment Criteria for Each RADAR Element
For each of the RADAR elements, there are specific criteria for assessing the maturity score (0–3). Approach: 0 = no approach. 1 = an unstructured approach, based on reactions. 2 = a structured approach, based on sound foundations, with evidence of integration. 3 = a highly structured approach, fully integrated, supported by innovation and external learning. Deployment: 0 = no deployment. 1 = limited deployment (in some departments or locations). 2 = good deployment (in most departments and locations). 3 = comprehensive deployment (in all departments and locations, with high consistency). Assessment: 0 = no assessment. 1 = limited assessment (irregular, unsystematic). 2 = regular and systematic assessment, with performance indicators. 3 = advanced assessment, with the use of data analytics and learning from best practices. Refine: 0 = no improvement. 1 = limited improvements (reactive, based on complaints). 2 = regular improvements based on assessment results. 3 = proactive and innovative improvements, with sharing of lessons learned across the organization. Results: 0 = no results. 1 = limited results, unclear trends. 2 = good results, positive trends, comparisons with a baseline. 3 = excellent results, sustained positive trends, positive comparisons with industry standards.
Data Collection for Assessment
Data sources: (1) Documents: strategic plans, policies, procedures, reports (annual, financial, performance), training records, meeting records. (2) Interviews: interviews with senior leadership, managers, employees, and external stakeholders (customers, suppliers). (3) Surveys: employee satisfaction surveys, customer satisfaction surveys, organizational culture surveys. (4) Direct observation: field tours at the workplace to observe processes, behaviors, and culture. (5) Quantitative data: performance data (production rates, product quality, customer satisfaction, employee turnover, revenue, profits). Data Triangulation: use multiple sources to verify the validity of the results (for example, compare what employees say in interviews with what is documented in the policies and what is observed in the field).
Practical Workshop (a full assessment using the BEM for a hypothetical organization)
Objective: to conduct a full self-assessment of a hypothetical organization (a logistics services company) using the BEM, with the participation of all teams. Required (small working teams, each team responsible for two criteria): (1) distribute a detailed case study of the hypothetical organization (20 pages) containing information about: its strategy, culture, processes, results, and stakeholder relationships. (2) each team assesses the criteria assigned to it using the BEM, based on the evidence provided in the case study. (3) for each sub-criterion, the team enters a score (0–3) for each of the RADAR elements (Approach, Deployment, Assessment, Refine, Results). (4) the team notes down comments explaining the reason for each score (based on the case study). (5) after finishing, all teams meet to present their results and merge them into a single BEM. (6) calculate the organization's overall score (the average of the seven criteria scores). (7) identify the criteria with the highest scores (strengths) and the lowest scores (performance gaps).
Gap Identification
Determining the Target Level: based on the organization's vision and strategic goals, determine the target level for each criterion (for example, targeting the "Advanced" level (70%) for most criteria, and "Outstanding" (85%) for the strategically-prioritized criteria). Gap Calculation: the gap = the target level (as a percentage) – the current level (from the BEM). Example: the current level of Criterion 1 (Purpose, Vision & Strategy) = 45% (Intermediate). The target level = 70% (Advanced). The gap = 70% – 45% = 25% (a large gap). Classifying the gaps: (1) a small gap (0–10%): requires minor improvements. (2) a medium gap (11–25%): requires substantial improvements. (3) a large gap (>25%): requires radical change or restructuring.
Practical Workshop (identifying the gaps for all criteria)
Objective: based on the BEM results from the previous workshop, identify the gaps for each criterion and classify them. Required (small working teams, same teams): (1) determine the target level for each criterion (assuming the hypothetical organization aims to reach the "Advanced" level (70%) within 24 months). (2) calculate the gap for each criterion as a percentage (the target level – the current level from the BEM). (3) classify each gap into (small, medium, large) according to the table above. (4) create a table (Excel) that summarizes: the criterion name, the current level (%), the target level (%), the gap (%), the gap classification. (5) present the table to the trainer for review.
03

Day 3: Root Cause Analysis of the Gaps

The Importance of Root Cause Analysis in Gap Analysis
Why is identifying the gaps alone not enough? Identifying the gap tells you "what" the difference is, but it does not tell you "why" this difference exists. Without understanding the root causes, you may address only the symptoms, leading to the gap recurring. Example: a gap in employee satisfaction (the result). The possible causes: weak communication, lack of training, a high workload, ineffective leadership. If you only increase salaries (a symptomatic treatment), employee satisfaction may not improve if the root causes are a lack of training and weak leadership.
Root Cause Analysis Tools (RCA) – The Ishikawa Diagram
The Ishikawa Diagram (the cause-and-effect fishbone): a visual tool to identify the possible causes of a specific problem (effect). The causes are usually classified into main categories: (1) People: skills, training, motivation, communication. (2) Processes: procedures, steps, flexibility, complexity. (3) Equipment / Technology: tools, systems, maintenance, availability. (4) Materials: input quality, supply, inventory. (5) Measurement: performance indicators, data collection, analysis. (6) Environment: culture, regulations, market, competition. Steps to build an Ishikawa diagram: (1) write the problem (the effect) on the right side of the drawing. (2) draw a horizontal line (the fish's spine). (3) draw diagonal lines (the ribs) representing the main categories. (4) brainstorm the possible causes and add them as smaller "bones" on the main ribs. (5) continue to go deeper (ask "why?" several times) until you reach the root causes.
The 5 Whys Technique
The 5 Whys technique: a simple and effective tool to reach the root cause of a problem by asking "why?" repeatedly (usually 5 times). Example (a gap in innovation): why is the innovation rate low? → because the number of ideas submitted by employees is low. Why is the number of ideas low? → because employees do not have a channel to submit ideas. Why is there no channel? → because management has not set up a system to manage ideas. Why has management not set up the system? → because it did not see innovation as a strategic priority. Why did it not see it as a priority? → because it was focused only on cost reduction. → The root cause: a short-sighted strategy that focuses only on cost reduction at the expense of innovation. Helping to guide the analysis: repeating "why?" helps move from the symptoms to the deep causes.
Applying RCA to Specific Gaps from the Previous Assessment
Scenario: based on the assessment results from day two, a large gap (25%) was identified in "Criterion 3: Engaging Stakeholders." The current level: 45% (Intermediate). The target: 70% (Advanced). Required (small working teams): (1) define the main problem: "the level of stakeholder engagement is below the required level." (2) using the Ishikawa diagram, identify the possible causes under the categories: People, Processes, Measurement, Technology, Environment. (3) for each main possible cause, use the 5 Whys technique to reach the root cause. (4) identify at least 3 key root causes. (5) document the results in a brief RCA report.
Practical Workshop (root cause analysis for the top 3 gaps)
Objective: to conduct Root Cause Analysis (RCA) for the top 3 gaps identified from the BEM assessment (from day two). Required (small working teams): (1) select 3 priority gaps from the gaps table created on day two (for example, the largest gaps or those with the greatest strategic impact). (2) for each gap, use the Ishikawa diagram to identify the possible causes (with the team members participating in a brainstorm). (3) identify the 3 most probable causes for each gap. (4) for each of these causes, use the 5 Whys technique to reach the root cause (write the sequence of the 5 questions). (5) document the results in a table (Excel) for each gap: the gap, the possible causes, the root causes. (6) present the results to the trainer for review.
04

Day 4: Prioritization and Building the Improvement Roadmap

Prioritizing the Gaps – The Impact vs. Effort Matrix
The matrix: Y-axis: the impact on institutional performance (low, medium, high). X-axis: the effort required to close the gap (low, medium, high). The four cells: (1) High Impact / Low Effort: top priority (Quick Wins). Must be addressed first. (2) High Impact / High Effort: high priority (Major Projects). Warrant a large investment but achieve large returns. (3) Low Impact / Low Effort: medium priority (Fill-ins). Can be addressed after finishing the top priorities. (4) Low Impact / High Effort: low priority (Thankless Tasks). May not be worth the effort; can be ignored or addressed in very later stages.
Applying the Priorities Matrix to the Hypothetical Organization's Gaps
Scenario: use the gaps table (created on day two) and the root causes (identified on day three) to prioritize the gaps. Required (small working teams): (1) for each gap (at least 6 gaps), estimate the impact on institutional performance (on a scale of 1–5) and the effort required to close it (on a scale of 1–5). (2) plot the gaps on the impact × effort matrix (using Excel or manually). (3) identify the gaps that fall in the "high impact / low effort" cell (top priority – Quick Wins). (4) identify the gaps that fall in the "high impact / high effort" cell (high priority – Major Projects). (5) document the results.
Formulating Improvement Initiatives
For each priority gap (top or high), formulate a specific improvement initiative. The initiative structure: (1) Initiative name: should be descriptive and short (for example, "developing an innovation management system"). (2) Objective: a clear and measurable statement of what the initiative will achieve (for example, "increasing the number of ideas submitted by employees by 50% within 6 months"). (3) Scope: which departments or processes will the initiative cover? (4) Key activities: a list of the main tasks required to implement the initiative (5–10 tasks). (5) Timeline: the start date and the expected end date (for example, 3 months). (6) Required resources: the estimated budget, the number of staff, tools, training. (7) Owner: the person or department responsible for implementing the initiative. (8) Key Performance Indicators (KPIs): specific metrics to measure the success of the initiative (for example, the number of ideas submitted, the percentage of ideas implemented).
Building the Excellence Roadmap
A roadmap (Excel or PowerPoint) that usually spans 12 to 24 months. The elements: (1) Time Horizon: divide the roadmap into time phases (quarterly or semi-annually). (2) Initiatives: for each initiative, determine the time phase in which it will start and end. Use Gantt bars to represent the duration. (3) Quick Wins: should be completed within 3–6 months. (4) Major Projects: may take 12–24 months. (5) Dependencies: clarify which initiatives depend on the completion of other initiatives (for example, the "innovation management system" initiative cannot be started until the "updating the innovation strategy" initiative is completed). (6) Review Milestones: add periodic reviews (quarterly) to assess progress.
Practical Workshop (building an excellence roadmap for a hypothetical organization)
Objective: to build a 12-month excellence roadmap for the hypothetical organization, including the initiatives identified from the previous step. Required (small working teams): (1) using the priorities results (Quick Wins and Major Projects), convert each gap into an improvement initiative (using the initiative structure). (2) determine the implementation priority for each initiative (for example, initiative A should start in the first quarter, and initiative B in the second quarter). (3) use Excel to create a roadmap (column: the initiative, rows: the four quarters). Draw time bars for each initiative. (4) identify the dependencies between the initiatives (for example, the "developing a performance management system" initiative depends on the "training leadership on effective feedback" initiative). (5) add quarterly reviews to the roadmap. (6) present the roadmap to the trainer for review.
05

Day 5: Preparing the Gap Analysis Report and Course Review

The Structure of the Gap Analysis Report
The final report must be professionally structured and include the following sections: (1) The cover page: the organization's name, the report title ("Gap Analysis According to the EFQM Model"), the date. (2) Executive Summary: (one page) summarizing: the objective of the analysis, the methodology, the key results (the top 3–5 gaps), and the key recommendations (the top 3–5 initiatives). (3) Introduction: the background about the organization, the analysis objectives, the analysis scope. (4) Methodology: an explanation of the tool used (the BEM), the data sources (documents, interviews, surveys), the analysis team, the timeline. (5) Assessment Results: tables and charts for the maturity scores for each criterion (current and target). Identifying the gaps (a table with all the gaps). (6) Root Cause Analysis: a presentation of the top 5–10 gaps (high priority), with an explanation of the root causes (using Ishikawa diagrams or 5 Whys tables). (7) Prioritization: the impact × effort matrix and the gap classification. (8) Improvement Roadmap: a timeline for the proposed initiatives (12–24 months). (9) Appendices: a copy of the completed BEM, the list of references, the list of analysis team members.
Visualizing Results – Charts and Tables
For the visual presentation of the assessment results: (1) Bar Chart: displays the current and target maturity scores for each criterion (7 columns for the criteria, each column divided into two parts: current and target). (2) Radar Chart: displays the organization's Performance Profile – the score of each criterion as a percentage. (3) Gap Chart: displays the size of the gap for each criterion (for example, bars representing the gap as a percentage, with the large gaps highlighted in red). For the root-cause analysis: display Ishikawa diagrams (cause-and-effect fishbone) as graphics (can be created in PowerPoint or Excel). For the roadmap: a Gantt Chart showing the initiatives on a time axis.
Writing Actionable Recommendations
Characteristics of good recommendations: (1) Specific: avoid general statements such as "improving leadership." Instead, say "developing a 3-day leadership training program on strategic thinking and communication." (2) Measurable: add a performance indicator (KPI) for each recommendation (for example, "increasing the employee satisfaction score with leadership from 65% to 75% within 12 months"). (3) Achievable: must be realistic in light of the organization's resources and budget. (4) Relevant: directly linked to the root causes of the gaps. (5) Time-bound: each recommendation must have a timeline (for example, "completing the training program by the end of the third quarter of 2026"). The recommendation structure: (1) the recommendation title, (2) the gap it addresses, (3) the specific actions, (4) the owner, (5) the timeline, (6) the performance indicators.
Report Review and Quality Assurance
Peer Review: ask colleagues who are not part of the analysis team (or external consultants) to review the report and provide feedback on: (1) Accuracy: do the results accurately reflect the organization's performance? (2) Completeness: have all criteria been covered? (3) Clarity: is the report easy to understand for a non-specialist audience? (4) Actionability: are the recommendations specific and actionable? Linguistic and technical proofreading: ensure there are no spelling, grammatical, or typographical errors. Ensure the accuracy of all numbers and calculations. Ensure the report is coherent (no contradictions between the text, tables, and charts). Management Review: present the draft report to senior management to obtain their comments and their approval of the recommendations before issuing the final version.
Case Study – A Successful Gap Analysis for a Saudi Organization (adapted)
An adapted and modified case study: a review of a gap analysis conducted by a (hypothetical) Saudi government organization in preparation for applying for the King Abdulaziz Quality Award. The results: large gaps were identified in the "innovation," "sustainability," and "performance measurement" criteria. The root causes: a weak innovation culture, the absence of a clear sustainability strategy, and a traditional performance system that does not link the strategic to the operational. The recommendations: developing a digital platform to manage ideas (innovation), issuing an annual sustainability report compliant with the GRI standards, and redesigning the Balanced Scorecard system. The results (after 18 months): a 200% increase in the number of ideas submitted by employees, an improvement in the sustainability score in international ratings, and a 15% increase in the customer satisfaction score.
Comprehensive Review and Final Test for the Third Course
Final test (a practical case): Scenario: a hypothetical organization (a medium-sized industrial company) conducts a gap analysis per EFQM. You are provided with the following data: (1) BEM results (the maturity scores for each criterion), (2) results of interviews with employees, (3) financial and operational performance reports. Required: (1) identify at least 3 main gaps. (2) for each gap, analyze the root causes using the Ishikawa diagram or 5 Whys. (3) prioritize the gaps using the impact × effort matrix (with justification). (4) formulate at least one improvement initiative to address a top-priority gap (a Quick Win). (5) add this initiative to a simple excellence roadmap (3 quarterly columns). (6) write an executive summary page for the report (200–300 words). Comprehensive review: a review of the key points across the five days: the assessment tools (BEM), gap identification, root cause analysis (RCA), prioritization, formulating initiatives, building the roadmap, and preparing the report.
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