Monthly Quality Audit Tool - Day Surgery & Endoscopy

  • DD slash MM slash YYYY
  • Ward/Department Environment - First Impressions

  • What can I smell, see, feel? Is it tidy? Does it feel disorganised, calm, or chaotic?
  • Am I greeted - can I help? Is there eye contact as I walk in the door, am I smiled at, am I left waiting, am I ignored? How does the ward clerk/ receptionist answer the telephone?
  • What is the reception area/ nursing station like? Is it tidy? Are phones answered in a timely manner?
  • Things that feel worrying, patients looking unkempt, bed spaces untidy, is the ward area tidy? Is the environment noisy
  • Do daily Patient Safety Huddle meetings happen? Nursing, Medical and others
  • Leadership and Staffing

    CURRENT STAFFING LEVELS | Review off duty info on ward (roster and paper copy) and cross ref to bank agency

  • LS02 Have staff had a local induction? LS09 Staff can name the 18WS Chief Executive LS10 Staff can name their Chief Nurse LS11 Staff can name their Lead Nurse (and/or Head Nurse where appropriate)? LS12 Staff are compliant with the uniform policy LS13 Staff are wearing name badges (non-Covid environment) LS14 Staff treat patients and ward visitors courteously LS15 Staff are NOT talking over patients, are not speaking in another language over patients or stood chatting informally LS16 Are the safeguarding Trust contacts available to the 18WS support staff? Actions
    Please observe 5 staff throughout your visit across all roles/positions
  • Health Records Review

  • N01 Were the patient’s NEWS / observations recorded on admission to the current area? N02 Has the frequency of observations been documented on the chart? N03 For the in-patient episode, a complete set of observations is documented every time and where NEWS is used, calculated accurately N04 Staff know how to escalate a deteriorating patient. The escalation is recorded (need to understand that the trust link nurse needs to be informed) Actions
    Review 5 records
  • AD01 There is a documented full initial assessment of the patient using the activities of daily living and completed in conjunction with their clinical diagnosis/condition? AD02 Does the documentation demonstrate evidence of implementation of care & evaluation of care based on the assessment? AD03 Has the Discharge Planning Information section been completed including relatives being informed of planned discharge and location? AD04 Where applicable, are the HCA signatures counter signed by the registered nurse? Actions
    Review 5 records
  • MA01 Is there an addressograph on the prescription chart and is it accurate? MA02 On the drug chart has the allergy and intolerances section been completed? (Including no known allergies) MA03 Is the patient’s weight recorded on the Drug chart? MA04 Are all details for each medication clearly legible? MA05 All prescriptions on the chart are signed and with a legible name printed MA06 Staff undertake positive patient identification at the point of care (when appropriate e.g. for administration of medication) MA07 If medications have been omitted have omission codes been recorded on the chart EVERY TIME? Actions
    Review 5 records
  • Environment

  • E05 Do patients have call bells to hand? E06 Do patients have tables close by with their essentials? E07 Is hand gel available at each bed space? E08 Are call bells and telephones answered in a timely manner? Actions
    Please make 5 observations
  • Safety and Quality

    Please observe throughout your visit

  • SQ01 Do you see positive Interactions between staff/patient/visitors? SQ02 Permission is gained before entering any private areas/side rooms i.e. curtains, bathroom SQ03 Dignity and modesty is maintained for those patients moving between care settings Actions
    Please make 5 observations
    i.e. every day for the last month
    i.e. every day for the last month
    i.e. every day for the last month
    i.e. every day for the last month
  • SQ12 NICs are aware that they are responsible for the HCA/AHP staff within their teams SQ13 Staff know how to report an incident SQ14 Staff know what to do if equipment is faulty or broken and how to report it for repair SQ15 Staff use sharps bins at the point of use SQ16 Sharps safety is observed in all clinical areas SQ17 Staff are aware of correct procedure after sustaining a sharps injury SQ18 Are Staff aware of their responsibilities under the Mental Capacity Act and what it means to their practice SQ19 Staff aware of WHO safer surgery checklist consent and surgical site marking SQ20 Staff are aware of where to access a manual sphygmomanometer to check deteriorating patient’s blood pressures Actions
    Ask 5 staff
  • Hand Hygiene

  • HH01 The 5 moments for hand hygiene were observed after contact with a patient HH02 The 5 moments for hand hygiene were observed after contact with the environment HH03 Was the member of staff ‘bare below the elbow’? Actions
    Please make 5 observations
  • Safeguarding

  • Safer Surgery “Silent Observational” checklist audit

  • Sign in - Before starting anaesthesia

  • MM slash DD slash YYYY
  • Time out - Theatres before surgery starts

  • Sign on - Theatres before surgeon leaves