Monthly Quality Audit Tool - Outpatients

Reviewer name*
Audit date*
DD slash MM slash YYYY
Hospital site*
Ward/department
Specialty*
Nurse in Charge during Review*
Staff receiving feedback following review
Ward/Department Environment - First Impressions
W01 How does this ward make me feel?*
What can I smell, see, feel? Is it tidy? Does it feel disorganised, calm, or chaotic?
W02 What is the atmosphere like?*
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?
W03 What have I noticed that builds my confidence and trust?*
What is the reception area/ nursing station like? Is it tidy? Are phones answered in a timely manner?
W04 What makes me less confident?*
Things that feel worrying, patients looking unkempt, bed spaces untidy, is the ward area tidy? Is the environment noisy
W05 Can I observe effective communication between the team?*
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
LS01 Was the shift fully staffed?*
- Yes
- No

Staffing Observations

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

There are no Staff members.

Please observe 5 staff throughout your visit across all roles/positions

LS03 Did all relevant staff (HCAs, nurses, AHPs and doctors) attend the Patient Safety Huddle?*
- Yes
- No
- N/A
LS04 Is the Patient Safety Huddle Checklist completed appropriately?*
- Yes
- No
LS05 Did all relevant staff attend the WHO check list (where appropriate) and was it completed appropriately?*
- Yes
- No
- N/A
LS06 Is the NIC visible to staff, patients and or visitors?*
- Yes
- No
Environment
E01 are bathing//toilet facilities clean?*
- Yes
- No
E02 When cleaning is in progress, are wet floor signs used as appropriate?*
- Yes
- No
- N/A
E03 Are hand cleaning facilities available to all patients after toileting? (hand wipes, soap and water)*
- Yes
- No
E04 Is linen and rubbish disposed of appropriately and not laying around?*
- Yes
- No

Environment observations

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

There are no observations.

Please make 5 observations

Patient safety and quality observations

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

There are no observations.

Please make 5 observations

SQ04 Emergency equipment checked daily?*
- Yes
- No
i.e. every day for the last month
SQ05 Medical gas cylinders checked daily?*
- Yes
- No
- N/A
i.e. every day for the last month
SQ06 Are the Controlled Drugs checked daily?*
- Yes
- No
i.e. every day for the last month
SQ07 Controlled drug keys held by Registered Nurse?*
- Yes
- No
SQ08 Drug trollies/cupboards locked and secure?*
- Yes
- No
SQ09 Drug Fridge is locked and secure?*
- Yes
- No
SQ10 Drug Fridge temperatures monitored daily?*
- Yes
- No
i.e. every day for the last month
SQ11 Health records are stored correctly*
- Yes
- No

Staff safety and quality observations

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

There are no staff members.

Ask 5 staff

Hand hygiene observations

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

There are no staff members.

Please make 5 observations

HH Suggestions
Safeguarding
SG01 Ask staff to verbally describe a potential safeguarding issue and what they would do about it*
Safer Surgery “Silent Observational” checklist audit
Sign in - Before starting anaesthesia
Confirm patient identity and operation*
Confirm Surgical site marked*
Confirm machine and medicines checked*
Confirm allergy status*
Confirm difficult airway / aspiration risk*
Confirm risk of blood loss*
Time out - Theatres before surgery starts
All team introduced themselves*
Team confirm patient id and operation*
Surgeon critical events*
Anaesthetist critical events*
Scrub nurse instrumentation*
Antibiotics*
Patient warming*
Hair removal / shave*
Glycaemic control*
VTE prophylaxis*
Imaging required available / displayed*
Sign out - Theatres before surgeon leaves
Name of procedure recorded*
Swabs & Instrument count confirmed*
Specimens labelled*
Any equipment issues identified*
Surgeon concerns for recovery*
Anaesthetist concerns for recovery*

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