Performance evaluation towards a tobacco-free organisation Each year, members of the Victorian Network of Smokefree Healthcare Services (VNSHS) are asked to complete a self-audit against the ENSH standards in order to support their ongoing improvement in addressing the health risks of smoking. Please use this template to document your audit results for the current year and show a comparison with your previous audit. Scoring for each standard and sub-standard is based on the level of implementation (from 0 to 3). Please record the sub total for each standard as well as the total audit score. Please also briefly summarise your planned actions for the coming year based on your audit results. The completed audit is then signed off by the health service CEO to demonstrate your ongoing commitment to the smokefree goals of VNSHS. The Coordinating Centre will peer review your audit with members from the network and submit your audit results to ENSH. This data is held by ENSH in order to enable monitoring of overall progress of member organisations globally. The data is not published or shared with other member organisations without the expressed permission of the health service. Healthcare service: ENSH Audit history Member since: YEAR SCORE Date of last audit: Current audit due: Demographic details (The following details assist ENSH in making comparisons between similar health services. Please provide an estimate if precise details are not available) Number of beds: Service type (tick all that apply): Number of staff: University Day care Regional Nursing home Main funding source (select one): Private General Primary care centre Public Specialty GP Clinic Other (specify) Community Other Hospital / Healthcare CEO: I declare that our organisation is committed to continuing to implement the aims of the Network and will actively work to implement smoke free policies and strategies. Signature: Date: Name (printed): Email:
Performance evaluation towards a tobacco-free organisation Each year, members of the Victorian Network of Smokefree Healthcare Services (VNSHS) are asked to complete a self-audit against the ENSH standards in order to support their ongoing improvement in addressing the health risks of smoking. Please use this template to document your audit results for the current year and show a comparison with your previous audit. Scoring for each standard and sub-standard is based on the level of implementation (from 0 to 3). Please record the sub total for each standard as well as the total audit score. Please also briefly summarise your planned actions for the coming year based on your audit results. The completed audit is then signed off by the health service CEO to demonstrate your ongoing commitment to the smokefree goals of VNSHS. The Coordinating Centre will peer review your audit with members from the network and submit your audit results to ENSH. This data is held by ENSH in order to enable monitoring of overall progress of member organisations globally. The data is not published or shared with other member organisations without the expressed permission of the health service. Healthcare service: ENSH Audit history Member since: YEAR SCORE Date of last audit: Current audit due: Demographic details (The following details assist ENSH in making comparisons between similar health services. Please provide an estimate if precise details are not available) Number of beds: Service type (tick all that apply): Number of staff: University Day care Main funding source (select one): Regional Nursing home Private General Primary care centre Public Specialty GP Clinic Other (specify) Community Other Hospital / Healthcare CEO: I declare that our organisation is committed to continuing to implement the aims of the Network and will actively work to implement smoke free policies and strategies. Signature: Date: Name (printed): Email: