MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS Minimum Lead Tool Frequency of Report Reporting arrangements Lead(s) for acting on requirement to be of Compliance Recommendations monitored Patient satisfaction Eileen wood Questionnaire Monthly Policy audit report to: All staff Survey Friends and family CD CHAT / patient experience steering group NPSA audits / Eileen wood Spread sheet Monthly Policy audit report to: All Staff hand hygiene Matron CHAT- Sue Twiss POA education Shirley Lobo Attendance Monthly Policy audit report to: All staff forum / knowledge Jo Fairless KSF Yearly Eileen wood and skill updates SOPs for Eileen wood Policy Yearly All Staff OM Sue Twiss department guidelines Specialty Crib Eileen wood Spread sheet Yearly All Staff OM Sue Twiss Cards Documentation Debbie Spread sheet 6 Monthly CM Eileen wood All Staff Audit Boyland Pre-Operative Rachel weeks Questionnaire Yearly NA assessment format booking guide audit This document will be monitored to ensure it is effective and to assurance compliance
MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS Minimum requirement to be monitored Lead Tool Frequency of Report of Compliance Reporting arrangements Lead(s) for acting on Recommendations Patient satisfaction Survey Eileen wood Questionnaire Friends and family Monthly Policy audit report to: CD CHAT / patient experience steering group All staff NPSA audits / hand hygiene Eileen wood Spread sheet Monthly Policy audit report to: Matron CHAT- Sue Twiss All Staff POA education forum / knowledge and skill updates Shirley Lobo Jo Fairless Attendance KSF Monthly Yearly Policy audit report to: Eileen wood All staff SOPs for department Eileen wood Policy guidelines Yearly OM Sue Twiss All Staff Specialty Crib Cards Eileen wood Spread sheet Yearly OM Sue Twiss All Staff Documentation Audit Debbie Boyland Spread sheet 6 Monthly CM Eileen wood All Staff Pre-Operative assessment booking guide audit Rachel weeks Questionnaire format Yearly NA This document will be monitored to ensure it is effective and to assurance compliance
Preoperative%20Assessment%20for%20Adults%20Policy.docx