Self Audit Questionnaire: Preliminary results in Ireland

Ann O’Riordan, Miriam Gunning European Network of Smoke-free Hospitals

Prof. Luke Clancy (Chair) Ann O’Riordan (Director)

Irish Health Promoting Hospitals Network

Self audit questionnaire in Ireland• Irish Smoke-free Health Service Initiative developed in

line with the European Code for Smoke-free Hospitals and national legislation was established 2000.

• ENSH Self audit questionnaire was incorporated into the Irish Smoke-free Health Service Initiative in 2001.

• The Irish Initiative has four distinct stages, hospitals that reach stage four can categorise themselves as being bronze, silver or gold by using the self audit questionnaire.

• Results presented here are from 25 (68%) of the initial 37 hospitals invited to use the self audit questionnaire

Irish Smoke-free Health Service Initiative

Process• Expression of Interest• Statement of Commitment • Completion of Self-Appraisal Assessment Form• Return of Baseline Survey Questionnaire• Development of Action Plans• Evaluation - Process, Impact & Outcome• Document and Share Experiences

Developmental Stages Irish Smoke-free Health Service Initiative

• First stage: InterestRegister interest, nominate a focal person and establish a working group

• Second stage: Membership Status Review current practices within the organisation and develop an action plan.

• Third stage: Dedicated Status

Evaluate progress after 12 months participation in the national initiative.

• Fourth stage : European Registration Bronze, Silver or Gold on the European Smoke-free Hospital Register.

Participation in Initiative up to

June 2003

• Invited: 271

• 1st Stage: 60

• 2nd Stage: 7

• 3rd Stage: 7

• 4th Stage: 37

National & European SFHI

The initial 37 hospitals to participate in the initiative were surveyed pre and post 2 year project period (Jan`01–Dec `02)

60

7 7

37

0

10

20

30

40

50

60

Phase I Phase II Phase III Phase IV

Initial 37 Committed Hospitals by Hospital Type

Hospital Type

4

1

5

10

4

13

0

2

4

6

8

10

12

14

University Regional General District/community

Specialised MissingData

Num

ber

of hospita

ls

Research and analysis of data conducted for the Irish HPH Network by the Department of Public Health Medicine and Epidemiology, UCD (NUI Dublin)

Irish Smoke Free Health Service InitiativeIrish Smoke Free Health Service InitiativePreliminary ResultsPreliminary Results

• At the end of 2002, the 37 hospitals had reached stage 4 and were sent the self audit questionnaire

• To date 68% (25) of the 37 have returned completed questionnaires and have been awarded certificates reflecting the categorisation on the register for the European Network of Smoke Free Hospitals– 9 organisations received Membership Level– 6 organisations received Bronze Level– 10 organisations received Silver Level

1. POLICY

0

5

10

15

20

Policy on official documents Information to patients & staff

0 1 2 3 4 NA

2. WORKING GROUP

0

5

10

15

20

Designatedcommitteeappointed

Chair fromSenior

Management

New strategydesigned

Actions &strategiesevaluated

Analysed results

0 1 2 3 4 NA

Education & Prevention

0

2

4

6

8

10

12

Staff trained / briefed Training during workingtime

01234NA

Information & Cessation Service

05

10152025

Lea

flet

s,ed

uca

tio

na

lm

ate

ria

ls

On

e to

on

eco

un

sell

ing

Gro

up

co

un

sell

ing

NR

T/P

ha

r.T

her

ap

y

Alt

ern

ati

ve/

Co

mp

. Th

era

py

0 1 2 3 4 NA

Smoking Cessation Service

0

5

10

15

20

25

For staff For patients For visitors

0 1 2 3 4 NA

Cessation Support

0

5

10

15

20

25

Smoking Cessation Facilitator Free of charge Staff attend during workinghours

0 1 2 3 4 NA

Cessation Service Follow Up

0

2

4

6

8

10

12

Is there a follow up

0 1 (1 Mth) 2 (3 Mth) 3 (6 Mth) 4 (1 yr) NA

Smoking Cessation Rates

0

2

4

6

8

10

12

Rates are established annually

0 1 2 3 4 NA

Tobacco Control

0

5

10

15

20

Smoking forbidden everywhere

Separate smoking/nonsmoking areas

Appropriate ventilation

0 1 2 3 4 NA

Environment

0

5

10

15

20

25

Clear signage Ashtrays in designated areasonly

Tobacco not sold on premises

0 1 2 3 4 NA

Review & Compliance

0

2

4

6

8

10

12

Action plan renewed every two years Ongoing education for patients and staff

0 1 2 3 4 NA

Monitoring

02468

101214

Policy monitored &reviewed annually

Responsibility of the working group

Includes policy compliance,cessation services &

communication systems

0 1 2 3 4 NA

Problems Encounteredwith self audit questionnaire

• To overcome incorrect scoring, the main question, along with sub-questions in a different shade

• Under Section 4.6 - Identify Clients, eg. Staff, Patients, Visitors etc. and offer separate scoring options

• Under Section 5.2 - suggest this be divided into two parts

• Under Section 5.3 - suggest this be deleted as scientists say that there is no safe level of exposure to carcinogens

• Under Section 6.1 - suggest dividing into two parts

• Under Section 9.3 - suggest dividing into three parts

• Total amount was incorrect and has been changed

• Offer different options for scoring - some answers not relevant

General Questionnaire Feedback• General feedback - positive, helpful tool to identify

what areas need attention, provides a guide for policy development and an opportunity to ensure that progress is kept on track.

• Organisations - viewed it as a good tool to bring back to management as evidence of what has been and needs to be achieved.

• The main negative feedback on the questionnaire appears to be with the scoring system, which seems to have caused some confusion.

• Recommendation - provide supportive literature to accompany the questionnaire.