Spreadsheet: 85719d1285767985-conditional-formatting-testing-
Sheet: QMP Results Record sheet

QMP INFECTION CONTROL - THEATRES AND DSU 2009/10 AUDIT SUMMARY
 |  |  |  |  |  |  |  | QUALITY MONITORING PROGRAMME
THEATRE/UNIT:
BUSINESS UNIT  : |  |  |  |  |  |  |  |  |  |  |  |  | AS FROM 1ST APRIL 2009
HOSPITAL  :
DATE  : | 1900-01-01 00:00:00
CONDUCTED BY  : |  |  |  |  |  |  |  | AUDIT RESULTS RECORD SHEET
 |  |  |  |  |  |  |  | AS FROM 1ST APRIL 2010
 |  |  |  |  |  |  |  | THEATRE/UNIT |  |  |  |  |  |  |  | BUSINESS UNIT |  |  |  |  |  |  | SITE
 | Number of Yes |  | % | Number of No | Total number of Questions excluding those deemed N/A
SECTION 1:  Auditor(s) to ask three members of staff (Standard Awareness) | 0 |  | N/A | 0 | 0 |  |  | INFECTION PREVENTION AND CONTROL DEPARTMENT
SECTION 2 Standard: The perioperative environment will be maintained appropriately to negate the risk of cross infection (Anaesthetic Rooms) | 22 |  | 0.7586206896551724 | 7 | 29 |  |  | DATE: |  | 1900-01-01 00:00:00
SECTION 3 Standard: The perioperative environment will be maintained appropriately to negate the risk of cross infection (operating rooms & scrub bays) | 14 |  | 0.875 | 2 | 16 |  |  | AUDITOR 1 |  |  |  |  |  |  |  |  |  |  |  |  | TITLE & WORK PLACE
SECTION 4 Standard: The perioperative environment will be maintained appropriately to negate the risk of cross infection (setting up rooms) | 0 |  | N/A | 0 | 0
SECTION 5 Standard: The perioperative environment will be maintained appropriately to negate the risk of cross infection (sluice-waste disposal room) | 0 |  | N/A | 0 | 0
SECTION 6: Ask three members of the perioperative team how the surgical outcomes are enhanced by the promotion of a safe and clean environment | 0 |  | N/A | 0 | 0 |  |  | SCORES
SECTION 7: LINK PRACTITIONER Standard: Clinical practices will reflect compliance with infection prevention & control guidelines | 0 |  | N/A | 0 | 0 |  |  |  |  |  |  |  | TOTAL YES'S |  |  |  | AVAILABLE YES'S |  |  |  | % AGE SCORE
SECTION 8 Standard: The perioperative environment will be maintained appropriately to negate the risk of cross infection (Recovery area) | 0 |  | N/A | 0 | 0 |  |  | Section 1 |  |  |  |  | 0 |  |  |  | 0 |  |  |  | N/A
SECTION 9: Standard: The environment will be maintained appropriately to negate the risk of cross infection (communal areas) | 7 |  | 0.875 | 1 | 8 |  |  | Section 2 |  |  |  |  | 22 |  |  |  | 29 |  |  |  | 0.7586206896551724
Total: | 43 |  | 0.8113207547169812 | 10 | 53
 |  |  |  |  |  |  |  | Section 3 |  |  |  |  | 14 |  |  |  | 16 |  |  |  | 0.875
 | <80% | <=80% |  | Unacceptable |  |  |  | Section 4 |  |  |  |  | 0 |  |  |  | 0 |  |  |  | N/A
 | 80 to 89.9% | 81 to 90% |  | Acceptable
 | 90 to 94.9% | 91 to 99% |  | Very Good |  |  |  | Section 5 |  |  |  |  | 0 |  |  |  | 0 |  |  |  | N/A
 | 95%+= |  |  | Excellent
 |  |  |  |  |  |  |  | Section 6 |  |  |  |  | 0 |  |  |  | 0 |  |  |  | N/A
 |  |  |  |  |  |  |  | Section 7 |  |  |  |  | 0 |  |  |  | 0 |  |  |  | N/A
 |  |  |  |  |  |  |  | Section 8 |  |  |  |  | 0 |  |  |  | 0 |  |  |  | N/A
 |  |  |  |  |  |  |  | Section 9 |  |  |  |  | 7 |  |  |  | 8 |  |  |  | 0.875
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | >95 | 90-94.9 | 80-89 | >80
 |  |  |  |  |  |  |  | Total Score |  |  |  |  | 43 |  |  |  | 53 |  |  |  | 0.8113207547169812 |  |  |  |  |  |  |  |  |  | 0.8113207547169812 | 89 | -7.87 |  | 0 | 0 | 1 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 1 | 1 | 1
 |  |  |  |  |  |  |  | Enter score in relevant box below |  |  |  |  |  |  |  |  |  |  |  |  | Re audit |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 1 | 2 | 1
 |  |  |  |  |  |  |  | Less than 80% |  |  |  |  |  |  |  |  | 0.8113207547169812 |  |  |  | 3 months
 |  |  |  |  |  |  |  | Between 80 - 89.9% |  |  |  |  |  |  |  |  | 0.8113207547169812 |  |  |  | 6 months
 |  |  |  |  |  |  |  | Between 90 - 94.9% |  |  |  |  |  |  |  |  | 0.8113207547169812 |  |  |  | 9 months
 |  |  |  |  |  |  |  | Greater than or equal to 95% |  |  |  |  |  |  |  |  | 0.8113207547169812 |  |  |  | 12 months
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 89
 |  |  |  |  |  |  |  | Date of re-audit: |  |  |  |  |  |  |  |  | Re-Audits that score >5% less than previous score will result in re-audit time reduction. This will be reflected on the master copy of QMP scores |  |  |  |  |  |  |  | Previous audit score:
 |  |  |  |  |  |  |  | 7.87% less than previous score |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 89
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0.7613207547169811 |  |  | 0.8113207547169812
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | -0.0787
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | -7.87
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 7.87% less than previous score
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 76.13207547169812
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | #N/A