The healthcare organisation seeks relevant representation to develop and to implement a strategy and action plan based on the self-audit and policy monitoring and evaluation results. The strategy and action plan is developed and managed by an implementation team. The strategy and action plan is reviewed annually taking into account the results of the monitoring and evaluation results. The healthcare organisation allocates the human and financial resources necessary for all aspects of policy implementation. Financial and human resources are allocated according the strategy and action plan. Subtotal score for Standard 1 (Maximum possible score: 30) Current audit: STANDARD 2: Communication The healthcare organisation has a comprehensive communication strategy to support awareness and implementation of the tobacco-free policy and tobacco cessation services. IMPLEMENTATION CRITERIA SELF AUDIT Summary of current situation and plans for next 12 months (Please describe the current situation for each implementation criteria This will provide a context for your planned actions for the next 12 months) No / Not implemented Less than half implemented More than half implemented Yes / Fully implemented (0) (1) (2) (3)
Interactive and targeted media is used to communicate the organisation’s tobacco-free policy and availability of tobacco cessation services to all staff and subcontractors before and during employment. All staff and subcontractors are informed about the healthcare organisation’s tobacco-free policy and tobacco cessation services. Interactive and targeted media is used to communicate the organisation’s tobacco-free policy and availability of tobacco cessation services to all service users prior to and/or on admission. All service users are informed about the organisation’s tobacco free policy and tobacco cessation services. Interactive and targeted media is used to communicate the organisation’s tobacco-free policy and availability of tobacco cessation services in the community including specific target groups. The community including specific target groups is informed about the healthcare organisation’s tobacco-free policy and tobacco cessation services. Subtotal score for Standard 2 (Maximum possible score: 9) Current audit:
STANDARD 3: Education and training The healthcare organisation ensures appropriate education and training for clinical and non-clinical staff. IMPLEMENTATION CRITERIA SELF AUDIT Summary of current situation and plans for next 12 months (Please describe the current situation for each implementation criteria. This will provide a context for your planned actions for the next 12 months) No / Not implemented Less than half implemented More than half implemented Yes / Fully implemented (0) (1) (2) (3) Policy briefings and instruction are mandatory for all staff, including managers. All staff including managers participate in policy briefings and instructions. The healthcare organisation ensures that all staff know how to approach tobacco, associate devices/e-cigarette users, including visitors, to inform them of the tobacco-free policy and tobacco cessation services. All staff are instructed on how to approach tobacco and associate devices/e-cigarette users to inform them about the tobacco-policy and tobacco cessation services. All clinical staff are trained in brief advice and best care measures for tobacco addiction /dependence in line with researched best practice. All clinical staff are trained in brief advice to motivate tobacco and associated devices/e-cigarette users to quit. Key clinical staff are trained in motivational tobacco cessation techniques in line with researched best practice. Key clinical staff are trained in motivational tobacco cessation techniques in line with researched best practice. Subtotal score for Standard 3 (Maximum possible score: 12) Current audit:
STANDARD 4: Identification, diagnosis and tobacco cessation support The healthcare organisation identifies all tobacco users and provides appropriate care in line with international best practice and national standards IMPLEMENTATION CRITERIA SELF AUDIT Summary of current situation and plans for next 12 months (Please describe the current situation for each implementation criteria. This will provide a context for your planned actions for the next 12 months) No / Not implemented Less than half implemented More than half implemented Yes / Fully implemented (0) (1) (2) (3) The healthcare organisation has a systematic procedure in place to identify, diagnose and document the tobacco addiction/ dependence status of service users (including users of associated All tobacco/associated users are systematically identified and have their addiction/dependence status diagnosed and documented. The healthcare organisation has a systematic procedure in place to identify and document all service users including babies, children and pregnant women who are exposed to secondhand smoke/e-cigarette vapour. All service users exposed to second-hand smoke/e-cigarette vapour are identified and document. Information about the risk of tobacco consumption (including the use of associated and tobacco cessation methods is widely available for all service users. Information about the risk of tobacco consumption (including the use of associated and tobacco cessation methods is widely available. All identified tobacco and associated devices/e-cigarette users receive brief advice in line with best researched practice. All tobacco and associated devices/e-cigarette users receive brief advice in line with best researched practice. All interventions to motivate tobacco users to quit are documented. The service user’s care plan identifies and meets the needs of the tobacco and associated devices/e-cigarette user and those identified as exposed to secondhand smoke/e-cigarette vapour. Tobacco and associated devices/e-cigarette users and those exposed to secondhand smoke/e-cigarette vapour have their needs identified and documented in the care plan.
STANDARD 5: Tobacco-free environment The healthcare organisation has strategies in place to achieve a tobacco-free campus. IMPLEMENTATION CRITERIA SELF AUDIT Summary of current situation and plans for next 12 months (Please describe the current situation for each implementation criteria. This will provide a context for your planned actions for the next 12 months) No / Not implemented Less than half implemented More than half implemented Yes / Fully implemented (0) (1) (2) (3) The healthcare organisation has completely tobacco-free buildings (including associated devices/e-cigarettes). All buildings within the organisation are completely tobacco-free (including associated The healthcare organisation has completely tobacco-free grounds and transport systems (including associated The grounds and transports systems of the organisation are completely tobacco-free (including associated devices/e-cigarettes). The healthcare organisation has clear and unambiguous signage that defines the products prohibited and identifies boundaries for buildings and grounds of the tobacco-free campus. Signage identifies prohibited products and the tobacco-free campus boundaries for buildings and grounds. The healthcare organisation prohibits the sale, distribution and advertisement of tobacco products and associated devices/ e–cigarettes, anywhere within the organisation. Tobacco and associated devices/e-cigarettes are not sold, distributed or advertised within the organisation. The healthcare organisation has a procedure in place to ensure that all service users, staff and visitors are never exposed to secondhand smoke/e-cigarette vapour within the boundaries of the tobacco-free campus. There is a procedure to record and prevent secondhand smoke/e-cigarette vapour exposure.
STANDARD 7: Community engagement The healthcare organisation contributes to and promotes tobacco control/prevention in the local community according to the WHO FCTC and and/or national public health strategy. IMPLEMENTATION CRITERIA SELF AUDIT Summary of current situation and plans for next 12 months (Please describe the current situation for each implementation criteria. This will provide a context for your planned actions for the next 12 months) No / Not implemented Less than half implemented More than half implemented Yes / Fully implemented (0) (1) (2) (3) The healthcare organisation works with community partners and other organisations to promote and contribute to local, national and international tobacco-free activities. The healthcare organisation works with community partners and other organizations to promote and contribute to national and international tobacco-free activities. The healthcare organisation works with community partners to encourage and support the users of tobacco and associated devices/e-cigarettes to quit; it takes into account the needs of specific target groups (women, adolescents, migrants, disadvantaged and other cultural groups). The organisation works with community partners to encourage and support tobacco and associated devices/e-cigarette users to quit. The organisation works with community partners to address the needs of specific target groups (women, adolescents, migrants, disadvantaged and other cultural groups). The healthcare organisation shares best practice to support others in the development and implementation of tobacco-free policies. The healthcare organisation shares best practice in the development and implementation of policies. Subtotal score for Standard 7 (Maximum possible score: 12) Current audit:
STANDARD 8: Monitoring and evaluation The healthcare organisation monitors and evaluates the implementation of all the ENSH-Global standards at regular intervals. IMPLEMENTATION CRITERIA SELF AUDIT Summary of current situation and plans for next 12 months (Please describe the current situation for each implementation criteria. This will provide a context for your planned actions for the next 12 months) No / Not implemented Less than half implemented More than half implemented Yes / Fully implemented (0) (1) (2) (3) The healthcare organisation has internal and external review processes to monitor the implementation of all standards and takes into account feedback from staff and service users. An internal process is in place to review the implementation of the standards at least annually. The review process takes into account feedback from service users and staff. The healthcare organisation participates in external review activities. The healthcare organisation has processes to collect key data, including the self-audit results, to inform the annual action plan and to ensure quality improvement. Data collection processes are in place, including the to monitor implementation of the tobacco free policy. Data collected is used to improve implementation and the annual policy action plan. Subtotal score for Standard 8 (Maximum possible score: 15) Current audit: GRAND TOTAL (Maximum possible score: 144) Current audit: / 144