Inclusion, exclusion and audit criteria

DEMO DATA

Which board round reviews to include, which to exclude, and the 32 audit criteria measured in this cycle.

OverviewHow to useProject setupTeamInclusion / exclusionData collectionDashboardSubmissionsFindingsImprovementRe-auditResourcesExport centreSettings
Inclusion criteria
  • •Adult inpatient ward board rounds.
  • •Adult assessment unit board rounds where locally included.
  • •Daily board rounds reviewing patient progress, discharge planning, flow, barriers or escalation.
  • •Board rounds involving one or more selected wards, units, departments or pathways.
  • •Board rounds documented in electronic, paper or hybrid systems depending on local setup.
  • •Individual patient reviews within a board round, where patient-level audit is selected.
  • •Whole board round sessions, where session-level audit is selected.
Exclusion criteria and limitations
  • •Paediatric board rounds unless locally adapted.
  • •Maternity-specific board rounds unless locally adapted.
  • •Mental health inpatient board rounds unless locally adapted.
  • •Purely operational bed meetings without patient-level review, unless locally included.
  • •Informal ward updates not expected to be documented under local policy.
  • •Board rounds outside the selected audit period.
  • •Duplicate board round episodes.
  • •Records unavailable for review.
  • •Cases where local governance approval is required but has not been obtained.
  • •Direct patient identifiers entered into the tool.
Local audit standards
Editable in Project Setup. Aligned with local board round policy, NHS England hospital discharge guidance, NICE NG27 and NICE QS136.
  • •At least 90% of eligible board round reviews should document current clinical status.
  • •At least 90% should document criteria-to-reside status where relevant.
  • •At least 90% should document or update expected discharge date.
  • •At least 90% should document discharge pathway where relevant.
  • •At least 90% should document main barrier to progress or discharge.
  • •At least 90% should document action owner and next action.
  • •At least 90% should document action timeframe where relevant.
  • •At least 90% should review unresolved actions from previous board rounds.
  • •At least 90% should have escalation completed where local triggers are met.
  • •At least 90% should have documentation clear enough for another clinician, ward leader or discharge coordinator to understand the plan, barrier, owner and next action.
  • •At least 90% should have board round-related safety, flow or discharge concerns escalated or actioned where identified.
Audit criteria (32)
Compliance is calculated using Yes and No responses only. Not applicable and Unable to determine responses are excluded from the denominator.

Structure and timeliness

  1. C1
    Board round occurred as scheduled or reason for non-occurrence was documented.
    Target ≥ 90%
  2. C2
    Board round started within the locally expected timeframe where this is measured.
    Target ≥ 90%
  3. C6
    All eligible patients were reviewed or exclusions were documented.
    Target ≥ 90%

Attendance and leadership

  1. C3
    Board round was clinically led or supported by an appropriate senior decision-maker.
    Target ≥ 90%
  2. C4
    Nurse in charge or relevant nursing representative was involved.
    Target ≥ 90%
  3. C5
    Relevant MDT members were involved or available according to patient needs.
    Target ≥ 90%

Clinical review

  1. C7
    Current clinical status was reviewed.
    Target ≥ 90%
  2. C8
    Criteria-to-reside status was reviewed and documented where relevant.
    Target ≥ 90%
  3. C9
    Discharge readiness / medically fit status was documented where relevant.
    Target ≥ 90%
  4. C15
    Current clinical plan was documented.
    Target ≥ 90%
  5. C16
    Outstanding investigations, results or treatment tasks were documented where relevant.
    Target ≥ 90%

Discharge planning

  1. C10
    Expected discharge date was documented.
    Target ≥ 90%
  2. C11
    Expected discharge date was reviewed or updated.
    Target ≥ 90%
  3. C12
    Discharge destination was documented where relevant.
    Target ≥ 90%
  4. C13
    Discharge pathway was assigned where relevant.
    Target ≥ 90%
  5. C14
    Patient-specific discharge criteria were documented where criteria-led discharge is used.
    Target ≥ 90%

MDT actions

  1. C17
    Therapy actions were documented where relevant.
    Target ≥ 90%
  2. C18
    Pharmacy, TTO or medicines-related actions were documented where relevant.
    Target ≥ 90%
  3. C19
    Discharge summary, transport, equipment or community actions were documented where relevant.
    Target ≥ 90%

Safety and escalation

  1. C20
    Safeguarding, capacity, infection control or escalation issues were considered where relevant.
    Target ≥ 90%
  2. C27
    Escalation was completed where required by local policy.
    Target ≥ 90%
  3. C32
    Any board round-related safety, flow or discharge concern was escalated or actioned where identified.
    Target ≥ 100%

Actions and ownership

  1. C21
    Main barrier to progress or discharge was documented.
    Target ≥ 90%
  2. C22
    Action owner was documented.
    Target ≥ 90%
  3. C23
    Next action was documented.
    Target ≥ 90%
  4. C24
    Action deadline or timeframe was documented where relevant.
    Target ≥ 90%
  5. C25
    Previous board round actions were reviewed.
    Target ≥ 90%
  6. C26
    Unresolved actions were carried forward with a named owner.
    Target ≥ 90%

Communication

  1. C28
    Patient or family / carer communication need was documented where relevant.
    Target ≥ 90%

Documentation quality

  1. C29
    Board round outcome was documented clearly.
    Target ≥ 90%
  2. C30
    Reason for delayed, missing or incomplete board round review/documentation was recorded where applicable.
    Target ≥ 90%
  3. C31
    Documentation was clear enough for another clinician, ward leader or discharge coordinator to understand the plan, barrier, owner and next action.
    Target ≥ 90%