Governance reminder
Lazomis QI supports quality improvement planning and documentation. It does not replace clinical judgement, local policy, professional responsibility or organisational governance processes. Ensure all improvement activity is agreed and implemented in accordance with local requirements.
1. Baseline findings summary
Drawn from dashboard results where data is available.
2. Key problems identified
Lowest-performing criteria from the current dataset.
3. Root cause / contributory factors
People · Process · Environment · IT · Documentation · Communication · Training · Workload
4. Improvement aim
Specific, measurable, achievable, relevant, time-bound
5. Suggested local improvement actions
Editable — framed as local implementation ideas, not national guidance.
| Action | Linked problem | Owner | Target date | Status |
|---|---|---|---|---|
| Agree and publish a standard board round template covering criteria to reside, EDD, pathway and actions | Board round format varies between wards and days | Ward Manager / Clinical Lead | 6 weeks | Planned |
| Confirm a protected board round start time with named senior decision-maker cover | Board rounds start late or without a senior decision-maker | Clinical Director | 8 weeks | Planned |
| Add a named owner and timeframe field to the EPR board round note | Actions recorded without owner or timeframe | EPR / Digital Team | 10 weeks | Not started |
| Standing review of previous day's actions as the first item of every board round | Previous actions not routinely reviewed | Board round chair | 4 weeks | In progress |
| Agree a barrier escalation route to the site / flow team with a defined response time | Unresolved barriers not escalated | Site Manager | 8 weeks | Planned |
Most frequent board round gaps
Criteria most often answered "No" — use to prioritise improvement work.
Unresolved actions were carried forward with a named owner.18 · 13% cumulative
Patient-specific discharge criteria were documented where criteria-led discharge is used.16 · 24% cumulative
Previous board round actions were reviewed.16 · 35% cumulative
Action deadline or timeframe was documented where relevant.15 · 46% cumulative
Escalation was completed where required by local policy.14 · 56% cumulative
Therapy actions were documented where relevant.13 · 65% cumulative
6. PDSA cycle 1
Plan · Do · Study · Act
7. Intervention log
8. Re-audit plan
9. Sustainability plan
10. Learning points
11. Governance summary
12. ARCP / portfolio evidence summary
Populates the ARCP evidence output.
Improvement themes
Common action areas for board round effectiveness improvement.
Board round attendance and multidisciplinary input
Senior decision-maker involvement
Board round timing and start reliability
Structured board round format
Criteria to reside review
Expected discharge date setting and review
Discharge pathway assignment
Discharge planning and transfer of care referrals
Task ownership and named responsibility
Action timeframes and follow-through
Review of previous board round actions
Barrier identification and documentation
Escalation of unresolved barriers
Documentation quality and EPR recording
Patient and carer involvement in discharge planning
Weekend and out-of-hours board rounds
Feedback to ward teams
Re-audit and sustainability