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

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First stage: Interest

Register 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.

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Third stage: Dedicated Status

Evaluate progress after 12 months participation in the national initiative.

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Fourth stage : European Registration

Bronze, Silver or Gold on the European Smoke-free Hospital Register.

Participation in Initiative up to June 2003

• Invited: • 1st Stage: 271 60 • 2nd Stage: 7 • 3rd Stage: • 4th Stage: 7 37

National & European SFHI

60 60 50 40 37 30 20 10 7 7 0 Phase I Phase II Phase III Phase IV The initial 37 hospitals to participate in the initiative were surveyed pre and post 2 year project period (Jan`01–Dec `02)

Initial 37 Committed Hospitals by Hospital Type

Research and analysis of data conducted for the Irish HPH Network by the Department of Public Health Medicine and Epidemiology, UCD (NUI Dublin) Hospital Type 6 4 2 0 14 12 10 8 4 University 1 Regional 13 5 10 4 General District/ community Specialised Missing Data

Irish Smoke Free Health Service Initiative Preliminary 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

20 15 10 5 0 Policy on official documents 0 1 2 3 Information to patients & staff 4 NA

2. WORKING GROUP

20 15 10 5 0 Designated committee appointed Chair from Senior Management New strategy designed 0 1 2 3 4 Actions & strategies evaluated Analysed results NA

Education & Prevention

12 10 2 0 8 6 4 Staff trained / briefed Training during working time 0 1 2 3 4 NA

Information & Cessation Service

25 20 15 10 5 0 0 1 2 3 4 NA

Smoking Cessation Service

10 5 0 25 20 15 For staff 0 1 For patients 2 3 4 NA For visitors

Cessation Support

25 20 15 10 5 0 Smoking Cessation Facilitator Free of charge 0 1 2 3 4 NA Staff attend during working hours

4 2 0 12 10 8 6

Cessation Service Follow Up

0 1 (1 Mth) Is there a follow up 2 (3 Mth) 3 (6 Mth) 4 (1 yr) NA

12 10 4 2 8 6 0

Smoking Cessation Rates

Rates are established annually 0 1 2 3 4 NA

Tobacco Control

20 15 10 5 0 Smoking forbidden everywhere 0 Separate smoking/non smoking areas 1 2 3 4 NA Appropriate ventilation

Environment

25 20 15 10 5 0 Clear signage Ashtrays in designated areas Tobacco not sold on premises only 0 1 2 3 4 NA

Review & Compliance

12 10 2 0 8 6 4 Action plan renewed every two years 0 1 2 3 Ongoing education for patients and staff 4 NA

Monitoring

14 12 10 8 6 4 2 0 Policy monitored & reviewed annually 0 Responsibility of the Includes policy compliance, working group cessation services & communication systems 1 2 3 4 NA

Problems Encountered with 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

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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.

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

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

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Recommendation - provide supportive literature to accompany the questionnaire.