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
Pulled from dashboard where possible.
2. Key problems identified
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 |
|---|---|---|---|---|
| Add mandatory VTE assessment field to EPR admission clerking | Assessment not completed within 24h on OOH surgical admissions | IT & Thrombosis Committee | 8 weeks | Planned |
| Ward-level feedback pack with weekly compliance | Variation between wards | QI Lead | 4 weeks | In progress |
| Pharmacy screening of VTE prophylaxis on all AMU admissions | Renal dosing not documented | Lead Pharmacist | 6 weeks | Planned |
| Structured reassessment trigger at consultant post-take | Reassessment inconsistent | Clinical Director | 12 weeks | Not started |
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 VTE assessment improvement.
Admission VTE assessment reliability
EPR prompts and mandatory fields
VTE and bleeding risk documentation
Balancing VTE risk and bleeding risk
Pharmacological prophylaxis prescribing
Renal dosing and dose adjustment
Mechanical prophylaxis processes
Contraindication documentation
Reassessment at consultant review or clinical change
Patient information and discharge advice
Pharmacy review and medicines safety
Nursing workflow and mechanical prophylaxis application
Weekend and out-of-hours admission processes
Feedback to ward teams
Re-audit and sustainability