Governance reminder
Lazomis QI supports quality improvement planning and documentation. It does not replace clinical judgement, local DNACPR / ReSPECT / TEP policy, Mental Capacity Act requirements, safeguarding, palliative care advice, resuscitation policy, critical care advice, professional responsibility or organisational governance processes.
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 | Status |
|---|---|---|---|---|
| Structured ReSPECT / TEP template with mandatory fields for CPR recommendation, treatment escalation recommendations, ceiling of care and clinical rationale | Treatment escalation recommendations and ceiling of care inconsistently documented | Resuscitation Lead & EPR Team | 10 weeks | Planned |
| EPR prompt requiring documentation of patient capacity, involvement and best interests where applicable | Capacity and best interests documentation gaps | Clinical Director & MCA Lead | 8 weeks | In progress |
| Family / important-person communication documentation prompt on every DNACPR / ReSPECT / TEP entry | Family communication documentation missing | Palliative Care Lead | 6 weeks | Planned |
| Scheduled review of DNACPR / ReSPECT / TEP after any significant clinical change or transfer | Plans not reviewed after clinical change | Ward Managers & Nursing Lead | 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 DNACPR / ReSPECT / TEP documentation.
Recognition of patients needing DNACPR / ReSPECT / TEP
Admission clerking prompts
Consultant review and senior decision-making
CPR recommendation documentation
Broader treatment escalation planning
Clinical rationale documentation
Patient capacity documentation
Best interests decision-making documentation
Patient involvement and goals-of-care conversations
Family / important-person communication
ReSPECT or local TEP form completion
Visibility of plans in electronic records
Handover and MDT communication
Review after clinical change or transfer
Discharge communication
Palliative care referral process
Critical care outreach / ICU escalation discussion
EPR templates and prompts
Staff education and induction
Feedback to clinical teams
Re-audit and sustainability