The group warned of complacency and set out plans to compile an audit of the implementation of 295 recommendations from three public inquiries after the Paddington crash, which killed 31 passengers and left 400 people injured as a fireball engulfed the carriages.
A physician champion at each of the participating hospitals completed weekly audits of the bundle implementation.
The quality of care component in the guidelines was composed of various activities, such as continuity in conducting maternal death audits, and the implementation of a quality assurance service (QAS) team in the district hospital in charge of safety and enforcement of hygiene standards.
Patient notes were audited by members of the implementation teams (Table 1) to find evidence about the indication for the NG tube, the process of tube insertion, and how the position of the tube was initially verified and monitored on a continuous basis.
[DS1-S1-GA] In addition to the perinatal review meetings, which are described above as the backbone of the continuation of audit and the completion of the audit cycle through the implementation of recommendations, a well-defined pathway for the flow of data and findings from the primary health care level up to the provincial or national level was also considered essential.
To cover these objectives, official control audits of the manuals and their implementation in 1350 small and 66 medium size organizations: restaurants, hotels and cafeterias in one area of the Valencian region (Spain) were carried out from 2007 to 2010.
The applied measures were: 6-month feedback to professionals; audits to evaluate the implementation of the QI plan and a reference team (a doctor and a nurse) assigned to each PHCT.
The results of this audit suggests that the implementation of simple low-cost measures, such as a blood investigation order chart to specify and customise blood testing in the ICU, can significantly reduce the costs associated with patient stay in the ICU.
Quality indicators may be used for audit and feedback as part of the implementation strategy.
The study also showed that the indicators were feasible for audit and feedback as part of the implementation strategy.
