Aspect of Neonatal Service relevant to Quality Oversight Achieved?

Evidence-based care
Care Guidelines supported by Audit
Unit Lead for guidelines Unit
Guidelines on common neonatal problems Unit
Shared guidelines across a network Network
Clinical guidelines up to date Unit
Programme of audit Unit

Incomplete items 5
Secction complete NO
Team working and communication
Team communication
Escalation pathways and training Unit
Nursing and medical safety briefings Unit
Training in structured handover Unit
Mechanism for Team Debrief Unit

Incomplete items 4
Secction complete NO
Staff Safety Culture
Safety culture survey Unit
Safety culture action plan Unit
Learning Board Unit

Incomplete items 3
Secction complete NO
Pathways of Care and Referral for high risk babies
Network guideline on care pathways for high risk babies Network
Care pathway exception reporting Unit and Network

Incomplete items 2
Secction complete NO
Collaborative multidisciplinary care for babies with complex conditions
Neonatal cover for surgical units Network
Network guideline on MDT care of complex babies Network
Surgical units compliance with network guidelines Network
24/7 transport between surgical unit and NICU Transport service
and Network
Specialist advice and review of complex babies Unit and Network
Joint meetings with specialist teams Unit
Guidelines on palliative care Unit and Network

Incomplete items 7
Secction complete NO
Family as partners in care
Family facilities
Adequate parent facilities Network

Incomplete items 1
Secction complete NO
Family involvement in care planning and delivery
Parent/carer involvement in decisions about care Unit
Parents/carers invited on consultant ward rounds Unit
Informed consent taken where appropriate Unit
Parents/carers supported to take part in care Unit
Support for breast milk feeding Unit

Incomplete items 5
Secction complete NO
Parent/carer feedback
Survey of parents and carers Unit and Network
Parent comment mechanism Unit
Parent communication board Unit
Network parent advisory group Network

Incomplete items 4
Secction complete NO
Parent information
Welcome pack for parents/carers Unit
Antenatal unit visit Unit
“Meet the staff” board Unit
Approach to giving difficult news and to bereavement Unit
Early first communication from senior team member Unit
Information for families with communication difficulties Unit

Incomplete items 6
Secction complete NO
Parent/carer involvement in service development
Parent/carer involvement in service development Unit and Network

Incomplete items 1
Secction complete NO
Benchmarking
Existing Neonatal Service Standards
Performance against these Unit and Network
Existing standards action plan Unit and Network
Network contractual review with commissioners or Health Network
Board
Services which need to be commissioned with a neonatal Network
service
Place of delivery of <27 week GA babies Network
 Incomplete items 5
Secction complete NO
Engagement in National and International Audit and Benchmarking
Benchmarking lead Unit
Involvement in all mandatory national benchmarking Unit
processes
Performance outlier action plan Unit and Network

Incomplete items 3
Secction complete NO
Patient Safety
Adverse Event Review
Guidance on adverse event reporting Unit and Network
Multi-professional meetings Unit
Timely adverse event review Unit
Timely response to adverse events Unit

Incomplete items 4
Secction complete NO
Death and Serious Adverse Event Review
Neonatal mortality lead Unit
Multi-professional death reviews Unit
Timely death review Unit
Death reviews following guidance Unit
Criteria for Serious Adverse Event Review Unit
Multi-professional Serious Adverse Event Reviews Unit
Serious Adverse Event Reviews following guidance Unit
Serious Adverse Event Reports shared with family Unit

Incomplete items 8
Secction complete NO
Quality Improvement
Structure and Resources for Quality Improvement
Multi-professional quality group Unit
Medical Lead Unit
Nursing Lead Unit

Incomplete items 3
Secction complete NO
Annual Quality Strategy and Quality Report
Quality Strategy Unit
Quality Report Unit
Programme of QI Unit

Incomplete items 3
Secction complete NO
Training for Quality and Patient Safety
 Quality and Patient Safety in Induction Unit
Education for trainees and nurses Unit
Consultant training in QI Unit

Incomplete items 3
Secction complete NO
Research
Engagement in Research
Research Lead Unit
Recruitment to research Unit

Incomplete items 2
Secction complete NO
What is missing?
Planned actions
Implications for next Quality
Strategy