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 an SDEC suitability prompt to the ED streaming and clerking template | SDEC suitability not considered for all eligible attendances | ED Streaming Lead & Digital Team | 8 weeks | Planned |
| Publish a one-page local SDEC inclusion and exclusion summary at all referral points | Variation in application of local criteria | SDEC Clinical Lead | 4 weeks | In progress |
| Agree a direct ambulance and GP referral route with an agreed response time | Suitable patients routed through ED by default | Ambulance Liaison Lead | 12 weeks | Planned |
| Weekly feedback of missed SDEC opportunities to referring areas | Potentially suitable patients not referred | QI Lead | 4 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 same-day emergency care improvement.
SDEC suitability identification at first contact
Clarity of local inclusion and exclusion criteria
ED and UTC streaming reliability
Direct referral routes from GP, NHS 111 and ambulance
Senior decision-maker involvement
NEWS2 and acuity documentation
Frailty and cognition screening in SDEC
SDEC referral acceptance and transfer delays
Same-day diagnostics access
Same-day treatment delivery
Pharmacy and medicines support in SDEC
Specialty advice turnaround
Discharge planning and safety-netting
Documentation of reasons for admission or non-use
SDEC opening hours and weekend capacity
Feedback to referring teams
Re-audit and sustainability