DAFNE Audit Auditor Questionnaire

Transcription

1 DAFNE Audit Auditor Questionnaire Centre: «Centre» Lead Educator: «Lead_Educator» Date of QA audit visit: «Audit_Date» Auditor: «Auditor» Period covered by audit: From «Period_from» to «Period_to» Auditor Notes You will need to have access to the DAFNE Professional Development files for each DAFNE Educator in order to complete this form. These files must be made available to you. This questionnaire must be completed in ink DAFNE F03.004, Version 8 Feb 2013

2 List of Educators and Doctors Completed Goal PR No of No of 5x1 Pump Educator Discipline training setting training Int PR Ext PR training training «Educator_1» dd/mm/yyyy dd/ mm/yyyy dd/m m /yyyy dd/mm/yyyy dd/mm/yyyy «Educator_2» dd/mm/yyyy dd/ mm/yyyy dd/m m /yyyy dd/mm/yyyy dd/mm/yyyy «Educator_3» dd/mm/yyyy dd/ mm/yyyy dd/m m /yyyy dd/mm/yyyy dd/mm/yyyy «Educator_4» dd/mm/yyyy dd/ mm/yyyy dd/m m /yyyy dd/mm/yyyy dd/mm/yyyy «Educator_5» dd/mm/yyyy dd/ mm/yyyy dd/m m /yyyy dd/mm/yyyy dd/mm/yyyy «Educator_6» dd/mm/yyyy dd/ mm/yyyy dd/m m /yyyy dd/mm/yyyy dd/mm/yyyy «Educator_7» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_8» dd/mm/yyyy dd/ mm/yyyy dd/m m /yyyy dd/mm/yyyy dd/mm/yyyy «Educator_9» dd/mm/yyyy dd/ mm/yyyy dd/m m /yyyy dd/mm/yyyy dd/mm/yyyy «Educator_10» dd/mm/yyyy dd/ mm/yyyy dd/m m /yyyy dd/mm/yyyy dd/mm/yyyy «Educator_11» dd/mm/yyyy dd/ mm/yyyy dd/m m /yyyy dd/mm/yyyy dd/mm/yyyy «Educator_12» dd/mm/yyyy dd/ mm/yyyy dd/m m /yyyy dd/mm/yyyy dd/mm/yyyy «Educator_13» dd/mm/yyyy dd/ mm/yyyy dd/m m /yyyy dd/mm/yyyy dd/mm/yyyy «Educator_14» dd/mm/yyyy dd/mm/yyyy dd/ mm/yyy y dd/mm/yyyy dd/mm/yyyy «Educator_15» dd/mm/yyyy dd/mm/yyyy dd/ mm/yyy y dd/mm/yyyy dd/mm/yyyy DAFNE F03.004, Version 8 Feb of 23

3 Doctor Discipline Completed training Category Sessions dd/mm/yyy y dd/mm/yyy y dd/mm/yyy y dd/mm/yyy y dd/mm/yyy y dd/mm/yyy y dd/mm/yyyy DAP Advisors Discipline Completed DAP training Category dd/mm/yyyy dd/mm/yyyy DAFNE F03.004, Version 8 Feb of 23

4 Section A: Maintaining Educator status A1. All Personal Development files for all Educators (a) For all Educators listed in the table overleaf Auditor to: record whether PD file has been provided compare Audit Form A with Audit Form C for each Educator listed check sessions 4 and 6 are being delivered check correct curriculum is being used Note: Where a centre has more than 6 Educators, up to 8 files should be viewed (2 Educators observed plus up to 6 Educators, including Category 3 Doctor Educators, files randomly selected). (b) For a random selection of files (2 Educators observed during audit plus 2 Educators files randomly selected and reviewed by the Auditor) check Session Learning Outcome forms are available, and dated appropriately, for those sessions observed. Please ensure that a copy of the Audit Form C: Sessions to be Observed (F03.009) is available in section 4 of all DAFNE Professional Development files for each of the Educators listed in the table overleaf. If any are missing please ask the Lead Educator to provide a copy before you leave. If you are unable to get a copy of the Sessions to be Observed form for any Educator please provide details of why in the column of the table overleaf. DAFNE F03.004, Version 8 Feb of 23

5 Educator Name «Educator_1» PDP File provided for Auditor Yes No Note for Auditor: Complete for all Educators listed Audit Form C If No answered for provision of PDP Correct Educator provided, and Files, provision of Audit Form C, version of delivers matches comparison of Audit form C with Audit curriculum Session Audit Form Form A or Version of Curriculum provide used? A? reason here 4 6 Yes No Yes No Note for Auditor: complete for random selection Session Learning Outcome forms available, and dated appropriately, for those sessions observed «Educator_2» «Educator_3» «Educator_4» «Educator_5» «Educator_6» «Educator_7» «Educator_8» «Educator_9» «Educator_10» «Educator_11» «Educator_12» «Educator_13» «Educator_14» «Educator_15» Table 1: Session and curriculum comparison for all Educators (including Dr Educators) DAFNE F03.004, Version 8 Feb of 23

6 A2. If any Educator not delivering both Sessions 4 and 6, summarise discussion with Lead Educator the plan for when they will start to deliver the sessions. Educator name Summary of discussion with Lead Educator A3. What measures are in place to ensure that all DAFNE Educators maintain their status by delivering a patient course every 26 weeks? Auditor Note: This information should be obtained from discussions with the Lead DAFNE Educator. Comments: DAFNE F03.004, Version 8 Feb of 23

7 A4. Documentation present for alternative format course delivery Documentation present in Section 6 of PD files for 2 Educators being observed and Educators whose PD files randomly selected by Auditor (minimum of 2 files) 5 week curriculum Note: Central D AFNE to complete Note: Auditor to complete Educator Name Date 5 week training workshop Date of last 5 week course delivery Date Core Skills form completed Date Learning outcomes completed for additional Date Reflective Tool completed in PD file (first course following attended session training only) dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/ mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/ mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/ mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/ mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/ mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy Pump curriculum Note: Central DAFNE to complete Note: Auditor to complete Educator Name Date workshop attended Date of last pump course Date Core Skills form completed delivery dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy the DAFNE F03.004, Version 8 Feb of 23

8 A5. What is the centre policy for the reintroduction to the delivery of the DAFNE patient course following an extended break? Please provide details. Auditor Note: This information should be obtained from discussions with the Lead DAFNE Educator. Comments: A6. What systems are in place to ensure that all DAFNE Educators achieve development objectives outlined in their PDPs and that new development objectives are set? Auditor Note: This information should be obtained from discussions with the Lead DAFNE Educator. Comments: DAFNE F03.004, Version 8 Feb of 23

9 Section B: Evidence of Ongoing Internal QA within a 3 year period B1. Evidence that individual educators are being observed by their local colleagues. Audit Form A Internal QA A copy of completed Audit Form A (F03.026) for each Educator listed below will be provided by Central DAFNE. These forms can be located in the plastic wallet provided at the back of th e Auditor file. «Educator_1» «Educator_2» «Educator_3» «Educator_4» «Educator_5» «Educator_6» «Educator_7» «Educator_8» «Educator_9» «Educator_10» «Educator_11» «Educator_12» «Educator_13» «Educator_14» «Educator_15» To complete questions B2 to B5 you will need access to: Professional Development files for each Educator listed in B1 as you will need to reference Sections 3, 4 and 5 of the DAFNE Professional Development files for each DAFNE Educator in order to complete Section B. Completed Audit Form A (F03.026) for each Educator listed in B1 (provided via Central DAFNE). You need to sort the Professional Development files into those for Educators which have been internally observed (information on Audit Form A) and those that have not. In order to complete questions B2 B5, you must then randomly select 2 Professional Development files for Educators that have been internally observed. If possible do not select the files of the 2 Educators that are delivering the patient course, as the DAFNE Professional Development files for these two educators will be looked at in more detail later in Section C. Auditor Note: You will need to reference Sections 3, 4 and 5 of the DAFNE Professional Development files for each DAFNE Educator in order to complete Section B. DAFNE F03.004, Version 8 Feb of 23

10 B2. Does the information provided on Audit Form A (F03.026) reflect that recorded on Audit Form C: Sessions to be Observed (F03.009) located in Section 4 of the Educator s Professional Development file? Educator 1 Name: Audit Form A reflects Audit Form C? Yes No Partial If you have recorded No or Partial, record the differences below If applicable, summarise discussion with the Lead Educator of the above differences. Educator 2 Name: Audit Form A reflects Audit Form C? Yes No Partial If you have recorded No or Partial, record the differences below If applicable, summarise discussion with the Lead Educator of the above differences. Please ensure the Audit Form A (F03.026) for each Educator is replaced in the plastic wallet at the back of the Auditor file. DAFNE F03.004, Version 8 Feb of 23

11 B3. Have all Session Learning Outcome forms (located in Section 5 of the Educator s Professional Development file) been completed and correctly evidenced during internal review? Educator 1 Name: Session Learning Outcome form completed during Yes No Partial internal QA? Session Learning Outcome form adequately Yes No Partial evidenced? Approximate % of learning outcomes completed correctly: If you have recorded No or Partial, list Sessions concerned (if all Session Learning forms just write All ) and reason / evidence below to substantiate your decision Session No. Session Title Reason / Evidence If applicable, summarise discussion with the Lead Educator of the above reasons. DAFNE F03.004, Version 8 Feb of 23

12 Educator 2 Name: Session Learning Outcome form completed during Yes No Partial internal QA? Session Learning Outcome form adequately Yes No Partial evidenced? Approximate % of learning outcomes completed correctly: If you have recorded No or Partial, list Sessions concerned (if all Session Learning forms just write All ) and reason / evidence below to substantiate your decision Session Session Title Reason / Evidence No. If applicable, summarise discussion with the Lead Educator of the above reasons. DAFNE F03.004, Version 8 Feb of 23

13 B4. Have Core Skills forms (located in Section 5 of Educator s Professional Development file) been completed and correctly evidenced during internal? Educator 1 Name: Yes If yes complete sections a) and b) below. No If No complete section c) below a) How many of the 27 items on the Core Skills form have been correc tly evidenced? b) DAFNE Philosophy evident from Core Skills form completed during internal QA? Yes No Partial Evidence to support your decision. If No or Partial, complete section c) also. c) Summarise discussion with the Lead Educator. Educator 2 Name: Yes If yes complete sections a) and b) below. No If No complete section c) below a) How many of the 27 items on the Core Skills form have been correctly evidenced? b) DAFNE Philosophy evident from Core Skills form completed during internal QA? Yes No Partial Evidence to support your decision. If No or Partial, complete section c) also. c) Summarise discussion with the Lead Educator. DAFNE F03.004, Version 8 Feb of 23

14 B5. Have PDPs (located in Section 3 of Professional Development file) been completed and updated with new development objectives as indicated by the completed Session Learning Outcome forms and Core Skills forms? Educator 1 Nam e: P DP(s) Completed? PDP Updated? Yes Yes No No Partial Partial If you have recorded No or Partial for the completion and/or updating of PDPs, please summarise discussion with the Lead Educator regarding plan for the completion of PDPs and the need to identify new development objectives during internal observation. Educator 2 Name: PDP(s) Completed? Yes No Partial PDP Updated? Yes No Partial If you have recorded No or Partial for the completion and/or updating of PDPs, please summarise discussion with the Lead Educator regarding plan for the completion of PDPs and the need to identify new development objectives during internal observation. DAFNE F03.004, Version 8 Feb of 23

15 Section C: Validating the internal peer review: observing sessions of a patient course being delivered. The timetable(s) and corresponding completed Audit Form F, provided by the centre to Central DAFNE, will placed in the labelled plastic wallet in the Auditor file prior to the visit. C1. Record reasons why sessions are omitted, if applicable? Record the time table ID (from Aud it Form F) and details of sessions omitted for all timetables which have sessions omitted. Information to be obtained from Lead DAFNE Educator Timetable ID (from Audit Form F) Number of Session omitted Name of Session omitted Reason C2. Does the timetabling of sessions follow a logical order for all timetables detailed in Audit Form F? Timetable ID (from Audit Form F) Course Format (i.e. Standard, 5 week or Pump Flow in logical order (Y/N) If no, please list reason(s) why Refer to Example 1 overleaf as a guide to session flow for Standard DAFNE and Pump and Example 2 for 5 week curriculum.. DAFNE F03.004, Version 8 Feb of 23

16 Session Title Day / Time of Day 1 Introduction and Organisation 1 st session Day 1 2 What is Diabetes Day 1 3 Nutrition 1 CHO & CPs Day 1 Nutrition 1 Glycaemic Index Any time 4 Lunchtime CP Estimation & Dose Daily: Mon Fri Adjustment lunchtime 5 Control / Targets By end of day 3 Individual Dose Adjustment / Action Plans - Mon Thu: end of the 6 pm day Individua l Dose Adjustment / Action Plans - Tue Fri: start of the am day 7 Insulin Regimen By end of day 3 Insulin Injection Technique By end of day 3 8 Insulin Pump Anytime (Standard DAFNE) By end of day 3 (Pump) 9 Nutrition 2 CP Practise By end of day 3 Nutrition 2 Snacks By end of day 3 10 Hypoglycaemia minor hypos By end of day 3 Hypoglycaemia severe hypos / g lucagon By end of day 3 Nutrition 3 Labels By end of day 3 11 Nutrition 3 Recipes Anytime Nutrition 3 Sweeteners Anytime Nutrition 3 Difficult Foods By end of day 3 12a 13a Principles of Dose Adjustment Step-wise Approach By end of day 3 12 Insulin Dose Adjustment - Reduction By end of day 3 13 Insulin Dose Adjustment - Escalation By end of day 3 14 Corrections By end of day 3 Nutrition 4 Eating Out Anytime Nutrition 4 Alcohol Anytime 15 Nutrition 4 Healthy Eating / Weight Anytime Management 16 Illness / Sick Day Rules After day 3 17 Physical Activity / Exercise Anytime 18 Theory of Goal Setting / Action Planning Anytime 19 Annual Review / Complications After day 3 Social Aspects Pregnancy Anytime 20 Social Aspects Driving Anytime Social Aspects Travel Anytime Social Aspects Employment / Benefits Anytime Action Planning Day 5 21 Quiz / Evaluation / Follow-up / DUG & dafneonline Final session Day 5 Example 1: Guide to session flow for Standard DAFNE and Pump curriculum DAFNE F03.004, Version 8 Feb of 23

17 Session Title Day / Time of Day 1 Introduction and Organisation Beginning of Week 1 2 What is Diabetes Beginning of Week 1 3 Nutrition 1 CHO & CPs Week 1 Nutrition 1 Glycaemic Index Week 1 4 Lunchtime CP Estimation & Dose Adjustment Weekly at lunchtime Meters Week 1 BG Targets Week 2 5 Monitoring & Control Week 3 DKA & Ketone Testing Week 4 DCCT Anytime (Week 5 workbook) 5x1 Taster and Action Planning End of day, Weeks Individual Dose Adjustment / Action Plans Beginning of Weeks Insulin Regimen Beginning of Week 2 Insulin Injection Technique Week 1 8 Insulin Pump Anytime from Week 2 9 Nutrition 2 CP Practise Week 1 Nutrition 2 Snacks Week 2 Hypoglycaemia treatment (ref GI) Week 1 10 Hypoglycaemia minor hypos Week 3 Hypoglycaemia severe hypos / glucagon Week 3 Nutrition 3 Labels Week 1 11 Nutrition 3 Recipes Anytime (Week 4 workbook) Nutrition 3 Sweeteners Anytime (Week 4 workbook) Nutrition 3 Difficult Foods Week 1 12a 13a Principles of Dose Adjustment Step-wise Approach Week 2 12 Insulin Dose Adjustment Reduction Week 2 13 Insulin Dose Adjustment Escalation Week 2 14 Corrections Week 2 Nutrition 4 Eating Out Anytime (Week 3 workbook) Nutrition 4 Alcohol Anytime (Week 3 workbook) 15 Nutrition 4 Healthy Eating / Weight Anytime (Week 4 workbook) Management 16 Illness / Sick Day Rules Week 4 17 Physical Activity / Exercise Week 3 18 Theory of Goal Setting / Action Planning Anytime (Week 4 workbook) 19 Annual Review / Complications Week 5 Social Aspects Pregnancy Anytime (Week 5 workbook) 20 Social Aspects Driving Anytime (Week 5 workbook) Social Aspects Travel Anytime (Week 5 workbook) Social Aspects Employment / Benefits Anytime (Week 5 workbook) Action Planning (5x1) Weeks Quiz End of Week 4 Evaluation / Follow-up / DUG & dafneonline End of Week 5 Example 1: Guide to session flow for 5 week curriculum DAFNE F03.004, Version 8 Feb of 23

18 Two sessions of the patient course, to include dose adjustment, must be observed being delivered by each Educator. You must complete Core Skills forms (F03.005) and relevant Session Learning Outcome forms (F03.006) for each of the Educators, these forms can be found at the back of this folder. The Core Skills forms that you complete must be compared with the Core Skills forms completed as part of internal QA of these two Educators (reference Section 5 of the DAFNE Professional Development files for both Educators). Evidence of philosophy observed must be provided in the Evidence to support decision text boxes below. Failure to do so could impact on the centre s overall audit score. C3. Was the DAFNE philosophy evident during Auditor observation? Name of Educator 1: Was philosophy evident during auditor observation? Yes No Partial Evidence to support decision (must be completed): Name of Educator 2: Was philosophy evident during auditor observation? Yes No Partial Evidence to support decision (must be completed): DAFNE F03.004, Version 8 Feb of 23

19 C4. Was the DAFNE philosophy evident during internal observation? Name of Educator 1: Was philosophy evident during internal o bservation? Yes No Partial Evidence to support decision (must be completed): Name of Educator 2: Was philosophy evident during internal observation? Yes No Partial Evidence to support decision (must be completed): DAFNE F03.004, Version 8 Feb of 23

20 C5. Core Skills forms: Is there common agreement between the comments made during internal observation and the comments you recorded for the 2 Educators observed delivering sessions during the audit? Educator 1 Name: Agree with Auditors assessment? Y es No Partial How many of the 27 items on the Core Skills form completed during internal observation have been correctly evidenced? Evidence from Core Skills forms in PD file to support decision and summary of discussion with the Lead Educator of the above differences if applicable. Educator 2 Name: Agree with Auditors assessment? Yes No Partial How many of the 27 items on the Core Skills form completed during internal observation have been correctly evidenced? Evidence from Core Skills forms in PD file to support decision and summary of discussion with the Lead Educator of the above differences if applicable. DAFNE F03.004, Version 8 Feb of 23

21 C6. Have all Session Learning Outcomes forms (located in Section 5 of the Professional Development file) been completed and is there agreement between Session Learning Outcome forms completed during internal observation and those that you have completed for the 2 Educators observed during audit? Educator 1 Name observed: Session Learning Outcome form completed durin g Yes No Partial internal QA? Session Learning Outcome form adequately Yes No Partial evidenced? Approx % of Essential Learning Outcomes evidenced: % Agree with Auditors assessment? Yes No Evidence to support decision Educator 2 Name observed: Session Learning Outcome form completed during internal QA? Yes No Partial Session Learning Outcome form adequately evidenced? Yes No Partial Approx % of Essential Learning Outcomes evidenced: % Agree with Auditors assessment? Yes No Evidence to support decision DAFNE F03.004, Version 8 Feb of 23

22 C7. Document below any concerns/ issues highlighted during the observation (eg. Inaccurate, dangerous advice, DAFNE Myths ) along with any discussion with the Lead Educator and any agreed action plans. DAFNE F03.004, Version 8 Feb of 23

23 Section D: Declaration The information reported in this form and the evidence made available to the Auditor are an accurate, reflection of the current internal QA practices at «Centre» and ensure the quality of our DAFNE service is maintained. Lead DAFN E Educator «Lead_Educator» Please print name Signature Date Auditor «Auditor» Please print name Signature Date DAFNE F03.004, Version 8 Feb of 23