Governance reminder
Lazomis QI supports quality improvement planning and documentation. It does not replace clinical judgement, local consent policy, the Mental Capacity Act, safeguarding procedures, professional responsibility or organisational governance processes. Ensure all improvement activity is agreed and implemented in accordance with local requirements.
1. Baseline findings summary
Generated from current project data.
Overall compliance across all 31 criteria was 77.1% (is below the local standard of ≥ 90% (gap of 12.9 percentage points)). 6 criteria met the local target and 25 fell below it. Documentation of the specific decision was 97.9%, patient involvement 89.6%, material risks 72.9%, reasonable alternatives 60.4%, capacity consideration 79.6%, consent form completion where required 93.5%, communication support where required 84.1% and agreed decision and action plan 89.8%. The strongest criterion was criterion 1 at 97.9%. The weakest was criterion 11 at 51.1%.
2. Key gaps identified
Derived from criterion-level compliance and documentation gaps.
- Overall consent documentation compliance is 77.1% across 54 consent episodes reviewed, with 6 of 31 criteria meeting the local target and 25 below target.
- The weakest criterion is criterion 11 (51.1% against a 90% target): Likely consequences of accepting, declining or delaying the intervention were documented where relevant.
- Compliance varies by location, from 80% (Acute Medical Unit) to 73.4% (Endoscopy Unit); local workflow and template differences may explain part of this variation.
- The most frequently recorded reason for delayed, incomplete or absent consent documentation is "Risks not documented" (6 episodes).
- 2 consent-related safety, capacity, safeguarding or governance concerns were identified and should be reviewed through local escalation routes.
- 47 criterion responses were recorded as "Unable to determine"; where this is frequent, record availability may be limiting interpretation.
3. Possible causes
People · Process · Environment · IT · Documentation · Communication · Training · Workload
4. Improvement aim
What are you trying to improve, by how much, for whom, and by when?
5. Action plan
Suggested local improvement actions based on the findings — all fields are editable.
6. PDSA cycles
Record each test of change and what was learned.
Add details of PDSA cycle or intervention here.
7. Sustainability considerations
8. Learning points
9. Governance summary
10. ARCP / portfolio evidence
Improvement themes
Common local improvement themes for consent documentation.
Documenting the specific decision
Meaningful consent discussion documentation
Recording patient preferences and priorities
Documenting material risks
Documenting alternatives and option of no treatment
Consent form completion and review
Capacity consideration and escalation under the Mental Capacity Act
Interpreter and accessible information documentation
Consent for procedures and invasive interventions
Consent for transfusion, contrast, sedation or anaesthesia where relevant
Refusal or withdrawal of consent documentation
Chaperone documentation where relevant
Handover and transfer communication
Discharge communication where relevant
EPR consent prompts and templates
Procedure-specific consent checklists
Staff education and induction
Feedback to clinical teams
Incident learning and governance review
Re-audit and sustainability