Inclusion, exclusion and audit criteria

DEMO DATA

Confirm which referral episodes are in scope, review the local audit standards, then review the criteria applied to every episode.

OverviewHow to useProject setupTeamInclusion / exclusionData collectionDashboardSubmissionsFindingsImprovementRe-auditResourcesExport centreSettings
Inclusion criteria
Adapt locally before data collection begins.
  • •Adults aged 16 years or older unless locally adapted.
  • •Adult inpatient, ED, acute assessment, SDEC or ambulatory episodes where a specialty referral was made.
  • •Cases where a specialty referral should reasonably have been made but was delayed or omitted.
  • •Cases where delayed specialty review affected or may have affected diagnosis, treatment, discharge planning, length of stay or patient safety.
  • •Referrals to internal hospital specialty teams, advice services, liaison teams, therapy teams, pharmacy teams or critical care outreach where locally included.
  • •Referrals made using electronic referral, phone, bleep, email, EPR task, written form, paper referral or hybrid systems.
  • •Patients managed in selected wards, units, departments or pathways.
  • •Electronic, paper or hybrid records depending on local setup.
Exclusion criteria
Episodes outside the scope of this audit.
  • •Patients under 16 years old unless locally adapted.
  • •Maternity-specific referral pathways unless locally adapted.
  • •Outpatient referral waiting-list audits unless local scope includes them.
  • •External tertiary referrals where local governance scope excludes them.
  • •Emergency referrals requiring immediate life-saving escalation if these are reviewed through separate critical incident or emergency pathway audit.
  • •Referrals not clinically indicated or cancelled for appropriate clinical reasons.
  • •Duplicate records or duplicate referral episodes.
  • •Records outside the selected audit period.
  • •Records unavailable for review.
  • •Cases where local governance approval is required but has not been obtained.
  • •Direct patient identifiers entered into the tool.
Audit standards
Default local standards. Confirm or amend targets in Project setup before the audit cycle starts.
  1. S1
    At least 90% of relevant referral episodes should document the clinical question or reason for referral.
  2. S2
    At least 90% should document referral urgency or priority where required.
  3. S3
    At least 90% should have the referral made within the locally expected timeframe.
  4. S4
    At least 90% should have specialty review or advice completed within the locally expected timeframe.
  5. S5
    At least 90% should have advice or review outcome documented clearly.
  6. S6
    At least 90% should have action owner and next action documented where specialty advice is given.
  7. S7
    At least 90% of delayed referrals should have delay reason documented.
  8. S8
    At least 90% of referral delays affecting discharge should have discharge impact documented.
  9. S9
    At least 90% should have outstanding specialty advice handed over or included in discharge/follow-up where relevant.
  10. S10
    At least 90% should have specialty-referral-related safety concerns escalated or actioned where identified.
Audit criteria (29)
Each criterion is answered Yes, No, Not applicable or Unable to determine. Compliance is calculated from Yes and No responses only.
  1. 1
    Clinical question or reason for specialty referral was documented.
  2. 2
    Specialty referred to was documented clearly.
  3. 3
    Referral urgency or priority was documented.
  4. 4
    Referral was made within the locally expected timeframe after it became clinically indicated.
  5. 5
    Referral route used was appropriate to local policy and urgency.
  6. 6
    Referral information was complete enough for the specialty team to triage or respond.
  7. 7
    Referral was acknowledged, accepted or triaged where local system supports this.
  8. 8
    Specialty advice or review was completed within the locally expected timeframe.
  9. 9
    Senior specialty review was completed where required by local policy or clinical context.
  10. 10
    Advice or review outcome was documented clearly.
  11. 11
    Management recommendation was documented where advice was given.
  12. 12
    Investigation, procedure, transfer or treatment recommendation was documented where relevant.
  13. 13
    Action owner for specialty advice was documented.
  14. 14
    Specialty recommendation was actioned within local expected timeframe where required.
  15. 15
    Reason for delayed referral, delayed review or delayed action was documented where applicable.
  16. 16
    Interim clinical management plan was documented while awaiting specialty advice where relevant.
  17. 17
    Alternative specialty, pathway or escalation route was considered where appropriate.
  18. 18
    Outpatient, planned review or community option was considered where safe and appropriate.
  19. 19
    Impact on diagnosis was documented or inferable.
  20. 20
    Impact on treatment decision was documented or inferable.
  21. 21
    Impact on discharge readiness, expected discharge date or length of stay was documented or inferable.
  22. 22
    Criteria-to-reside or discharge readiness impact was reviewed where relevant.
  23. 23
    Referral delay was escalated according to local policy where escalation criteria were met.
  24. 24
    Specialty team was re-contacted or referral chased where delay persisted and review remained required.
  25. 25
    Outstanding referral or advice was handed over clearly where relevant.
  26. 26
    Discharge summary included outstanding specialty advice, follow-up or action where relevant.
  27. 27
    Patient was informed about delay, outcome or follow-up where appropriate.
  28. 28
    Documentation was clear enough for another clinician or coordinator to understand referral status, delay reason, owner and next action.
  29. 29
    Any specialty-referral-related patient safety concern was escalated or actioned where identified.
Services this audit supports
Configure the specific wards, departments, specialties and services in Project setup.
acute medicine
general internal medicine
emergency departments
acute medical units
same-day emergency care
inpatient medical wards
inpatient surgical wards
frailty units
older people’s medicine
respiratory medicine
cardiology
gastroenterology
renal medicine
neurology
oncology
haematology
endocrinology
infectious diseases / microbiology
palliative care
mental health liaison
surgical specialties
orthopaedics
critical care outreach
therapy teams
pharmacy teams
discharge teams
patient flow teams