Governance reminder
Lazomis QI supports improvement planning and documentation. It does not replace clinical judgement, local policy, professional responsibility or organisational governance processes. Agree all improvement activity locally before implementation.
1. Improvement summary
Generated from current project data — editable.
2. Analysis of findings
What is working well, where performance is variable, and where documentation is incomplete.
3. Key gaps identified
Derived from criterion-level compliance below the local target.
86%
Criterion 1: Clinical question or reason for specialty referral was documented.86%
Criterion 3: Referral urgency or priority was documented.57%
Criterion 4: Referral was made within the locally expected timeframe after it became clinically indicated.86%
Criterion 6: Referral information was complete enough for the specialty team to triage or respond.86%
Criterion 7: Referral was acknowledged, accepted or triaged where local system supports this.29%
Criterion 8: Specialty advice or review was completed within the locally expected timeframe.86%
Criterion 13: Action owner for specialty advice was documented.71%
Criterion 14: Specialty recommendation was actioned within local expected timeframe where required.83%
Criterion 15: Reason for delayed referral, delayed review or delayed action was documented where applicable.71%
Criterion 21: Impact on discharge readiness, expected discharge date or length of stay was documented or inferable.83%
Criterion 23: Referral delay was escalated according to local policy where escalation criteria were met.86%
Criterion 25: Outstanding referral or advice was handed over clearly where relevant.86%
Criterion 28: Documentation was clear enough for another clinician or coordinator to understand referral status, delay reason, owner and next action.4. Possible causes
Framed as possible contributing factors, not definitive diagnoses.
5. Improvement aim
Specific, measurable, achievable, relevant, time-bound.
6. Suggested local improvement actions
Suggested local implementation ideas based on current findings — not national guidance.
- •Make referral urgency and clinical question mandatory fields on the electronic referral form. (Criterion 1 at 86%)
- •Agree and publish local specialty response timeframes by urgency category. (Criterion 3 at 86%)
- •Record a named action owner for every piece of specialty advice. (Criterion 4 at 57%)
- •Review outstanding specialty referrals at daily board rounds and at weekend handover. (Criterion 6 at 86%)
- •Agree a re-contact/chase process where specialty review remains outstanding beyond the local timeframe. (Criterion 7 at 86%)
- •Include outstanding specialty advice and follow-up in discharge documentation. (Criterion 8 at 29%)
7. Action plan
Editable local action plan. Saved to this browser until live project saving is used.
Add local improvement actions here.
8. PDSA cycles
Add details of PDSA cycles or interventions here.
Add details of PDSA cycle or intervention here.
9. Sustainability considerations
10. Re-audit / next-cycle plan
11. Learning points
12. Governance summary
13. ARCP / portfolio evidence summary
Populates the ARCP evidence output in the Export centre.
Improvement themes
Common action areas for specialty referral delay improvement work.
early recognition of specialty advice need
referral question quality
referral completeness
referral urgency and prioritisation
correct referral route use
electronic referral workflow
referral acknowledgement and triage
urgent specialty escalation
specialty response times
senior specialty review availability
acting on specialty advice
ownership of specialty recommendations
re-contact / chase process for delayed reviews
weekend and out-of-hours specialty referral pathways
referral delay impact on discharge
criteria-to-reside and specialty referral review
board round review of outstanding referrals
handover of outstanding referrals
discharge communication and follow-up
patient communication and safety-netting
EPR prompts and referral tracking
feedback between parent and specialty teams
incident learning and governance review
re-audit and sustainability