Appendix 1: Examples of organisational and process audit standards

Question no	Standard	Rationale	Help notes	Where most likely documented
(A) Examples of organisational audit standards with help notes
Staff knowledge/skills
1.8	Expertise: Patients' management and care is planned and provided by professionals with expertise in the management of stroke	Research evidence demonstrates the importance of medicine and nursing with specialist interest and knowledge of stroke (A).²⁴	Medicine: a physician with special interest in stroke manages or provides advice on the management of stroke patients.
		Recommendations of the professional colleges.²⁵^–²⁷	Nursing: the system of nursing facilitates the involvement of qualified nurses (with postgraduate/registration education in stroke rehabilitation) in direct patient care.^{28 29}
	(a) Medical treatment
	(b) Nursing care
	(c) Occupational therapy
	(d) Physiotherapy		Occupational therapy: the occupational therapy stroke service is under the overall supervision of a senior occupational therapist with at least 5 years experience, of which at least 3 is in neurology.²⁷
	(e) Speech/language therapy
			Physiotherapy: senior physiotherapist experienced in stroke rehabilitation or with access to specialist supervision.²⁶
			Speech & language therapy: specialist in acquired neurological communication and swallowing difficulties or with access to specialist supervision.²⁵
Communication with patients and carers
1.17	The organisation of the ward/unit ensures that patients and carers have access to their management plan.	So the patient/carer can understand the rehabilitation/treatment plan and participate actively in its achievement. Research suggests that the involvement of carers in the rehabilitation process may be a significant factor in clinical outcomes from rehabilitation. (A).²⁴	The management plan is kept near the patient's bed (e.g. at the end of the bed) where she/he and the carer can refer to it.
(B) Examples of process audit standards with help notes
2.1	Initial assessment
2.1.1b i)	Full neurological assessment (cont): Patients are routinely screened with a standardised screening procedure to check for dysphagia.	The ability to swallow should be assessed within 24 hours of admission. Difficulties may be temporary but carry increased risk of complications (B).^{30 31}	Refers to a formal swallow screen (performed by any member of the team). Presence or absence of the gag reflex is not sufficient as it is proven to be of little prognostic value for the ability to swallow.³² (Cf 2.2.1 for speech therapy assessment)	Team, medical or nursing records
2.1.3	A brain scan is carried out within 24 hours where cerebral or subarachnoid haemorrhage is suspected, or if a patient is on warfarin, or if anticoagulation or thrombolysis is considered.	Haemorrhage is visible on CT scan immediately. Patients with haemorrhage may need surgical intervention. Imaging is also used to exclude haemorrhage before starting thrombolysis, aspirin, or anticoagulation (B).³³	Notes mention suspected haemorrhage and CT or MRI scan. NB This refers only to emergency scanning and is relevant only in the cases where haemorrhage is suspected in the first 24 hours after stroke. Where haemorrhage is not suspected the answer will be “No but ...”	Team or medical records
3	Management plan
3.1	There is written evidence of rehabilitation goals agreed by the multidisciplinary team.	Team goals (both short and longer term) promote forward planning and provide the framework for coordinated multidisciplinary care. If realistic, they can also help to motivate the patient. (C)	This refers to the team goals for each patient ie not those of individual disciplines. Auditors should identify with their clinicians how these would be documented within their trust. Where it is documented that the team plan is palliative care answer “No but . . .”	Team, medical, nursing or therapy notes