SELFAUDIT

QUESTIONNAIRE

 

Country:
Region:
Name of the institution:
Adress:
Zip Code: * If your country do not has Zip code please enter 0000
City:
Contact person:
Phone: Fax:
Mail : * The result will be sent to this address

Characteristics of the institution
Level of the health care centre
  • University Hospital
  • Regional Hospital
  • General Hospital
  • Specialty Hospital
  • Specify
  • Community Hospital
  • Day -care hospital
  • Nursing home
  • Primary care centre
  • GP Clinic
  • Others
  • Specify
Number of beds
Number of staff

 

The maximun score of the Self-audit Questionnaire is 168 points 1 Point 2 Points 3 Points 4 Points
 Standard 1: Commitment     No / Not implemented    Less than half implemented    More than half implemented    Yes / Fully implemented 
 1.1 The healthcare organisation documents specify commitment to a policy towards the implementation of the ENSH Standards.  
 1.2 The healthcare organisation does not accept any sponsorship from the tobacco industry.  
 1.3 A policy working group or committee is designated to coordinate the development, implementation and monitoring of the tobacco-free policy.  
 1.4 A senior manager has responsibility for the actions of the policy working group or committee.  
 1.5 Financial and human resources are allocated in the healthcare organisation’s operational plan and/or contract to implement and monitor the tobacco-free policy.  
 1.6 All staff understand their responsibility to take action in the implementation and management of the tobacco-free policy.   
 Standard 2: Communication     No / Not implemented    Less than half implemented    More than half implemented    Yes / Fully implemented 
 2.1  All healthcare personnel (including teachers, students and transient staff) are informed of the organisations tobacco-free policy.  
 2.2 All contract and outsourced employees working within or in direct contact with the healthcare organisation are informed of the tobacco-free policy.  
 2.3  All patients/residents (in and out-patients) are informed of the healthcare organisation’s tobacco-free policy.  
 2.4  Public is informed of the healthcare organisation’s tobacco-free policy.  
 Standard 3: Education & Training     No / Not implemented    Less than half implemented    More than half implemented    Yes / Fully implemented 
 3.1 Policy briefing/instruction is provided for all personnel on how to tobacco-users smokers and inform them of the organisations tobacco-free policy.  
 3.2 Managers and clinical personnel are provided with mandatory policy briefings/ instruction.  
 3.3 Brief intervention training is offered and available to all personnel.  
 3.4  Key clinical personnel are trained in motivational and tobacco cessation techniques.   
 Standard 4: Identification & Cessation Support     No / Not implemented    Less than half implemented    More than half implemented    Yes / Fully implemented 
 4.1 A systematic procedure is in place to identify and document the tobacco status of all patients/residents.  
 4.2 The systematic procedure includes and records  the passive smoking status (in accordance with national definitioin) of all patients/ residents (including babies/children).
 4.3 A tobacco cessation service or direct access to  cessation service is available for patients/  residents (in-patients and out-patients).  
 4.4 Interventions to motivate tobacco users to quit during  the healthcare stay are documented in the  patient/ resident care plans  
 4.5 NRT/Pharmacological therapy is available  within the organisation.  
 4.6 Specific resources have been allocated for  cessation support activities within the  organisation.  
 4.7 The cessation service provided or accessed  by the healthcare organisation, has in place a  systematic one year follow-up procedure.  
 4.8 Information on tobacco and tobacco cessation  methods are widely available in the organisation   
 Standard 5: Tobacco Control     No / Not implemented    Less than half implemented    More than half implemented    Yes / Fully implemented 
 5.1  The campus (grounds) and property owned by the healthcare organisation are completely tobacco-free.  
 If 5.1 is fully implemented, a total score for this section is automatically awarded IF NOT questions 5.1 – 5.5 must be completed   
 5.2  All facilities used by staff & visitors are tobacco free including all eating, work and common areas  
 5.3 All facilities used by patients/residents are tobacco free including all treatment, eating and common areas.  
 5.4 All transport, terrace and balconies operated and owned by the healthcare organisation are completely tobacco free.  
 5.5  If tobacco is used, it is completely away and separate from designated tobacco free areas, windows and entrances.   
 Standard 6: Environment     No / Not implemented    Less than half implemented    More than half implemented    Yes / Fully implemented 
 6.1  Signage indicating the tobacco free policy is visible to staff, patients/residents and visitors.  
 6.2 Smoking areas are not allowed, but if some still remain ashtrays are only found in these areas.  
 6.2.1 Staff are never exposed to passive smoking.  
 6.3.2 Patients/residents are never exposed to tobacco use or passive smoking.  
 6.3.3 Visitors are never exposed to passive smoking.  
 6.4 Tobacco is not sold or available anywhere within  the healthcare organisation.   
 Standard 7: Healthy Workplace     No / Not implemented    Less than half implemented    More than half implemented    Yes / Fully implemented 
 7.1.1 All personnel are informed of the healthcare  organisation’s tobacco-free policy during the  recruitment process.  
 7.1.2 All personnel employment contracts require a  commitment by staff to the healthcare  organisation’s tobacco-free policy  
 7.2 personnel tobacco use prevalence is monitored annually.  
 7.3 A tobacco cessation service or direct access to a  cessation service is available for all staff.  
 7.4 Non-compliance by personnel is managed within  existing local disciplinary procedures.   
 Standard 8: Health Promotion     No / Not implemented    Less than half implemented    More than half implemented    Yes / Fully implemented 
 8.1 The healthcare organisation has participated in one or more local, national or international tobacco free activities within the last 12 months.   
 Standard 9: Compliance Monitoring     No / Not implemented    Less than half implemented    More than half implemented    Yes / Fully implemented 
 9.1 The tobacco-free policy is internally monitored and reviewed annually.  
 9.2 The quality of the tobacco free action plan has been reviewed and updated within a three year period.   
 Standard 10: Policy Implementation    No / Not implemented    Less than half implemented    More than half implemented    Yes / Fully implemented 
 10.1 The healthcare organisation completes the ENSH self-audit questionnaire annually.  

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