Inclusion, exclusion and audit criteria

DEMO DATA

Who to include, who to exclude, and the 32 audit criteria measured in this cycle.

OverviewHow to useProject setupTeamInclusion / exclusionData collectionDashboardSubmissionsFindingsImprovementRe-auditResourcesExport centreSettings
Inclusion criteria
  • •Adult inpatients aged 16 years or older
  • •A capacity question arose for a specific decision during the current admission
  • •Decisions include: medical treatment or investigation, refusal of treatment, discharge destination, DNACPR / escalation of care, safeguarding, placement or residence, restraint or restriction, nutrition and hydration, or other significant decisions
  • •Electronic, paper or hybrid records depending on local setup
Exclusion criteria & limitations
  • •Patients under 16 years old
  • •Capacity assessments performed prior to the current admission
  • •Purely emergency doctrine situations where there was no time for a capacity assessment
  • •Cases where capacity was clearly presumed and no decision required assessment
  • •Records unavailable for review or outside the audit period
  • •Direct patient identifiers must not be entered into the tool
Documentation
Aligned with the Mental Capacity Act 2005, MCA Code of Practice, NICE NG108 and local trust policy. Compliance is calculated using Yes and No responses only; Not applicable and Unable to determine are excluded from the denominator.
  1. C01
    The specific decision being assessed was clearly documented.
    Target ≥ 90%
  2. C02
    The assessment was decision-specific.
    Target ≥ 90%
  3. C03
    The assessment was time-specific.
    Target ≥ 90%
  4. C05
    Evidence prompting the capacity assessment was documented.
    Target ≥ 90%
  5. C06
    Impairment or disturbance of mind or brain was documented where capacity was questioned.
    Target ≥ 90%
  6. C07
    The relevant information for the decision was documented.
    Target ≥ 90%
  7. C14
    A clear conclusion about capacity for the specific decision was documented.
    Target ≥ 90%
  8. C16
    The person's wishes, feelings, values, beliefs or preferences were documented where possible.
    Target ≥ 90%
  9. C17
    Risks, benefits and reasonable alternatives were documented where relevant.
    Target ≥ 90%
  10. C27
    Outcome, decision or action plan was clearly documented.
    Target ≥ 90%
  11. C30
    Reason for delayed, missing or incomplete assessment was documented where applicable.
    Target ≥ 90%
  12. C31
    Documentation was clear enough for another clinician or professional to understand the capacity assessment, conclusion and next actions.
    Target ≥ 90%
Process and support
Aligned with the Mental Capacity Act 2005, MCA Code of Practice, NICE NG108 and local trust policy. Compliance is calculated using Yes and No responses only; Not applicable and Unable to determine are excluded from the denominator.
  1. C04
    The presumption of capacity was reflected unless there was evidence requiring assessment.
    Target ≥ 90%
  2. C08
    Practical support to help the person make the decision was documented.
    Target ≥ 90%
  3. C09
    Communication support, interpreter, advocate or communication aid was used or considered where relevant.
    Target ≥ 90%
  4. C15
    Fluctuating capacity or need for reassessment was considered where relevant.
    Target ≥ 90%
  5. C28
    The decision was communicated to the MDT, ward team or relevant professionals where appropriate.
    Target ≥ 90%
  6. C29
    Review date, expiry date or reassessment plan was documented where local policy requires it.
    Target ≥ 90%
Functional elements (understand, retain, use/weigh, communicate)
Aligned with the Mental Capacity Act 2005, MCA Code of Practice, NICE NG108 and local trust policy. Compliance is calculated using Yes and No responses only; Not applicable and Unable to determine are excluded from the denominator.
  1. C10
    The person's ability to understand relevant information was assessed.
    Target ≥ 90%
  2. C11
    The person's ability to retain relevant information was assessed.
    Target ≥ 90%
  3. C12
    The person's ability to use or weigh relevant information was assessed.
    Target ≥ 90%
  4. C13
    The person's ability to communicate the decision was assessed.
    Target ≥ 90%
Best interests decision-making
Aligned with the Mental Capacity Act 2005, MCA Code of Practice, NICE NG108 and local trust policy. Compliance is calculated using Yes and No responses only; Not applicable and Unable to determine are excluded from the denominator.
  1. C18
    Best interests decision-making was documented where the person lacked capacity.
    Target ≥ 90%
  2. C19
    Options considered as part of best interests decision-making were documented where relevant.
    Target ≥ 90%
  3. C20
    Least restrictive option was considered where relevant.
    Target ≥ 90%
  4. C21
    Family, carer or important-person consultation was documented where appropriate.
    Target ≥ 90%
  5. C22
    IMCA referral was considered or completed where required.
    Target ≥ 90%
  6. C23
    LPA, deputy, ADRT or advance statement status was considered where relevant.
    Target ≥ 90%
Escalation and safety
Aligned with the Mental Capacity Act 2005, MCA Code of Practice, NICE NG108 and local trust policy. Compliance is calculated using Yes and No responses only; Not applicable and Unable to determine are excluded from the denominator.
  1. C24
    Safeguarding concern was considered or escalated where relevant.
    Target ≥ 90%
  2. C25
    DoLS or deprivation of liberty concern was considered or escalated where relevant.
    Target ≥ 90%
  3. C26
    Disagreement, conflict, uncertainty or unresolved legal concern was escalated where relevant.
    Target ≥ 90%
  4. C32
    Any mental capacity, consent, safeguarding or best interests safety concern was escalated or actioned where identified.
    Target ≥ 100%