2. Self Audit Questionnaire: Preliminary results in Ireland Ann O’Riordan, Miriam Gunning European Network of Smoke-free Hospitals Prof. Luke Clancy (Chair) Ann O’Riordan (Director) Irish Health Promoting Hospitals Network

3. Self audit questionnaire in Ireland Irish Smoke-free Health Service Initiative developed in line with the European Code for Smoke-free Hospitals and national legislation was established 2000. ENSH Self audit questionnaire was incorporated into the Irish Smoke-free Health Service Initiative in 2001. The Irish Initiative has four distinct stages, hospitals that reach stage four can categorise themselves as being bronze, silver or gold by using the self audit questionnaire. Results presented here are from 25 (68%) of the initial 37 hospitals invited to use the self audit questionnaire

4. Irish Smoke-free Health Service Initiative Process Expression of Interest Statement of Commitment Completion of Self-Appraisal Assessment Form Return of Baseline Survey Questionnaire Development of Action Plans Evaluation - Process, Impact & Outcome Document and Share Experiences

5. Developmental Stages Irish Smoke-free Health Service Initiative First stage: Interest Register interest, nominate a focal person and establish a working group Second stage: Membership Status Review current practices within the organisation and develop an action plan. Third stage: Dedicated Status Evaluate progress after 12 months participation in the national initiative. Fourth stage : European Registration Bronze, Silver or Gold on the European Smoke-free Hospital Register.

6. Participation in Initiative up to June 2003 Invited:271 1st Stage:60 2nd Stage: 7 3rd Stage:7 4th Stage:37

7. National & European SFHI The initial 37 hospitals to participate in the initiative were surveyed pre and post 2 year project period (Jan`01–Dec `02)

8. Initial 37 Committed Hospitals by Hospital Type Research and analysis of data conducted for the Irish HPH Network by the Department of Public Health Medicine and Epidemiology, UCD (NUI Dublin)

9. Irish Smoke Free Health Service Initiative Preliminary Results At the end of 2002, the 37 hospitals had reached stage 4 and were sent the self audit questionnaire To date 68% (25) of the 37 have returned completed questionnaires and have been awarded certificates reflecting the categorisation on the register for the European Network of Smoke Free Hospitals –9 organisations received Membership Level –6 organisations received Bronze Level –10 organisations received Silver Level

10. 1. POLICY

11. 2. WORKING GROUP

12. Education & Prevention

13. Information & Cessation Service

14. Smoking Cessation Service

15. Cessation Support

16. Cessation Service Follow Up

17. Smoking Cessation Rates

18. Tobacco Control

19. Environment

20. Review & Compliance

21. Monitoring

22. Problems Encountered with self audit questionnaire To overcome incorrect scoring, the main question, along with sub-questions in a different shade Under Section 4.6 - Identify Clients, eg. Staff, Patients, Visitors etc. and offer separate scoring options Under Section 5.2 - suggest this be divided into two parts Under Section 5.3 - suggest this be deleted as scientists say that there is no safe level of exposure to carcinogens Under Section 6.1 - suggest dividing into two parts Under Section 9.3 - suggest dividing into three parts Total amount was incorrect and has been changed Offer different options for scoring - some answers not relevant

23. General Questionnaire Feedback General feedback - positive, helpful tool to identify what areas need attention, provides a guide for policy development and an opportunity to ensure that progress is kept on track. Organisations - viewed it as a good tool to bring back to management as evidence of what has been and needs to be achieved. The main negative feedback on the questionnaire appears to be with the scoring system, which seems to have caused some confusion. Recommendation - provide supportive literature to accompany the questionnaire.