Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Recommendations
15. The Quality Co-ordinator and clinical staff should be involved in the evaluation
of the effectiveness of the recently established Quality Facilitator and Quality
Administrator positions.
16. Management and staff should identify key performance indicators for the
organisation and individual services (clinical and non-clinical) and establish
acceptable/non acceptable levels against which performance is measured.
Incident reporting and complaints procedure
1. A cross-functional team (with clear terms of reference) should be established to
evaluate and further develop the current incident reporting system, with a
particular emphasis on developing a framework that guides: what to report; which
incidents will be reviewed; and by whom.
2. The purpose of the Incident and Complaint Management Policy should be
extended to include a statement that reflects the value of complaints/incidents as
learning opportunities for the organisation and as a component of continuous
improvement.
3. An internal investigation of a complaint or review of a reported incident should
lead to internal disciplinary processes or mandatory training only where there is
evidence of repeated poor performance that breaches professional standards of
conduct or constitutes a major departure from the standard of care and skill
reasonably to be expected in the circumstances.
4. Definitions of reportable incidents should be reviewed and consideration given to
clearly differentiating “incidents”, “near misses” and “adverse events”.
5. The layout and content of the incident report form should be reviewed and
consideration given to further information that it may be valuable to capture, such
as the location where the incident occurred, the outcome, contributing factors,
and whether the incident was preventable.
6. Numbers should be printed on the incident forms to enable tracking, and hard
copies should be kept in the reporting department.
7. Consideration should be given to categorising incidents (eg clinical/non-clinical;
major/minor; actual/potential) to enable investigation, reporting, quality
improvement and monitoring to be effectively targeted.
8. The text of the Incident and Complaint Management Policy should be reviewed
and requirements relating to incidents and complaints should be more clearly
differentiated from each other.
9. A standardised approach to incident investigation should be adopted across
Tairawhiti District Health to enhance consistency of investigations, reduce staff
anxiety and provide the basis for educating staff who have this responsibility.
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