Gisborne Hospital Report - Health and Disability Commissioner

Chapter 2
Quality Assurance Systems
1. INTRODUCTION
Overview of quality structure
1.1 In 2000 the Tairawhiti Healthcare Ltd (THL) quality structure consisted of the
Chief Executive, Senior Management Group, Core Quality Group, Quality and
Risk Management Committee, Group Managers, Clinical Directors and three
quality resource roles (Quality Co-ordinator, the Infection Control Nurse and
the Occupational Health Nurse).
1.2 The committee structure supporting quality consisted of the Clinical Board and
a range of committees. These committees included Core Quality, Quality and
Risk, Clinical Records, Maternity Services, Medicines and Therapeutics,
Control of Infection, Medical Appointments, Medical Credentialling, the
Nursing Reference Group and the Wound Management Group.
1.3 Terms of reference were available for all committees except the Medical
Credentialling Committee, the Wound Management Group and the Maternity
Services Committee.
1.4 Also in place, but not presented on the quality structure diagram, is the Board
of Directors’ Audit Committee. This committee reported directly to the Board
and at any one time consisted of a chairperson and two other Board members.
The committee employed Mr Clive Gough from Gough, Brown Giffney Ltd as
an external contracted auditor. On its own initiative and with assistance from
management, this committee identifies the key projects to be reviewed each
year. The extent of clinical input to this process was not specified.
1.5 THL informed me that the Board has established an audit (financial)
committee and intends to establish a quality committee when additional Board
members are appointed.
1.6 The Senior Management Group minutes of 13 April 2000 recorded discussion
on an alternative draft structure diagram developed by the Human Resources
Manager, the Chief Executive and the Quality Co-ordinator showing how
quality related to the overall structure of THL. The Human Resources
Manager was to review all committees to determine where/if they should be
included in the quality structure. THL explained that “the drive came from the
Board’s desire to have an accredited hospital”.
Senior Management Group (SMG)
1.7 The Senior Management Group was established in November 1998. It is made
up of the Chief Executive, Group Managers, Hospital and Community,
Clinical Directors and the Corporate Managers (Human Resources, Finance,
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