Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Quality Assurance Systems
1.28 A new quality person has recently been appointed for mental health services.
No formal link to the Quality Co-ordinator has been identified. However, the
Quality Co-ordinator indicated that they could provide support to each other.
2. QUALITY PLANNING PROCESS
2.1 The Quality and Risk Management Policy states that the Chief Executive is
responsible for ensuring that a comprehensive and effective quality and risk
management programme is developed and evaluated at least annually.
2.2 THL’s 2000-2001 Business Plan notes that THL is wanting to shift to a culture
of continuous improvement. The quality component of the THL 2000-2001
Business Plan lists strategies for the current year. These are to:
• promote and support a customer service focus
• achieve and maintain compliance with appropriate standards
• integrate and co-ordinate delivery of care that meets or exceeds
expectations
• achieve external accreditation.
2.3 Accountabilities and time frames for achieving these strategies are not stated,
and there is no overview of other aspects of the quality programme – eg, the
audit and clinical indicator programmes. No evidence was sighted of an
annual evaluation of the quality and risk management programme. Terms of
reference for committees and groups that form the quality structure do not
state where accountability lies for annual evaluation. In reply, THL pointed
out that the service plans and Business Plan included numerous specific
quality projects and improvement targets, as well as requiring monthly
progress reports to the Board.
2.4 Interviews indicated a lack of staff involvement in the quality planning process
and a perception that it was a financially driven process, although THL stated
that there are no financial obligations tied to achievements with the quality
assurance programme. In an attempt to address staff’s lack of participation
and increase their knowledge the Quality Co-ordinator held workshops on
accreditation and standards around the hospital. The first workshop looked at
quality and staff were encouraged to participate in the development of their
own service quality plans.
2.5 The Quality Co-ordinator was concerned about the lack of alignment between
the THL Business Plan and individual service plans. It appears the links
between individual services and management, in relation to service goals, are
not well developed.
2.6 The Chief Executive stated that business and service plans set out individual
service objectives in terms of quality, and line managers are accountable for
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