Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Quality Assurance Systems
4.23 Activities THL sought to have covered by the notice include:
• examination of patient records
• analysis of patient data (admission, discharge, mortality, morbidity,
outcomes of treatment)
• identification and analysis of good and adverse outcomes
• holding of peer review meetings
• review of patients’ care/treatment decisions
• monitoring of performance of individual medical practitioners
• making of recommendations on how medical practitioners can improve
performance
• facilitation and monitoring of the implementation of any such
recommendations
• review of incidents.
4.24 Of these areas, monitoring of the performance of the medical staff has not yet
been addressed. The Human Resources Manager stated that “the ASPIRE
system has not been adopted by medical staff. There is no formal system for
performance assessment of medical staff. Credentialling has not been
introduced, although medical staff are motivated towards using credentialling
and know the models they want to use.”
Other forums for medical staff
4.25 Other forums for medical staff in the Paediatric and Medical departments to
discuss medical problems include senior medical officers’ lunches, Grand
Rounds and orthopaedic Grand Rounds (twice weekly). Regular monthly
Paediatric/Obstetrics meetings and monthly meetings with Radiology have
recently been set up and a combined Surgical meeting has now commenced.
Standard of nursing practice
4.26 Historically there had not been formal standards of nursing care, but
procedures and policies had been developed. In early 1999, formal standards
of nursing care were developed through the Clinical Practice Committee and
Nursing Reference Group, but enforcement of these had fallen by the wayside
in the absence of a Director of Nursing. The Group Manager (Hospital)
(formerly the Director of Nursing) advised that there are no formal strategies
in place to monitor nursing standards. There is a compliance checklist for
policies. The format for the development of organisational policies requires
outcome standards so it was proposed that an audit regime be developed to test
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