Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Quality Assurance Systems
policy compliance. The Group Manager (Hospital) advised that a tool to test
policy compliance began to be drafted in 1999 and it was intended that the
nursing leaders would develop a nursing audit regime but this never happened.
THL responded that, while monitoring may not have occurred, adherence to
nursing standards did continue during this period.
4.27 The recently appointed Director of Nursing described the fundamentals of
nursing care at Gisborne Hospital as “superb” but noted that nursing standards
are not in place at Gisborne Hospital, and the monitoring of standards of
nursing practice is extremely informal. There is no structure in place in theatre
to audit the quality of nursing care delivered. Nursing staff and anaesthetic
technicians stated seniors monitor juniors informally.
Nursing quality activities
4.28 With continuing staff shortages it has been difficult to get quality initiatives
off the ground but some progress has been made. Initiatives underway in the
surgical area include:
• an audit of care plans and feedback to staff
• quality initiatives on staff meeting agenda
• quality meetings on a Friday
• one policy a week put out to staff to draw their attention to it.
4.29 Other quality activities in place that relate to the quality of nursing practice are
audit programmes on infection control and staff education.
4.30 Perceptions of what is in place vary. The Inpatient Co-ordinator has
conducted an audit of nursing documentation. Her first priority is to assess the
effectiveness of a tool related to assessment and planning of care. Staff will
also audit each other to see how others work; in this way self-assessment will
be a component of the audit programme.
4.31 The Quality Co-ordinator noted that some nursing documentation audits have
been done recently. No formal staff satisfaction surveys are in place.
Incident reporting
4.32 Details of incident reporting and complaint management are set out in chapter
3.
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