Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Quality Assurance Systems
Policies and procedures
4.33 A number of groups are involved in the development and/or approval of
policies or procedures including:
• the SMG, which defines and sets quality goals
• the Q&RMC, which makes recommendations for policy development
to the Chief Executive
• the Clinical Board, which reviews, formulates and recommends clinical
decisions and policies to the THL Board of Directors
• the Infection Control Committee, which develops and recommends
clinical policy and procedures to the Chief Executive
• the Clinical Practice Committee, which formulates, reviews and revises
the policies/protocols and procedures that guide clinical
nursing/midwifery practice.
4.34 The Quality Co-ordinator has developed a database policy review mechanism
to indicate when policy updates are due. It is now specified in Unit Manager
job descriptions and performance requirements that unit policy review is their
responsibility. This occurred as a result of Quality Health New Zealand
feedback.
4.35 Departmental managers are responsible for updating manuals on their wards,
and there is an unwritten expectation that staff will then be updated on policy
updates.
Closing the loop
4.36 A number of interviews carried out by investigators highlighted that closing
the loop, or completing actions to finish or follow up issues, is not consistently
being achieved at THL. For example, there was a recommendation from the
Technician Training Board that anaesthetic technicians at Tairawhiti
Healthcare needed further training. One recommendation was that trainees go
to a larger hospital for about two weeks to increase their confidence, share
ideas with others about ways to manage issues and to see how procedures are
done elsewhere. To date this has not occurred. This is not to suggest that
every recommendation made by an external body must be followed, but it
should be considered and, if disagreed with, reasons given.
4.37 Nurses reported that one of their concerns is lack of feedback from the process
of filling in incident forms. It is not known if similar errors occur again as
there are no trends to look at. They reported there was more information
available two years ago. There used to be a report on incident forms sent to
the wards.
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