Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Quality Assurance Systems
l) an accident/incident and complaints policy and procedure
m) a communication plan to ensure every staff member is aware of the
organisation’s quality objectives and how they can contribute
n) annual quality objectives that set specific and achievable targets
o) the nomination of a range of indicators that will be used to assess quality
and outcomes and provide a basis for recording and monitoring variance
p) the auditing of existing policy and procedures (clinical and non-clinical)
to ensure they are being implemented effectively
q) a process to identify opportunities for improvement during the year
(when the quality plan is already in progress) and enable project plans to
be developed, implemented and monitored
r) monitoring of performance against standards to identify trends and
ensure action plans are developed, implemented and reported on
s) performance standards reflecting both patient expectation and
professional requirements
t) monitoring of patient satisfaction
u) annual evaluation of the effectiveness of the system.
7.19 Quality activities are designed to prevent poor quality occurring, detect it at
the earliest opportunity and make improvements where it does occur to ensure
it is not an ongoing issue (ie, services are continuously improved).
7.20 Organisations may also participate in external peer review processes such as
accreditation. However, this should be complementary to, and not in place of,
other quality activities outlined above.
8. RECOMMENDATIONS
8.1 The effectiveness of the Tairawhiti District Health quality system should be
evaluated and changes made immediately to ensure a systematic approach to
quality improvement that ensures all services and staff have responsibility for,
and are involved in, quality activities.
8.2 In consultation with staff the definition of quality to be used should be
reviewed.
8.3 A robust quality planning process with involvement of staff should be
established and implemented.
8.4 A range of quality activities that reflect the needs of internal and external
customers should be undertaken.
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