Gisborne Hospital Report - Health and Disability Commissioner

3. THE ENVIRONMENT
3.1 My investigation team found a traumatised community within Gisborne
Hospital, and a worried community beyond. Relationships between
management and clinical staff were strained. Senior doctors and nurses felt
disenfranchised, unable to exercise an effective clinical voice in management
decisions. Suspicion and distrust was endemic, and senior managers were
targets for criticism.
3.2 THL instituted major changes, including restructuring of the medical and
surgical wards and the nursing workforce, in 1999-2000. The key driver for
the changes was the financial imperative for THL to live within its budget.
Senior managers saw the necessary changes as an opportunity to improve
clinical practice, but encountered opposition from a workplace culture that
was resistant to change.
3.3 Relations between THL and the large Maori community that it serves in
Gisborne and the Tairawhiti region need significant improvement. This
presents both a challenge and an opportunity for the Tairawhiti District
Health Board.
4. QUALITY ASSURANCE SYSTEMS
4.1 Tairawhiti Healthcare had a plethora of quality processes in 1999-2000. But
the system was largely lines on paper. The reality of poorly co-ordinated
activities and insufficiently involved staff did not match the rhetoric about
quality.
4.2 Professional leaders, who play a vital role in promoting good quality
healthcare within a hospital, have been missing from Gisborne Hospital.
There was no Director of Nursing from August 1999 to July 2000, and (apart
from a brief interlude) there has been no Medical Director since April 1999.
4.3 The key quality activity in 1999-2000 was seeking accreditation after the
failure to gain accreditation in a Quality Health New Zealand survey in July
1999. Paradoxically, an unrealistic push for accreditation in 2000 seems to
have diverted staff from sustained and embedded quality improvement.
4.4 Problems with incident reporting in theatre, and lapses in quality control in
the biochemistry section of the laboratory, were symptomatic of a failure to
‘close the quality loop’. Staff and management contributed to this failure,
which had the potential to adversely affect patient care.
4.5 THL’s failure to provide a quality assurance system with due care and proper
co-ordination amounted to a breach of Right 4(1) and Right 4(5) of the Code.
5. INCIDENT REPORTING AND COMPLAINTS PROCEDURE
5.1 The THL Incident Reporting and Complaints Management Policy is
unsatisfactory in a number of respects. It fails to differentiate between
incidents (situations where harm could have occurred) and adverse events
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