There is no evidence of coercion or discrimination. Paediatric patients are supported to have an advocate present and maternity consumers are able to have a support person present in labour and overnight if they live out of town. Links with families and communities are supported. Improvement is required to ensure family violence screening is undertaken and recorded in the clinical record. In the maternity unit, the responsibilities of Lead Maternity Carers (LMC) are not well defined. There are situations in which communication is not effectively conveying (in written and verbal format) information regarding care. Midwives do not remain within their scope of practice at all times. The practice environment is an area for improvement. Staff are able to articulate the requirements of open disclosure and files reviewed during audit indicate open disclosure occurs. The DHB is monitoring compliance with open disclosure requirements. Written consent is not consistently completed as per the organisational policy and information on which consent is based is inconsistently documented. This is an area for improvement. The complaints process is observed to be well-managed and recommendations following investigation are used as opportunities to improve. Organisational Management SCDHB has a commitment to quality improvement and to improving patient outcomes. The first Quality Account published by the South Canterbury DHB provides its population with a summary of achievements and planned improvements. The DHB committee structure enables issues to be escalated to the appropriate committee or role. The clinical board with a consumer chair holds a pivotal role in monitoring clinical and quality safety issues being addressed. There is a structured process in place for the development and control of corporate and clinical documents. Areas for improvement include updating the 24% of policies out of date and addressing the risk that updated policies on the intranet may not be present in the hard copy manual held in the local units. Data is collated and used to improve services and processes within the DHB. Ensuring that the monthly incident summary reports are consistently completed by all services and provided to staff is an area for improvement. Corrective action planning after the review of quality data occurs. There is good overview by management groups and clinical committees of progress against the planned actions. The corrective action database is a promising initiative, but is not up-to-date and this is an area for improvement. Well defined processes in place allow risk identification and escalation at all levels of the organisation. The web based risk management tool allows risk owners to update the risks in a timely way, and provides senior staff with a current time overview.
There is no evidence of coercion or discrimination. Paediatric patients are supported to have an advocate present and maternity consumers are able to have a support person present in labour and overnight if they live out of town. Links with families and communities are supported. Improvement is required to ensure family violence screening is undertaken and recorded in the clinical record. In the maternity unit, the responsibilities of Lead Maternity Carers (LMC) are not well defined. There are situations in which communication is not effectively conveying (in written and verbal format) information regarding care. Midwives do not remain within their scope of practice at all times. The practice environment is an area for improvement. Staff are able to articulate the requirements of open disclosure and files reviewed during audit indicate open disclosure occurs. The DHB is monitoring compliance with open disclosure requirements. Written consent is not consistently completed as per the organisational policy and information on which consent is based is inconsistently documented. This is an area for improvement. The complaints process is observed to be well-managed and recommendations following investigation are used as opportunities to improve. Organisational Management SCDHB has a commitment to quality improvement and to improving patient outcomes. The first Quality Account published by the South Canterbury DHB provides its population with a summary of achievements and planned improvements. The DHB committee structure enables issues to be escalated to the appropriate committee or role. The clinical board with a consumer chair holds a pivotal role in monitoring clinical and quality safety issues being addressed. There is a structured process in place for the development and control of corporate and clinical documents. Areas for improvement include updating the 24% of policies out of date and addressing the risk that updated policies on the intranet may not be present in the hard copy manual held in the local units. Data is collated and used to improve services and processes within the DHB. Ensuring that the monthly incident summary reports are consistently completed by all services and provided to staff is an area for improvement. Corrective action planning after the review of quality data occurs. There is good overview by management groups and clinical committees of progress against the planned actions. The corrective action database is a promising initiative, but is not up-to-date and this is an area for improvement. Well defined processes in place allow risk identification and escalation at all levels of the organisation. The web based risk management tool allows risk owners to update the risks in a timely way, and provides senior staff with a current time overview.
southcant-dhb-audit-summary-may2014.docx