determine infection control activities, resources and education needs within the facility. This includes audits of the facility, hand hygiene and surveillance of infection control events and infections. The service engages in benchmarking with other Ryman facilities. Staff receive on-going training in infection control. Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical 2 48 0 0 0 0 0 Standards 3 98 0 0 0 0 0 Criteria UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited 0 0 0 0 0 0 0 0 Standards 0 0 0 0 0 0 0 0 Criteria Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) Continuous Improvement (CI) Report Code Name Description Attainment Finding Standard 1.1.8: Consumers receive services of an CI HDS(C)S.2008 Good Practice appropriate standard. Criterion 1.1.8.1 The service provides an CI The Ryman Accreditation Programme (RAP) is directed from head office and HDS(C)S.2008 environment that encourages good directs quality and risk management activity that facilities are required to complete practice, which should include on a monthly basis. Review of documentation and interview with staff indicate evidence-based practice. Ernest Rutherford is implementing the RAP programme as prescribed. Policies and procedures cross-reference other policies and appropriate standards. There is a RAP committee at Ryman head office that reviews best practice, legislation, standards, research, and policy and procedure review. All changes made to
determine infection control activities, resources and education needs within the facility. This includes audits of the facility, hand hygiene and surveillance of infection control events and infections. The service engages in benchmarking with other Ryman facilities. Staff receive on-going training in infection control. Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical Standards 2 48 0 0 0 0 0 Criteria 3 98 0 0 0 0 0 UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards 0 0 0 0 0 0 0 0 Criteria 0 0 0 0 0 0 0 0 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) Continuous Improvement (CI) Report Code Name Description Attainment Finding HDS(C)S.2008 Standard 1.1.8: Good Practice Consumers receive services of an appropriate standard. CI HDS(C)S.2008 Criterion 1.1.8.1 The service provides an environment that encourages good practice, which should include evidence-based practice. CI The Ryman Accreditation Programme (RAP) is directed from head office and directs quality and risk management activity that facilities are required to complete on a monthly basis. Review of documentation and interview with staff indicate Ernest Rutherford is implementing the RAP programme as prescribed. Policies and procedures cross-reference other policies and appropriate standards. There is a RAP committee at Ryman head office that reviews best practice, legislation, standards, research, and policy and procedure review. All changes made to
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