All meetings held includes discussion on infection control. Internal audits are completed. Infections are benchmarked across the organisation. There is an improvement required around follow through of meeting minutes. Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical 0 12 0 3 3 0 0 Standards 0 38 0 3 3 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 32 Standards 0 0 0 0 0 0 0 57 Criteria Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.2.4: All adverse, unplanned, or PA Low Adverse Event untoward events are Reporting systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. HDS(C)S.2008 Criterion 1.2.4.3 The service provider documents PA Low A review of incident stats Ensure analysis of incidents 60 adverse, unplanned, or across 2013 identified includes untoward events including that pressure areas were documented/implemented service shortfalls in order to high for April (7) May (6) corrective actions at a facility identify opportunities to improve and June (6) in the level to minimise further service delivery, and to identify hospital. No corrective incidents and manage risk. actions were established. Incident and accident analysis has been completed monthly but
All meetings held includes discussion on infection control. Internal audits are completed. Infections are benchmarked across the organisation. There is an improvement required around follow through of meeting minutes. Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical Standards 0 12 0 3 3 0 0 Criteria 0 38 0 3 3 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 32 Criteria 0 0 0 0 0 0 0 57 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.2.4: Adverse Event Reporting All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. PA Low HDS(C)S.2008 Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. PA Low A review of incident stats across 2013 identified that pressure areas were high for April (7) May (6) and June (6) in the hospital. No corrective actions were established. Incident and accident analysis has been completed monthly but Ensure analysis of incidents includes documented/implemented corrective actions at a facility level to minimise further incidents 60
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