Quality Improvement

Monitoring and measuring performance against key clinical, strategic, quality and financial markers is an important part of managing and improving the care you get at Hauora Tairawhiti. It is also important to do so in a transparent and publicly accountable way.

The Ministry of Health monitors District Health Boards (DHBs) to ensure they are providing patients with safe, high-quality care and service. Monitoring includes: 

- Reporting on serious adverse events –these are events when things have gone wrong and a patient has been harmed
- Quality and safety markers to evaluate the success of the Health Quality and Safety Commission’s national patient safety campaign Open for Better Care
- Auditing and certifying DHBs against the Health and Disability Services Safety Standards

Reporting and Learning from adverse events

Each year Hauora Tairāwhiti releases information about adverse events, which have occurred within their hospital. The purpose of adverse events reporting is to understand the experience of the affected people, families and whānau. This understanding is used to improve safety, encourage open communication, learn from what happened, and put in place systems to reduce the risk of recurrence.

An adverse event is one which has resulted in significant additional treatment, major loss of function, is life-threatening or has led to unexpected death. Hauora Tairāwhiti is required to review these events and report them to the Health, Quality & Safety Commission. The Commission then collates this information and it is published on their website www.hqsc.govt.nz 

Each adverse event is thoroughly reviewed to look for opportunities to learn and make improvements to avoid such incidents in the future.

Hauora Tairawhiti’s 2018 - 2019 Learning from adverse events report

Hauora Tairawhiti’s 2017 - 2018 Learning from adverse events report

Quality & Safety Markers

The Health Quality & Safety Commission has developed a series of quality and safety markers (QSMs) to track progress and improve healthcare by reducing patient harm and the cost of that harm. 

The QSMs are based on the following areas of harm:

- Falls

- Pressure injuries

- Healthcare associated infections:

- Safe surgery

- Medication safety

- Patient deterioration

- Central line associated bacteraemia (marker retired in December 2014)

- Hand hygiene

- Surgical site infection (cardiac and orthopaedic (hip and knee arthroplasty) surgeries

The Health Quality & Safety Commission has a publicly available national dashboard. The dashboard of health system quality shows at a glance how individual district health boards are performing in a variety of areas. (Select Hauora Tairawhiti from the list of DHBs under the Help icon then click on the individual boxes on the circle to see our results).

The dashboard takes information from a range of published sources, including the Commission’s quality and safety markers, the primary care and inpatient patient experience surveys, the Atlas of Healthcare Variation and data from the Ministry of Health, and puts it together in one place. A simple-to-read, interactive chart allows users to see the data. 

Adult In-Patient/Consumer Survey

The Health Quality & Safety Commission designed a 20-question adult inpatient survey which began in August 2014 to identify where improvements in patient experience could be made. Patient experience measures are now routinely in place for hospitals. The survey runs quarterly in all district health boards and covers four key domains of patient experience: communication, partnership, co-ordination and physical and emotional needs.

A selection of adult patients who spent at least one night in hospital are sent an invitation via email, text or post inviting them to participate in the national survey. The survey responses are anonymous unless patients choose to provide their contact details.

To see Hauora Tairawhiti’s patient experience survey, click dashboard of health system quality  then select Hauora Tairawhiti from the list of DHBs under the Help icon and then click on the Patient-Centred box of the circle.

National Health Targets

The Ministry of Health reports on quarterly progress towards achieving agreed annual health targets with each district health board.

There are six national health targets to track how well DHBs are providing services to their communities. The targets include both preventative health and hospital service measures and are publicly reported each quarter. Click here to read more: https://www.health.govt.nz/new-zealand-health-system/health-targets

Note: The Government has directed the Ministry of Health to develop a new set of performance measures to improve health outcomes for New Zealanders. While work is underway to develop the new measures DHBs will continue to report to the Ministry against the current set of health targets, as well as against a previously established suite of wider measures. How DHBs are performing is reported on a quarterly basis on the Ministry of Health website.

Certification and accreditation

Hauora Tairawhiti inpatient facilities are certified and audited to ensure we provide safe, appropriate care for our patients and meet the standards set out in the Health and Disability Services (Safety) Act 2001. These standards are outlined in NZS8134:2008 Health and Disability Services Standards.

As a legislative requirement our hospital and facilities must:

- Be certified by the director-general of health to provide the health care services
- Meet all relevant service standards 
- Be in compliance with the Health and Disability Services (Safety) Act

A certification audit is undertaken every three years to assess whether we are meeting the health and disability service standards.

A surveillance audit is undertaken part-way through our period of certification to assure the Ministry of Health that we continue to meet all relevant standards.

- A summary of this report is available here:  https://www.health.govt.nz/system/files/documents/pages/tairawhiti-dhb-audit-summary-may2016.pdf

 

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