Te Runanganui o Te Atiawa ki te Upoko o te Ika a Maui Inc.
Quality and Risk Plan
Annual Review Due / Reviewed by / Date ReviewedJune 2015 / BFM/W Luke / 26 June 2015
TABLE OF CONTENTS
Quality and Risk Overview 3
Principles of Continuous Quality Improvement 5
Maori Concepts of Health 8
Risk Management 10
Clinical Audit 12
Monitoring and Evaluation of Risk Plan 14
Quality Improvement Projects 15
Unit-Based Quality and Risk Plans 17
Values - Tikanga 21
Quality and Risk Overview / TROTA P & P’s / 2.1Date Policy Approved / June 2015
Approved by / Wi Luke
Page / 1 of 5
QUALITY & RISK PHILOSOPHY
Te Runanganui o Te Atiawa ki te Upoko o Te Ika a Maui (hereinafter referred to as the Runanga) have a commitment to providing a high quality governance to management and service providers of the Runanga’s agencies.
Vision: To create the necessary safe and encouraging environments for care from which our health services can be accessed and delivered within the local communities that we aspire to service
Mission goal 1: To improve the health of individuals and families in our local communities by providing qualitative Health Education, Health Promotion, Health Counselling and helping people to adopt healthy lifestyles.
The Runanga’s values reflect traditional Tikanga values. These are summarised as:
· To work with individuals and groups acknowledging ethnic and cultural diversities and respecting other values and beliefs to achieve and sustain optimal health status
· To respect the rights of individuals to health information and privacy
· To acknowledge the Treaty of Waitangi as guidelines for delivery of health services
· To be a good employer, value staff and provide positive workforce development and leadership
The Quality & Risk Plan provides a clear guide to the range of quality and risk principles that promote safe, efficient and effective health services.
The Quality & Risk Plan underpins the mission, vision and values statements by outlining a framework for continuous quality improvements to be identified, planned, actioned, monitored and evaluated in a systematic way.
The Runanga’s governance will continue to be integral to the successful achievement of our quality objectives.
FOREWORD
This Quality & Risk Plan provides a framework within which the Runanga’s individual management groups and service providers will base their specific quality plans.
Various Quality Improvement projects outline the focus of the Quality & Risk Plan for 2007. These objectives will be monitored on an annual basis through Management meetings, where quality & risk are regular agenda items.
This review of Quality and Risk policies and procedures is to ensure that systems are in place preceding the second accreditation audit by Quality Health NZ (QHNZ) during the first quarter of 2008.
Activities leading up to the 2011 QHNZ survey included:
· Review of the 2008 Quality Health New Zealand Audit recommendations.
· In depth interviewing of staff contributing to the formal development of policies and procedures in all areas of the Runanga and its service providers.
· The documentation of policies and procedures
· Reviewing and updating the seven Policies and Procedures manuals
· Auditing procedures to ensure quality measures are working
The Quality Health NZ standards have provided the Runanga and its service providers with a framework that is based on the principles of continuous quality improvement.
Accreditation with QHNZ will enable the Runanga and its service providers to implement quality systems that will be recognised as appropriate by the Ministry of Health.
Future projects include the design and implementation of Quality Plans and quality improvement projects for all areas of the Runanga and its service providers.
Annual Review Due / Reviewed by / Date ReviewedJune 2015 / BFM/W Luke / 26 June 2015
Principles of Continuous Quality Improvement / TROTA P & P’s / 2.2
Date Policy Approved / June 2015
Approved by / Wi Luke
Page / 1 of 5
PRINCIPLES OF CONTINUOUS QUALITY IMPROVEMENT
The following chart outlines the standard Quality Health New Zealand framework for understanding, defining and improving the quality of healthcare.
Access:
Access to all health services should be equitable, on the basis of consumer need, regardless of age, gender, ethnicity, socio-economic group, or geography.
Tool for measuring this quality dimension:
o Analysis of client population accessing the service every quarter, based on staff reports and database review. Statistical and narrative.
Appropriateness:
Services should be designed around the needs of the consumer, communities and populations and based on established standards.
Tools for measuring this quality dimension:
o Annual consumer satisfaction surveys
o Consumer feedback (i.e. suggestion box)
o Key health issues (under each age group) guided by Maori Health Plan, government level strategies – Primary Health Care Strategy, NZ Health Strategy, Maori Health Strategy, Strategy for Older people, Strategy for younger person.
o Biannual review of contracts with DHB - taking into account feedback from staff in the field, the aims/vision/values/goals of that specific service
o Staff feedback – hui, annual performance reviews, workshops, narratives
Continuity:
Continuity is the ability to provide uninterrupted, coordinated service and care across relevant programmes, practitioners, services, organisations and levels over time.
Tools for measuring this quality dimension:
o Database analysis of flow of patients within WH services, 12 step care and treatment process within each service to ensure patients have continuity of care- the responsibility lying within the primary service involved.
Effectiveness:
Effectiveness is the achievement of desired results in the time frame expected.
Tools for measuring this quality dimension:
o Constantly imparting the goals, values, mission of the primary health care services so all services are going in the same direction. Workshops, knowledge slides - overseen by WH manager.
o Measuring statistics, reporting on growth, comparing results, database analysis, reporting to governance.
o Each service has their client treatment life cycle
o Work plan with monthly focus
o E.sheets – for accountability for staff (time and activities)
Efficiency:
Efficiency is the achievement of desired results with the most cost effective use of resources. Resources must be allocated to provide the greatest benefit to consumers.
Tools for measuring this quality dimension:
o Review of money expenditure – annual financial reporting and accountability.
o Creating treatment versus cost model for each service.
Responsiveness:
Responsiveness includes the concepts of acceptability and participation for the client and their family/Whanau, a responsive service is client orientated, respects persons dignity, confidentiality and autonomy to participate in choices about one's health and support.
Tools for measuring this quality dimension:
o Acceptability and participation/ client orientated – pt questionnaires, policy on Whanau Support
o Health and Disability – all staff are trained and have access to written information regarding their rights and responsibilities.
Safety:
Safety means that the potential risks of an intervention or the environment are systematically identified and avoided or minimised.
Tools for measuring this quality dimension:
o Occupational health and safety – hazard manuals, incident forms, complaints procedure and forms,
o Emergency procedures.
Annual Review Due / Reviewed by / Date ReviewedJune 2015 / BFM/W Luke / 26 June 2015
Maori Concepts of Health / TROTA P & P’s / 2.3
Date Policy Approved / June 2015
Approved by / Wi Luke
Page / 1 of 5
MAORI CONCEPTS OF HEALTH
Models such as the Te Whare Tapa Wha model by Mason Durie and Te Kani Kingi is consistent with Maori concepts of health and wellness, and includes the following dimensions:
Taha Wairua - Spiritual Dimension
Taha Hinengaro - Mental Dimension
Taha Tinana - Physical Dimension
Taha Whanau - Family Dimension
The following diagram is useful when relating to continuous quality improvement activities.
Environment
Sun Food Land
Air Shelter Employment
Water Community
Te Whare tapa Wha model
The Runanga committed to responding appropriately to the following principles of the Treaty of Waitangi:
Partnership: Continue the active partnership relationship with Maori of the Hutt Valley/Te Awakairangi region, using feedback to develop efficient and effective strategies for the improvement of Maori health
Participation: Continue to actively promote Maori involvement and participation at all levels of Tamaiti Whãngai Whanau Hauora
Protection: Actively protect Maori cultural concepts, values, beliefs and practices to ensure the improvement of Maori well being
Annual Review Due / Reviewed by / Date ReviewedJune 2015 / BFM/W Luke / 26 June 2015
Risk Management / TROTA P & P’s / 2.4
Date Policy Approved / June 2015
Approved by / Wi Luke
Page / 1 of 5
RISK MANAGEMENT
A risk framework is essentially a compendium of risk theory and tools. Like all frameworks the specific contents of theory and tools are evolutionary in that they grow and improve over time.
The method of risk analysis will follow that implemented by the Runanga in its annual Strategic and Business Plans.
Tools and templates:
· Performance reviews – allowing feedback from staff to management.
· Surveys and suggestion feedback forms for clients of the Runanga’s service providers.
· Contract templates
· Checklists
· Incorporating the recommendations of the 2004 HSL Associates report ‘Strengthening Management and Governance”.
Examples of possible risk areas include:
· Clinical risks
· Strategic risks
· Legal/Contractual risks
· Organisational risks
· Financial risks
· Information and information technology risks
· Environmental risks
· Funding risks
SCOPE OF QUALITY & RISK PLAN
The Quality & Risk Plan embraces the following:
The Runanga:
Quality and risk management are part of an organisation-wide commitment. To this end the Quality & Risk Plan encompasses all services, clinical, non-clinical and administrative support services provided by the Runanga.
Patients/Clients:
Patients/clients who use our services are recognised as the most important link in terms of providing opportunities to improve our services. The Runanga’s services will ensure that ongoing consultation, feedback through satisfaction surveys and the complaints/feedback procedure is encouraged.
KEY RESPONSIBILITIES
At first level, the Runanga Governance takes a leadership role with regard to all line management and service providers quality and risk programmes. The Runanga are also responsible for annually reviewing the effectiveness of their own performance.
At second level, the Waiwhetu Medical Group and Tamaiti Whangai PHO manager shall support the philosophy that, together with their staff, they have a shared responsibility for maintaining and improving quality of service.
At third level, team leaders and senior medical staff are responsible for ensuring that all clinical staff are encouraged and supported to become actively involved in quality & risk activities as well as Peer Review.
The Quality Co-ordinator is responsible for supporting and reviewing clinical audit and non-clinical audit activities and reporting through to the respective managers on overall compliance, trends and results. Also, ensuring that the overall co-ordination of the Quality programme and objectives set in the Quality & Risk Plan are met.
The Human Resources Manager is responsible for implementing a performance management system for appraisal of all staff.
Annual Review Due / Reviewed by / Date ReviewedJune 2015 / BFM/W Luke / 26 June 2015
Clinical Audit / TROTA P & P’s / 2.5
Date Policy Approved / June 2015
Approved by / Wi Luke
Page / 1 of 5
CLINICAL AUDIT
Clinical audit is defined as the systematic critical analysis of the quality of clinical care, including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome for the patient. The framework typically uses the classical structure, process and outcome concept.
· Structural issues deal with the organisation of a particular service
· Process with the clinical pathway of treatment of the patient
· Outcome with the resultant benefit to the patient
The process of clinical review may be undertaken through:
· audit/case review
· peer review
· review of quality indicators
· outcome studies
· criteria auditing
· developing best practice guidelines/pathways
· observer error studies
· developing utilisation management guidelines
and may encompass:
· process of care
· indications for care
· short and long-term outcomes:
* mortality
* major morbidity and complications
* disability
* quality of life
* new technology / treatment assessments
· monitoring and review of incidents e.g.: accidents, falls, medication errors
Audit schedules are recommended to be accessible to staff, indicating the type of audit, frequency, responsibilities, timeframes and reporting and evaluation mechanisms.
Annual Review Due / Reviewed by / Date ReviewedJune 2015 / BFM/W Luke / 26 June 2015
Monitoring and Evaluation of Risk Plan / TROTA P & P’s / 2.6
Date Policy Approved / June 2015
Approved by / Wi Luke
Page / 1 of 5
MONITORING & EVALUATION OF QUALITY & RISK PLAN
The Quality & Risk Plan is used to provide key information that is prioritised and reported to the Runanga through the service provider Managers on a periodic basis.
The key information that should be regularly reported includes:
· Progress against the Quality & Risk Plan.
· The planning, implementation and resulting action plans of all internal and external audit and survey reports.
· Emerging quality and risk issues and trends.
· Reports and feedback from staff
Annual Review Due / Reviewed by / Date ReviewedJune 2015 / BFM/W Luke / 26 June 2015
Quality Improvement Projects / TROTA P & P’s / 2.7
Date Policy Approved / June 2015
Approved by / Wi Luke
Page / 1 of 5
QUALITY IMPROVEMENT PROJECTS
Several methods of reporting on quality activities are recommended to be used within TROTA. The following elements should be present in all Quality Improvement Projects: