GAUTENG DEPARTMENT OF HEALTH
HEALTH CARE PROFESSIONALS’
District
REVISED
STANDARDS AND AUDIT TOOLS
(March 2007)
TABLE OF CONTENTS:
Introduction to the Quality Assurance Programme / 3
Implementation / 4
Profession Specific Quality Assurance Co-ordinators / 4
List of Standards / 5
Schedule for Audits / 6
· Environment, Equipment and Facilities Audit Tool / 7-8
· Client/Patient Record-Keeping Audit Tool / 9-10
· Management Audit Tools / 12-14
· Client Satisfaction Audit Tool / 15-16
THE QUALITY ASSURANCE
PROGRAMME
The Gauteng Department of Health strives to provide QUALITY SERVICES to all its clients. This is embodied in one of its strategic goals: “…provide caring, responsive and quality health services at all levels”. In order to evaluate whether this has been achieved, a Quality Assurance programme was implemented.
Quality Assurance may be defined as “taking positive action to assess and evaluate performance against agreed, defined standards in order to create and manage a service which demonstrates that desired levels of quality are always present.”
The goal of this quality assurance programme is to consolidate and encourage efforts to improve the quality of care of patients by reducing clinical errors and improving hospitality and the standard of customer service.
Standards have been set from the viewpoint of both the clients and the clinicians. Therefore rendering a quality service implies providing a service, which conforms to these standards set by the internal and external customers. For each standard to be achieved, criteria have been drawn up to measure achievement or compliance to the standard.
The Quality Audit Cycle can be described pictorially as follows:
Implementation:
· Heads of departments are to ensure that this Quality Assurance programme is implemented in their departments.
· Completed audits must be summarised, with a work plan attached and sent in before the given due date to your Profession-Specific Quality Assurance Co-ordinator.
· Profession-specific-quality-assurance co-ordinators will then compile the results for each profession and submit this to Head Office.
· Feedback will be given from Head Office
· Managers are requested to record and monitor their individual performances as well as to compare their results with other departments.
· Managers are to take action on those problem areas identified.
IMPORTANT POINTS:
· Quality Assurance is not an additional administration task, but is part of the job description and should be one of the objectives of every department and be included in every manager/head of department’s PMDS
· Please make use of these updated forms
PROFESSION SPECIFIC QUALITY ASSURANCE CO-ORDINATORS
All completed audits must be sent to the person who represents your profession
NAME / DISCIPLINE / HOSPITAL / TELEPHONE / FAX.
HEALTH CARE PROFESSIONALS’
STANDARDS*:
*The following standards apply to the Occupational Therapy, Physiotherapy, Speech Therapy and Audiology and Social Work professions only:
ö Working Environment and Equipment Standards
ö Record Keeping
ö Management Standards
ö Client Care Standards
HEALTH CARE PROFESSIONALS’
SCHEDULE FOR AUDITS:
The quality assurance project is run on an annual basis. A different audit is completed every quarter. Depending on the manager, audits can be completed as often as desired, however compulsory submissions are the ones enlisted below. The timetable below runs as a perpetual calendar.
NAME OF AUDIT: / MONTH TO BE COMPLETED: / DUE DATE: / CO-ORDINATORS TO SEND RESULTS TO HEAD OFFICE BY:Environment and Facilities / February / 1st Friday of March / 3rd Friday of March
Record-Keeping / May / 1st Friday of June / 3rd Friday of June
Management / July / 1st Friday of August / 3rd Friday of August
Client Care / September / 1st Friday of October / 3rd Friday of October
HEAD OFFICE WILL CONDUCT SPOT CLINICAL AUDITS. Managers are advised to have a file containing details of all their completed audits, reports on action taken and changes implemented etc. The feedback from the spot checks will be given to the senior management at the institution as part of the complete clinical audit conducted by the Quality Assurance Directorate from Head Office.
HEALTH CARE PROFESSIONALS
(Occupational Therapy, Speech Therapy and Audiology, Physiotherapy, Social Work)
MANAGEMENT AUDIT TOOLS
IMPLEMENTATION GUIDE:
The management audit takes place during July of every year and must be submitted to the Quality Assurance Workgroup. There are two tools to audit the management standards:
1. Procedural Audit – This should be completed by the manager of the department on an annual basis. The standards relate to procedures and structures in the department and it should be used to assist you with identifying areas needing attention before the next audit.
2. Manager Audit – This is only completed by departments who comprise of more than two staff members. The Audit is to be completed by the staff of the department either individually or together. The results again should identify areas of weakness and strength and they can be compiled to a percentage in order to monitor changes. This should be completed at least annually.
Compliance for each of these audits is 75%
After both these audits are completed the staff of the department should sit together and develop plans for change. This is your opportunity to strive for change and excellence.
HEALTH CARE PROFESSIONALS
(Occupational Therapy, Speech Therapy and Audiology, Physiotherapy and Social Work)
MANAGEMENT PROCEDURAL AUDIT TOOL
To be completed by the manager
Department: ______Institution: ______Date: ______
Score: 0 = non-compliant; 1 = partially comply; 2 = fully comply
Standard / Score / N/A1. The relevant Guidelines, Acts and Policies are available
2. There is a system in place to ensure that Guidelines, Acts and Policies are adhered to
3. The manager is a member of the extended management team of the hospital
4. Staff are professionally dressed according to the dept/code of conduct
5. There is a financial management system to compile and control the budget
6. All staff have a job description
7. There is a system to monitor annual registration with the relevant statutory bodies
8. All staff function within the scope of practice
9. All staff are adequately trained for the posts held
10. There is a system of continuing education
11. There is a record of all staff’s participation in continuing education
12. There is at least a monthly staff meeting
13. There are minutes of all staff meetings
14. There is access to administrative and support staff
15. There is a procedure for reporting adverse incidents related to clients
16. There is a procedure for managing adverse incidents relating to clients
17. There is a multidisciplinary approach to rehabilitation
18. Audits are completed and followed up as required
19. Research is encouraged and supported within the department
20. The Gauteng Department of Health’s mission and vision statements are displayed
21. The manager negotiates for new posts and the filling of posts when needed
22. There is a system to recruit appropriate staff for the needs of the department within head office guidelines
23. The manager is involved in the recruitment and appointment of new staff
24. Selection policies are known by the manager
25. There is a system of archiving records
26. All staff complete workload statistics as well as other statistics required by head office as appropriate
27. The manager ensures that the department statistics are completed, compiled and submitted.
28. Staff are involved in student training where applicable
29. The manager or dept representative liaises with the training institutions
30. The manager monitors sick and vacation leave
31. The manager co-ordinates vacation leave in the department
32. The Performance Management and Development System is implemented in the department
33. Batho Pele principles are applied in the department
34. There is access to a complaints management system
TOTAL SCORE:
Compliance = Total Score / (34- total “n/a”) X 100 = _____ %
HEALTH CARE PROFESSIONALS
(Occupational Therapy, Speech Therapy and Audiology, Physiotherapy and Social Work)
MANAGER AUDIT TOOL
Note about this audit:
· To be completed by staff in departments which have more than 2 staff members
· Compliance for this audit is 75%
Department: ______Institution: ______Date: ______
Score: 0 = non-compliant; 1 = partially comply; 2 = fully comply
Standard / Score / N/a1. There is an identified manager
2. There is access to administrative and support services where relevant
3. The manager has adequate management skills
4. The manager encourages participative leadership
5. The manager ensures that there is adherence to policies, procedures and standards
6. Audits are completed as required and feedback is given
7. There is a system of orientation and induction of new staff
8. Staff are made familiar with organograms as appropriate
9. The manager ensures that all staff functions within the scope of practice.
10. Staff are encouraged to work within their area of expertise where possible (not applicable to clinic staff)
11. The division of work is fair according to the work load of the department
12. Staff are allowed to rotate if appropriate (not applicable to clinic staff)
13. Staff are encouraged to develop their skills
14. There is a supervision system in place
15. The PMDS system is implemented
16. Representative/s of the department attend/s the Gauteng Rehabilitation and profession specific forums and feedback is given
17. There is a multi disciplinary approach to Rehabilitation
18. There is a system for continuing education
19. The manager ensures that research is encouraged and is supported
20. The manager ensures that all staff are familiar with the progressive disciplinary system
TOTAL:
Compliance = Total Score / 20 X 100 = _____ %
Clinic Staff Compliance = Total Score /18 X 100 = ______%
The head of department should use all staff members’ individual compliance %’s to calculate the average compliance for the department
- 14 -
WORKING ENVIRONMENT ANDEQUIPMENT AUDIT
FOR THE COMMUNITY BASED REHABILITATION PROFESSIONALS
(Occupational Therapy, Physiotherapy, Speech Therapy & Audiology and Social Work)
Notes about this audit :
· Audit to be completed by the Sub-district Rehabilitation Co-ordinator or the Quality Assurance Co-ordinator for the Rehab department in consultation with staff members.
· The department itself should be audited and not other work areas such as clinics etc.
· The * indicates that the specific standard is NOT-APPLICABLE a to social workers
· A plan of action as well as a time-frame for achieving the standard, must be submitted
SubDistrict: ______District ______Date: ______
Score: 0 = non-compliant; 1 = partially comply; 2 = Fully compliant
STANDARD
/Score
/PLAN OF ACTION
/Achievable by when:
A. CLEANLINESS
The system for cleaning complies with the following:
/ / /1. Floors are cleaned at least once a day
/ / /2. Toilets are cleaned regularly during the day after use / / /
3. Toilets and taps are functional / / /
4. *Rehab equipment (sheets, mats, balls, machines etc) are kept clean and cross-infection is minimised / / /
5. The rubbish is disposed of / / /
6. Medical waste is disposed of / / /
B: ACCESS
7. There is adequate signage to facilitate location of the department. / / /
The department is predominantly physically accessible:
/8. Doorways and access ways in the department have a minimum width of 750 mm -900mm
/ / /9. If there are objects in the department such as tables, chairs, pot plants etc, is there sufficient space of 1100-1800mm for people to pass if they are in a wheelchair
/ / /C. OCCUPATIONAL HEALTH AND SAFETY
10. There is a Fire and evacuation procedure in place for the department
/ / /11. There is an emergency patient care procedure in place.
/ / /12. There is a system in place for injury on duty.
/ / /13. The department meets the infection control procedures for the GDH (e.g. hand washing; waste disposal; infection control of equipment) / / /
14. The department has access to an OHS officer / / /
15. The department has access to the OHS Act. / / /
16. There is adequate lighting in the department. / / /
17. There is adequate ventilation in the department. / / /
18. The temperature is within acceptable range for patient treatment/consultation. / / /
19. The department has access to a space for staff relaxation during official breaks. / / /
20. Staff has access to administration space / / /
21. There is adequate space in the department for private assessment and treatment / / /
22. The maximum amount of people per square metre is according to the minimum building guideline / / /
23. There is a system in place which ensures a safe and secure working environment for all members of staff and their belongings / / /
24. All staff can use equipment safely* / / /
D. EQUIPMENT * (not applicable to social workers)
25. The minimum amount of profession specific equipment is available in line with the National/ Provincial equipment Guideline.* / / /26. There is a procedure to ensure regular maintenance and safety checks of the equipment.* / / /
27. There is adequate secure storage space for equipment and consumables* / / /
28. There is evidence that inventory lists are maintained.* / / /
29. There is an ordering procedure in place which ensures stock levels are maintained (equipment and consumables)* / / /
30. There is a dedicated budget for consumables and/or equipment.* / / /
TOTAL =
/COMPLIANCE = Total Score / 60 X 100 = _____ %
SOCIAL WORKERS COMPLIANCE = Total score / 44 = _____ %
NB: COMPLIANCE FOR THIS AUDIT IS 75%
CLIENT SATISFACTION AUDIT TOOL
HEALTH CARE PROFESSIONALS
(Occupational Therapy, Speech Therapy and Audiology, Physiotherapy and Social Work)
IMPLEMENTATION GUIDELINES:
1. Patient/Client selection: Five clients need to be randomly selected from clients who have been seen by a member of staff on more than three occasions by a colleague of yours who will implement the audit. The colleague need not be of the same profession. Wherever possible the questionnaire should be completed by the client independently, but assistance should be given where necessary without cueing the client.