Case Studies

ATAWHAI ASSISI HOME AND HOSPITAL

Atawhai Assisi Home and Hospital, a facility owned and operated by the Sisters of Mercy in Hamilton, has been continuously accredited with Quality Health New Zealand since 1996.

As a facility we made the decision to be surveyed to the new Evaluation and Quality Improvement Programme (EQuIP4) standards when we were due for our routine Ministry of Health audit, and recertification in March 2009. That brought into focus a whole new way of preparing for both accreditation survey and certification audit!

How were we to prepare our documentation; how will be demonstrate our commitment to closing quality circles; how will we get our heads around a web based system?

Around July 2008, following several conversations with staff at Quality Health New Zealand, we identified the following :
• We would document all our evidence in a word based document, then have it loaded onto the web at the time of survey
• We identified our event coordinator, who had in-depth knowledge of EQulP4 and evidence based documentation.

We also had copies of drafts of the EQuIP4 standards that we were able to “dissect”, so we had the standards, criterion and guidance next to the evidence we were documenting. This allowed different staff members to take a section of the criterion to work on at any time.

Team work was also an essential component of developing and documenting our evidence. We worked on our processes regularly with weekly designated times.

For the past four-five years we have been part of QPS Benchmarking, and have been able to utilise validated benchmarking data to support our successes, and identify our gaps. Our internal auditing is focussed on one month every year. “Action Albert” is undertaken in August when, around lots of fun, some 70% of staff take part in an auditing frenzy, finishing with a thank you lunch attended by almost all those involved in the audit programme.

And it works!

We were surveyed in March 2009 by two credentialed surveyors and an EQulP4 trainee surveyor.
We found the process to be positive and supportive. The work we had done in preparation for the process was validated, our evidence was clear for the surveyors to assess and to find that the place buzzed!

We further found, when our accreditation report arrived, that in most instances our evaluations were validated by the surveyors. In some instances we had rated ourselves too high. In others we were too hard on ourselves! A great learning process for all concerned!

We were proud to learn that we had achieved two ‘Excellence’ “(EA) ratings- one for Clinical Standard; Infection Control systems Criterion 1.5.2 and one for Support Standard; Quality Improvement system Criterion 2.1.1.

Now the challenges really start. How to get ourselves to the next level in every criterion? By our attention to detail under the EQulP4 process, we gained Ministry of Health certification for three years with no recommendations. Now we have our strong focus on Quality Improvement in place, along with a strong history in benchmarking, our next aim is to gain 4 or 5 years certification at our next accreditation survey. The EQuIP4 accreditation programme has enabled us to go so much further than basic safety and good care and has given us added confidence about the quality of care provided within our service.

We held a ceremony in June where we celebrated our accreditation and certification successes and also dedicated our new chapel window and our Heart of Mercy bronze.