EQUASS ASSURANCE
AUDIT REPORT
Site visit: 08.-09.12.2015
SA Pärnu Haigla
Triin Kraavi
© 2012 by European Quality for Social Services (EQUASS)
All rights reserved. No part of this document may be reproduced in any form or by any means, electronic, mechanical,
photocopying and recording or otherwise without the prior written permission of the EQUASS.
1. Information of the social service provider
Na me of th e s o ci al SA Pärnu Haigla - Foundation Pärnu Hospital,
se rv i c e p rov id er hereinaf ter PH
Ad d re s s: Rist iku 1, Pärnu 80010 , Estonia
Po st bo x: N/A
P er so n re sp on sib le Urmas Sule, chairman of the board
(C EO ):
Cont ac t p e rs on: Olga Sumbajeva, coordinator of rehabilit ation
ser vices
Pho ne: (+372) 5341 6543
Fa x: N/A
E- m a il:
[email protected]
W eb s ite: www. ph.ee
Na me of Au dit o r: Triin Kraavi
Dat e s of aud it : 08.-09.12. 2015
Cli en ts: Number of person served: 255
As of (date): 09.12.2015
St aff: Number of Full time staff : 12
Number of Part time staff : 43
Number of Contracted staff : 4
Number of volunteer s: 0
S erv ic e s: Day Center of Pärnu Hospital Psychiatric
Clinic:
1. Assistance in ever yday lif e
2. Assistance in working
3. Support person
Rehabilitat ion Units of Pärnu Hospital
Psyciatric Clinic and Internal Disease Clinic
4. Rehabilitat ion ser vice
2
2. Audit program
3. kuup ä ev P äev 1
Ae g T egev us ( l üh ik e k irj e l dus )
9: 0 0- 9 .3 0 Av a k oo sol e k, k e s kus eg a tu tv umi ne
( G 3 30 I lm i, O l ga , E st er , K ad ri , Kr i sto, Epp )
9. 3 0- 1 0. 1 5 Int erv j uu t e enu st e kv al ite ed i e est v a stut av a t ööt aj ag a
( G 3 30 I lm i L e es m an )
10 . 15- 1 0. 3 0 P aus
10 . 30- 1 2. 3 0 Dok um en ta ts io o ni g a t ut v um in e ( O l g a G 3 30 )
12 . 30- 1 3. 0 0 Lõ u na p aus
13 . 00- 1 4. 0 0 In ter vj u u r a has taj a es i nd aj ag a
Sot si a al ki ndl ust us am et , e r ihoo l ek and et e e nust e
juht u mi ko r ra ld aj a Lin da Li ll em a a
14 . 00- 1 5. 0 0 In ter vj u u r e ha b i l it ats i o on i ük s us e p ers o na l i ga
( G 3 30 : E st er R e in sa l u , Ka j a Ra nd , J an ne T amm , An u
M art šu k, M er it S ini jä rv )
15 . 00- 1 5. 1 5 P aus
15 . 15- 1 6: 4 5 Dok um en ta ts io o ni g a t ut v um in e ( O l g a G 3 30 )
kuup ä ev P äev 2
Ae g T egev us ( l üh ik e k irj e l dus )
9: 0 0- 9. 4 5 In ter vj u u p äe v ak es k us e p ers o n a li g a
( P äe v ak es k us : Kad r i E en ra id , Di an a V ain o nen , L a ine T ag am ,
M eril i Rõõ m, E pp Jü r is son )
9. 4 5- 10 . 30 In ter vj u u p äe v ak es k us e k l i en t id e ga + K a dr i
10 . 30- 1 1. 0 0 (PPaus
äe v ak es k us : e i t äps us t a n im es i d e tt e)
11 . 00- 1 1. 4 5 In ter vj u u p äe v ak es k us e j uh i j a r eh a bi l i ta ts io on i te e nus t e
ü ldk o or d i n aa to r i g a
( G 3 30 K r ist o Ka ukv er , O lg a Su mb aj ev a )
11 . 45- 1 2. 3 0 Lõ u na p aus
3
12 . 30- 1 3. 1 5 In ter vj u u r e ha b i l it ats i o on i ük s us e k li e nt i d eg a (G 3 30)
13 . 15- 1 4. 0 0 In ter vj u u k o os t öö p art n er it e es i nd aj a t eg a
1. M T Ü Hing e r ahu ju hat us e li ige I nd re k Li nn ust e
2. P är nu T oi me tul e ku ko oli e s ind aj a K ri stj an Õ unpuu
3. P är nu Ko ll edž i sot si a alt öö ko r ra ldu s e o s a konn a
juh at a j a An n e Rä hn
14 . 00- 1 4. 3 0 P aus
14 . 30- 1 5. 3 0 In ter vj u u j uh a tus e l i ik m ega
( V ei ko Vah ul a )
15 . 30- 1 5. 4 5 Lõ p uk oos o lek
( G 3 30 I lm i, O l ga , Ka d ri , K ri sto , Epp )
4
4. Detailed feedback on performance
1. The social ser vice provider def ines documents and implements its
vision and mission values on ser vice provision.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH has d oc um ent e d i ts v is io n, m is s i o n Cri t er io n is m et bu t it is a d v is a b l e t o
an d v al u es . It is p u b lis h ed i n var i o us up d at e t he d e v e lo pm en t p l an of P H s o
doc um en ts , f or ex am pl e i n de v e lo pm en t its t i t le a n d c o nt en t c orr es p o nds t o t he
p la n, hos p it a l we bs i te , ye a r b ook etc . c urr en t p er io d of tim e.
Dur i n g i nt er v i e ws it was v er if i e d t ha t t he Kr it e er ium on t ä i d et u d, k u id on
pers o n ne l is a wa r e of PH m is s i o n, s oo v i ta t a v u ue n da d a PH ar en g uk av a, et
v is io n a n d v a lu es . s e ll e pe a lk ir i ja s is u vas tak s
k äes o l e va l e p er io o d il e .
2. The social ser vice provider def ines, documents, and implements its
qualit y policy by determining long term qualit y goals, and its
commitment to cont inuous improvement.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS As surance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
5
PH h as d oc um ent e d its lo n g t erm
qu a l it y g oa ls a nd c om m itm ent to
c on t in u ous im pr o v em ent in d e v e lo pm en t
p la n an d m an ag em en t h a nd b ook . L o ng
term g oa ls ar e c o n nec t ed wi t h th e
an n ua l p l a n ac t i v i ti es .
PD C A- c yc l e is us ed in t he h os p i ta l
proc e d ures a nd p er s o nn e l d em ons tr at ed
its a wa re n es s of t he q u a li t y go a ls
dur i n g i nt er v ie ws .
3. Persons ser ved, family members and ser vice user organisations are
able to give f eedback on their individual and collective experience of
programmes and ser vices.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
6
T here ar e pr oc e d ur es i n p lac e f or g i v i n g
f ee db ac k e it h er via we b pa g e, via
s ur ve ys , on p a per a t th e hos p it a l, i n
m eeti n gs , d ir ec tl y t o t he p er s o nn e l etc .
Fe ed b ac k is doc um en t ed , a na l ys e d,
ans we re d , s um m ar i ze d a n d d is tr ib ut e d
reg u l ar l y wi t hi n t h e or ga n is at i on .
T his was v er if i e d by i n s p ec t in g th e
doc um en ta t io n and dur i ng th e
i nt er v ie ws wit h t he c l i en ts , c o - o p era t io n
par t ners , re pr es en ta t i v e of f un d in g bo d y
an d p ers on n e l th at t he y ar e a war e of
th e d if f ere n t p os s i b i l i ti es h o w to gi v e
f ee db ac k .
4. T h e s oc i a l s er v ic e pr o v i d er inf o rm s al l s tak e ho l de rs a b ou t t h e of f er ed
pro gr am m es a n d s er v i c es a v ai l a bl e .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
St ak eh o l der s ar e inf or m ed a bo u t th e
pro gr am m es a nd s er v ic es via PH
hom ep a g e, inf or m at i on l eaf le ts ,
c us t om er , p er s o n n e l a nd p ar tn er
m eeti n gs , e - m ai l etc .
T his was c o nf ir m e d dur i n g i n ter v i e ws
th at s tak e ho l d er s ar e a war e of th e
pro gr am m es a n d s er v i c es a v ai l a b l e .
5. T he s oc i a l s er v ic e pr o v i der m an ag em en t es t a bl is h es a nd d oc um ents an
an n ua l p l a nn i n g an d r e v ie w pr oc es s .
7
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T here ar e s e ver a l pr oc e d ur es i n p lac e
f or an n ua l p la n n in g a n d r e v i e w pr oc es s .
PH is us in g B SC m etho d. A nn u a l
p la n ni n g is l ink e d wi t h d e ve l o pm ent
p la n an d a n n ua l ac t i on p la ns .
Im plem e nt at i on is f o l lo we d
e lec tro n ic a ll y thr o ug h ou t t he ye a r a n d
th e proc es s an d r es u lts ar e r e v i e we d
an n ua l l y b y m an a ge m ent an d qu a l it y
un i t.
T his was c o nf i r m ed b y ex am in i ng th e
an n ua l p l an n i ng d o c um ent at i o n an d
i nt er v ie ws wit h t he per s on n e l a nd
m anag er s .
6. T he p l a n i nc lu d es :
an n ua l o u tc om es / tar ge ts
th e ac ti v i t ies t o b e u n der t ak en i n ac h ie v i n g th e a nn u a l tar g ets
m onit or i ng of th e pe rf orm anc e of t he or g an is at i o n i n m eet in g its
an n ua l t ar ge ts
tim e- s c al es a n d pr oc e dur es f or r e v i e w a n d r e v is i o n.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
8
A nn u a l plan is we ll s tr uc t ur e d – it Cri t er io n is m et bu t it is a d v is a b l e t o
c ons is ts of o bj ec t i ve s , k e y ac t i v it i es , an a l ys e t he p o s s ib i l it y t o de v e l op a nd
de t ai l e d ac t i ons , e x pec t ed r es u lts , im pl em ent K e y P erf or m anc e In d ic at ors .
res p o ns ib l e p er s ons . Im plem e nt at i on is
Kr it e er ium on t ä i d et u d, k u id on
f ol l o wed el ec tr o n ic al l y t h r o u gh o ut t he
s oo v i ta t a v a na l ü ü s i da v õ im al us t
ye ar an d s um m ar ies ar e do n e onc e a
ye ar dur i n g pe r f or m an c e i nt er v i e ws . to im i vus e v õtm ei n d ik aa tor i te
v ä lj a tö öt am is ek s ja k as ut us e l e
A nn u a l p la n is a ppr o v e d by th e v õtm is ek s .
m anag em en t.
7. T h e s oc i a l s er v ic e p r o v i der d em ons tr at es org a n is a t io n ’s s uc c es s i n
s at is f yi n g th e n e eds a nd ex p ec t a ti o ns of t h e s oc i et y.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH c o l l ec ts f e e d bac k f r om the d if f ere nt
s tak e ho l de r s - c l i e nt s , p er s on n el , c o -
op er at i o n par t ner s .
Dur i n g the i nt er v i e ws it wa s
dem ons tr at e d b y s t ak eh o l der s t ha t PH
is ac t i v e l y c o n tr ib ut i ng t o s at is f y t he
ne e ds a n d ex p ec t at i o ns of t he s oc ie t y
by or g an is i n g and par t ic ip at i n g in
v ar io us ac t i v it i es wi t h c o - o per a ti o n
par t ners , c l i en ts a nd p er s o n n el .
8. T h e s oc i al s er v ic e pr o v i d er dem o ns tr at es or ga n is at i on ’s s oc i a l res p o ns ib i l it y
thr o ug h ac t i vi t ies c on t r i bu t in g t o th e s oc i et y.
9
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH c arr i es o ut m an y c om m uni t y b as ed
ac t i v it es , f or ex am pl e or ga n i zes f a irs ,
th e atr e, c om pet i ti o ns , c om m uni t y
gar d e n, ex c ur s io ns e tc .
T his was ve r if ie d t hr o u g h in t er v ie ws
wi t h s t ak eh o ld er s a nd r e v i e wi ng
org a n is e d e v e nts d oc u m enta t io n.
9. T h e s oc i a l s er v ic e pr o v i d er h as a s t af f rec r ui tm ent a nd r e te n ti o n p o l ic y
th at pr om otes t he s e lec t io n of q ua l if i e d pe rs o n ne l b as e d o n r eq u ir ed
k no wle d ge , s k i l ls a n d c om pet e nc es .
Remark from the auditor: The ser vices of the social ser vice pr oviders mee t
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH has doc um en te d s taf f r ec r u itm en t
an d re t en t io n p o lic y wh ic h inc l u des
def in e d k no wl e d ge , s k il ls a nd
c om pet e nc ies .
10 . T h e s oc i al s e r vi c e pr o vi d er o per a tes i n c om pl i a nc e wi th m anda t or y
na t io n a l le g is l at i on , pr o v id i ng a p pr opr i at e w ork in g c o nd i t io ns , a d e qu a te a n d
agr e e d s t af f le v el a n d s t af f rat io , a n d a p p rop ri a te r e war d in g f or s taf f an d
v o lu nt e er s .
10
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH pr oc e d ur es ar e i n c om pl i a nc e wi t h
th e n at i on a l l e g is l a ti on an d t he y are
re v ie we d wh e n th e l e gis l a ti o n is
c ha n ge d .
PH has pr oc e du r e s in p l ac e f or
rec o g n is in g s t af f ac h i e v em ents .
T he work i ng c o n d it i o ns ar e e v a l ua te d
via s taf f s at is f ac ti o n s ur v e ys th a t
c on t ai ns t hes e s p ec if i c q u es t i ons .
11. The social ser vice trains all staff based on a plan f or lea r ning and
development and evaluates the eff ectiveness of the training.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
A nn u a l tr a i n in g p l an is a na l ys e d
reg ur ar l y a nd f e ed b ac k is d is tr ib u te d i n
org a n is a t io n . A l l tr a i n i ngs ar e r ec or de d
an d p ar t ic i pa n ts e v a lu at e t he
ef f ec t i ve n es s of th e tr a i n in g e i th er in
th e pers o n ne l m e et i ngs or wit h
e va l u at i on f or m s .
T his was v er if i ed by e x am i n in g the
doc um en ta t io n a n d b y i n te r vi e wi n g t he
pers o n ne l .
11
12 . T he s oc ia l s er vic e pr o v i de r a pp l i es re q u ir em ents f or c om pet e n c e i n t h e
i de nt if ie d r o l es a nd f u nc t i ons of s t af f a nd e v a lu at es t hem o n a n nu a l b as is .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Com pe te nc e r e q u ir em en ts of t h e s t af f
are d oc um ent e d in the work
des c r i pt i o ns . P er s o n ne l is e v a l ua te d
an n ua l l y d ur i n g de v e l opm en t
d is c us s i ons . A ls o c l i en t f e e db ac k
s ys tem an d p er s o n n e l m eet in gs ar e
us e d f or p er s o n ne l e v a lu at i o n.
13 . T he s oc i a l s er v ic e pr o v id er r ec o g n is e s th e s taf f as a r es ourc e f or
f ee db ac k on or ga n is at i on a l perf orm anc e , s er v ic e d e ve l o pm ent an d s taf f
de v e l opm en t
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
St af f i n v ol v em en t an d f e e db ac k f rom
s taf f is r ec or d e d in m in ut es of th e
m eeti n g, s a t is f ac t i o n s ur ve y.
It was c onf ir m ed dur i ng i nt er v i e ws th at
d if f ere nt s taf f pr o pos a l s t o m od if y or
im pro v e th e s er v ic e s or to d e v el o p th e
pers o n ne l wer e im pl e m ente d.
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14. The social ser vice provider has mechanisms in place to enhance
satisf action and mot ivat ion of staff
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
P ers o n ne l s at is f ac ti on s ur ve ys are Cri t er ia is m et b u t i t is a d vis a b le to
c arr ie d o ut an n ua l l y. an a l ys e if th e a ns wer in g r at e i n t h e
s at is f ac t io n s ur ve y is s uf f ic i e nt to
T here ar e m e as ur es an d pr oc e d ur es in
e va l u at e th e p ers on n e l s a tis f ac t i on .
p lac e f or r ec o gn is i ng an d m ot i v at i ng t he
s taf f – le tt er s of ac k no wl e dg em en t, Kr it e er ium on t ä i d et u d, k u id on
org a n is in g e v en ts , inc en t i ve pa y e tc . s oo v i ta t a v an a l üüs i d a, k as ra h u lo l u
k üs it l us e v as t am is e m äär on p i is a v
pers o n al i ra h u lo l u h i n dam is ek s .
15 . T h e s oc i a l s e r vi c e p ro v i de r as s ur es th e r i gh ts of p ers o ns s e r ve d
ou t l in e d in a Ch ar ter of R ig h ts wh ic h is bas e d on t he E U C har t er of
Fu nd am en ta l Ri g hts , t he E ur op e an C on v e nt i on f o r t he Pr ot ec t io n of Hum an
Ri g hts a n d Fu n dam e nt a l Fre e dom s of the Cou nc i l of E uro p e an d o th er
i nt er n a ti o n al h um an r i gh ts c on v e nt i ons , es p ec ia l l y t h os e e l ab or at ed u nd er
th e U ni t ed N at i o ns .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
13
T he ri g hts of t he pe r s ons s er v ed are
doc um en te d i n s e v er a l d oc um ents (f or
ex am p le i n t h e R u les of th e D a y C e nt er ,
th e R u l es of t h e H os p i ta l , C us t om er
S er v ic e St a n dar d) an d t he y c or r es p o nd
to t h e i nt er n a t io n al hu m an r ig hts .
It was c onf ir m ed dur i ng i nt er v i e ws th at
pers o n ne l is a war e of th e r i g hts an d
du t ies of t he per s o ns s er ve d .
16 . T h e s oc i a l s er v ic e pr o v i d er inf orm s th e pers o n s er ve d a bo ut h is / h er
ri gh ts a nd d ut i es es pe c i al l y t o eq u a l tre atm e nt o n gr ou n ds of a g e, d is a b i li t y,
ge n de r , r ac e , r e l ig i o n or be l i ef an d s ex u al or ie nt a ti o n b ef or e rec e i vi n g t he
s er v ic es .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he r ig h ts a n d du t ie s of t he p ers ons
s er ve d ar e i nf or m e d to the c l ie nts at t he
be g i nn i ng of th e s e r v ic e. E it h er t he
c l ie n t or t he ir r e pr e s en t at i v e c o nf irm
wi t h the s i g na tur e t ha t th e y have
un d ers t o od t he d oc u m ent. T h e r ig hts
an d d ut i es ar e a ls o o n th e inf or m at i o n
bo ar ds o n t he wa l ls an d ar e r e g u lar l y
d is c us s e d wit h t he c li en ts a t th e c li e nt
m eeti n gs .
It was c onf ir m ed dur i ng i nt er v i e ws th at
th e c l i e nts wer e a wa r e of th e ir r ig hts
an d d u tes an d k ne w wh er e t o f in d t he
i nf orm at io n wh e n n ec e s s ar y.
14
17 . T he s oc i a l s er v i c e pr o v id er h as ac c es s ib l e c om pl a i nt m ana g em ent
s ys tem wh ic h r e gis t e r s f ee d bac k o n perf orm anc e f rom pers o n s s er v ed ,
purc h as er s an d o th er r e le v a nt s t ak eh o ld ers .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH h as a do c um en t ed c om pl a in t
ha n d li n g s ys tem . St ak eh o ld er s h a ve
d if f ere nt p os s i b i l it i e s to is s ue a
c om pl a in t ( o n p a per , thr ou g h webs i te ,
v i a e- m ai l) . Com p la i nts a r e a n a l ys e d ,
ans we re d and r e v i e wed r e gu l ar l y.
S um m aries of th e c o m pla i nts ar e a ls o
pu b l is h e d at t h e h os p i ta l ye ar b o ok s .
18 . T h e s oc i a l s er v ic e pr o vi d er res p ec ts t he f u nd am en ta l r ig h t t o s e lf -
de t er m in at i on of t h e per s o n s er ve d . T he y f ree l y de te rm ine t he ir po l i t ic a l
s ta tus an d f r ee l y p ur s ue t h e ir ec on om ic , s oc i al an d c u lt ur a l d e ve l o pm ent .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
15
Cl i e nts ar e pr es en t wh en t h e ir i nd i v i d ua l
p la ns ar e d o ne a n d t he y de te r m in e th e
ac t i v it i es a nd obj ec t i v es th e y wa n t t o
reac h . T hes e p la ns a r e r e v i e we d e ve r y
qu ar ter wi t h t he c l i en t s to e va l ua t e wha t
has b e en ac h ie v e d, wh a t wer e the
obs t ac l es an d wh at ne e ds to be
c ha n ge d .
P er s o n ne l d em on s tr a te d d ur in g
i nt er v ie ws hi g h a p pr e c i at i on to t he r i g ht
to s e lf - de t er m in at i on of th e p ers ons
s er ve d .
19 . T he s oc i a l s er v ic e pr o v i der f ac i l i ta t es th e pers o n s er v e d in c ho os i ng
an d h a v in g ac c es s t o ad v oc at es a nd / or s u pp ort i ng pers o ns .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
W hen in d i v id u a l p l a ns ar e p r e p are d
pers o n ne l i nf or m s c l ie n ts ab o ut t he
pos s i b i li t y of a d v oc a tes or t he y are
d irec te d to s up p or t p e r s on s er v ic e whe n
th e ne e d is dis c o v er e d . Ac c es s to
s up p ort pe r s o n s er v ic e is e va l ua t ed
an n ua l l y wi t h t h e f u nd i n g b o d y Pär n u
Ci t y G o v er nm ent . T h is was v erif ie d
dur i n g p er s on n e l a nd f u n d in g body
i nt er v ie ws .
16
20 . T h e s oc ia l s er v ic e pr o v i d er def in es a n d doc um en ts its p o l ic y o n et h ic s
th at r es p ec ts a nd as s ur es th e d i gn i t y of th e p ers o ns s er v e d, pro tec ts th em
f rom un du e r is k an d pr om otes s oc i a l j us t ic e
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance cert if ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH h as d oc um ent e d pr oc e d ure of
org a n is in g t h e c l i en t s er vic e an d t h e
i ns tr uc t i o n of the go o d c on d uc t in
c us t om er s er v ic e . T hes e pr oc ed ur es
an d or ga n is at i on va l u es ar e k no w n t o
th e pers o nn e l . T his w as ve r if ie d d uri n g
pers o n ne l i n ter v i e ws .
21 . T he s oc ia l s e r vic e pr o v id er op er at es m ec han is m s wh ic h pr e ve n t th e
ph ys ic a l, m ent a l a nd f i na nc i al ab us e of u s ers .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Me as ur es to pr e v e nt th e p h ys ic a l ,
m enta l a nd f i na nc ia l a bus e of us ers ar e
doc um en te d i n th e h os p i ta l pr oc ed ur es
th at is s i gn e d b y c l i e nts . T hes e to p ic s
are a ls o r eg u l ar l y d is c us s e d at th e
c us t om er m eet i ngs . M i nu tes of the
m eeti n gs ar e d oc um ent e d a nd pu t o n
th e inf o rm ati o n b o ar d . T his was ver if ie d
b y s t ud yi n g th e d oc u m enta t io n a n d b y
i nt er v ie wi n g t he per s o nn e l.
17
22 . T he s oc i a l s er v i c e pr o v id er pr o v i des s erv ic es i n a s af e s ys tem of
work i n g wit h in a s af e e n v iro nm en t t o e n s ure th e ph ys ic a l s e c ur it y of
pers o ns s er v ed , t he ir f am il i es a nd c ar e tak ers .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH has s e v er a l pr oc e dur es f or e ns ur i n g
he a lt h y an d s af e e n v ir o nm en t, pl a ns
ho w to ac t in c r is i s or em er ge nc y.
T hes e pr oc ed ur es an d r es u lts ar e
re v ie we d a n nu a l l y, tr ai n i ngs and
s im ul at i o ns ar e c ar r i ed ou t. Per s o nn e l
was a wa re of th e pr oc e d ur es , a ls o
re le v a nt d oc um ent at i o n was ins p ec t e d.
23 . T h e s oc i a l s er v ic e pr o vi d er d ef i nes , doc um ents , m on it ors a nd e va l u at es
a s e t of pr inc i p les , v a l ues a nd pr oc e d ur es t ha t go v er n b e ha v i o ur i n s er v ic e
de l i v er y c o nt a in i n g as p ec ts of c o nf i d en ti a l it y, ac c u rac y, pr i v ac y an d
i nt egr i t y.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Et h ic al pr i nc i pl es ar e doc um en te d i n t h e
i nt ern a l wor k i ns tr uc ti o ns a nd in t h e
i ns tr uc t i o n of the go o d c on d uc t in
c us t om er s er v ic e .
It was v er if i e d d ur i n g in te r vi e ws t h at
pers o n ne l was a war e of th e et h ic a l
pr inc i p les .
18
24 . T h e s oc i a l s er v ic e pr o vi d er d ef i nes , doc um ents , m on it ors a nd e va l u at es
proc e d ur es f or as s ur i n g c o nf i d en t ia l it y of d at a re g ard i n g t he pe rs o ns s er v e d
an d t he s er v ic e pr o v i d ed t o t hem .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH h as d oc um e nt ed pr oc e d ur e h o w t o
ha n d le de l ic at e p er s on a l i nf or m at i o n
an d h o w to us e c om pu ter n et wor k i n th e
hos p it a l whe r e t h e d e l ic a t e i nf or m at io n
is s t ore d.
Co nf i d en t ia l it y is s u e s ar e d is c us s e d
reg u l ar l y wi t h c l i en t s at th e c l i e nt
m eeti n gs a nd in per s o nn e l m e et i ngs .
It was c o nf ir m ed d ur i ng i n ter v i e w wi t h
c l ie n ts an d p er s o n n e l t h at t he y ar e
a war e of th e c o nf i de nt i a li t y r u l es a nd
th at it was d is c us s e d wi t h th em .
25 . T h e s oc ia l s er v i c e pr o v i d er def in es th e r o les a n d r es po ns ib i l it i es ,
au t hor i ti es a nd t he i nt er r e la t io n of a l l p ers o n n el wh o m a na g e, d es ig n,
de l i v er , s up p or t a n d e v a lu at e t he s er v ic e pr o v is i o n to pers o n s er v ed .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
19
Ma n ag em en t r o les a nd r es p ons i b i li t i es
are d ef i n ed i n t h e d oc um ent at i o n t h at is
a va i l ab l e in t h e h os pi ta l in tr an et . R o les
an d r es po ns ib i l it i es of th e f u nc t i o ns
d irec t l y i n vo l v ed wi th s er v ic es ar e
doc um en te d in j ob des c r i pt i o ns and
s oc ia l s er v ic e pr oc ed u r es .
26 . T h e s oc i a l s er v ic e pr o vi d er work s i n p art ners h i p wi th o th er or g an is at i o ns
i n th e pr o v is io n of s er v ic es .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH has c o - o p er a t i on wi th S oc i a l
Ins ur anc e Fu n d, Pä r n u c i t y go v er nm en t
as f u nd i n g ag e nc ies a nd s e v er a l c o -
op er at i o n p ar tn er s a s s oc i al p ar tn ers .
A l l c o - op er at i on par tn er s ar e l is t e d a nd
th e ir f e ed b ac k is a s k ed r e gu l ar l y at
l eas t o nc e a ye ar .
27 . T h e s o c i a l s er vic e p r o v i de r work s i n p art n ers h i p wi t h p ers o ns s e r ve d,
purc h as er s an d o th er s tak e ho l de rs i n th e d e v e lo pm en t of s er v ic es .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
20
It was c o nf ir m ed d ur i ng i nt er v i e ws wi t h
c l ie n ts an d c o - op er at i on p ar t n er s th at
th e f e e db ac k ab o ut th e s er v ic e
de v e l opm en t is as k ed an d s e v er a l i de as
are a ls o im pl em en te d ( “ m en ho ur ” at th e
Da y Ce n ter , r e h a bi l i ta ti o n t eam is go i n g
ou ts id e t h e h os p i ta l to t h e s c h oo l t o
pro v i d e th e s er v ic e et c .) .
28 . The s oc i a l s er v ic e p ro v i de r inc l ud e s p ers o ns s er v ed as ac t i v e
par t ic ip a nts in p la n n in g a nd h a ve s et u p ap pra is a l m ade up of on - go i n g of
an o n- go i ng s tr uc t ur e d d i a lo g u e pr oc es s in th e m an ag em en t of t h e s er v ic e ,
i nc l u d in g th e d ef i ni t io n of th e n ee ds , t h e d ef i n it i on of t h e s er vic es , as we l l
as of t h e e v al u at i on of q u al i t y.
Remark from the auditor: The ser vices of the social ser vice pr ovide rs meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Dif f er en t s oc i a l s er v ic e pr oc e d ur es
s ta te h o w per s o ns s e r v ed ar e inc l ud e d
i n as s es s i n g th e ir n ee ds , p l a nn i ng wh at
s er v ic es they wi l l g et and how th e
f ee db ac k ab ou t t he s er v ic es is
ga t her e d.
It was ver if ie d d ur i n g i nt er v i e ws an d
ex am i n in g t he d oc um en ts t ha t p ers o ns
s er ve d a re inc l u de d i n a bo v em en t io n ed
ac t i v it es .
29 . T he s oc i al s er v ic e pr o v id er i ns t it u tes an a nn u a l e v a l ua t io n of
par t ic ip a ti o n of per s o n s s er v e d bo t h o n i nd i v i du a l a nd / or gr ou p b as i s .
21
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
In d i v id u al pl a ns ar e s i gn e d b y th e c l i en t
or c l ie n t r epr es e nt at i v e. Ser v ic e
par t ic ip a ti o n r ul es ar e dis c us s ed a n d
agr e e d wi th t h e c l ie nt s at t h e m ee ti n gs .
T his was v er if i ed by s tu d yi n g the
doc um en ta t io n an d m inut es of th e
m eeti n gs .
T here is a pr oc e du r e in p lac e f or
re v ie wi n g a l l pr oc ed ur es a nn u al l y.
30 . T h e s oc i a l s er v ic e pr o vi d er o pe ra tes s pec if ic i ns tr um ents f o r us ers t o
im pr o v e t he ir pe r s o n a l em po werm e nt a n d pers o na l s it u at i on a nd . t ha t of
th e ir c om m un it y
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Im pro vem e nt of per s o na l em po werm en t
is on e p ar t of the s oc i a l s er v ic e
obj ec t i v es . T h e r es u lt s ar e d oc um ent e d
i n th e in d i v i du a l p l an e va l u at i on . I t was
v er if i ed b y s t ud yi n g e x am pl es of c l i en t
i nd i v i du a l p l ans a n d e v a lu at i o ns .
31 . T he s oc i a l s e r v ic e pr o v id er o p er a tes s pec if ic m ec h a n is m s f or
es t a bl is h in g a n em po w er in g e n v iro nm en t.
22
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Em po wer i n g e n v ir onm en t is c r e at e d b y
tra i n in g t h e p er s on n e l a n d d is c us s io ns
i n pers o n ne l m eet i ngs .
T his was v er if ie d dur i n g pe r s o n ne l
i nt er v ie ws .
32 . T he s oc i al s er v ic e pr o v i der s e lec ts pr ogr am m es wh ic h are bas e d o n a
ne e ds as s es s m ent at th e l oc at i on wh ic h i s m os t c o n ve n i en t f o r th e p ers on
s er ve d , f am i l y a nd c a r e tak er s
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he l oc at i on of th e h os p it a l is
c on v e n ie nt f or t he c l i en ts a n d m ak es
pos s i b le to h a ve v er y go o d c o - o per a t io n
an d i nt egr a ti o n wi t h o th er h os p i ta l
s er v ic es . T his was ve r if ie d d ur i ng
i nt er v ie ws wit h c l i e nts an d c o - op er at i o n
par t ner s .
33 . T he s oc i a l s er v i c e pr o v id er of f ers p rog ram m es c ons is te n t wit h t h e
i de nt if ie d n ee ds of i ts c us t om ers an d o bj ec t i v es f or t h e pr ogr am m e.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
23
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Fu nd i n g bo d ie s h a ve s ig n ed an
agr e em ents wi t h P H t ha t c or r es po n ds t o
th e ir n ee ds . O t her s tak e ho l de r ne e ds
are d et erm in e d b y s ur v e ys . T h e r es u l ts
of th e obj ec t i v es ar e s um m ar is e d in
ye ar b ook s , a n nu a l p l an r e por ts , c l ie n t
i nd i v i du a l p l an e v a l ua t i on d oc um ents .
34 . T he s oc i a l s er v ic e pr o v i der o per at es in d i v i du a l pr oc es s es t h at are dr i ve n
b y th e n e eds of t he p e r s on s er ve d .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
In d i v id u al p l ans of c l i en ts ar e dr a wn u p
ac c or d i ng to their i nd i v i du a l n ee ds .
Id e nt if i e d n e eds a nd ex p ec ta t io ns are
doc um en te d in t h e i n d i vi d ua l p la n. It is
pos s i b le f or a c l ie n t to r ec e i v e m ore
th a n on e s er v ic e a t th e s am e t im e.
35 . T h e s oc i al s e r vic e pr o v id er d oc um ents t he p l a nn i n g of s er v ic e s b as e d o n
th e id e nt if ic a ti o n of in d i vi d ua l n ee ds an d ex pec t at i ons of p ers ons s er ve d i n
an I n d i vi d ua l P la n.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
24
In d i v id u al pl a n c o ns is ts of t he d es ir ed
s it u at i on , o v er al l obj e c ti v es , m eas ur ab l e
obj ec t i v es , m eth o ds a nd t ec hn i qu es t ha t
are pl a nn e d to us e a nd r es p o ns i b l e
pers o ns wh o wi l l c ar r y o ut t h e ac t i v i ti es .
In d i v id u al p la ns a r e s i gn e d b y c li e nt or
c l ie n t r e pres e nt at i v e.
36 . T he s oc i al s er v ic e pr o v i d er i d e nt if i es , d oc um en ts , a nd m a in t ai ns t he k e y
s er v ic e d e l i ver y pr oc es s es t o th e p ers o ns s er v ed in l i n e wi th its vis i o n,
m is s io n s ta t em ent a n d q u al i t y p ol ic y.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
All s oc i a l s er v ic e pr oc es s es ar e
i de nt if ie d, d oc um ent ed and r e v ie we d
an n ua l l y or m or e of t en if c ha n ges ar e
ne e de d . The pr o c es s es are in
ac c or d a nc e wit h PH v i s i on , m is s io n a nd
qu a l it y p o l ic y an d c o nt r ac ts wi th f un d i ng
bo d i es .
37 . T h e s oc i a l s er v ic e pr o v id er r e vi e ws th is d e l i ver y p roc es s a n d m ain t ai ns
c on tr ol o ver t h e d el i v e r y of th e s er v ic e.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
25
Pr oc es s es ar e m on it or e d a nd res u lts
e va l u at ed r e gu l ar l y. I nt er na l au d its are
c arr ie d o ut ac c or d in g to the an n ua l
au d it p l a n. F in d i ngs a r e r e por t ed i n t he
org a n is a t io n and c or r ec t i v e ac t i o ns
im pl em ent e d.
38 . T he s oc i a l s er v ic e pr o v id er e ns ur es th at the pers o n s er v ed c a n ac c es s a
c on t in u um of s er v ic e s th at s p a n f rom ea rl y i n ter v e nt i o n to s u pp or t a nd
res p o n d t o c h a ng i n g r eq u ir em ents o v er t im e .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH of f ers m an y s er vi c es f or th e c li e nts
th at c a n b e us e d wh en th e ne e ds ar e
c ha n ge d . A l l i nf or m at i on is doc um en te d
i n th e i n di v i d ua l p l a ns .
PH h as c o ntr ac ts wi t h f u nd i n g b o d ies
th at ens ur e th e c o nt i n uum of s er v ic es .
39 . T he s oc ia l s er v ic e pr o v i d er d e ve l o ps a s eam l es s c o nt i n uum of s er v ic es a nd
red uc es b ar r ier s i n a m ult i - d is c i p li n ar y or m u lt i - ag e nc y s et t in g .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
26
A nn u a l re p or ts h a ve i nf or m at io n ab o ut
th e s er v ic e q ue u es .
S er v ic e pr o v id er has v er y g oo d co-
op er at i o n wi t h ot h er h os pi t al s er vic es
th at a l l o ws to of f e r s er v ic es wi t h
m ult id is c i p li n ar y a ppr o ac h .
40 . T h e s oc i a l s er v ic e pr o vi d er o pe ra tes s er v ic es f rom a h o l is t i c a p pro ac h
bas e d o n t he ne e ds a nd ex p ec ta t io ns of t h e p ers o n s er ve d wit h th e a im of
im pro v i ng t h e qu a l it y of lif e f or t h e pe rs o n s er ve d .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Q u al i t y of lif e of t h e p er s on s er v e d is
e va l u at ed in the in d i v i du a l p l a n,
m eas ur es f or im pr o v em en t a re
de t erm in ed an d the r es u l ts of th e
ac t i ons are e va l ua t ed r eg u l ar l y.
41 . T h e s oc i al s er v ic e pr o vi d er i d en t if i es t he ne e de d c om pe te nc es , s k il ls
an d s u p por t f or s taf f t o e nh a nc e t h e qu a l it y of lif e f or p ers o n s er v ed .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
27
P ers o n ne l s k i l ls an d c om pet e nc ies th a t
he l p t o im pr o v e t he q ua l i t y of l if e of th e
pers o ns s e r ve d ar e d oc um en t ed i n t h e
j ob d es c r ip t io ns and per s o nn e l is
e va l u at ed a nn u a ll y d ur in g de v e lo pm en t
d is c us s i ons .
42 . T h e s oc i a l s er vic e pr o vi d er i de nt if ies i ts bus i n es s r es u l ts a n d pr o vi d es
f orm al p er io d ic a n d i nd e pe n de n t re v i e w a nd pr oc e d ures to ac h ie v e t h e
tar g et ed r es u l ts .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Res u lts of t he a n nu a l pl a ns a re
m eas ur ed a nd r e v ie w ed r e gu l ar l y. T h e
res u l ts are d oc um ent ed i n a nn u al p l a n
rep or t a nd PH ye ar b o ok .
PH s oc i a l s er v ic e d ar e a ud i te d a ls o b y
i nd e pe n de nt ex t er n a l b od y ( Soc i a l
Ins ur anc e F u nd , Q u a li t y N e t work f or
Com m unit y C A M H S)
43 . T h e s oc i al s er v ic e pr o vi d er i d en t if i es an d re g is t ers t he ou t c om es a n d
be n ef i ts f or p er s o n s er ve d of th e rec e i v e s er v ic es on in d i v i du a l a nd
c o ll ec ti v e b as is .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
28
In d i v id u al p la n r es u l ts ar e m eas ur e d
an d doc um en te d in t he i nd i v i d ua l p la n
re v ie ws .
Co l l ec t i v e r es u lts ar e s um m ar is e d in
ye ar bo ok an d d is c u s s ed i n pe r s o n ne l
an d c l i e nt m eet i ngs .
44 . T he s oc i a l s er v ic e pr o v id er e v a l ua tes its bus i n es s res ul ts i n or der to
de t er m in e b es t va l u e f or purc h as ers an d f u nd ers ( ‘b es t v a lu e ’ c a n a ls o be
ex pr es s e d i n r e la t io n to t h e i nc re as ed qu a l i t y of lif e of f ere d t o th e p ers o n
be i n g s er v ed) .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he a d de d v a lu e f or pur c h as e r s a n d
f un ders is e va l u at ed i n i nd i v i du a l p la ns
b y th e res u lts of t he q ua l i t y of lif e.
45 . T h e s oc i a l s er v i c e pr o v i d er e va l ua t e s th e i nd i v i d ua l a nd c o l lec t i ve
s at is f ac t io n of pe r s o n s s er ve d an d ot h er s tak e ho l de rs b y i nt er n a l a n d/ or
ex t er na l e v a l ua t io n.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH c o nd uc ts r e g u lar c l ie n t and c o-
op er at i o n p ar t n er s a t is f ac ti o n s ur v e ys
(s ep ar at e l y f or r e ha b il i ta t io n s er v ic e
par t ners an d Day Ce nt er p ar tn ers ) .
Res u lts ar e a na l ys ed , s um m ar is ed a n d
d is tr i bu t ed wi th i n th e or g a n is a t io n .
29
46 . T he s oc i a l s e r v ic e pr o v id er p ro v i des ac c es s i b le an d e as il y
un d er s t a nd a b le r ec or ds on o utc om e, i nc l ud i n g p ers o na l p erc e pt i on a n d
ac h i e v em ents
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Re p orts a bo u t PH ac t i v it i es an d r es u lts
are pu b l is h e d i n P H we bs it e, pr in te d in
broc h ur es , d is c us s e d in m ee ti n gs ,
doc um en te d i n in d i v i du a l p l ans . T he y
i nc l u de p er s o n a l a c h ie v em en ts a nd
perc e pt i o n ( f or ex a m ple m in ut es of
c l ie n t m eet i ngs , i n d i v i du a l p l an r es u lt
e va l u at i on r ep or t ) .
47 . T h e s oc i a l s er v ic e pr o v i d er ac t i v el y d is s em in at es org a n is a t io n perf orm anc e
am ong its s t af f , s er v ic e us er s an d ex t ern a l s tak e ho l de rs .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Inf orm at i o n a bo ut or g an is at i o n ac t i v i t i es
are d is tr ib u te d i n v a r i ous wa ys – v i a
we bs it e, d if f er en t r ep or ts , m ee t in gs ,
broc h ur es etc . E v er y ye a r an an n ua l
rep or t is c r e at e d.
48 . T h e s oc ia l s er v i c e pr o v i d er has a s ta n dar d pr oc e d ur e f o r c o nt i nu o us
im pro v em ent on t h e b as is of a n im pr o vem en t c yc l e.
30
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH has im pl em ent e d a pr oc e dur e t o
c arr y o u t im pr o v em e nt ac t i v it i es t h at
f ol l o w PD C A - c yc le . O bj ec t i ves are s et ,
im pro v em ent ac t i vi t ie s ar e c a r r i e d ou t,
res u l ts ar e e va l u at ed an d c o r r ec te d if
nec es s ar y. PH h as a r e gis t er of
c orr ec t i v e ac t i on .
49 The s oc i a l s er v i c e pr o v i der i d en t if i e s perf orm anc e i n d ic at ors f or
m eas ur in g t he r es u l ts of t h e im pro v em ent ac ti o ns .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH h as d oc um ent e d pr oc e d ur e f or
im pro v em ent pr oc es s . I np u t f or th is
proc es s c a n c om e f r om var io us s ou rc es
(i nt er na l a ud i ts , d e v e lo pm en t p l a n,
l eg is l at i on c h a ng es etc ) . Im pr o v em ent
proc es s i nc lu d es d ef i n in g im pr o v em ent
pos s i b i li t ies , p l an n i ng the im pr o v em ent
ac t i ons , im p lem e nt i ng th e ac t i o ns a nd
re v ie w.
50 . T h e s er v ic e p r o v i der in tr od uc es an d m an a ges in n o va t i ve wa ys of work i ng
th at ha v e b ee n i d en t if i ed bas e d on t h e n ee ds of s tak e ho l d ers .
31
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication prog ram
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH h as im p lem en t ed m an y in n o va t i ve
i ni t ia t i ves ( f or ex am p le H am et work
c ap a b il i t y e v a l ua t io n tes t p i l ot proj ec t ,
gre e n ho us e pr oj e c t, ex p er ie nc e
c ou ns e ll i n g p i lo t pr oj ec t) . T hes e
proj ec ts ar e f o l lo we d and r es u lts of
th es e p roj ec ts ar e doc um en te d ye a r
bo ok .
32
5. Agreed additional development / improvements
T he a pp l ic an t d ec i d ed on th e f o l lo wi n g im pro v em ent ac t i on s an d/ or
ad d it i o na l d e v e lo pm e n t f or t h e pe ri o d of t wo ye ars :
Sho rt d es c ri ptio n of the a cti on s
( in clud ing SM ART ob je ctiv es )
1 Up d at e t he de v e l opm en t p l an of PH s o i ts ti tl e a n d c o nt e nt
c or r es p o nds t o t he c u r ren t p er io d of t im e.
Uu e nd a da P H ar e ng u k ava , e t s el l e p e a lk ir i j a s is u vas tak s
k äes o l e va l e p er io o d il e .
De ad lin e /tä hta eg : 3 1 . 12 . 20 1 6
2 A na l ys e th e p os s ib i l it y to d e ve l o p an d im p lem en t Key
P er f or m anc e In d ic at or s .
A na l ü üs i d a v õ im al us t t o im i vus e v õtm ei n d ik aa tor i te
v ä lj a tö öt am is ek s j a k a s ut us el e võ tm is ek s .
De ad lin e /tä hta eg: 3 1 . 12 . 20 1 7
3
4
5
6
33
6. Closing remarks
P ärn u Hos p it a l ’s m is s i on is t o s up p ort h um an h ea l th a nd q ua l it y of l if e. B es id es
m edic a l c ar e Pä r n u H os p i ta l pr o v i des s pec i a l c are s er v ic es , r e ha b il i ta t io n s er v ic es
an d s u p por t p er s o n s e r v ic e.
Curr e nt EQ U A S S As s u r anc e a u d it is t h e s ec on d a u di t f or P är nu H o s p it a l .
PH h as we l l im pl em ent e d q u a li t y s ys tem t ha t f o l l o ws P DC A - c yc l e . Pr oc es s es ar e
doc um en te d an d r eg u la r l y r e v ie we d . An n ua l p la n n in g c yc le is perf orm in g we ll .
Cl i e nts i n di v i d ua l n ee ds ar e t ak en i nt o ac c ou n t. T h er e is go o d c o - o p er at i on wit h
d if f ere nt c o - o p er a t io n par t ner s i n or der t o of f er b et ter s er v ic es . P er s on n e l is va l ue d
an d t he y a r e s at is f i e d wi t h th e i r j o b.
T here wer e d if f er e nt i nt er v ie ws wi t h c l i en t s , pers o nn e l, m an ag e rs , f u n di n g b od y
an d c o- op er at i o n pa r tn er s d ur in g th e a ud i t. I nt er v ie w p art ic i pa nts wer e co -
op er at i v e a nd ex pr e s s ed t h eir s a t is f ac t i on wi th P är n u H os p it a l’s ac t i v it i es .
Re q ui re d d oc um e n t at i on was we ll pre p ar ed an d s uf f ic i en t.
Dur i n g th e v is it au d i tor f o u nd v er if ic at i on m ateri a l f or a l l EQ UA S S As s ura nc e
c rit er i a.
A ud i tor pr es e nt ed o ne r em ar k s ta t ed in c r it er i a 14 and t wo im pr o vem en t
s ug g es t i ons :
Cri t er ia 1 : U p da te t h e d e ve l opm e nt p la n of P ärn u Hos p it a l s o its ti t le a n d c o n te nt
c orr es p o nds t o t he c u r r en t p er io d of t im e.
Criteria 6 : A nalyse the possibility to develop and implement Key Performance
Indicators.
Af t er v er if ic at i on of t he i n d ic a t or s dur i n g t he s i t e v is it , r e vi e wi n g doc um en ta t io n,
c on d uc t i ng s e v er a l i nt er v ie ws wi t h pers o ns s er ve d , s t af f a nd ex t e rna l s t ak eh o ld ers
(pa rt ners , f u nd er s ) , t he a ud i tor r e ac h e d t o c onc l us io n t h at Pär n u H os p i ta l m ee ts
f ul l y t he c r it er ia f or E Q U A SS As s ura nc e c er tif ic a t io n pr o gram m e.
P ärn u ha i g la m is s io o n ik s on t o et ad a in i m es te t er v is t j a e l u k va li t ee t i. Lis ak s
ter v is ho i u te e nus te l e os ut a tak s e re h ab i l it ats i o on i , er ih o o lek an d e (t öö tam is e
to et am in e j a i g ap ä e va e lu t o et am in e) j a tu g i i s ik u te e nus e id .
34
K äes o l e v EQ U AS S as s ur a nc e a ud i t o l i P ärn u h ai g l al e t e is tk or dn e.
P ärn u h a ig l a l o n hä s ti j u ur ut at u d k v a l it e ed ij uh t im is s üs te em , m is j äl g i b P DC A -
ts ük l it . Pr ots es s id on k ir j e ld a tu d ni n g reg u l aars e lt ü l e va ad a tu d. A as t as e
p la n eer im is e ts ük k el o n h äs t i t o im iv . K l i en t id e le lä h en e tak s e i n d i vi du a a ls e l t s i lm as
p id a des ne n de v aj a d us i . T ee n us t e p ar em ak s os ut am is ek s to i m ub he a k oos t ö ö
er in e v at e k oos t öö p ar t ner i te g a. Pers o na l i v äär t us t at ak s e ni n g na d on om a t ö ög a
rah u l.
A ud i ti l äb i v i im is e l t o im us i d er i ne v a d i nt e rvj uu d k li e nt i de , p er s on a l i, j u h ti d e,
rah as taj a j a k oos tö ö par t ner i te g a. I nt er vj u ud es os al ej ad o l i d k oos t öö a lt i d n in g
v ä lj e nd as i d om a r a hu l o lu P är n u h a i gl a t e ge v us e g a. K on tro l l i ta v d ok um ent ats i oo n
o li häs t i et te v a lm is t at u d n in g am m enda v .
A ud i ti l ä b i v iim is e l le i d is a u d ii t or t õ en d us m aterj a l i k õ ik id e EQ UA S S As s ur a nc e
k rite er ium i te k oh t a .
A ud i it or es i tas üh e m ä r k us e 14 . k ri te er i um is j a k ak s p are n dus e tt ep an ek ut :
Kr it e er ium 1: Uu e nd ad a PH ar en g uk av a , et s el l e p ea lk ir i ja s is u v as t ak s
k äes o l e va l e p er io o d il e .
Kr it e er ium 6: Analüüsida võimalust toimivuse võtmeindikaatorite väljatöötamiseks
ja kasutusele võtmiseks .
P ea l e as ut us e k ül as t u s t, d ok um ent a ts i o o ni ü le v a at us t n in g in te r v j uu d e l ä bi v i im is t
te e nus e s a aj a t eg a, t öö t aj a te j a v ä lis t e h u v ip o ol t eg a (p ar tn er i d j a ra h as t aj a d) ,
j õu d is a ud i i tor o ts us e le , et P är n u H a ig l a tä id a b tä i e l ik ul t EQ UA S S As s u ra nc e
s ert if ik a a di nõ u de i d.
Ta l li n n, 15 .1 2 .2 0 15
Tri i n Kr a av i
35
Maarika Aro
Saatja: Guus van Beek <
[email protected]>
Saatmisaeg: 21. detsember 2015. a. 12:52
Adressaat: Maarika Aro; Keiu Talve
Koopia: Marie Dubost; Madeleine Clarke - EPR
Teema: Re: Pärnu Haigla audit report
Tähtsus: Kõrge
Dear Mari ka / K eiu,
I have reviewed the audit report from P ä r n u H a i g l a (R e f e r e n c e n u mb e r : E E 2 0 1 5 - 0 2 3 ) and
I conclude that the services (within the scope of the application) of this
organization meet all the EQUASS assurance criteria. Base d on the delegated
power, which is described in the EQUASS internal procedures and
approved by the International EQUASS Awarding Committee, t he
services (within the scope of the application) of P ä r n u H a i g l a (R e f e r e n c e
n u mb e r : E E 2 0 1 5 - 0 2 3 ) will be certified with EQUASS Assurance in Social
Services.
According the agr eed communication procedure, I kindly ask you to disseminate
the decision to cer tify the services (within the scope of the
application) of P ä r n u H a i g l a (R e f e r e n c e n u mb e r : E E 2 0 1 5 - 0 2 3 ) with EQUASS
Assurance in Social Services.
Marie Dub ost will s end the certificate (and guidelines for using the EQUASS
Assurance logo) directly to P ä r n u H a i g l a (R e f e r e n c e n u m b e r : E E 2 0 1 5 - 0 2 3 ) .
Kind regards,
Guus van Beek
European Quality in Social Services (EQUASS)
c/o EPR, Avenue des Arts 8, c/o CCI, B-1210 Brussels
Belgium
Phone: +31653770121
Email:
[email protected] / website: www.equass.be
1
Van: Maarika Aro <
[email protected] >
Datum : vrijdag 18 december 2015 08:22
Aan: Guus van Beek <
[email protected]>
CC: Marie Dubost <mdubost@e pr.e u>
Onderwerp: RE: Pärnu Haigla audit re port
Good morning,
I recived a prepared report (Pärnu Haigla) from auditor Triin Kraavi.
Best,
Maarika
From: Guus van Beek [mailto:
[email protected]]
Sent: Thursday, December 17, 2015 11:44 AM
To: Maarika Aro <
[email protected]>; Keiu Talve <
[email protected]>
Cc: Marie Dubost <
[email protected]>; Madeleine Clarke - EPR <
[email protected]>
Subject: Re: Pärnu Haigla audit report
Importance: High
Dear Marika/ Keiu,
I h a ve r e vi e w e d t h e a u d i t r e p o r t f r o m P ä r n u H a i g l a (R e f e r e n c e n u mb e r : E E 2 0 1 5 - 0 2 3 ) a n d I
c o n c l u d e t h a t I n t h e a u d i t r e p o r t P ä r n u H a i g l a (R e f e r e n c e n u m b e r : E E 2 0 1 5 - 0 2 3 ) i s w r i t t e n a t
c r i t e r i o n 5 t h e f o l l o w i n g : " T h e c r i t e r i o n i s m e t b u t it i s a d v i s a b l e t o r e v i e w t h e t a r g e t s u s e d i n a n n u a l
p l a n s s o t h a t t h e y c o r r e s p o n d t o S MA R T c r i t e ri a o r a n a l y s e t h e p o s s i b i l i t y t o d e v e l o p a n d i m p l e m e n t
K e y P e r f o r m a n c e I n d i c a t o r " . Th e r e q u i r e me n t ' h a vi n g r e vi e w e d t a r g e t s i n t h e a n n u a l p l a n n i n g
p r o c e s s ' i s a r e q u i r e m e n t f o r c e r t i f i c a t i o n . I n t h e e x c e l f i l e t h i s i s ' t i c k e d o n – c o n f i r me d b y t h e
a u d i t o r ' . Th i s l o o k l i k e s a n c o n s i s t e n c y i n va l i d a t i o n / o b s e r va t i o n Th e r e ma r k / r e c o m m e n d a t i o n i n
t h e a u d i t o r r e p o r t m a y g i ve t h e t h e i mp r e s s i o n t h a t t h e s o c i a l s e r vi c e p r o vi d e r d o e s n o t m e e t t h e
d e m a n d o n i n d i c a t o r 1 1 d . I n t h i s c a s e t h e s o c i a l s e r vi c e p r o vi d e r d o e s N O T me e t t h e c r i t e r i o n n r
5 . B u t t h e a u d i t o r c o n f i r ms t h a t t h e s e r vi c e p r o vi d e r m e e t s t h e i n d i c a t o r d e m a n d s a n d t h e r e f o r e
m e t t h e c r i t e r i o n . I w o u l d a d vi c e t o r e f o r mu l a t e t h e r e c o m m e n d a t i o n s i n a w a y t h a t t h e r e i s mo r e
c o n s i s t e n c y i n t h e o b s e r va t i o n s a n d ve r i f i c a t i o n s .
Af t e r r e c e i vi n g t h e a d j u s t e d a u d i t r e p o r t , E Q U AS S c e r t i f i c a t i o n c o u l d b e v a l i d a t e d . I f re c e i vi n g
t h e a d j u s t e d r e p o r t t o d a y … I w i l l g i ve f e e d b a c k i n t h e e ve n i n g s o t h e c e r t i f i c a t e m a y b e s e n t
o n F r i d a y t o t h e s o c i a l s e r vi c e p r o vi d e r .
Kind regards,
Guus van Beek
European Quality in Social Services (EQUASS)
c/o EPR, Avenue des Arts 8, c/o CCI, B-1210 Brussels
Belgium
Phone: +31653770121
Email:
[email protected] / website: www.equass.be
Van: Maarika Aro <
[email protected]>
Datum: donderdag 17 december 2015 09:35
2
Aan: Guus van Beek <
[email protected]>
CC: Marie Dubost <
[email protected]>
Onderwerp: Pärnu Haigla audit report
Dear Marie, Dear Guus,
Attache d you’ll find an audit report and ot her documents of Pärnu Haigla EE2015-023.
Please let Keiu to kno w in case t here are so me comments about t he report .
Maarika Aro
Sotsiaalteenuste kvaliteedi keskus
Arendusspetsialist
Astangu Kutserehabilitatsiooni Keskus
tel +372 687 7223
mob +372 521 3563
[email protected]
Astangu 27 Tallinn 13519
www.equass.ee
www.astangu.ee
3