EQUASS ASSURANCE
AUDIT REPORT
Site visit:08.12-09.12.2014
PÔlva Haigla
Tiina Unukainen
© 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
Name of the social service
provider AS PÔlva Haigla
Address:
Uus 2, PÔlva 63308
Post box:
Person responsible (CEO): Margit Rikka
Contact person: Tiina Tammik
Phone: 7999152/ 7999153
Fax: 7999105
E-mail:
[email protected];
[email protected]
Web site:
Name of Auditor: Tiina Unukainen
Dates of audit: 08.12-09.12.2014
Clients: Number of person served:
Social rehabilitation- 568
Medical rehabilitation- 1254
As of (date):01.10.2014
Staff: Number of Full time staff: 40
Number of Part time staff:
Number of Contracted staff:
Number of volunteers (if applicable)
2
Services: Medical and social rehabilitation
3
2. Audit program
Esimene pÀev
10.30-11.00 Avakoosolek, auditi protsessi tutvustamine
11.00-13.00 Tutvumine dokumentatsiooniga
13.00-13.45 LÔuna ja vÔimalusel tutvumine asutusega
13.45-14.30 Intervjuu klientide rĂŒhmaga 1 (aega on arvestatud ka hilisem mĂ€rkmete
tegemine)
14.30-15.30 Intervjuu personali rĂŒhmaga 1 (aega on arvestatud ka hilisem mĂ€rkmete
tegemine)
15.30-18.00 Auditi dokumentatsiooni koostamine
Teine pÀev
8.00-9.00 Dokumentatsiooniga tutvumine
9.00-9.45 Intervjuu rahastajaga (SKA)
9.45-10.30 Intervjuu koostööpartneritega
10.30-11.00 Intervjuu rehabilitatsioonikeskuse juhiga
11.00-11.35 Intervjuu rahastajaga (Haigekassa)
11.45-12.30 Intervjuu PÔlva Haigla juhiga
12.30-13.00 LÔuna (kui esimesel pÀevale kÔike vaadata ei jÔudnud, siis ka tutvumine
asutusega)
13.00-14.00 Auditi dokumentatsiooni koostamine.
14.00-15.00 Intervjuu klientide rĂŒhmaga 2
15.00-15.30 Intervjuu personali rĂŒhmaga 2
15.30-16.00 Auditi dokumentatsiooni koostamine
16.00-17.00 LÔpukoosolek
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3. Detailed feedback on performance
1. The social service provider defines documents and implements its vision and
mission values on service provision.
Remark from the auditor: The services of the social service providers meet this criterion of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider has defined its
vision and mission values on service
provision in a quality handbook and made
publicly available also on webpage.
The tour and interviews with staff proved
these values are followed. The staff
described how they defined vision, mission,
values and set goals together.
There are practical examples how the
values observed in a daily life.
For example:
Professional- the staff is educated and
there is also a training plan;
The services are individual- the clients said
that service provider always considers their
needs and wishes.
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2. The social service provider defines, documents, and implements its quality
policy by determining long term quality goals, and its commitment to continuous
improvement.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
In a quality handbook are defined long term
quality goals and its commitment to
continuous improvement. The service
provider has defined clients, staff,
organization and resources long term
quality goals and principles of quality.
ï· The staff were awere of the quality
handbook. The employees analysed the
values and described how the values are
used in a daily life.
3. Persons served, family members and service user organisations are able to give
feedback on their individual and collective experience of programmes and
services.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
6
The feedback system is described in a The quantitative questionnaire is not always
quality handbook. the best way to ask feedback.
There are once a year patients (medical The social provider should analyse is the
rehabilitation) and clients (social quantitative questionnaire statistically
correct when there are few respondents.
rehabilitation) satisfaction survey.
Alati ei ole parim viis tagasiside kĂŒsimisks
The clients and patients could give their kasutada kvantitatiivseid meetodeid. Kui
feedback also after the service. vastajaid on vÀhe, siis ole tulemused
ĂŒldistatavad.
The service user organizations feedback
questionnaire is used once a year.
The feedback has been documented.
In the course of the interviews, clients said
their feedback is taken into account in the
provision of services.
4. The social service provider informs all stakeholders about the offered
programmes and services available.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
On the service provider web page and also
on consortium web page is sufficient amount
of information about offered programmes
and services available.
The stakeholders were very satisfied with
the new rehabilitation programs. There are
some good examples how the intervention
changed clients life quality.
7
5. The social service provider management establishes and documents an annual
planning and review process.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has documented The service user could use technological
annual planning and reviewing process. resources for annual planning and
reviewing process.
The action plan for 2014 has been applied.
Most of the developments are based on The technological resources will help to
Equass quality system. use resources effectively.
Teenuse osutaja vÔiks kasutada
planeerimis- ja hindamisprotsessis
infotehnoloogilisi vahendeid.
Infotehnoloogiliste vahendite kasutamine
aitab ressursse kasutada efektiivsemalt.
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6. The plan includes:
ï· annual outcomes / targets
ï· the activities to be undertaken in achieving the annual targets
ï· monitoring of the performance of the organisation in meeting its annual
targets
ï· time-scales and procedures for review and revision.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has a plan (for 2015) In the plan 2014 the service provider has
which includes the following aspects: not clearly defined actions and goals (goals
1. General goals and actions; and actions are mixed up and goals should
2. Expected results; be more accurate).
3. Time frame;
For example:
4. Analysis. The social service provider should think
what is a goal and what is an action. For
The plan for 2014 is based on Equass
example- a goal training the staff. Actually
actions. All actions are applied.
training is an action. The goal could be- the
staff have the necessary knowledge and
skills.
Clearly defined goals and actions will help
to analyze the results and make the future
plans.
Aasta 2014 tegevusplaanis ei ole selgelt
sÔnastatud, mis on eesmÀrk ja mis on
tegevus. Teenuse osutaja vĂ”iks analĂŒĂŒsida,
mis on eesmÀrk ja mis on tegevus. NÀiteks
personali koolitamine ei ole iseenesest
eesmÀrk, vaid tegevus. EesmÀrkide ja
tegevuste selge sĂ”nastus aitab analĂŒĂŒsida
saavutatud tulemusi ja teha paane
edaspidiseks.
9
7. The social service provider demonstrates organisationâs success in satisfying the
needs and expectations of the society.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider have a feedback
from local stakeholders how their needs and
expectations are satisfied.
There are good communication between the
social service provider and stake holders.
Because of the good communication one
client works on the open labor market. The
social service provider offers to the students
options for school practice.
8. The social service provider demonstrates organisationâs social responsibility through
activities contributing to the society.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
10
The service provider cooperates with
universities. The service provider offers
practical teaching programs for the students.
There are regular information days ( about
the rehabilitation sytem, preparation of
applications, healthy lifestyle).
We can say that most of the social service
provider activities are connected to local
community in one way or another.
9. The social service provider has a staff recruitment and retention policy that
promotes the selection of qualified personnel based on required knowledge, skills
and compentence
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The staff recruitment and retention policy is The service provider should analyse what
set up on consortium level and incudes are the clear staff competences. At the
necessary criteriaâs for recruitment and staff moment the competences are too general.
retention. The analyse helps to plan the services future
vision.
The management described what is
important for selection of staff. Teenuse osutaja vĂ”iks analĂŒĂŒsida, mis on
tÀpsed personali kompetentsusnÔuded.
Personali kompetentsusnĂ”uete analĂŒĂŒs ja
tÀpsustus aitab luua teenuste
tulevikuvisiooni.
11
10. The social service provider operates in compliance with mandatory national
legislation, providing appropriate working conditions, adequate and agreed staff level
and staff ratio, and appropriate rewarding for staff and volunteers.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider operates in a
compliance with mandatory national
legislation.
The Social Insurance Board and Estonian
Health Insurance Fond has confirmed that
service provider operates in a compliance
with mandatory national legislation.
The service provider has a special
procedure for rewarding staff.
The staff was aware of the rewarding
procedure. The staff mentioned christmas
bonus and team events. The staff said that
the manager is very open minded and
helpful.
12
11. The social service trains all staff based on a plan for leaning and development
and evaluates the effectiveness of the training.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider has trained staff The are ohther ways to evaluate the training
based on a plan. The staff plan for learning effectivness. For example after the training
and development is reviewed once a year. the social service provider could analyze are
there any substantive changes provining the
After every training the social provider services. The feedback analyse is one
analyse feedback. criteria to evaluate the effectiveness of the
training. The accurate effectiveness analysis
After every traing the praticipant organizes
helps to plan the future trainings.
the information day.
Koolituste tagasiside analĂŒĂŒs vĂ”iks olla
tĂ€psem. TĂ€pne koolituste tagasiside analĂŒĂŒs
aitab planeerida vÔimalikke koolitusi
tulevikus.
12. The social service provider applies requirements for competence in the identified
roles and functions of staff and evaluates them on annual basis
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
13
The social provider has applied general The service provider could create the
requirements for competence in the system to evaluate the staff compentence
identified roles and functions. The staff roles, (who, when and how). The system helps to
general competence and functions has achieve better results providing the services.
defined in a job descriptions and some of the
Some of the job descriptions are not
job descriptions are evaluated in a meeting. updated.These job descriptions should be
reviewed.
Teenuse osutaja vÔiks selgelt vÀlja töötada
sĂŒsteemi, kuidas hinnata personali
kompententsusnÔudeid- kes, kuidas ja millal
hindab.
MÔned ametijuhendid on uuendamata ja
need peaks ĂŒle vaatama
13. The social service provider recognises the staff as a resource for feedback on
organisational performance, service development and staff development
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider is organizing The staff could have an opportunity to give
regularly anonymous questionnaires. feedback during an individual progress
review. Durining the individual progress
Most of the staff gave the positive feedback. review the staff have a chance to give
individual positive and negative feedback.
Teenuse osutaja vÔiks kaaluda
arenguvestluste sĂŒsteemi loomist.
Arenguvestlusel on töötajal vÔimalik
edastada juhtkonnale oma soovid ja
juhtkond saab aidata töötajal tööalaseid
eesmÀrke seada.
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14. The social service provider has mechanisms in place to enhance satisfaction and
motivation of staff
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has a special
procedure for rewarding staff. The staff was
aware of the document. The staff is also
motivated to plan team events.
15. The social service provider assures the rights of persons served outlined in a
Charter of Rights which is based on the EU Charter of Fundamental Rights, the
European Convention for the Protection of Human Rights and Fundamental
Freedoms of the Council of Europe and other international human rights
conventions, especially those elaborated under the United Nations.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
15
The social service provider has a document
called âThe clientâs/patient`s fundamental
rights and restrictionsâ. The staff were aware
of the document. The staff was able to
analyze why the document âThe
clientâs/patient`s fundamental rights and
restrictionsâ is important. There were many
good examples how the staff is following the
document in a practical work.
16. The social service provider informs the person served about his/her rights and
duties especially to equal treatment on grounds of age, disability, gender, race,
religion or belief and sexual orientation before receiving the services.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
There is regular work ongoing to explain to
clients/patients their rights in an appropriate
way. The same is about duties â knowing
and remembering them is made very easy
clients and patients.
The person served said that the sevice
provider always explains (sometimes using
practical examples) their rights and duties.
17. The social service provider has accessible complaint management system which
registers feedback on performance from persons served, purchasers and other
relevant stakeholders.
16
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
Complains management system is
connected to the clientsâ right awareness
and built up considering persons served
skills to communicate if they are unsatisfied.
There was a model to settle the complaint.
The clients/patients said that usually they do
not have complaints. They were worried
about the national system (they need more
services).
18. The social service provider respects the fundamental right to self-determination
of the person served. They freely determine their political status and freely pursue
their economic, social and cultural development
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
17
The fundamental rights of clients and
patients are respected and supported by
staff.
Every year the service provider organizes
the feedback questionnaire. Durning the
rehabilitation process the clients/patients are
explaining their wishes and goals.
19. The social service provider facilitates the person served in choosing and having
access to advocates and/or supporting persons.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider has examples of
the rehabilitation plans how the
clients/patients are supported. The clients
said that service provider offers to them
support person when they need one.
20. The social service provider defines and documents its policy on ethics that
respects and assures the dignity of the persons served, protects them from undue
risk and promotes social justice
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
18
The social service provider has
its own ethics policy. The policy
respects and assures the dignity of the
persons served, protects them from
undue risk and promotes social justice.
The staff were aware of the document. The
staff explained how they created
organization ethics policy. There were
regular workshops and the staff had
opportunity to comment.
21. The social service provider operates mechanisms which prevent the physical,
mental and financial abuse of users.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider
has its own ethics policy and a document
which is called âThe specialistâs fundamental
rights and restrictionsâ. These two
documents are regulating mechanisms
which prevent the physical, mental and
financial abuse of clients.
Durining the meetings the service provider
has analyzed the ways to prevent the abuse.
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22. The social service provider provides services in a safe system of working within
a safe environment to ensure the physical security of persons served, their families
and caretakers.
Remark from the auditor:The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider environment is
adapted to needs of persons served
considering their safety and not limiting the
freedom to be active.
The social provider is oranizes regulary
organization's risk analysis.
23. The social service provider defines, documents, monitors and evaluates a set of
principles, values and procedures that govern behaviour in service delivery
containing aspects of confidentiality, accuracy, privacy and integrity.
Remark from the auditor:The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
20
The social provider has documented
its own ethics policy.
The staff were aware of clients/patients
confidentiality, accuracy, privacy and
integrity.
There were practical examples how the staff
is following the ethics policy. During the
meeting the service provider discussed how
to resolve the complaint and follow the
ethics policy.
24. The social service provider defines, documents, monitors and evaluates
procedures for assuring confidentiality of data regarding the persons served and the
service provided to them.
Remark from the auditor:The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider has
defined a document âConfidentiality
requirementsâ. There are meetings
protocols which are proving that the social
service provider is monitoring and evaluating
procedures assuring confidentiality of data
regarding the persons served and the
service provided to them.
25. The social service provider defines the roles and responsibilities, authorities and
the interrelation of all personnel who manage, design, deliver, support and evaluate
the service provision to person served.
21
Remark from the auditor:The services of the social service providers meet this
criteria of the EQUASS Assurance certification program
Strengths Improvement & developments
Most of the roles and responsibilities are
defined in job descriptions.
The service provider has created the
document âThe procedure of provding
medical and social serviceâ. The staff were
aware of the document.
During the tour I analyzed that procedure is
followed.
26. The social service provider works in partnership with other organisations in the
provision of services.
Remark from the auditor:The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
22
The social provider works in
partnership with other organizations.
The social service provider has developed
with other organizations rehabilitation
programs.
The service provider organizes information
days about the services.
The service provider cooperates with
universities. The service provider offers
practical teaching programs for the students.
27. The social service provider works in partnership with persons served, purchasers
and other stakeholders in the development of services.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
There are meetings
protocols which are proving that the social
service provider works in partnership with
persons served.
There are regular meetings with purchasers.
Purchasers were satisfied with the quality of
services. AS PÔlva Haigla could be one day
competence centre of medical service.
23
28. The social service provider includes persons served as active participants in
planning and have set up appraisal made up of on-going of an on-going structured
dialogue process in the management of the service, including the definition of the
needs, the definition of the services, as well as of the evaluation of quality.
Remark from the auditor:The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has created the
documents which are called âRehabilitation
service (medical and social) proceduresâ.
Based on interviews, tour and documents
we can say that clients and patients are
included to the process.
29. The social service provider institutes an annual evaluation of participation of
persons served both on individual and/or group basis.
Remark from the auditor:The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The participation is documented and
evaluated (rehabilitation plans and case
reports).
At the beginning of the service the clients
and patients have an opputunity to describe
their excpectatitions. The service provider
prepares (with the client ) the action plan. At
the end of the sevice the service provider
evaluates the results with the clients.
24
30. The social service provider operates specific instruments for users to improve
their personal empowerment and personal situation and. that of their community
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The service provider is using instruments
evaluating life quality and there are a lot of
good results. For example one client was
able to walk at the end of the service. The
other client explained that after the service
she is emotionally stable.
31. The social service provider operates specific mechanisms for establishing an
empowering environment.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
25
The environment supports persons served -
its safety, cosy and creative in a many ways.
Durning the tour i saw that the enviroment is
adjusted to clients and patients.
There is a system of ongoing external
(including international) and internal training.
The service provider also organizes
information days about the social and
medical rehabilitation service.
32. The social service provider selects programmes which are based on a needs
assessment at the location which is most convenient for the person served, family and
care takers
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
On the webpage is an accurate information
about the service provider location.
During the rehabilitation process the social
service provider is analysing the clients and
patients needs.
33. The social service provider offers programmes consistent with the identified
needs of its customers and objectives for the programme.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
26
Strengths Improvement & developments
Based on interviews and feedback analyses
we can say that the service provider is
evaluating regularly partners needs.
The purchasers have analyzed the services
and submitted suggestions.
34. The social service provider operates individual processes that are driven by the
needs of the person served.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
Based on interviews and rehabilitation
plans/case reports the process is mainly
individual.
1. The clients/patients said that the sevice
provider takes account of their substantive
and formal proposals.
35. The social service provider documents the planning of services based on the
identification of individual needs and expectations of persons served in an Individual
Plan.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
27
Based on interviews and rehabilitation
plans/case reports and clients interviews-
the social service provider reflects the clients
individual needs and expectations in a plan.
At the beginning of the service the clients
and patients have a opputunity to describe
their excpectatitions. The service provider
prepares (with the client ) the action plan.
Durning the process there are regular
meeting and clients can change their actions
plans. At the end of the sevice the service
provider evaluates the results with the
clients.
36. The social service provider identifies, documents, and maintains the key service
delivery processes to the persons served in line with its vision, mission statement
and quality policy
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider is analysing
regularly are the service processes in line
with its vision, mission statement and quality
policy. There are meetings protocols which
are evidence material.
The main regulatory document is
âRehabilitation service (medical and social)
proceduresâ.
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37. The social service provider reviews this delivery process and maintains control
over the delivery of the service.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider is analysing
and controlling regularly the service
processes. There are meetings
protocols which are evidence
material.
38. The social service provider ensures that the person served can access a
continuum of services that span from early intervention to support and respond to
changing requirements over time.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
29
The service provider has examples of the The service provider could create end of the
contracts with the purchasers and year the activity report. The document could
documents which are proving that the prove in a collective way how the services
service aspects are regularly evaluated. are evaluated and will help to plan the
future development.
Teenuse osutamise tulemuslikkuse
hinamiseks (asutuse tasemel) vÔiks
koostada aruandeaasta lÔpus
tegevusaruande. Koostatud tegevusaruande
abil on vÔimalik planeerida jÀrgmise aasta
arendustegevusi.
39. The social service provider develops a seamless continuum of services and reduces
barriers in a multi-disciplinary or multi-agency setting.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider informs the partners .
about service problems (examples of the
letters).
The social service provider has
defined a document which is called
âRehabilitation service processâ.
This document proves that service provider
develops a seamless continuum of services
and reduces barriers in a multi-disciplinary
setting. During the interviews the clients said
that the service provider is very
approachable.
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40. The social service provider operates services from a holistic approach based on
the needs and expectations of the person served with the aim of improving the
quality of life for the person served.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The client/patient is involved in rehabilitation
processes (medical and social). When the
service ends the service provider evaluates
(with the client) changes of the client life
quality.
Durning the interviews the clients/patients
said that they are more active after the
service.
41. The social service provider identifies the needed competences, skills and
support for staff to enhance the quality of life for person served.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
31
The social provider has applied general Some of the job descriptions are created in
requirements for competence in the the year 2002.These job descriptions
identified roles and functions. The staff roles, should be reviewed. Reviewed job
general competence and functions has descriptions will help to evaluate the
defined in a job descriptions and some of resources.
them are evaluated in the meetings. MÔned ametijuhendid on aastast 2002 ja
need peaks ĂŒle vaatama. Uuendatud
ametijuhendid aitavad hinnata teenuse
osutamiseks vajalikke ressursse.
42. The social service provider identifies its business results and provides formal
periodic and independent review and procedures to achieve the targeted results.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has created the The service provider should create end of
financial report at the end of the year. the year the activity report. Activity report
helps to evaluate the results. The report
There are regular meetings with purchasers. must be published. The activity report should
Purchasers were satisfied with the quality of be based on year plan.
services
Teenuse osutaja vÔiks iga aasta lÔpus
koostada tegevusaruande, et hinnata oma
astuse tegevuse tulemusi ja pÔhinedes
tulemustele planeerida arendustegevusi.
43. The social service provider identifies and registers the outcomes and benefits for
person served of the receive services on individual and collective basis.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
32
Strengths Improvement & developments
When the service ends the service
provider evaluates (with the client/patient)
changes of the life quality.
The service provider has a statistical
summary of services.
44. The social service provider evaluates its business results in order to determine
best value for purchasers and funders (âbest valueâ can also be expressed in relation
to the increased quality of life offered to the person being served).
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider has collected
feedback (in that analyse service provider
evaluates its business results in order to
determine best value for purchasers and
funders).
45. The social service provider evaluates the individual and collective satisfaction of
persons served and other stakeholders by internal and/or external evaluation.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
33
The social service provider evaluates
the clients/patients needs.
The are regular regular meetings with the
Estonia Health Insurance Fond.
The Social Insurance Fond has evaluated
the service provider. The Social Insurance
Fond evaluated that AS PÔlva Haigla offers
high quality medical service.
Purchasers were satisfied with the quality of
services.
46. The social service provider provides accessible and easily
understandable records on outcome, including personal perception and
achievements
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
Every year the service provider organizes
the feedback questionnaire (for staff,
clients). The client`s survery results are
available on a homepage.
The staff was aware of the survery results
and the results reflect the reality.
47. The social service provider actively disseminates organisation performance
among its staff, service users and external stakeholders.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
34
Strengths Improvement & developments
The reports are published .
on a homepage. There are meetings
protocols which are proving that the
social service provider actively disseminates
organisation performance among its staff.
48. The social service provider has a standard procedure for continuous improvement
on the basis of an improvement cycle.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has a plan (for 2015) The 2014 annual plan could be more
which includes the following aspects: accurate. At the moment the plan includes
too general actions and goals.
1. Goals and actions;
1. The precisely targeted plan helps to achieve
2. Expected results;
results.
3. Time frame; Aasta 2014 plaanis on peamiselt kirjeldatud
4. Analysis. liiga ĂŒldised tegevused ja eesmĂ€rgid.
. Teenuse osutaja peaks looma sĂŒsteemi
tulemuslikuma aastaplaani koostamiseks.
35
49 The social service provider identifies performance indicators for measuring the
results of the improvement actions.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
In the year 2014 the social provider has
implemented Equass quality system and
indetified indicators and analyzed the
actions results.
In the annual plan (2015) the service
provider has identified performance
indicators.
50. The service provider introduces and manages innovative ways of working that
have been identified based on the needs of stakeholders.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The service provider offers new The social provider should use
rehabilitation programs. The programs are technological resources to manage the
disained for children. There are some good projects. The technological reources will
examples how the intervention changed help to save resources.
clients life quality.
Teenuse osutaja vÔiks kasutada
infotehnoloogilisi vahendeid projektide
juhtimisel.
36
4. Agreed additional development / improvements
The applicant decided on the following improvement actions and/or additional development for the
period of two years:
Short description of the actions
(including SMART objectives)
1 The quality of social service
The social service provider has developed a new rehabilitation
program for children by end of the year 2015
Uus rehabilitatsiooniprogramm laste sihtrĂŒhmale on vĂ€lja töötatud
2016. aasta lÔpuks.
2 The quality of medical service
By the may 2016 the service provider has implemented team
evaluating method (for stationary patients) to evaluate the functional
condition (team training, technical solutions).
MeeskonnapÔhise hindamise meetodi sisseviimine statsionaarse
taastusravi patsientide funktsionaalse seisundi hindamisel ja
dokumenteerimisel (meeskonna koolitus, tehnilised lahendused)
2016.a. maikuuks.
3 The quality of the services
1. The service provider has updated the staff job descriptions
(physiotherapist, psychologist, nurse, administrator, occupational
therapist) by the may 2015.
AS PÔlva Haigla on lÔpetanud personali ametijuhendite
ĂŒlevaatamise ja uuendamise protsessi taastusravi osakonna ja
rehabilitatsioonikeskuse töötajate osas 2015.a. maikuuks
(fĂŒsioterapeudi, psĂŒhholoogi, taastusĂ”e, administraatori ja
tegevusterapeudi ametijuhendi uuendamine)
37
5. Closing remarks
AS PĂ”lva Haigla â is an organization providing medical and social services. The aim is to
offer social and medical rehabilitation service to the clients/patients who want to have a good
health. Their services are available for persons with mental, physical or physical disabilities
of all ages.
The social service provider has defined his vision and mission. During the interviews I found
out that vision and mission came from practical life. The vision and mission is written down in
a Quality Handbook and we could find it from the homepage.
The social service provider has a document called âThe clientâs fundamental rights and
restrictionsâ. The staff and clients were aware of the document.
The social service provider has its own ethics policy. The policy respects and assures the
dignity of the persons served, protects them from undue risk and promotes social justice.
The staff was aware of the document.
The services process is designed (processes are based on clients/patients needs).
Purchasers were satisfied with the quality of services. AS PÔlva Haigla could be one day
competence centre of medical service.
There are also some general developments what the service provider should consider
(detailed developments are written in a report):
1. The service provider should analyze what is the best way to ask feedback;
2. The service user could use technological resources for annual planning and reviewing
process;
3. The annual planning and reviewing process should be systematic (regular, targeted and
evaluated).
It was a very good cooperation between representative of the social service provider and
auditor. All requested documents were prepared for auditing.
In conclusion I can say that the social service provider generally meets criterias of the
EQUASS Assurance certification program. The services are individual and well-planned. The
staff is motivated to work with clients.
38
PÔlva Haigla on tervishoiuastus, kus pakutakse rehabilitatsiooni- ja taastusravi teenuseid.
Teenuseid pakutakse kĂ”ikidele klientide sihtrĂŒhmadele. PĂ”lva Haigla soovib aidata oma
klientidel saavutada vÔimalikult head elukvaliteeti.
PÔlva Haigla on defineerinud oma asutuse visiooni, missiooni ja vÀÀrtused. Personal oli
missioonist, visioonist teadlik ning oskas tuua praktiliseid nÀiteid igapÀevases töös
kehtivatest vÀÀrtustest.
PÔlva Haigla eetikakoodeks on loodud koos personaliga ja personal tÔi intervjuude kÀigus
nÀiteid, missuguste eetiliste printiipide osas on tekkinud arutelu. Aantud aspekt viitab sellele,
et eetikakoodeks ei ole PÔlva Haigla jaoks formaalne dokument.
PÔlva Haigla teenuse osutamise protsessid on lÀbi mÔeldud ja pÔhinevad klientide
vajadustel ning vÔimalikult sÀÀstlikul ressursikasutusel.
Rahastajad hindasid PÔlva Haigla teenuste kvaliteeti kÔrgelt ning leidsid, et PÔlva Haigla
vÔiks kunagi olla kompententsikeskus.
Auditi lÀbiviimise kÀigus ilmnesid jÀrgmised arendusvaldkonnad:
1. Oluline mĂ”elda, mis oleks kĂ”ige efektiivsem viis sisulise tagasiside kĂŒsimiseks;
2. Infotehnoloogiliste vahendite kasutamine aitab optimaalselt ressursse kasutada;
3. Aastaplaani koostamine peaks muutuma sĂŒsteemsemaks (mÔÔdetavad eesmĂ€rgid ja
tegevused eesmÀrkide saavutamiseks, vastustajad ja tulemuste selge mÔÔdetavus).
AS PÔlva Haigla rehabilitatsiooni- ja taastusravi teenus vastab Equass Assurance
kvaliteedisĂŒsteemi kriteeriumitele. PĂ”lva Haigla personal on motiveeritud osutama klientidele
isikukeskseid teenuseid.
Tallinn, 09.01.2015
Tiina Unukainen
39
Maarika Aro
Saatja: Guus van Beek <
[email protected]>
Saatmisaeg: 28. jaanuar 2015. a. 15:06
Adressaat: Keiu Talve
Koopia: Maarika Aro; Marie Dubost
Teema: Re: Audit report EST2014-006 PÔlva Hospital Ltd. physical and rehabilitation
medicine department
JĂ€reltegevuse lipp: JĂ€reltegevus
Olekulipp: Lipuga mÀrgitud
Dear 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 Ă” l v a H o s p i t a l L t d . p h y s i c a l a n d r e h a b i l i t a t i o n me d i c i n e
d e p a r t me n t (E S T 2 0 1 4 - 0 0 6 ) a n d I c o n c l u d e t h a t t h e s e r vi c e s (w i t h i n t h e s c o p e o f t h e a p p l i c a t i o n )
o f t h i s o r g a n i z a t i o n m e e t a l l t h e E Q U AS S a s s u r a n c e c r i t e r i a . B a s e d o n t h e delegated power, which
is described in the EQUAS S internal procedures and approved by the International EQU ASS
Aw arding Commi ttee, th e s e r vi c e s (w i t h i n t h e s c o p e o f t h e a p p l i c a t i o n ) o f P Ă” l v a H o s p i t a l L t d .
p h y s i c a l a n d r e h a b i l i t a t i o n me d i c i n e d e p a r t m e n t (E S T2 0 1 4 - 0 0 6 ) w i l l b e c e r t i f i e d w i t h E Q U AS S
As s u r a n c e i n S o c i a l S e r vi c e s .
Ac c o r d i n g t h e a g r e e d c o m m u n i c a t i o n p r o c e d u r e , I k i n d l y a s k y o u t o d i s s e mi n a t e t h e d e c i s i o n t o
c e r t i f y t h e s e r vi c e s (w i t h i n t h e s c o p e o f t h e a p p l i c a t i o n ) o f P Ă” l va H o s p i t a l L t d . p h y s i c a l a n d
r e h a b i l i t a t i o n m e d i c i ne d e p a r t me n t (E S T 2 0 1 4 - 0 0 6 ) w i t h E Q U AS S As s u r a n c e i n S o c i a l S e r vi c e s .
M a r i e D u b o s t w i l l s e n d t h e c e r t i f i c a t e (a n d g u i d e l i n e s f o r u s i n g t h e E Q U AS S As s u r a n c e l o g o )
t o P Ă” l va H o s p i t a l L t d . p h y s i c a l a n d r e h a b i l i t a t i o n me d i c i n e d e p a r t m e n t (E S T2 0 1 4 - 0 0 6 ) .
Kind regards,
Guus van Beek
European Quality in Social Services (EQUASS)
c/o EPR, 15, Rue de Spa , B-1000 Brussels
Belgium
Phone: +31653770121
Email:
[email protected] / website: www.equass.be
Van: Keiu Talve <
[email protected]>
Datum: zaterdag 24 januari 2015 17:37
Aan: Guus van Beek <
[email protected]>
1
CC: Marie Dubost <
[email protected]>, Maarika Aro <
[email protected]>
Onderwerp: RE: Audit report EST2014-006 PÔlva Hospital Ltd. physical and rehabilitation medicine department
Dear Guus,
The auditor has tryed to rephrase the wording of an improvement suggestion.
Please review and give some feedback about it!
Regards,
Keiu
From: Guus van Beek [mailto:
[email protected]]
Sent: Thursday, January 22, 2015 12:57 PM
To: Keiu Talve
Cc: Marie Dubost; Maarika Aro
Subject: Re: Audit report EST2014-006 PÔlva Hospital Ltd. physical and rehabilitation medicine department
Importance: High
Dear Keiu,
I have reviiewed the audit report of PÔlva Hospital Ltd. physical and rehabilitation medicine department (EST2014-006). In
the audit report the auditor make the following comment: "The 2014 annual plan includes only actions.The social service
provider should think what is a goal and what is an action. For example- a goal training the staff. Actually training is an
action. The goal could be- the staff have the necessary knowledge and skills.Defined goals and actions will help to
analyze the results and make the future plans.â The feedback give the impression that the organization do not meet the
criteria. If the annual plan do not have goals and objectives, the criteria will not be met. If it si the case that the social
service provider mixed up goals and activities and the the feedback should be more carefully formulated in a way that
it is clear that all elements are there and that the is room for improvement.
I kindly aks you to contact the auditor and asked her to reformulate the feedback or to adjust her decision of meeting
the criteria.
Kind regards,
Guus van Beek
European Quality in Social Services (EQUASS)
c/o EPR, 15, Rue de Spa , B-1000 Brussels
Belgium
Phone: +31653770121
Email:
[email protected] / website: www.equass.be
Van: Keiu Talve <
[email protected]>
Datum: zaterdag 10 januari 2015 11:05
Aan: Marie Dubost <
[email protected]>, Guus van Beek <
[email protected]>
Onderwerp: Audit report EST2014-006 PÔlva Hospital Ltd. physical and rehabilitation medicine department
Dear Marie, Dear Guus,
2
Attached youâll find an audit report and other documents of PĂ”lva Hospital Ltd. physical and rehabilitation medicine
department (EST2014-006).
For some reason in the Application form criteria no 10 shows âpartial complianceâ although all the indicators are
met.
Please let me know in case there are some comments about the report.
Keiu
EQUASS Eesti
Astangu KRK
Tel: +372 5682 9104
www.equass.ee
www.astangu.ee
3