EQUASS ASSURANCE
AUDIT REPORT
Site visit: 21.-22.11.2013
Pärnu Haigla
Mariliis Männik-Sepp
© 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 SA Pärnu Haigla - Foundation Pärnu Hospital,
service provider hereinafter PH
Address: Rist iku 1, Pärnu 80010
Post box: N/A
Person responsible Urmas Sule, chairman of the board
(CEO):
Contact person: Ilmi Leesman, qualit y unit manager
Phone: (+372) 4473101
Fax: N/A
E-mail:
[email protected]
Web site: www. ph.ee
Name of Auditor: Mar iliis Männik -Sepp
Dates of audit: 21.-22.11.2013
Clients: Number of person served: 76
As of (date): 21.10.2013
Staff: Number of Full time staff : 8
Number of Part time staff : 64
Number of Contracted staff : 9
Number of volunteer s: 0
Services: Day Center of Pärnu Hospital Psychiatric
Clinic:
1. Assistance in ever yday lif e
2. Assistance in working
3. Support person
Rehabilitation Units of Pärnu Hospital
Psyciatric Clinic and Internal Disease Clinic
4. Rehabilitation ser vice
2
2. Audit program
21.11.2013 Day 1
Time Acti vit y
9.00-12.00 Opening meeting , documentation review
12.00-13.00 Interview with qualit y unit manager Ilmi Leesman
13.00-14.00 Lunch break
14.00-14.15 Documentation review, up -dat ing f iles
14.15-15.00 Interview wit h cooperation partners:
Toomas Mihkelson (Pärnu Puuetega Inim este Koda)
Linda Lillemaa ( Social Insur ance Boar d Pärnu bureau)
15.00-15.15 Documentation review, up -dat ing f iles
15.15-16.00 Interview with rehabilitat ion unit staff :
Natalja I vanov ( social worker)
16.00-16.15 Documentation review, up -dat ing f iles
16.15-17.00 Interview with persons ser ved by the r ehabilitation
units of :
Pärnu Hospital Psyciatric Clinic and
Internal Disease Clinic
22.11.2013 Day 2
Time Acti vit y
9.00-10.00 Documentatio n review, up-dat ing f iles
10.00-10.45 Interview with member of the board of Pärnu Haigla
(Veiko Vahula) and head of r ehabilitation unit Ester
Reinsalu
10.45-11.00 Documentation review, up -dat ing f iles
3
11.00- 11.45 Interview with f inancing bodies:
Katrin Tsuiman ( local government )
Margit Laurson – (Social Insurance Board )
11.45-12.00 Documentation review, up -dat ing f iles
12.00-13.00 Lunch break
13.00-13.15 Documentation review, up -dat ing f iles
13.15-14.00 Interview with manager (Indrek Linnuste) of Day
Center and deput y manager ( Kadr i Eenraid ) of Day
Center
14.00-14.15 Documentation review, up -dat ing f iles
14.15-15.00 Interview with Day Center staff - Kadri Melnits
(activit y super visor )
15.00-15.15 Documentation review, up -dat ing f iles
15.15-16.00 Interview with persons ser ved by Day Center
16.00-16.45 Documentation review, up -dat ing f iles
16.45-17.00 Closing meeting
3. Detailed feedback on performance
1. The social servi ce provider defines documents and implements its
visi on and mission values on servi ce 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
Strengths Improvem ent & developments
The mission, vision and values of PH
are documented in the organization’s
development plan and on its website
4
www. ph.ee.
It was demonstrat ed through the
inter views that the employees are
well aware of the organization’s
mission, vision and core values.
2. The social servi ce prov ider defines, documents, and implements its
qualit y policy by determining long term qualit y goals, and its
commitment to continuous improvement.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assura nce certif ication program
Strengths Improvem ent & developments
The qualit y standard of PH is
document ed in the management
handbook.
The long -term goals of PH ar e
descr ibed in the organizat ion’s
development plan.
PH has appr oximat ely t wo decades
of perf ormance management
exper ience.
It appeared f rom the inter views that
the staff is well inf ormed of the
qualit y standard, is devoted to
deliver qualit y ser vices and pursue
f or continuous improvem ent.
3. Persons served, famil y members and servi ce user or ganisations are
able to give feedback on their individual and collecti ve experience of
programmes and services.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
5
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
PH has developed ways to ask and It would be advisable to make a l ist
receive f eedback from the person of PH’s cooper ation partners /
ser ved, staff and stakeholders. The stakeholders (and gr oup t hem by the
organizat ion uses various met hods t o f ield of partnership).
achieve this.
Also, revise f eedback questionnair es
F.e ambulat or y patients’ satisf action in t ime to give mor e inf ormative and
sur vey, employee satisf action sur vey. necessar y f eedback.
There is procedur e f or handling Soovitatav on k oostada nimekir i PH
customer f eedback and guidance f or koostööpartner itest / huvigruppidest
handling complaints. (ja grupeerida need valdkonn it i).
All the meet ings are summarized in Samuti, vaadata üle ta gasiside
wr itten m inutes of the meetings . küsimustikud, et saada
inf ormatiivsemat ja vajalikku
tagasisidet.
4. The social service provider i nforms all stakeholders about the
offered programmes and services avai lable.
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
Strengths Improvem ent & developments
PH has inf ormed all stakeholder s
about its ser vices. This was verif ied
implemented through inter views wit h
persons ser ved, staff and partners.
Inf ormation about services is
available on the homepage of PH.
There are brochur es available to
6
promote the awareness of people.
There are client meetings, staff
meetings, hospital brief ing (weekly
meetings). The hospital intranet is
also a source of all kinds of
inf ormation. Besides that, also Pärnu
Hospital magazine is issued.
The partners demonstrat ed
awareness of the ser vices of PH.
The opportunit ies f or involvement
are descr ibed in the policies and
procedures of the organizat ion.
5. The social service provider management establishes and
documents an annual planning and review process.
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
Strengths Improvem ent & develo pments
The annual planning and review
process is well int egrated into the
perf ormance management process of
the organization. This is described
in the perf ormance management
procedure, which is available to all
of the staff through intranet . The
process is reviewed annually by the
qualit y unit.
There are annual action plans and
perf ormance plans , also annual
reporting on the implementat ion of
the plans. PH uses scorecar d
7
methodolog y.
6. The plan includes:
annual outcomes / targets
the acti vities to be undertaken in achieving the annual targets
monitoring of the performance of the organisation in meeting its
annual targets
time-scales and procedures for revi ew and revi sion.
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
Strengths Improvem ent & developments
The annual planning process of PH
has a cyclic character. The annual
action plan includes SMART
objectives, key act ivities, tangible
results and targets.
The annual plan is approved by the
management.
7. The social servi ce provider demonstrates organisation’s success
in satisf ying the needs and expectations of the societ 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
Strengths Improvem ent & developments
Feedback f rom staff and clients is
collect ed, summarized and analyzed
regularly.
F.e Cust omer Ser vice Report is
drawn up.
8
PH Day Center does cooperat ion
with nonprof it organizat ion
Hingerahu, organizes all kinds of
events, is training base f or the
students of Tartu Universit y and
Pärnu College, and participat es in
the activit ies of the Food Bank. It
also plans to issue a Year Book f or
2013.
8. The social servi ce provider demonstrates organisati on’s social
responsibilit y t hrough acti vities contri buting to the societ y.
Remark from the auditor:
The services of the social ser vice providers meet this criter ion of the
EQUASS Assurance certif ication program
Streng ths Improvem ent & developments
PH is involved in communit y based
activities.
The Day Center of PH organizes all
kinds of events, is t raining base f or
the students of Tartu Universit y and
Pärnu College, and participat es in
the activit ies of the Food Bank. It
also plans to issue a Year Book f or
2013.
9. The social servi ce provider has a staff recruitment and retention
policy that promot es the selection of qualified personnel based on
required know ledge, skills and compet ences.
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
9
Strengths Improvem ent & developments
Staff policy (including recruitment
and select ion procedures) has been
developed. There is also job analy sis
and workf orce planning procedure. A
value system of job posit ions and
corresponding wage policy has been
complied. For new employees there
is a pr ocedure f or the f acilitation of
their adapt ion.
Also, the internal work procedur e
rules apply to all emplo yees.
All employees have individual job
descr iptions which include required
knowledge, skills and competences.
There is training policy and annual
training plans. Each year employees’
assessments are car ried out.
It appeared f rom the inter views wit h
the personnel that t hey all are well
aware of their roles, r ights and
duties. It also came out that the
employees are highly mot ivat ed, like
their jobs and are devoted to
delivering high qualit y ser vice.
10. The social service provider operates in compli ance w ith
mandator y national legislation, providing appropriate w orking
conditions, adequate and agreed staff level and staff ratio, and
appropriate rew arding for staff and vol unteers.
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
10
Strengths Improvem ent & developments
The documentation of PH meets
legal r equirements and is reviewed
to do this. The staff level is kept at
optimum and this is reviewed also
regularly.
The principles f or showing
recognit ion to employees are
descr ibed in the staff policy and staff
recognit ion policy.
The working condit ions are evaluated
regularly according to risk
assessment procedure (risk
assessments are carried out ) and
necessar y amendmen ts are made.
The work condit ions are also
evaluated by staff through staff
satisf action sur veys.
11. The social service provider trains all staff based on a plan for
leaning and development and evaluates the effecti veness of the
training.
Remark from t he auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication program
Strengths Improvem ent & developments
Staff training policy regulates the It would be advisable to collect
arrangement of trainings. Annual f eedback (and assessment of
training plans are dr awn up based on eff ectiveness) prom ptly after ever y
the needs of the employees and passed training (f .e using web based
expectat ions of PH. applications) an d then analyzing the
inf ormation gained.
The staff of PH is trained regular ly
11
and all the inter viewed employees Soovitatav on koguda tagasisidet (ja
showed high appreciation concer ning hinnanguid ef ektiivsuse kohta)
the trainings received. koheselt pär ast igat koolitust (nt
kasutades veebipõhist rakendust)
Training needs are discussed during ning seejär el analüüsida saadud
annual staff evaluation s. inf ormatsiooni.
Feedback on trainings is collected
through annual staff satisf action
sur veys, which is then analyzed.
12. The social servi ce prov i der applies requirements for competence
in the identified roles and functions of staff and evaluates them on
annual basis.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication pro gram
Strengths Improvem ent & developments
The competence r equirements f or
employees are described in their job
descr iptions.
Annual staff evaluat ions are carried
out, as descr ibed in the staff policy,
where the before mentioned
requirements are assess ed.
It was ver if ied by the inter views and
related documentation t hat
perf ormance reviews of staff
members who are directly involved in
ser vice deliver y, are carried out.
13. The social servi ce provi der recognizes the staff as a resource for
feedback on organizational perf ormance, service development and
staff development
12
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
Strengths Improvem ent & developments
The in volvement of staff in the
planning and evaluation of services
is descr ibed in the corresponding
ser vices’ deliver y pr ocedur es.
PH recognizes staff as a usef ul tool
f or gaining inf ormation. It has a well-
developed system of regular
meetings, where various l evels and
groups of staff meet.
Minutes of meetings are prepared
and are available f or all staff through
the organization’s int ranet.
Also annual staff questionnaires are
used f or gaining f eedback.
14. The social service provi der has mechanisms in pla ce to enhance
satisfaction and motivation 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
Strengths Improvem ent & developments
Staff evaluations, staff
questionnaires and annual
employees’ evaluat ions are used to
gain f eedback on satisf action and
motivat ion.
Mechanisms to provide satisf action
and mot ivat ion are described in staff
13
recognit ion policy.
15. The social servi ce provi der assures the rights of persons served
outlined in a Chart er of Rights w hich 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 int ernati onal human ri ghts conven tions, especiall y those
elaborat ed under the United Nations.
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
Strengths Improvem ent & developments
PH has developed the rights and
duties of persons ser ved, which
conf orm to international human
rights convent ions. The rights and
duties of persons served are part of
the client ser vice standard, which is
available on the web page of PH.
They are introduced to the persons
ser ved by staff . Clients also sign the
related documentation (contract).
The staff and clients demonstrated
their knowledge of their rights and
duties through the interviews.
16. The soci al service provider informs the person served about
his/her rights and duties especiall y to equal treatment on grounds of
age, disabilit y, gender, race, religion or belief and sexual orientation
before recei ving the services.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of t he EQUASS Assurance certif ication program
14
Strengths Improvem ent & developments
The rights and duties of persons
ser ved are introduced to the clients
by the employees of PH.
The rights and duties of persons
ser ved are part of the client ser vice
standard, which is available on the
web page of PH.
The staff and clients demonstrated
their knowledge of their rights and
duties through the interviews. Clients
also sign the r elated documentation
(contract).
17. The social service provider has accessibl e com plai nt
management s ystem w hich registers feedback on performance from
persons served, purchasers and other relevant stakeholders.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif icati on program
Strengths Improvem ent & developments
Complaint handling procedures and
associated documentation is
document ed in PH’s management
system policy. Ther e is a procedur e
f or handling custom er f eedback and
guidance f or handling complaints.
Inf ormation is available on t he web
page of PH.
Complaints and pr oposals may be
communicated also through the
15
mentioned web page.
The system can be assessed as
accessible and transparent.
If was verif ied during the interviews
that the persons served, purchaser s
and other relevant stakeholders were
aware of the ways of making
proposals and complaining.
18. The social service provider respects the fundamental right to
self-determination of the person served. They freel y det ermine their
political status and freel y pursue their economic, soci al and cultural
development.
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
Strengths Improvem ent & developments
PH procedures, instr uctions and
f orms have been prepared, taking
into account the persons’ ser ved
right to self -determination.
It became evident through the
inter views that the staff was aware of
this issue and the persons ser ved
were handled wit h respect.
The criterion was v erif ied f ulf illed by
the evidence f ound concerning the
topic in the minutes of meetings of
personnel and persons ser ved.
16
19. The social service provi der facilitates the person served in
choosing and having access to advocates and/or supporting
persons.
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
Strengths Improvem ent & developments
The need f or an advocate and/or
support ing person is discussed wit h
the persons ser ved and related
inf ormation is presented in individual
plans.
The criterion was verif ied f ulf illed by
the evidence f ound in client work
documentat ion.
20. The social service provi der defines and documents its policy on
ethics that respects and assu res the dignit y of the persons served,
protects them from undue risk and promotes soci al justice
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
Strengths Improvem ent & developments
Customer ser vice management
procedure and client service pract ice
guide include the ethical pr inciples.
New members of staff (including
volunteers) are intr oduced with the
ethical principles of customer
ser vice.
17
21. The social servic e provider operat es mechanisms w hich prevent
the physi cal, mental and financial abuse of users.
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
Strengths Improvem ent & developments
Customer ser vice management
procedure and client service pract ice
guide include the ethical pr inciples
(also policies to prevent physical,
mental and f inancial abuse of person
ser ved).
New members of staff (including
volunteers) are intr o duced with the
related principles.
22. The social servi ce provi der provides services in a safe system of
w orking w ithin a safe environment to ensure the physical securit y of
persons served, their families and caretakers.
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
Strengths Improvem ent & developments
18
PH has pr ocedures f or ensuring the
provision of saf e and healthy working
conditions.
F. e there are health an d saf ety
assurance procedur es, guidance on
risk assessments etc.
Risk are assessed regularly and
related impr ovement activities ar e
carried out.
Related trainings are provided to
staff .
23. The social service provider defines, documents, monitors and
evaluat es a set of principles, values and procedures that govern
behavi our in servi ce deli ver y containing aspects of confidentialit y,
accuracy, pri vacy and integrit 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
Strengths Improvem ent & developments
The principles, values and
procedures in ser vice deliver y are
descr ibed in the PH’s inter nal work
procedures, ser vices’ deliver y
procedures, client ser vice standar d
etc.
There is a manual f or processing
delicate personal data.
It was demonstrated through the
inter views of staff that they ar e
aware of the et hical principles
related to their work.
19
24. The social service provider defines, documents, monitors and
evaluat es procedures for assuring confidentialit y of data regardi ng
the persons served and the service provided to them.
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
Strengths Improvem ent & developments
The principles, values and
procedures in ser vice deliver y are
descr ibed in the PH’s inter nal work
procedures, ser vices’ deliver y
procedures, client ser vice standar d
etc.
There is a manual f or processing
delicate personal data.
The policies are over viewed
regularly according to the guidance
on the administ ration of the
management handbook.
25. The social service provider defines the roles and
responsibilities, authorities and the interrelation of all personnel
w ho manage, desi gn, deli ver, support and evaluate the service
provision to person served.
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
Strengths Improvem ent & development s
20
The necessar y roles and
responsibilities are descr ibed in the
job descript ions of employees. Job
descr iptions are available to all
employees through the intranet of
PH.
Related tasks are also descr ibed in
the ser vices’ deliver y procedures.
26. The so cial service provi der w orks in partnership w ith other
organisations in the provision of servi ce 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
Strengths Improvem ent & developments
PH does a lot of cooperat ion wit h its It would be advisable to list PH’s
partners. F.e there is tight cooper ation partners (and group
cooper ation with Puuetega Inimest e them by the f ield of partnership ).
Koda and the representation union of
patients. Soovitatav on koostada nimekir i PH
koostööpartner itest (ja grupeerida
PH has contracts with f inancing need valdkonnit i.
bodies.
PH evaluates the cooperat ion related
to the services delivered by contract
partners.
27. The social service p rovider w orks in partnership w ith persons
served, purchasers and other stakeholders in the development of
services.
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
21
Strengths Improvem ent & developments
The persons ser ved, purchasers and
other stakeholders are involved in
the development of services of PH
through meeting s and sur veys.
28. The social service provi der includes persons served as acti ve
partici pants 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, incl uding t he definition of the needs, the
definition of the services, as w ell as of the evaluation of qualit 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
Strengths Improvem ent & developments
The services’ delivery policies and
procedures are regulated by diff erent
ser vice managem ent procedures and
the client work documentation is
regulated by diff erent client work
procedures.
The criterion was ver if ied sat isf ied
through exploring client work
documentat ion and through
inter views with staff and clients.
29. The social service pro vi der institutes an annual evaluation of
partici pation of persons served bot h on indi vidual and/or group
basis.
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
22
Strengths Improvem ent & developments
The measures, activities and polic y
f or client participat ion ar e agreed
with the persons served or
representat ives of persons ser ved.
The policy is reviewed regular ly.
30. The social service provi der operates specific i nstruments f or
users to improve their personal empow er ment and personal situation
and that of their communit 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
Strengths Improvem ent & developments
Empowerment of persons ser ved is The criter ion is met, but it is
an integral part of ser vice deliver y. suggested to def ine empowerment in
Related act ivities were evidenced in the processes and procedures of the
ser vices’ deliver y pr ocesses and also organizat ion.
came out f rom the inter views wit h
staff and persons served. Kriteer ium on täidet ud, kuid
soovitatav on def ineerida jõustamine
asutuse protsessides ja
protseduur ides .
31. The social service provi der operates spec ific mechanisms for
establishing an empow ering environment.
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
Strengths Improvem ent & developments
23
Empowerment of per sons ser ved is
an integral part of ser vice deliver y.
Related act ivities were evidenced in
ser vices’ deliver y pr ocesses and also
came out f rom the inter views wit h
staff and persons served.
The employees ar e trained about
empowerment and the subject is
discussed dur ing organizat ion’s
meetings.
32. The social servi ce provider sel ects programmes w hich are based
on a needs assessment at the location w hich is most convenient for
the person served, famil y and care takers
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
Strengths Improvem ent & developments
PH has an over view of the needs of
the persons served (queues,
meetings wit h cooperation partners,
questionnaires).
The locat ion of PH is pleasant, awa y
f rom the Pärnu cit y center. All the
ser vices are delivered at the sam e
complex, which is convenient f or the
clients.
33. The social service provider offers programmes consistent w ith
the identified needs of its custom ers and objecti ves for the
programme.
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
24
Strengths Improvem ent & developments
PH is in t ight cooperation with the
f unding bodies and has ascertain ed
the needs and expectations of them.
The needs of other stakeholder s
have also been discussed dur ing
meetings and during dail y
cooper ation (though e -mails,
telephone) .
The success and results of the
exist ing ser vices have bee n
determined.
34. The social service provi der operates indi vidual processes that
are dri ven by the needs of the person served.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif icati on program
Strengths Improvem ent & developments
All related inf ormation is documented
in the individual plan s of the persons
ser ved, which was ver if ied by
examples of client documentation
seen during the site visit.
The process itself is described in t he
organizat ion’s policies and
procedures.
35. The social service provider documents the planni ng of services
based on the ident ification of indi vi dual needs and expectations of
persons served in an Indi vidual Plan.
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
25
Strengths Improvem ent & developments
The clients’ individual needs and
expectat ions are wr itten down in the
individual plan s.
The individual plans invo lve all the
inf ormation set by the criter ion and
are agreed by the persons ser ved.
This was ver if ied by examples of
client documentation seen during the
site visit.
36. The social service provider identif ies, documents, and maintains
the key servi ce del i very processes to the persons served in line w ith
its vision, mission statement and quali t y policy.
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
Strengths Improvem ent & developments
The service deliver y processes are
descr ibed in the management
handbook of the organization, which
is a ver y well str uctured intranet
based system of procedures and
procedures covering the whole
organizat ion. The key ser vice
deliver y processes are in line wit h
PH’s vision, mission and qualit y
principles.
All processes are regularly reviewed.
37. The social service provi der review s this delivery process and
maintains control over the deli very of t he servi ce.
26
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
Strengths Improvem ent & developments
PH reviews the ser vice deliver y
process es. Perf ormance reports are
composed by all units f or all of th e
ser vices.
The perf ormance is summed up in
the activit y reports.
The processes t hemselves are
reviewed per iodically.
The processes and the deliver y of
ser vices is also audited by the
internal audit f unction (audit reports
are issued) .
38. The social service provider ensures that the person served can
access a continuum of servi ces that span from earl y int ervention to
support and respond to changing requi rements over time.
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
Strengths Improvem ent & developments
PH provides a large variet y of
ser vices. Needs of persons ser ved
are evaluated and accordingly
necessar y ser vices are provided.
Ser vices are linked with each other,
rehabilitat ion and social ser vices are
combined with healt h care ser vices.
The continuation of service deliver y
27
is monitored and evaluated regular ly.
39. The social service provi der develops a seamless continuum of
services and reduces barriers in a multi -disciplinary or multi -agenc y
setting.
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
Strengths Improvem ent & developments
The barriers are discussed in
meetings and report ed as necessar y.
The criterion was verif ied f ulf illed by
also explor ing the client work
documentat ion, where evidence was
f ound about multidisciplinar y
approach.
40. The social service provi der operates servi ces from a holistic
approach based on the needs and expectations of the person served
w ith the aim of improving the qualit y of life for the person served.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ic ation program
Strengths Improvem ent & developments
PH uses client -centered holistic
approach, which is aimed to improve
client ’s qualit y of lif e.
The qualit y of lif e init iat ive’s
eff ectiveness is measured and
reported.
The criterion was verif ied f ulf i lled by
also explor ing the client work
28
documentat ion, where evidence was
f ound about measur ing the qualit y of
lif e.
41. The social service provider identif ies the needed competences,
skills and support for staff to enhance the qualit y of life for person
served.
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
Strengths Improvem ent & developments
The necessar y competences and
skills are described in job
descr iptions. These are evaluated
during annual employees’
perf ormance reviews.
Trainings are provided to employees,
which was evidenced by training
plans of PH and came out f rom
inter views.
42. The social service provider identifies its business results and
provides formal periodic and independent revi ew and procedures t o
achieve the targeted results.
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
Strengths Improvem ent & developments
Targeted results are measured and
reported. PH has procedure named
reporting arrangements, which gives
a good over view of the reporting
system. Also perf ormance
29
management procedure applies,
according to which perf ormance
conversations are he ld related
reports issued.
External audits have been carried
out regularly concerning the
activities of PH.
43. The social servi ce provi der identifies and registers the outcomes
and benefits for person served of the recei ve services on individual
and collecti ve basi 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
Strengths Improvem ent & developments
PH gathers and documents
inf ormation regarding results of
providing ser vices (both on
individual and collective basis).
This was evidenced in client work
documentat ion and in the reports of
PH.
44. The social service provider evaluates its business results in order
to determine best value for purchasers and fun ders (‘best value’ can
also be expressed in relation to the increased qualit y of life offered to
the person bei ng served).
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
Strengths Improvem ent & developments
30
PH evaluates the results and added
value of its work during meetings.
This is also ref lected in related
reports.
45. The social service provider evaluates the indi vidual and
collecti ve satisfact ion of perso ns served and other stakeholders by
internal and/or external evaluation.
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
Strengths Improvem ent & developments
PH organizes regular sur veys to
receive f eedback f rom the persons
ser ved.
The inf ormation is analyzed and
necessar y improvem ent activities are
ref lected in the annual act ion plans.
46. The social service provider provides accessible and easil y
understandable records on outcome, including personal perception
and achievements
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
Strengths Improvem ent & developments
The record on outcome are
communicated to stakeholders, staff
and persons ser ved.
The content and f ormat depends on
31
the target group.
47. The soci al service provider acti vel y disseminates organization
performance among its staff, service users and external
stakeholders.
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
Strengths Improvem ent & developments
PH reports its perf ormance to It would be advisable to draw up
f unding bodies, staff and ser vice such an all-embracing annual activit y
users using diff erent methods. report (including organization
perf ormance), that would be
The content and f ormat depends on disclosed on the web site of the
the target group. organizat ion.
Soovitatav on koostada selline
kõikehõlmav iga-aastane
tegevusaruanne (sisaldades asutuse
tegevusi), mis avaldatakse asutuse
kodulehel.
48. The social service provider has a standard procedure for
continuous improvement on the basis of an improvement cyc le.
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
Strengths Improvem ent & developments
The PDCA cycle is used and
descr ibed in the perf ormance
management proced ure. There is
also procedur e f or carrying out
improvement activit ies.
PH has a good system of internal
32
audits.
All the process and activit ies are
reviewed regular ly. The results and
perf ormance of PH is measured and
descr ibed in related reports.
All qualit y improv ement projects ar e
document ed.
49. The social service provi der identifies performance i ndicators for
measuring the results of the improvement actions.
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
Strengths Improvem ent & developments
All improvement programs are
document ed, include goals and
respect ive perf ormance indicators.
This was verif ied through inspecting
f ew examples during site visit.
50. The servi ce provider introduces and manages innovative w ays of
w orking that have been identified based on the needs of
stakeholders.
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
Strengths Improvem ent & developments
PH f inds ways of being innovative,
taking into account the needs and
expectat ions of stakeholders.
33
F.e the developm ent of regional
mental health center s.
All related inf ormation was verif ied
to be docum ented.
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. (criterion It would be advisable to make a list of PH’s cooperat ion
3) partners/ stakeholders (and group them by the f ield of
partnership).
Also, revise f eedback questionnaires in time to give
more inf ormative and necessar y f eedback.
Soovitatav on koostada nimekir i PH koostööpartner itest/
huvigruppidest (ja grupeer ida need valdkonniti).
Samuti, vaadata üle tagasiside küsimust ikud, et saada
inf ormatiivsemat ja vajalikku tagasisidet.
Person responsible / vast utaja: qualit y m anager
Due date / tähtaeg: 31.12.2014
34
2. (criterion It would be advisable to collect f eedback (and
11) assessment of effectiveness) prompt ly after ever y
passed training (f .e using web based applications) and
then analyzing the inf ormation gained.
Soovitatav on koguda tagasisidet (ja hinnanguid
ef ektiivsuse kohta) koheselt pärast igat koolitust (nt
kasutades veebipõhist rakendust) ning seejärel
analüüsida saadud inf ormatsiooni.
Person responsible / vast utaja: qualit y m anager
Due date / tähtaeg: 31.12.2014
3. (criterion It would be advisable t o list PH’s cooperation partners
26) (and group them by t he f ield of partnership).
Soovitatav on koostada nimekir i PH koostööpartneritest
(ja grupeerida need valdkonnit i.
Person responsible / vast utaja: qualit y m anager
Due date / tähtaeg: 31.12.2014
4. (criterion It is suggested to def ine empowerment in the processes
30) and procedur es of the organizat ion.
Soovitatav on def ineer ida jõustamine asutuse
protsessides ja protseduur ides.
Person responsible / vast utaja: qualit y m anager
Due date / tähtaeg: 31.12.2014
35
5. (criterion Besides the reports drawn up today (that are not
47) disclosed to the public ), and besides “ Pärnu haigla
raamat 2013” and annual “Pärnu haigla teatmik”, d raw
up an all- embracing annual act ivit y report (including
activities and r ecords on outcome), that would be
disclosed to the public f .e on the web site of the
organizat ion ( alter native would be complement ing the
exist ing reports) .
Lisaks tänasel päeval olemasolevale aruandlusele (mida
ei avaldata avalikkusele) ning lisaks “ Pärnu haigla
raamatule 2013” ja iga-aastasele “Pärnu haigla
teatmikule”, koostada iga -aastane kõikehõlmav ar uanne
tegevust est -tulemusest, mis avaldatakse avalikkusele nt
asutuse veebilehel ( alternatiivina täiustada olemasolevat
aruandlust).
Person responsible / vast utaja : qualit y m anager
Due date / tähtaeg: 31.12.2014
5. Closing remarks
The mission of Foundation Pärnu Hospital (PH) is to support human health
and qualit y of lif e, and besides medical care PH provides special care
ser vices, rehabilitation ser vice and support person ser vice.
The Day Center is a part of out -patients’ department of The Psychiatric Clinic
in PH. The Day Center of The Psychiatric Clinic in PH offers ser vice of
support person and special car e ser vices: Assistance in ever yday lif e (f or 44
persons per month) and Assistance in working (f or 11 persons per month).
Rehabilitation Units are a part of out -patients’ department of The Psychiatric
Clinic and The Internal Disease Clinic in PH. Rehabilitation ser vices are
provided in rehabilitation and aftercare in-pat ient unit and in rehabilitat ion
ambulator y unit.
PH implements and develops continuously its organization wide qualit y
management system. PH has f ew decades exper ience in perf ormance
management, which ensur es the qualit y of work arrangement and
36
manag ement. It enables to achieve targeted results with f irm methodolog y
and to eliminate subjective assessment methods. To guarantee
prof essionalism and qualit y ser vice, PH has developed intranet based
management handbook; it uses system of internal audits and carries out the
satisf action sur veys of its clients.
The preparations f or EQUASS enabled to improve the qualit y management
system of the organizat ion f rom the aspect of the requirements set to socia l
sector ser vice pr ovider s. The existing functioning qua lit y system was used
as much as possible, adding the specif ic elements arising f rom EQUASS
qualit y principles. The corresponding additions were added to the procedures
and guidance notes of the organization and the activities of the organizat ion
were impro ved in or der to respond to the ten qualit y principles of EQUASS.
The auditor experienced on site that the social ser vice provider PH perf orms
in compliance with the EUQASS Assurance crit eria. The inter viewed
representat ives of partners, f inancing bodies, e mployees of PH and persons
ser ved conf irmed this , which was ref lected in their satisf action . Also the
qualit y management system and the documentation of the organizat ion wer e
impressive.
During the audit the organization showed many examples of best practi ce
that would be usef ul also f or other organizations. The whole staff was ver y
kind and cooperat ive in introducing the work of PH, f inding necessar y
evident ial materials and sharing inf ormation about f ulf illing EQUASS criter ia.
For the period of f ollowing two years, some improvement actions and
additional developm ents were agreed that are brought out in part 4 of the
audit report . A more detailed over view of suggestions f or improvement that
are ment ioned under the specif ic criter ia is given in detail in pa rt 3. The
improvement areas included in general t erms paying more at tention to asking
regular and concr ete f eedback f rom stakeholders, complement ing the
processes and pr ocedures of the organizat ion and also drawing up a more
thorough annual report, that wo uld be disclosed to the public.
After verif ication of the indicators by r eviewing documentation, conduct ing
inter views and performing site visit, the auditor was conf irmed that the
criteria f or qualit y assurance of the European Qualit y f or Social ser vices
were f ulf illed. The auditor was convinced entirely that PH is devoted to
qualit y assurance and improvement in its work and delivers services of high
37
qualit y.
***
SA Pärnu Haigla (PH) missiooniks on toetada inimeste ter vist ja elukvalit eet i
ning lisaks ter vishoiuteenustele osutatakse tugiisiku teenust,
rehabilitatsiooniteenust ja erihoolekandet eenuseid.
PH psühhiaatriakliiniku ambulatoorse osakonna alla kuulub Päevakeskus.
Päevakeskuses osutatakse erihoolekandeteenusena igapäevaelu toetamise
teenust (44 kohta kuus) ja toetatud töötamise teenust (11 kohta kuus) ning
tugiisiku teenust.
Psühhiaatriakliiniku ambulatoorse osakonda ja sisehaiguste kliiniku
taastusraviosakonda kuuluvad rehabilitatsiooniüksused, mis osutavad
statsionaarselt ja ambulatoorselt rehabil itatsiooniteenust.
PH-s on välja töötatud ja rakendatakse ning arendatakse pidevalt
organisatsioonipõhist kvaliteedijuhtim issüsteemi. PH - l on paarkümne aastane
tulemusjuhtim ise kogemus, millega tagatakse töökorralduse ja juhtimise
kvaliteet. See võim alda b saavutada kindla metoodikaga eesmärgipärased
tulemused ning kõrvaldada subjektiivsed hindamismeetodid.
Prof essionaalse - ja teenindamisk valiteedi tagamiseks on PH -s välja töötatud
siseveebipõhine juhtimiskäsir aamat, kasutusel on siseauditi te süsteem ja
toimub patsient ide rahulolu hindam ine.
EQUASSi rakendamiseks ettevalm istamine võimaldas täiustada asutuse
kvaliteedijuhtim ise süsteem i sotsiaalvaldkonna teenuseid osutava tele
asutusteele esitat ud nõuet est lähtuvalt. Olemasolevat toimivat
kvaliteedisüsteemi kasutati võimalikult palju ära, lisades sinna EQUASSi
kvaliteedi pr intsiipidest tulenevat eripär a. Vastavad täiendused viidi siise
asutuse protseduuridesse ja juhenditesse ning täiustati oma tegevust, et see
vastaks EQUASSi kümnele k valiteedi põhimõttele.
Kohapeal koges audi itor, et sotsiaalteenuse osutaja tegutseb vastavuses
EQUASS Assurance kriteeriumitega. Intervjueer itud huvigruppide ja
rahastajate esindaj atega , PH tö ötajatega ja teenuse saajatega samut i
kinnitasid seda, mis väljendus nende rahulolus. S amuti olid muljetavaldavad
asutuse k valiteedi juhtimise süsteem ning dokumentatsioon.
Auditi käigus oli asutusel ette näidata mitmeid häid näiteid ja saavutusi
38
EQUASS- i põhimõtete täitmisel, mis on parima praktika näited ka teistele
asutustele. Kogu asutuse töötajaskond oli väga lahke ja koostööaldis PH töö
tutvustamisel, vajaliku tõendusmaterjali leidmisel ning inf ormatsiooni
jagamisel EQUASS - i kriteeriumite täitmise kohta.
Järgnevaks kaheks aastaks lepit i kokku mõned parendustegevused ja
täiendavad arendu sed, mis on välja toodud aruande 4 -ndas osas. Detailsem
ülevaade parendussoovitustest konkreetsete kriteeriumite lõikes on esitatud
aruande 3-ndas osas. Parendusvaldkonnad hõlmasid laias laast us enam
tähelepanu pööram ist regulaarse ja konkreetse tagasiside küsimisele
huvigruppidelt, asutuse protsesside ja protseduuride täiustamist ning
täielikuma aastaaruande koostamist, mis avaldatakse avalikkusele.
Peale indikaator itele vastamise tõendam ist, tut vudes dokumentatsiooniga
ning viies läbi inter vjuud, oli audi itor veendunud, et kriteeriumid Eur oopa
kvaliteedimärgi jaoks sotsiaalteenustes on täidetud. Audiitor sai täieliku
veendumuse, et PH on pühendunud k valiteedi tagamisele ja täiustam isele
oma töös ning osutab kõrge kvaliteediga teenuseid.
Tallinn, 02. 12.2013
Mar iliis Männik -Sepp
39
Kristi Reimets
Saatja: Keiu Talve
Saatmisaeg: 17. detsember 2013. a. 12:02
Adressaat: Kristi Reimets
Teema: FW: Audit report- Pärnu haigla- EST2013-13
Manused: EQ-ASS_AUD_Audit Report_PH2.doc
From: Keiu Talve
Sent: Monday, December 02, 2013 8:18 PM
To: 'Guus van Beek'
Subject: RE: Audit report- Pärnu haigla- EST2013-13
Hello,
The auditor for Pärnu Haigla has made some improvements to the report and her comment to you:
Pärnu Haigla has a very sophisticated quality system and EQUASS is
well integrated into this system. I found evidence covering all the
criteria (f.e minutes of meetings etc), but understood that the box
"Improvement & developments" was meant for additional possible
imporvements for the future.
AS Pärnu Haigla has very detailed procedure rules for all its
activities, I had made suggestions for describing EQUASS related
activities also in those policies. But to remove the impression that
they are in conflict with the required performance on the indicators,
I have now removed those suggestions. (Also, keeping in mind that
there is no need for creating more bureaucracy for the sake of the
EQUASS quality mark.) I dont' want to leave an impression that the
organization does not meet the criteria and underlying indicators. I
have kept the suggestions that might improve the performance of the
organization, but confirm again, that these are additional suggestions
and the criteria are met in reality.
Mariliis Männik-Sepp
Keiu
From: Guus van Beek [mailto:
[email protected]]
Sent: Monday, December 02, 2013 11:24 AM
To: Keiu Talve
Cc: Jan Spooren; Marie Dubost
Subject: Re: Audit report- Pärnu haigla- EST2013-13
Importance: High
Dear Keiu,
I have reviewed the documentation sent about the performance of Pärnu haigla (Reference number
EST2013-13) against the EQUASS criteria and underlying indicators.
After reviewing the audit report I noticed that the feedback given (suggestions for improvement) may
give the impression that they are in conflict with the required performance on the indicators
(questions). The feedback may give the impression that the organization does not meet the criteria
and underlying indicators. (see; feedback on criteria: 18 – 19 – 21 – 26 – 30 - 31)
1
Based on this audit report, the organization Pärnu haigla (Reference number EST2013-13) cannot be
certified with EQUASS Assurance in Social Services.
I kindly aks you to inform the auditor about this and to adjust the relevant documentation (Excel file
and/or Audit report).
Note:
1. In many of the suggestions for improvement it is asked to provide MORE evidence in meeting
the criteria / indicators. I would like to stress that MORE does not guarantee that it will be
BETTER. Other information as evidence might be much more relevant.
2. In many if the suggestions for improvement the auditor is suggestion to establish evidence
in written and documented form. I would like to stress that it is up to the social service
provider how to proof the performance of the criteria / indicators. (within the restricting
that some of the indicators (50 %) will require documented evidence. (I.e. If it is asked to
have procedures and/or policies) The suggestions for more documentation as evidence on
performance on EQUASS criteria / indicators may create more (unnecessary) bureaucracy
for the sake of the EQUASS quality mark. It may also limit the flexibility of meeting the
Equass requirements for small organization and in various sectors.
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: vrijdag 29 november 2013 10:10
Aan: Guus van Beek <
[email protected]>
CC: Marie Dubost <
[email protected]>
Onderwerp: Audit report- Pärnu haigla- EST2013-13
Dear Guus,
Attached you’ll find audit documents of Pärnu Hospital’s social services.
Please review the documents and let me know if any questions, comments!
Keiu
2
EQUASS Eesti
Astangu KRK
Tel: +372 5682 9104
www.equass.ee
www.astangu.ee
3