Problem Statement

All providers of healthcare services in New Zealand are required to be certified by the Ministry of Health under the Health and Disability Services (Safety) Act 2001 to meet the NZS8134:2008 Health and Disability Services Standards.

The Ministry of Health certifies healthcare services for up to five years. District health boards normally receive certification for three years, at which time a designated auditing agency undertakes a certification audit on behalf of the Ministry of Health, followed by a mid-point surveillance audit.

What are we trying to achieve?

CM Health’s goal for the 2019 certification audit was to reduce the number of corrective actions received from the previous certification audit in 2016 (n=19) and to increase the number of continuous improvement ratings received (see table below).

What have we done?

The certification audit is a two-stage process. Stage one required CM Health to submit self-assessment evidence to the designated auditing agency 20 days before the audit. The self-assessment evidence is against the core standards including: consumer rights, organisational management, service delivery, safe and appropriate environment, restraint minimisation and safe practice, and infection prevention and control.

In addition, the auditors reviewed CM Health’s policies and procedures (covering, for example, management systems and clinical systems).

Stage two comprised an on-site audit undertaken by 16 auditors and technical expert advisors across four days (7 to 10 May 2019). This on-site audit included 14 patient tracers in each service stream, which concentrated on the journey of the patient through the hospital system; and three system tracers (infection prevention and control, medication management, and care capacity demand); plus incidental sampling to augment the tracer samples.

What did we find?

The auditors were very complimentary on how CM Health’s values were lived, the positivity of staff, the high level of collegial discussion between the multi-disciplinary teams, and the outstanding ward culture.

Following CM Health’s review and feedback on the Draft HealthCERT Service Provider Audit Report, 12 corrective actions were received. Nine were low risk and three were moderate risk. Six of these were corrective actions from the previous surveillance 2018 audit, meaning seven corrective actions were effectively closed.

Two continuous ratings were received for the Fundamentals of Care programme and Infection Prevention Control’s response to an outbreak of multiple carbapenem resistant organisms.

How did we make a difference?

The work undertaken by all of the clinical areas and support services in preparation to the May 2019 certification audit resulted in over a 30 percent reduction in the number of corrective actions received.

Where to from here?

The designated auditing agency submitted its HealthCERT Service Provider Audit Report to the Ministry of Health in June 2019.

The Ministry of Health will now provide CM Health with a copy of the final signed-off audit report and corrective actions, and confirm the period of certification.

Progress is continuing to be made on the existing corrective actions. Work plans are currently being developed to address the new corrective actions.

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