Private Hospitals
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Applicable Standards
Applicable Standard(s):
Required: For all private hospitals with in-patient beds, regulation requires Certification to the Health and Disability Service Standard NZS8134. The MoH award the Certification and make decisions about the length of Certification including surveillance requirements.
Choice: Additionally, to stretch your organisation and focus on improvement, the EQuiP Accreditation can be useful. The period of Accreditation would align with the MoH Certification timeframes. Note: these can be completed together as a dual event.
General Process:
To view the general audit process please click here
To view the EQuiP accreditation process please click here
Frequently asked questions
General
How long is the certification period?
The Certification period is up to four years, with the majority of certificates awarded for three years. Half way into this period a surveillance audit is required to ensure that the hospital is maintaining the standard and to follow up any corrective actions that were raised at the certification audit.
Who is the certifying body for this certification?
The certifying body is the Ministry of Health. DAA Group Ltd may also be the Certifying body if you choose to have dual certification with another programme such as Equip.
Where can I find information on the relevant standards?
The Health and Disability sector standards are available from Standards New Zealand (https://www.standards.govt.nz/).
What happens if my organisation is co-located / split located?
When we are compiling the itinerary we will take into account all the locations involved in your organisations and will include them into the itinerary if it is applicable.
What is the right standard for my organisation?
If you have stays longer than one day your organisation will likely come under standard NZS8134. Otherwise, if you only have stays up to one day, you can likely choose between EQuIP for Daystay Hospitals or NZS 8164 Day Stay surgery and procedures standard. If you need help to understand the differences and what is applicable for your organisation please feel free to call us on freephone 0508 246 776.
Surveillance
Is there a surveillance audit required?
Yes - A surveillance audit occurs at mid point of the three (or four) year certification period.
What is the process for a surveillance audit?
There is no document review or self assessment required for a surveillance audit. A sub set of the standards are audited against during the onsite audit (as defined by the Ministry of Health). If following the certification audit there were findings raised, these will be followed up at the surveillance audit for progress.
Who do you need to be present from my organisation for the surveillance audit?
When you receive the itinerary prior to the surveillance audit, it is advisable to go through each section and assign the most responsible, knowledgeable person(s) from your organisation for that session. The auditors will want to hear how you do things to meet or exceed the standard. Whilst covering the organisation and management as well as the CEO it is helpful if a board member could be available.
How long does a surveillance audit take?
This varies depending on the size of your organisation but is usually about two days.
What happens if my organisation moves premises post audit?
You are required to undergo a partial provisional audit. You will need to notify the Ministry of health of your move and they will advice you and us of their requirements.
Certification
How is the audit team chosen?
Audit teams are based on location, experience and knowledge of the private hospital sector. For a certification audit the team must change by 50% from the last certification audit, which does add some complexity at times to the selection of the audit team.
Do I need to fill out a self-assessment form?
Yes. Prior to each certification audit we will send you a document that requires completion. This is part of the document review and helps inform the auditors about your organisation prior to them attending the on site audit. It is important that you fill out the entire form.
What is in scope for the certification?
The Ministry of Health administers the Health and Disability Services (Safety) Act 2001 (‘the Act’). The Act requires providers of health services to be certified against the relevant Standards. This covers Consumer Rights, Organisation and Management, Service delivery and the Environment.
What happens on-site during an audit?
Prior to the onsite audit the client manager from DAA Group will be in communication with you and will answer any questions you may have regarding the onsite audit. A draft of the itinerary will also be sent to you prior to the audit for you to peruse and give feedback as to how the itinerary will work for your organisation. The audit will commence with an opening meeting where the lead auditor will explain how the audit will unfold. Each auditor will be assigned standards to audit against and these are organised in a way that enables the audit to "flow" in a logical way for the auditor and the organisation.
Who needs to be present from my organisation during the audit?
When you receive the itinerary prior to the audit, it is advisable to go through each section and assign the most responsible, knowledgeable person(s) from your organisation for that session. The auditors will want to hear how you do things to meet or exceed the standard. Whilst covering the organisation and management as well as the CEO it is helpful if a board member could be available.
What documents are required by the auditors?
The auditor who is looking at service delivery will need to look at clinical records and may need access to your policy and procedures. The auditor covering organisation and management will review other records on site. Please have these readily available during the audit. These include but are not limited to: - Quality/Staff Meeting minutes - Internal audit results and action plans - Accidents, Incidents and Near miss records. - Corrective action plans - Hazard / risk register - Quality projects/improvements - Human resource files, including staff files and credentialing records - Complaints register and supportive documentation
How is audit sampling decided?
Sampling is based on resources bed numbers and staffing levels as determined by the provider. They may change on the day of audit based on actual patient numbers. For patient tracer's a minimum of one individual tracer per service type. Incidental sampling will also be undertaken to ensure sufficient information is gathered.