Private Hospitals


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Applicable Standards
Applicable Standard(s):
Required: For all private hospitals with in-patient beds, regulation requires Ngā Paerewa 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.
General Process:
To view the general audit process please click here
When we are arranging any audit there are many things we take into consideration. First and foremost is having auditors who understand and are credible in the aged care sector. Each audit will have one health manager and at least one clinical auditor (a registered nurse with current aged care experience and a current annual practicing certificate.) Secondly, we also try as much as we can to use local auditors in order to keep disbursement costs down. This is not always possible but we do our best, and are always mindful of not incurring more costs than those that are necessary.
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.
Please call us to discuss your organisations needs. We need to understand more about your needs to provide the right advice.
We will make it easy for you! The first step is to fill in the 'Request for Proposal' form or to call us on 0508246776. We can send you information with the benefits of selecting DAA Group as your auditing agency. Once we have your information, we will send you a proposal of our costs and breakdown of our services. Then, once you have agreed for us to be your auditing agency, we will begin working with you to find an audit date that will suit you and the auditor/assessor team.
The Residential Disability scope covers the following three different types of disability support.
- Intellectual Disability
-Physical Disability
- Sensory Disability
The Certificate issued by HealthCERT details the scope of the disability services that the provider is certified to provide.
This depends on the preparation work you wish to or need to do. If your current system for Allied Health Standard is working well and you do not need to do anything before the audit you will have no additional work resources to prepare for the audit.If you choose to move to the new contract you will need to put resources into revising your documented policies and procedures to meet the requirements of the new standard.
The Retirement Villages Association is the certifying body. They will only accept reports and certify organisations who fully attain all the criteria.
We will make it easy for you! The first step is to fill in the 'Request for Proposal' form or to call us on 04 499 0367. We can send you information with the benefits of selecting DAA Group as your auditing agency. Once we have your information, we will send you a proposal of our costs and breakdown of our services. Then, once you have agreed for us to be your auditing agency, we will begin working with you to find an audit date that will suit you and the auditor/assessor team.
Home and community support services (HCSS) providers that hold a contract with the DSS (MOH), a district health board, and/or ACC (Accident Compensation Corporation) must be certified against Home and community support sector Standard NZS 8158:2012.
Providers who have only private paying clients could voluntarily choose to have an audit if they would desire too.
The certification audits are usually made up by a two person audit team. Wherever possible we locally-based auditors for your site to help keep costs to a minimum.
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.
The applicable standards for Residential Disability providers are NZS 8134:2008 Health and Disability Services Standards, specifically;
NZS 8134.1.1 – Consumer Rights
NZS 8134.1.2 – Organisational Management
NZS 8134.1.3 – Continuum of Service Delivery
NZS 8134.1.4 – Safe and Appropriate Environment
NZS 8134.2.1 – Restraint Minimisation
NZS 8134.2.2 – Safe Restraint Practice
NZS 8134.2.3 – Seclusion
NZS 8134.3.1 – Infection Control Management
NZS 8134.3.2 – Implementing the Infection Control Programme
NZS 8134.3.3 – Policies & Procedures
NZS 8134.3.4 - Education
NZS 8134.3.5 - Surveillance
NZS 8134.3.6 – Antimicrobial Usage
You can purchase a copy of these standards from Standards New Zealand - https://shop.standards.govt.nz/catalog/ics/
The first decision is whether you would like to be audited against the Rooms/ Office Based Surgery and Procedures Standard NZS 8165 or the Day-Stay Surgery and Procedures Standard NZS 8164.
To help with this:
The Rooms/Office Based Surgery and Procedures 8165 Standard is for facilities that undertake procedures without the use of sedation i.e. may use local or regional anaesthetic and complete minor procedures.
The Day-Stay Surgery and Procedures 8164 Standard addresses the clinical support necessary when clients are sedated, from minor sedation through to general anaesthesia.
These standards can be obtained from Standards NZ via their website www.standards.govt.nz (select “buy standards” at top of their website page).
The Retirement Villages Code of Practice 2008 (& Variations of April 2017) is what you will be audited against.
To gain a copy of the code you can download from here: https://www.cffc.org.nz/retirement-villages/the-act-regulations-and-codes/code-of-practice/
That depends on a number of things, the most important being how big and complex your service is. Our costs are always based on how many auditors/assessors are required and how long the work will take. We want the process to be of value to you, so it's important to have adequate time for the audit. We want to provide you with an audit process you can trust. Be aware that the cost includes planning and preparation, the off-site document review (if required), on site audit and reporting, and the final preparation for your 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.
The cost is influenced by the standard you've chosen to be audited against and the size of your service. We can provide a proposal to you, which includes the cost information, once we know more about the needs of your organisation.
Generally certification is required when a provider has more than 5 people living in their service. The provider should contact HealthCERT or their Contract Relationship Manager to discuss if they are required to have certification.
For this certification there is a three year certification period. The certificate is issued by the Retirement Village association who will send this directly to you once they receive the final audit report from us and have reviewed your audit report.
We are very aware that this is your process, and we are always mindful of being a guest in your service. Having said that, there are many rules (rightly) set by the Ministry of Health about how audits must be conducted and so we must follow these rules to meet your needs and ours. An important part of the audit is talking to people, and this includes staff. We generally talk with staff in groups, that way it's less scary for them, but sometimes we need to talk with people individually. We assure you this is always done sensitively and with respect. It works best when we can talk with staff who undertake the work.
The surveillance audit is usually comprised of only one auditor and takes approximately one day, but can be more or less depending on the size and number of locations of your organisation.
The Health and Disability sector standards are available from Standards New Zealand (https://www.standards.govt.nz/).
We are very aware that this is your process, and we are always mindful of being a guest in your service. Having said that, there are many rules (rightly) set by the Ministry of Health about how audits must be conducted and so we must follow these rules to meet your needs and ours. An important part of the audit is talking to people, and this includes staff. We generally talk with staff in groups, that way it's less scary for them, but sometimes we need to talk with people individually. We assure you this is always done sensitively and with respect. It works best when we can talk with staff who undertake the work.
That depends on a number of things, the most important being how big and complex your service is. Our costs are always based on how many auditors are required and how long they need to be onsite for. We want the process to be of value to you, so it is important not to rush the audit - that way we can be sure we have all the information we need, and you finish the audit feeling satisfied and like you have learnt some new things. Bearing in mind our auditors have heaps of experience they can bring to any audit having seen it done a hundred different ways in other facilities.
A documentation request letter will be sent pre-audit, as part of stage one of the audit process. Your policy and procedure documents and completed self-assessment are required approximately six weeks prior to the audit date. This is for your first certification audit only and will not be required for subsequent audits.
We also provide a handy checklist which assists you with preparing the documents we need for the first stage of the audit – the document review.
In addition to the Residential Disability Certification process, some disability providers are also certified for the Allied Health Services Standard NZS8171:2005, or accredited to the EQuIP Evaluation and Quality Improvement Programme. Generally these are larger disability providers, who provide physical disability services, or rehabilitation services.
We have a mandatory requirement to follow up on the following items in the Standard for every surveillance audit:
Consumer rights: 1.1, 1.7, 1.9
Organisational management: 2.2, 2.3, 2.4
Human resource management: 3.2
Service delivery: 4.1, 4.2, 4.5, 4.11
Selection of a minimum of one of the following standards:
Service delivery: 4.6, 4.7, 4.8, 4.9, 4.10, 4. 12
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.
Please refer to page 28, 29, 30, 31, 32, and diagram on page 33 of the code.
Also you can refer to the CFFC (Commission for FInancial Capability) - regarding complaints and disputes: https://www.cffc.org.nz/retirement-villages/complaints-and-disputes/
The certification period is a 3 year certification, with a surveillance audit at the midpoint of the certification period (18 months).
You need to comply with the Urgent care standard 2015. A copy of the standard is available through the Royal New Zealand College of Urgent care.
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.
There are two stages to the certification audit process. The first stage of the audit involves an offsite document review, by the lead auditor, of the disability provider’s policies and procedures. The second stage of the audit involves the onsite audit of the provider’s office and services.
Following the onsite audit, all of the reporting and peer review processes are the same as for all of the other HDSS MoH audits.
Any Corrective Action Requests identified as part of the audit process, are followed up by the DAA Group Client Manager.
The audit can be combined and cover both parts of your business.
We require the name and location of the retirement village, the contact details of the Village Manager and date/s the audit is preferred to occur. If you have registered with the Retirement Village Association they will have discussed when they require you to complete the audit by.
Prior to the onsite audit, your organisation is required to complete a self-assessment and send us your policy and procedure documentation along with organisational information. The lead auditor will undertake a document review and analysis of the self-assessment approximately 6 weeks prior to the onsite audit. You will receive feedback following this review.
All of our auditors have a clinical background and compet
In the interests of remaining independent we are not able to assist you with improvements of your policy and procedure documents. However, we can provide you with the contact details of consultants who would be happy to assist you with this process.
We will provide you with an itinerary prior to the audit. The audit commences with an opening meeting, where the auditor(s) will introduce themselves and discuss how the day will unfold plus explain the methodologies that will be used to gather information. The auditors are flexible and will make changes if required on the day. They will answer any questions you may have. The DAA Group are cognisant of the need for your organisation to run smoothly and will always work around whatever is happening on the day. At the end of the audit a closing meeting will be held to give feedback on the audit findings. Everything discussed at this meeting will have already been raised with you during the audit and discussed in detail. You will be presented in writing any corrective actions that have arisen from the audit.
Yes. This form is for you to prepare for the audit. You simply select yes or no, and add a comment if applicable.
Prior to the onsite audit, the clinic are required to complete a self-assessment and send us all their policy and procedure documentation along with organisational information. The lead auditor will undertake a document review and analysis of the self-assessment approximately 6 weeks prior to the onsite audit. The clinic will have feedback sent to them following this review.
For larger residential disability providers who have multiple sites or services, a sampling plan is completed to determine how many sites are visited as part of the audit process.
For a certification audit the sampling plan is based on the square root of the total number of services that support 5 or more people. This figure is rounded up to the next whole number. The types of service, and when each service last had an audit event, are all factors which are considered when developing the sampling plan. HealthCERT approve the sampling plan prior to each multi site/service audit.
If you are a stand-alone Retirement Village without an aged-care facility, you do not receive a formal proposal (as per other sectors. Rather we simply charge a flat fee of $1,350+GST for the event and disbursements.
The auditors have a clinical background and competencies within the surgical services area. They are also trained to recognised standards for auditing. They are supported by our office based team and have regular mentoring and other trainings to minimise variance between auditors.
We always endeavour to pick auditors who are based local to your organisation, in order to minimise travel costs, although this is not always possible due to other audit events or mandatory changing of auditors per audit (50% change of audit team per audit).
The surveillance audit occurs at the midpoint of the certification period, so at the 18 month mark of the 3 year certification period. The surveillance audit can occur up to two months either side of the midpoint.
NZS 8171:2005 Allied Health Services Sector Standard
You can purchase from Standards New Zealand -https://shop.standards.govt.nz/catalog/8171%3A2005%28NZS%29/view
ACC Requirements for Physiotherapy Services.
Provided free online
https://www.acc.co.nz/assets/contracts/2a1228abdf/ACC-Requirements-for-Physiotherapy-and-Hand-Therapy-Services.pdf
The certification audit only requires one auditor. We have experienced auditors based in many locations. We try to get the closest available auditor to attend.
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.
There are two auditors who undertake each audit, one being a lead auditor who is a qualified auditor with experience of the sector and the other person is a technical expert who works in Urgent Care and is a qualified auditor.
A report is written and peer reviewed prior to your organisation receiving a copy of the draft audit report. You receive this draft to enable you to check if the report is factually correct. You will have a month following the audit to prepare an action plan advising how you will correct any areas requiring improvement. The lead auditor will explain this part of the process at the closing meeting. The report and action plan is then submitted to the Certifying body to endorse the certification. Once this endorsement is given we commence preparation of the certificate.

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