kiri välja_PE Taastusravikeskus auditi raport Brüsselisse

EQUASS ASSURANCE APPLICATION ADDITIONAL INFORMATION 1. Short information about the organisation in the nati ve language Põhja-Eesti Taastusr avikeskus on kaasaegse taastusravi suuna rajaja Eest is. Keskuse loomisel ja arendam isel on olnud eeskujuks paljud taas tusravi haiglad Taanis, Soomes, Kanadas ja Inglismaal. Läht ume raviprotsessis ja patsiendi käsitluses tõenduspõhist est meetodit est ja praktikatest ning rakendame kaasaaegseid ravimetoodikaid. Põhja-Eesti Taastusr avikeskus on asutatud 1995. aastal ning on s uuruselt teine statsionaarse taastusravi teenuste osutaja Eest is. Meie peamiseks partneriks teenuste finantseer imisel on Eesti Haigekassa. Põhja-Eest i Taastusravikeskus on praktika ja residentuuribaasiks nii taast usarstidele ja neuroloogidele kui teistele spetsialistidele (f üsio - ja tegevust erapeudid, logopeedid, taastusr avi õed). 2. Short information about the organisation in English ( acti vities, clients, etc.) North-Estonian Rehabilitat ion Center is the f ounder of the modern neuro- rehabilitat ion in Est onia. Many rehabilitat ion hospitals Denmar k, Finland, Canada and Eng land have been as an example in developing the center. In patient treatment we f ollow evidence-based methods and practices . North-Estonian Rehabilitat ion Center has been established in 1995. an d is the second largest inpatient rehabilitat ion services provider in Estonia. Our main part ner in f inancing the ser vices is Estonian Health Insurance Fund. North-Estonian Rehabilitat ion Center is a residensy base f or both doctors and rehabilitation pr of e ssionals (physio and occupt ional ther apists, speech therapists and rehabilitation nurses). Our main area of competence is neuro -r ehabilitat ion, we provide comprehensive inpat ient rehabilitat ion pr ogrammes to patients who present with head injur y, spinal co rd injur y, stroke, neuropat hy and other complex disabilities. We also treat patients with or thopedic and car diac conditions. 3. Name of t he organisation as you w ould w ant it to appear on the EQU ASS Assurance certificate AS Põhja-Eesti Taastusravikeskus 1 4. Name of services / departments of the organisat ion in the scope of the application as you would want it to appear on the EQUASS Assurance certif icate: Taastusraviteenused Rehabilitatsiooni teenused In English (Rehabilitation sevices) 5. Organisation’s logo Information to be published on EQUASS website: Name of the organisation : AS Põhja-Eest i Taastusravikeskus Post address: Sõle 16, Tallinn Director: Dag Nurm Contact person: Merje Ser vet Email: inf o@taastusr avi.ee Web: www.taastusr avi.ee 2 EQUASS ASSURANCE ASUTUSE KÜLASTUSE ETTEVALMISTAMISE VORM Asutuse külastus: 15.-16.12.2015 AS Põhja-Eesti Taastusravikeskus Mariliis Männik-Sepp © 2012 by European Quality for Social Services (EQUASS) Kõik õigused kaitstud. Antud dokumendi elemente ei tohi paljundada, kopeerida ega muul elektroonilisel moel salvestada ilma EQUASS kirjaliku loata.  Asutuse külastuse ettevalmistamise küsimused EQ U AS S As s ur a n c e t ao t lus v or m i le j a a nt ud l is ai nf orm ats i oo n i l e p õh i n ed es pa l um e te i l e tt e va lm is t us ek s v as t at a j är g ne v at e l e s e l gi t us t n õ ud v at e l e k üs i m us tel e : Üldised teemad 1. Miks alustasite EQUASSi rakendamisega ja mida on kvaliteedi süsteemi rakendamisega saavutatud? 2. Mida olete teinud teenuste kvaliteedi tagamiseks ja tõstmiseks oma asutuses? 3. Kuidas o n kvaliteedisüsteemi rakendamine m õjutanud asutuse juhtimist ja perso nalijuhtimist? Millised muutused on toimunud? 4. Kirjeldage oma asutuse põhiprotsesse: planeerimise protsessi, kestva arengu protses si (PDCA tsükli) ja teenuste o s utamise protsessi rakendamist oma asutuses. 5. Millised on asutuse huvigrupid? 6. Kellega ja millist koostööd teete ning millist lisaväärtust seeläbi olete saavutanud? 7. Kuidas kaasate teenuse saajaid, personali ja muid huvigruppe teenuste arendamisse? 8. Milliste ko gukonnpõhiste tegevustega olete seotud olnud ja kuidas ühiskonnale lisaväärtust pakkunud? 9. Milliseid parendusprojekte/ innovatsiooniprojekte olete ellu viinud? Version 1.0 2  1. Kvaliteedi põhimõtet ele ja EQ U ASS Assurance kriteeriumitele vastavuse küsimused/ teemad: Te en us e s a aj a d Huv i gr up i d P er s o n a l J uh a ta j a Juht im in e 1. Missioon, visioon ja kvaliteedistandard 1.1. Millised on visioon, missioon ja väärtused ? Kus need on dokumenteeritud ja kuidas nendest töötajad teav itatakse? 1.2. Millised on kvaliteedi alased eesmärgid ? Kus need on dokumenteeritud? x x 1.3. Millised on pikaajalised eesmärgid ? Kus need on dokumenteeritud ja kuidas nendest töötajad teavitatakse? 1.4. Kuidas o n tagatud järjepidev areng (PDCA tsükli toimimine)? 2. Kommuni katsi oon 2.1. Kuidas o n klientidel, nende pereko nnaliikmetel ja teenuse saajate organisatsioonidel võimalus anda tagasisidet teenuste ja programmide ko hta (nii isikliku, kui kollektiivse kogemuse alusel)? Kuidas huv igruppide (rahastajad, kliendid, perso nal) tagasiside dokumenteeritakse? 2.2. Kuidas asutus informeerib pakutavatest x x x x programmide ja teenustest kõiki huvigruppe? Sh 2.2.1. teenuste ja programmide arendamine 2.2.2. protsessid ja protseduurid 2.2.3. organisatsiooni tegevuse 2.2.4. eesolevad sündmused/ üritused 2.2.5. töötajate kaasamise ja arenguvõimalused 3. Aastaplaani koostami ne 3.1. Kirjeldage aastase planeerimise ja ülevaatamise/ x hindamise protsessi (sh rakendam ne ja ülevaatamine) ! Kus on see dokumenteeritud? Version 1.0 3  3.2. Kas aastaplaan sisaldab endas: 3.2.1. SMART eesmärke? 3.2.2. vajalikke tegevusi? 3.2.3. Mõõdetavaid tulemusi? 3.2.4. tegevuse ülevaatamist eesmärkide saavutamisel (sh hindamiseks ja läbivaatuseks ette nähtud ajakavad ja tegevused)? 4. Panus ühiskonda 4.1. Kuidas asutus rahuldab ühiskonna ootusi ja vajadusi? 4.1.1. Kuidas küsitakse tagasisidet ühiskonna erinevatelt huvigruppidelt? 4.1.2. Tooge näiteid tegevuste kohta , mis on suunatud ühiskonna vajaduste x rahuldamiseks? 4.2. Milliste tegevustega asutus näitab üles sotsiaalset vastutust; millega panustab ühiskonda? 4.2.1. Milliste ko gukonnapõ histe tegevustega asutus tegeleb? Millised tegevused on andnud lisaväärtust ühiskonnale? P er so na l 1. Personali juhtimi ne 1.1 Kirjeldage personali värbamis - ja ametis hoidmise korda ! Kus see on dokumenteeritud? 1.1.1 Kas see sisaldab kriteeriume personali värbamiseks? 1.1.2 Kas see põhineb töötajate teadmistel, oskustel ja kompetentsidel ? 1.2 Kirjeldage asutuse võrdsuse ja x x diskrimineerimis e vastasuse põhimõtteid! Kus need on dokumenteeritud? 1.3 Kuidas o n tagatud, et töö toimub õigusaktidega kooskõlas? 1.3.1 Kuidas o n tagatud töö ks sobivad tingimused ? Kuidas asutuses hinnatakse töötingimusi ? 1.3.2 Millised on töötajate tunnustamise põhimõtted? 2. Personali kvalifikatsioon j a arendamine x x Version 1.0 4  2.1 Kuidas toimub koolitus- ja arengukava koostamine ja elluviim ine? 2.1.1 Kas plaan on dokumenteeritud ja seda vaadatakse üle? 2.1.2 Kuidas toimub töötajate arenguvajaduse väljaselgitamine? 2.1.3 Milliseid andmeid säilitatakse toimunud koolituste kohta? 2.1.4 Kuidas asutus hindab koolituste efektiivsust ? 2.2 Kuidas o n määratletud ja kus on kirjeldatud perso nali rollidele ja funktsioonidele vastavad kompetentsusnõuded? 2.2.1 Kuidas neid hinnatakse? 2.2.2 Kuidas o n korraldatud otseselt teenust osutava personali jälgimine ? 3. Personali kaasami ne 3.1 Millised on töötajate kaasamise põhimõtted (asutuse tegevuste täiustamisse, teenuste arendamisse ja personali arendamisse)? 3.1.1 Kus need põhimõtted on kirjeldatud? x x 3.1.2 Kuidas dokumenteeritakse kaasamise läbi saadud tagasiside? 3.2 Millised on perso nali rahulolu tagamise ja motiveerimise põhimõtted ? Kas neid mõõdetakse, dokumenteeritakse, analüüsitakse? Õ igu se d 1. Õigused j a kohustused 1.1 Kirjeldage teenuse saajate õiguseid ja kohustusi ! Kus need on dokumenteeritud? 1.2 Kas need on vastavuses rahvusvaheliste hartadega? Millistega? 1.3 Kuidas teavitatakse personali klientide õigustest ja x x x kohustustest? 1.4 Kuidas teavitatakse kliente nende õigustest ja kohustustest? 2. Kirjeldage kaebustega tegelemise süsteemi ! Kuidas saab kaebusi esitada ja nende lahendamise kohta infot? 3. Enesemääramisõigus x x x Version 1.0 5  3.1 Kuidas näidatakse üles poolehoidu teenuse saaja enesemääratluse osas ? 3.1.1 Kuidas asutus hindab oma sellekohast tegevust? 4. Kuidas asutus toetab teenuse saajat eestkostja (eestkõneleja) ja/või tugiisiku leidmisel? 4.1.1 Kuidas asutus hindab oma sellekohast tegevust? E eti k a 1. Eetika eeskiri/ kord 1.1 Millised on asutuses kehtivad eetilised põhi mõtted, väärtus hinnangud j a tegevused, millest lähtutakse teenuse osutamisel? Kus need on dokumenteeritud? Kuidas neist o n töötajaid teavitatud? 1.1.1 Kas eetika koodeks käsitleb teenuse saajate väärikuse temaatikat, kaitseb neid lubamatu riski eest ja edendab sotsiaalset õiglust ? 1.1.2 Milliseid tegevusi tehakse teenuse saaja füüsilise, vaimse ja m ajandusliku ärakasutamise ennetamiseks ? 1.2 Mida on asutuses tehtud töökeskkonna tur valisuse x x kindlustamiseks ning teenuse saajatele turvalise keskkonna ja füüsilise turvalisuse tagamiseks? 1.2.1 Milline on asutuse töötervishoiu ja turvalisuse plaan? Kuidas on korraldatud riskianalüüs? Milliseid tegevusi tehakse töötervishoiu ja turvalisuse tagamiseks? 1.3 Kuidas o n tagatud andmete konfidentsiaalsus ? 1.3.1 Kus on andmekaitse protsess dokumenteeritud ja kuidas toimub selle ülevaatamine? 1.3.2 Kuidas teenuse saajad oma andmetele ligi pääsevad? 2. Rollid ja vastutus 2.1 Kuidas ja on määratletud teenuse juhtimise, disaini, osutamise, toetamise ja hindamisega tegeleva x x perso nali rollid ja vastutused , volitused ning omavahelised suhted ? 2.2 Kuidas neist rollidest teavitatakse? Koo stöö - suht ed 1. Partnerid teenus e osutamisel 1.1 Milliste organis atsioonidega teeb asutus ko ostööd? x x (sh sotsiaalpartnerid, rahastajad, teenuse saajate organisatsioonid, teenuse saajad) Tooge näiteid koostööst! Version 1.0 6  1.2 Kuidas ja millist koostööd teeb asutus teenuste arendamisel? 1.3 Kuidas selgitatakse välja väliste huvigruppide vajadused? 1.4 Kuidas asutus hindab koostööst tulenevat lisaväärtust ? O s al em in e x x x 1. Teenuse s aaj ate kaasamine 1.1 Kuidas kaasatakse teenuse saajaid vajaduste väljaselgitamisse, teenuse planeerimisse, hindamisse ja arendamisse ? (nii asutuse tasandil kui üksikisiku tasandil) 1.2 Kuidas koos kõlastatakse osalemine (protsessid, meetmed) teenuse saajatega? 1.3 Kuidas toimub teenuse saajate osalemisega seotud protsesside (tegevuse kirjelduste) ülevaatamine ja hindamine (nii individuaalsel, kui kollektiivs el tasandil)? x x 2. Teenuse s aaj ate j õustamine 2.1 Milliseid võttei d/ meetodeid kasutatakse teenuse saajate j õustamiseks ? Tooge näiteid, milliseid tulemusi on saav utatud erinevate jõustamise meetodite läbi? 2.2 Tooge näiteid, mida on asutus teinud, et luua jõustavat keskkonda ? 2.3 Milliseid koolitusi on töötajatele korraldatud, et aidata kaasa teenuse saajate jõ ustamisele? Is ik u - x x x x ke s ks us 1. Kliendi vajaduste välj aselgitami ne 1.1 Kuidas teete kindlaks teenuse saajate praeg used ja lähituleviku vajadused ? 1.2 Kuidas teete kindlaks huvigruppide (sh rahastajad, sotsiaalpartnerid) vajadused? 1.3 Kas asute teenuse saajale, tema pereliikmetele ja hooldajatele kõige sobivamas kohas ? 1.4 Kuidas teete kindlaks, et osutatud teenused (tulemused) vastavad seatud eesmärkidele ja teenuse saajate vajadustele ? x 2. Individuaal ne planeer imine 2.1 Kuidas selgitatakse välja teenuse saajate individuaalsed vaj adused ja ootused (sh teenuse osutamise osas)? Version 1.0 7  2.2 Kuidas individuaalsed vajadused dokumenteeritakse ? 2.3 Kas tegevusplaan põhineb teenuse saaja individuaalsetel vajadustel ja ootustel ? 2.4 Kas tegevusplaan hõlmab: 2.4.1 teenuse saaja oodatavat olukorda? 2.4.2 üldeesmäke? 2.4.3 kindlaid mõõdetavaid eesmärke? 2.4.4 kasutatavaid meetodeid i? 2.4.5 kaasatavat perso nali ja vastutusalasid? Lai ah a ar d x x el is us 1. Teenuse osutamise protsess 1.1 Kirjeldage teenuse osutamise protsessi. Kus on see dokumenteeritud? 1.2 Kas see on kooskõlas asutuse v isiooni, miss io oni ja kvaliteedipõhimõtetega? 1.3 Kas see on kooskõlas rahastajate märkustega? 1.4 Kuidas teenuse osutamise protsessi vaadatakse üle ? 1.5 Kas teenuse osutamise protsesse analüüsitakse siseauditite käigus? x x 2. Katkematu teenuse osutami ne 2.1 Kuidas o n tagatud teenuse osutamise järjepidevus (sh katkematus, sujuv üleminek, multidistsiplinaarne lähenemine, asutuste vahelin e koostöö )? 2.2 Kuidas hinnatakse ja arvestatakse teenuse saajate muutuvaid vajadusi ? 2.3 Kuidas reageeritakse takistustele teenuste osutamisel / nendele juurepääsul? 2.4 Kuidas takistustest raporteeritakse ? x x 3. Ter viklik lähenemi ne 3.1 Kuidas o n määratletud ja mõõdetakse teenuse saajate elukvaliteeti ? 3.2 Kuidas raporteeritakse elukvaliteedi hindamise tulemustest? 3.3 Millised on ja kus on dokumenteeritud töötajate kompetentsid, oskused ja perso nali toetamise meetodid teenuse saajate elukvaliteedi tõstmisega Version 1.0 8  seoses? T ulemu st e x x le 1. Tulemuste mõõtmine ori en te e rit 1.1 Kuidas mõõdetaks e asutuse tegevuseesmärkide us saavutamist ? 1.2 Kuidas dokumenteeritakse / raporteeritakse asutuste tegevuste tulemustest? 1.3 Kas tulemusi auditeerib sõltumatu väline üksus? 1.4 Kuidas hinnatakse individuaalsete tegevusplaanide täitmist / eesmärkide saavutamist (sh lisaväärtus)? 1.5 Kuidas hinnatakse kollektii vsel tasemel teenuste tulemusi / eesmärkide täitmist (sh lisaväärtus)? x 2. Tulemuste hi ndamine 2.1 Kuidas selgitatakse välja parim väärtus (seoses teenuste osutamisega) teenuse rahastajatele ? 2.2 Kuidas hinnatakse teenuse lisaväärtust teenuse saajate elukvaliteediga seoses? 2.3 Kuidas hinnatakse teenuse saajate rahulolu ? 2.4 Kuidas hinnatakse teiste huvigruppide rahulolu ? x x x 3. Tulemuste raporteeri mine 3.1 Kuidas avaldataks e asutuse tegevusar uanded huvigruppidele? 3.2 Kas aruanded on kättesaadavad ja lihtsasti arusaadavad ning sisaldavad personaalseid hinnanguid ja saavutusi ? 3.3 Kuidas jagatakse infot asutuse tegevuste ko hta perso nalile, teenuse saajate le ja teistele välistele huvigruppidele? Pi dev x ar en g 1. Kestva arengu ts ükkel 1.1 Kirjeldage kestva arengu protsessi ! Kus on see dokumenteeritud? 1.2 Kas protsess on tsüklilise iseloomuga : 1.2.1 planeeritud tegevused saavutavad seatud eesmärgi; 1.2.2 tegevused rakendatakse ellu; 1.2.3 tegevuste tulemusi hinnatakse; 1.2.4 parendustegevused rakendatakse ellu ( ja nende tulemused dokumenteeritakse? 1.3 Milliseid indikaatoreid kasutatakse, et mõõta Version 1.0 9  parendustegevuse tulemusi? 1.4 Tooge näiteid parendustegevustest , nende eesmärkidest ja tulemustest! x 2. Innovatsi oon 2.1 Tooge näiteid innovaatilistest töömeetoditest ! 2.2 Kuidas dokumenteeritakse innovatsiooniprojektid ja nende tulemused? 2. Nõutav dokumentat sioon EQ U AS S As s ur anc e ta ot l us es s e m ärg i tu d i nf o le j a lis a de l e p õh i n ed es pa l um e v aa t lus ek s e tt e v a lm is ta d a j är g n e v d ok um ent ats i oo n : 1. Et t e võ tt e k äs ir aam at 2. St a ts i o na ar s e t ee n us e os ut am is e p ro ts es s 3. Re h ab i l it ats i o on i te e nu s e os ut am is e pr ots es s 4. Am bu l at oo r s e t e en us e os ut am is e p ro ts es s 5. P ers o n a li p o l ii t ik a 6. Am et ij u h en d id 7. K ae b us t e l a he n dam is e k or d 8. In d i v id u aa ls e p l aa n i k oos t am is e j u he n d 9. Õ i gus e d j a k o hus tus e d 10 . E et ik ak oo dek s Version 1.0 10  3. Personali, teenuse saajate ja tei ste oluliste huvi gruppide intervjueerimine EQ U AS S As s ur anc e t ao t lus es an tu d v as t us te l e j a t õ en d it e l e p õh i ne d es p a lum e k orral d ad a i n ter vj u ud j är gm is te in im es t eg a (f unk ts io o n j a k es t v us ) : Juhtkond Kestvus 1. J uh a taj a 45 m in ut i t Personal Kestvus 1. Er i ne v at e t ee n us t e e e s t v as t ut a v ad a 3 0 m in ut i t is ik ud ( s t ats i o na ar ne r a v i, reh a b i li t ats i oo n i te e nu s , am bu la t oor s e d te e nus ed ) 2. EQ U AS S i k on tak t is ik - M er j e S er ve t 60 m in ut i t / r eh a b il i t ats i oo n it e en us e j u h t Teenuse saajad Kestvus 1. Er i ne v at e t ee n us t e s a aj a d 30 m in ut i t (gr up i i nt er vj u u) Teised huvigrupid Kestvus 1. K oos tö ö p ar t ne r 30 m in ut i t 2. Ra h as t aj a 30 m in ut i t Version 1.0 11  Asutuse külastuse ajakava 15 . 12 .2 0 15 P äev 1 Ae g T egev us 9: 0 0- 1 2: 0 0 A v a s õ n ad , tö ö d ok um ent i de g a 12 : 00- 1 3: 0 0 Lõ u na p aus 13 : 00- 1 4: 0 0 Int erv j uu - EQ U AS S i k ont ak tis ik - Merj e S er v et / r eh a b i li t ats i oo n it e en us e j uh t 14 : 30- 1 4: 4 5 Mä r k m ete t eg em in e 14 : 45- 1 5: 4 5 Int erv j uu pe r son al ig a 15 : 15- 1 5: 3 0 Mä r k m ete t eg em in e , 15 : 30- 1 6: 0 0 Int erv j uu ko ost ööp a r tne ri ga 16 : 15- 1 6: 3 0 Mä r k m ete t eg em in e 16 : 30- 1 7: 0 0 Int erv j uu r ah as ta ja ga 17 : 00- 1 7: 3 0 T öö dok um en t id e ga 16 . 12 .2 0 15 P äev 2 Ae g T egev us 10 : 00- 1 1: 3 0 T öö dok um en t id e ga 11 : 30- 1 2: 0 0 Int erv j uu t e enu s e s a aj at eg a 12 : 00- 1 3: 0 0 Lõ u na p aus 13 : 00- 1 4: 0 0 Int erv j uu juh at aj ag a 14 : 00- 1 7: 0 0 V aj a d us e l t ä ie n da v a d i nt er vj u u d . T öö dok um en t id e ga 17 : 00- 1 7: 3 0 Lõ p uk oos o lek Version 1.0 12 Maarika Aro Saatja: Maarika Aro Saatmisaeg: 30. detsember 2015. a. 9:46 Adressaat: 'Guus van Beek'; Marie Dubost Koopia: Keiu Talve Teema: AS Põhja-Eesti Taastusravikeskus auditi report Manused: EQUASS Assurance taotlusvorm Taastusravi.xlsx; PE_taastusravi_audit report.doc; Additional Information Form EQUASS.doc; Asutuse auditi külastuse ettevalmistuse vorm_Põhja_Eesti taastusravikeskus.docx Dear Marie, Dear Guus, Attached you’ll find an audit report and other documents of AS Põhja-Eesti Taastusravikeskus EE2015-025. Please let Keiu to know in case there are some comments about the report. Best, Maarika 1 EQUASS ASSURANCE AUDIT REPORT Site visit: 15.-16.12.2015 AS Põhja-Eesti Taastusravikeskus 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 AS Põhja-Eesti Taastusravikeskus service provider (hereinafter rehabilitation center ) Address: Sõle 16, 10611 Tallinn Post box: N/A Person responsible : Dag Nurm Contact person: Merje Ser vet Phone: (+372) 6390400 Fax: (+372) 6390401 E-mail: [email protected] Web site: www.taastusravi.ee Name of Auditor: Mar iliis Männik -Sepp Dates of audit: 15.-16.12. 2015 Clients: 2300 Staff: 74 (as of 16.11.2015) Full time: 62 Part time: 12 Services:  Inpatient treatment  Outpatient treatment  Rehabilitation ser vice 2  2. Audit program 15.12.2015 Day 1 Time Acti vit y 8:00-12:00 Opening meeting , Documentation review 12:00-13:00 Lunch break 13:00-14:30 Interview w ith EQUASS contact person – Merje Ser vet / head of rehabilitat ion ser vices 14:30-14:45 Documentation review, up -dat ing f iles 14:45-15:30 Interview w ith staff – Katrin Oinitš ( head nurse) 15:30-15:45 Documentation review, up -dat ing f iles 15:45-16:15 Interview w ith cooperation partner – Margus Vasar (OÜ Rehabilitatsiooniabi) 16:15-16:30 Documentation review, up -dat ing f iles 16:30-17:00 Interview w ith funding bod y – Andrus Kr eis (PERH) 16.12.2015 Day 2 Time Acti vit y 10:00-11:30 Documentation review, up -dat ing f iles 11:30-12:00 Interview w ith perso ns served – Armin Hansen, Silvi Roomets, Inga Eglit 12:00-13:00 Lunch break 13:00-14:15 Interview w ith general manager – Dag Nurm 14:15-15:00 Interview w ith staff – Kadr i Labu (psychologist) 14:00-15:30 Documentation review, up -dat ing f iles 15:30-16:00 Closing meeting 3  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 As the visual identit y and logo of the the rehabilitation center are stated organizat ion were r enewed recently in the Organization’s Manual and on (including words: Prof essionaalne, the website www.taastusravi.ee, Presonaalne, Multidistsiplinaarne ), it which is at the moment available in might be usef ul to evaluate how they Estonian. relate to the existing values of the organizat ion. The employees of the rehabilitation center are aware of the mission, Make the home page available also vision and values and they soon in Russian (and English) as implement them on ser vice planned. provision. Kuivõrd organisatsiooni visuaalne identiteet ja logo läbisid hiljut i suurema muudatuse (sisaldades sõnu: Pr of essionaalne, Presonaalne, Multidistsiplinaar ne) , on soovitatav hinnata, kuidas ne ed suhestuvad olemasolevatesse o rganisatsiooni väärtustesse. Soovitatav on k oduleht lähiajal ka vene (ja inglise keel es) kättesaadavaks teha, nagu planeer itud. 2. The social servi ce provider 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 Assurance certif ication program 4  Strengths Improvem ent & developments The qualit y standard and qualit y The development plan of the related goals / commitment to organizat ion expires this year and a continuous improvement are stated new plan nees to be made. A good in the Organization’s Manual . practice would be to review and update the development plan It appeared f rom the inter views that annually. The importance of the the staff of the rehabilitation cent er development plan stands in the is knowledgeable of the qualit y inclus ion of the organizat ion’s long standard. term goals. Also, the staff seemed to be devoted Organisatsiooni arengukava lõpeb to deliver qualit y services and käesoleva aastaga ning seetõttu pursue f or continuous improvement. tuleb välja töötada uus ar engukava. Hea tava oleks arengukava iga - aastaselt üle vaadata ja uuendada. Arengukava olulisus seisneb organisatsiooni pik a-ajalist e eesmärkide sisaldamises . 3. Persons served, famil y members and servi ce user organisations 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 this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The rehabilitation center has asked As the organization changed its f eedback from stakeholders using location of activit y – it moved diff erent methods. Somet imes a recently (in this summer) and a great meeting, other t ime a sur vey, also amount of staff has changed, it might through conversation s f .e. be usef ul to conduct a personnel sur vey and target groups’ f eedback sur vey in near f u ture to gain f eedback and inf ormation on how this change has impacted the sat isf action 5  of the mentioned groups and t o f ind out what the new arising expectat ions are. The f eedback gained should not onl y be summarized, but also analysed. Kuivõrd organisatsi oon vahetas tegevuskohta, kolides hiljut i uude asukohta (sel suvel) ning suur hulk personali (eestkätt hool dust öötajad) vahetusid, oleks soovitatav peatselt läbi viia personali ning teiste huvigruppide seas uuring ud, et saada tagasisidet ning inf ormatsioon i selle kohta, kuidas see muudatus on mõjutanud nimetatud gruppide rahulolu ning selgitada välja, millised on uued üleskerkinud ootused. Saadud tagasisidet peaks lisaks kokkuvõtte koostamisele ka analüüsima. 4. The social service provider i nforms all stak eholders 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 The rehabilitati on center has Even though the organizat ion has inf ormed its possible stakeholder s inf ormed its partners about the about its ser vices using mainly the change in the name and location of home page of the organizat ion, the organizat ion, many of them still which is quite inf ormative about the have not updated the related ser vices and other related inf ormation on their web pages. The inf ormation. cooper ation par tners should be contacted and asked this inf ormation As the name and the location of the 6 organizat ion changed, a co nf erence to be changed. was organized by t he rehabilitation center this spring to inf orm the target Kuig i asutus on teavitanud oma groups and other stakeholders about partnereid oma nim es ja asukohas the change. toimunud muudatusest, pole paljud neist nimetatud inf ot oma Stakeholders are aware of the koduleht edel är a muutnud. ser vices of the rehabilitat ion center, Koostööpartner itega tuleks which was verif ied implemented kontakteeruda ja paluda neil see through inter views wit h per sons inf ormatsioon är a muuta. ser ved, staff and partners. 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 EQ UASS Assurance certif ication program . Strengths Improvem ent & developments The planning procedure is descr ibed in the Organization’s Manual and is f ollowed as descr ibed. There are annual action plans , which are reviewed regular ly. 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 work plan of the The annual plan includes due dates, rehabilitat ion center includes the but not always – make a separate 7 f ollowing data in a table f ormat: column f or this. purpose, expected result, indicator, inter im result and indicator, person The goals/objectives are sometimes responsible. worded as actions – rephrase them not to include planned activities The annual plan is approved by the (activities could be presented in a general mananger of the separate column) but expected rehabilitat ion center. outcomes. Indicators/targets should be more measurable – tur n attention to setting specif ic in dicators and target values in the f uture. Aastaplaan sisaldab tähtaegu, aga mitte läbivalt – soovitatav on tähtaegade jaoks teha eraldi tulp. Eesmärgid on mõnikord sõnast atud tegevust ena – need tuleks ü mber sõnastada, et need ei sisaldaks planeer itud tegevusi (tegevused võib eraldi tulbana kajastada) , vaid oodatavaid eesmärke/tulemusi. Indikaator id/sihtmäärad peaksid olema mõõdetavad – pöörata tulevikus enam tähelepan u spetsiif iliste indikaatorite ja soovitavate sihttasemete määratlem isele. 7. The social s ervi 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 Strengt hs Improvem ent & developments 8 The rehabilitation center has taken action, when it comes to sat isf ying the needs and expectations of the societ y. F.e it has participated in the organizat ion of conf erences concerning the topic of rehabilitation. There were several T hank You notes f rom various authoritot ies and persons proving this. The rehabilitation center has been a place f or traineeship f or students f rom diff erent inst itutions of educat ion. 8. The social service provider demonstrates organisati on’s s ocial responsibilit y t hrough acti vities contri buting to 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 The rehabilitation center has demonstrated social responsibilit y through diff erent activit ies contributing to the communit y and also to wider societ y. The rehabilitation center has organized various seminars, its personnel has made lectures in var ious seminars, wr itten articles, spoken on radio shows etc. 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. 9 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 staff of the rehabilitation center The personnel policy f ocuses mostly includes 75 em ployees whose on staff recruitment and less on staff exper ience and prof essional know - retention. Also the topic of equalit y how ensur es the qualit y and and non-discr imination is addr essed consistency of the services. There is ver y brief ly. no personnel manager position, the dut y is f ulf illed by t he general It would be usef ul to address t he manager. staff retention principles and the principles of equalit y and non - The principles f or personnel discr imination more prof oundly. recruitment are described in the personnel policy as well as the Personalipoliitika keskendub principle f or equalit y and non- enamjaolt töötajate värbamisele ja discr imination. vähem töötajate ametis hoidmisele. Samuti on töötajate võrdsuse ja All employees have individual job mittediskrimineerim ise põhimõtted descr iptions, which include required esitatud väga lühidalt. knowledge, skills and competences. Soovitatav on rohkem tähelepanu It appeared f rom the inter views wit h pöörata töötajate ametis hoidmise the staff that they are aware of the ir põhimõtete ning võrduse ja roles, r ights and duties and are mittediskrimineerim ise põhimõttete devoted to deliver in g services of kirjeldamisele. high qualit y. 10. The social service provider operates in compli ance w ith mandator y national legislation, providing appropr iate 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 Strengths Improvem ent & developments 10 The documentation of the As the organizat ion has mo ved to a rehabilitat ion center meets legal new location, the working condit ions requirements and is reviewed to do of the new locat ion have to be this. The staff level is kept at evaluated in near f uture (risk optimum. assessment carried out and related action plan drawn up) , as already The principles f or showing planned. recognit ion to employees have been developed. Joint events f or Kuna asutus on kolinud uuele employees ar e organized, birthdays pinnale, tuleb lähitulevikus läbi viia are celebrat ed and other personal töötingimust e hindam ine events are remembered, etc. (riskianalüüs koostada koos vastavasisulise tegevuskavaga) , The working condit ions are evaluated nagu on plaanis . regularly (r isk assessments are carried out and related action plans made). 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 development and training needs An annual training plan should be in are assessed annually during place (i.e the procedure rules should perf ormance reviews. be f ollowed) and the training opportunit ies tha t arise in t ime, There is no off icial annual training should be added there. At the plan, even though the personnel moment the training plan (being part policy f oresees drawing up a plan. of the annual plan) is too superf icial in order to f ulf ill its objective. It came out of the interviews that t he staff is trained based on their needs The f eedback on trainings should not and expectat ions and the trainings only be summar ized, but also are provided as training possibilit ies analysed. arise. Paika tuleks panna ko olituskava (st 11 Feedback on trainings is collected olemasolevat presonalipoliit ikat after each training (training report) , tuleks järgida) ning aja jooksul where the value and success of the lisanduvad koolitused tuleks lisada training is evaluated. plaani. Olemasolev koolituskava (osana aastaplaanist) on liiga pealiskaudne, et om a eesmärki täita. Koolituste kohta saadud tagasisidet peaks lisaks kokkuvõtte koostamisele ka analüüsima. 12. The social servi ce provi 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 se r vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The competence r equirements f or Think about and describe more ways employees are descr ibed in their job f or periodic reviewing of the descr iptions and are reviewed perf ormance of employees, in annually dur ing perf ormance addiston to conducting int ernal reviews. audits. Mõelge ja kirjeldage ka muid viise teenuse osutamisega seotud personali per ioodiliseks jälgimiseks siseaudit ite läbivi imisele kõrval. 13. The social servi ce provi der recognizes the staff as a resource for feedback on organizational perf ormance, service development and staff 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 12 The involvement of staff in the planning and evaluat ion of services is described in the Organization’s Manual. The rehabilitation center recognizes staff as a usef ul tool f or gaining inf ormation. It has staff meetings , perf ormance reviews, satisf action sur veys, etc. There is open-doors policy and the manager is available to all employees. 14. The social service provi der has mechanisms in place 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 Ways of providing satisf action and motivat ion are described in the Personnel Policy. Besides f .e highlighting personal achievements and important events, also sp ecial events f or showing recognit ion to staff have been organized. Feedback is gained through sur veys, perf ormance reviews and meetings. 13  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 conventions, 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 The rehabilitation center has developed the rights and dut ies of persons ser ved. The rights and duties are available on the walls of the rehabilitat ion center and are available on the home page of the organization. The persons served and staff demonstrated their knowledge of the rights and duties through the inter views. 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 the EQUASS Assurance certif ication program Strengths Improvem ent & deve lopments The rights and duties are introduced to persons ser ved by staff and are available on the walls of the rehabilitat ion center. 14 Their ser vice provision is also regulated by the service provision procedures, which involves introducing the rights and duties to clients. The clients demonstrated their knowledge of the rights and dut ies through the inter views. 17. The social service provider has accessibl e complai nt management s ystem w hich registers feedback on performance from persons served, purchaser s 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 ication program Strengths Improvem ent & developments Rehabilitation cent er has developed Develop addit ional ways f or a procedure f or handling complaints , submitt ing complaints , f.e sending an which is also available on the hom e e-mail, using the web page etc . page of the organization. Develop a f orm of comp lanits and descr ibe all t his in t he procedure f or A wr itten complaint can be placed in handling complaints . the complaints’ box or given to the head nurse or social worker. Töötada välja täiednavad kaebust e esitamise viisid, nt e-mail, kodulehe If was verif ied during the inte rviews vahendusel jne. T öötada välja that the persons serve d and other kabuste vorm ning kirjeldada see relevant stakeholder s were awar e of kaebuste esitamise korras. the ways of submitting complaints . All wr itten complaints are dealt wit h and answer ed. 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. 15 Remark from the auditor: The ser vices of the social ser vic e pr oviders does meet this crit erion of the EQUASS Assurance certif icat ion program Strengths Improvem ent & developments The self -determination supporting As the rehabilitation center conducts related pr inciples are descr ibed in its annual self -assessment on the var ious ser vice provision respect ing the r ight to self - procedures. determination, the records of this evaluat ion should be maintained. It became evident th rough the inter views that the staff supported Kuivõrd t eenuse osutaja viib iga- the right to self -determinat ions of aastase lt läbi enesehin damise, mille clients and that the persons ser ved käigus antakse hinnang te enuse were handled wit h respect. saajate enesem ääratlemise õigusest kinnipidamise kohta , tuleks sellekohase hindamise kohta tõendeid säilitada. 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 do es meet this crit erion of the EQUASS A ssurance certif icat ion program Strengths Improvem ent & developments The f acilitation in choosing and As the rehabilitation center conducts having access to advocates and/or its annual self -assessment on their support ing persons is descr ibed in perf ormance in f acilitating persons the var ious ser vice provision ser ved in having access to procedures. advocates and/or supporting persons, the records of this Help is provided if there is a need. evaluat ion should be maintained. Kuivõrd teenuse osutaja viib i ga- aastaselt läbi enesehindamise, mille käigus antakse hinnang oma käitumisele teenuse saajat e 16  abistamisel eestkostja/tugiisiku leidmisel, tuleks sellekohase hindamise kohta tõendeid säilitada. 20. The social service provi der defines and documents its po licy on ethics that respects and assures 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 i cation program Strengths Improvem ent & developments In their work the employees of the rehabilitat ion center f ollow the principles set in the code of ethics of the center. It was verif ied through the inter views that the employees and the ser vice users were aware of the ethical principles of the rehabilitation center. The ethical principles respect and assure the dignit y of the persons ser ved, pr otect them f rom undue risk and promote social justice. The clients have been inf ormed about the et hical princi ples by staff . 21. The social service 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 It is the dut y of the staff to ensure The topic of principles / mechanisms, 17 that the customers are protected which prevent the physical, menta l f rom physical and mental and and f inancial abuse of users, was f inancial abuse. addressed superf icially in the documentat ion, and s hould be The rights and duties of persons descr ibed in a more detailed manner. ser ved are introduced to them during drawing up the individual plans. As the organizat ion evaluates its prevent ion act ivities f or the physical, Members of staff showed awareness mental and f inancial abuse of users , about the importance of abuse the records of this evaluation should prevent ion. be maintained. Teenuse saajate f üüsilise, vaimse ja majandus liku ärakasutamise ennetamise temaatikat on käsitletud asutuse dokumentatsionis pinnapealselt ning seda tuleks detailsemalt kirjeldada. Teenuse saaja viib läbi regulaarseid enesehindam isi ennetamistegevust e osas, kuid sellekohase hindam ise kohta tuleb tõendeid säilitada. 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 socia l ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Rehabilitation cent er providesMake sure that the health and its ser vices in a saf e system of working safety related risk assessment will within a saf e environment (until June be conducted as soon as possible. 2015 in Keila), sin ce July 2015 it has moved to a new location . Tagada, et töötervios hoiu ja – ohutusega seotud risikianalüüs Risk assessment of the new location viiakse läbi esimesel võimalusel. has not yet been conduct ed, but is 18 planned in 2016. 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 The principles, values and procedures in ser vice deli ver y are descr ibed in the Organization’s Manual and in the service deliver y procedures. Employees also f ollow the code of ethics of the organizat ion. It was demonstrated through the inter views of staff that they ar e aware of the values and procedures that govern behavior in the ser vice deliver y process and the et hical principles related to their work. 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 The procedures f or assuring conf ident ialit y of data have been def ined and documented. They have been over looked dur ing 19 the course of this year with the members of staff and the per sons ser ved. 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 & developments The roles and responsibilities of the management and are described in the Statue of the Rehabilitation center. The roles and responsibilities of the persons, who are direct ly involved with ser vice provision are described in the job descr ipt ions of employee s. The relat ed roles and responsibilit ies are presented in mor e detail in the in the service deliver y processes of rehabilitat ion center. Relevant inf ormation has been communicated to the clients. 26. The social service provi der w orks in partnership w ith other organisations in the provision of servi ces. 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 rehabilitation center w orks with In the f ield of cooperation, it would diff erent types of cooperation be advisable to draw up a plan of 20 partners. partners, indicating what is the common point of interest, related It has cooperat ion meetings with its activities and desired outcome. This partners f .e hospitals, f amily doctors, other re habilitat ion ser vice could be used when evaluating the providers, educational added value of partnership. establishments, etc. In f uture it would be expected to pay There have been successf ul joint more attention to analyzing the projects with some of the added value f rom partnership (and cooper ations partners, f .e one of them is planned with Astangu KRK document the results of such f or the coming years . analysis if possible). The rehabilitation center evaluates Koostöö kohta oleks soovitatav cooper ation annually, bef ore drawing koostada plaan, milles tuuakse välj a up the annual act ivity plan. ühised huvipunktid, seotud tegevused ja oodatavad tulemused. Seda oleks hea kasutada koostöö lisaväärtuse hin damisel. Tulevikus tuleks enam tähelepanu pöörata partner lusest tulenevale lisaväärtuse hindamisele (ning võimalusel dokumenteerida sellise analüüsi tulemused). 27. The social service provider 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 Strengths Improvem ent & developments There is cooperation especially with In f uture more attention should be with f amily doctor s and hospitals paid to the assessm ent of the needs (PERH) in the f ield of improving the of stakeholders using var ious studies ser vices. and or sur veys. The persons ser ved, co -operat ion Tulevikus võiks enam tähelepanu partners, f inancing bodies and other pöörata huvirühm ade vajaduste 21 stakeholders are involved in t he hindamisele, kasutades selleks development of services of the uuringuid. rehabilitat ion center through meetings and written f eedback. 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, t he 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 principle of involving the persons ser ved in t he management of the service is described in the var ious ser vice provision procedures of the organizat ion. Clients are involved in the ser vice planning, deliver y and appraisal procedure. The criterion was ver if ied sat isf ied also through exploring client work documentat ion and through inter views with staff and clients. 29. The social service provi 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 Strengths Improvem ent & developments 22 The activit ies of client participation are agreed with the persons ser ved. Clients’ f eedback is gained through individual work, through meetings and sur veys. The procedures f or the involvement of the persons served have been discussed with the clients. 30. The social service provi der operates specific instruments f or users to improve t heir personal empow erment 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 an int egral part of service deliver y. Empowerment is described in the Organization’s Manual. Empowerment related activit ies were evidenced in ser vices’ deliver y processes - the client work is aimed at improving the qualit y of lif e of the customers. The criterion was ver if ied sat isf ied through exploring client work documentat ion and through inter views with staff and clients. 31. The social service provi der operates specific mechanisms for establishing an empow ering environ ment. 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 23  Strengths Improvem ent & developments Empowerment of persons ser ved is an int egral part of service 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. The results of e mpowerment activities can be evidenced in the individual plans of the persons ser ved. 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 car e 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 The rehabilitation center has an over view of the needs of the persons ser ved ( waiting lists, meetings wit h cooper ation partners, clients’ f eedback, individual plans of persons ser ved). The rehabilitat ion center is located nearby the cit y center and is well accessible by public transportat ion. It is accessible by wheelchair as 24 well, although this is not ver y convenient. On the home page of the rehabilitat ion center, the map was presented showing the location of the organization. 33. The social service provider offers programmes consistent w ith the identified needs of its customers 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 Strengths Improvem ent & developments The rehabilitation center does cooper ation f ,e with PERH (f unding body) and has ascertained t he needs and expectations of them. Contract has been signed with them that includes inf ormation about their expectat ions r elated to ser vice amounts. The needs and f eedback of diff erent stakeholders (social partners, educat ional inst itutions etc) have been discussed during meetings and during daily cooper ation (though e - mails, telephone). The results of the services have been determined and are descr ibed in the annual report . 34. The social ser vice provi der operates indi vidual processes that are dri ven by the needs of the person served. 25 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 Individual plans are compiled in It appear ed f rom the sur veillance cooper ation with customers. report of the f under that the wording of the individual plans is expected to Procedure rules f or compiling be more thorough and detailed. individual plans have been dr awn up Sometimes there are specialists’ that involve client participation. activities descr ibed instead of clients’ object ives. I n sever al cases The needs of the persons ser ved are same activities/ objectives are asked and taken into account when repeated, but change is expected to drawing up the plans. be shown. Focus on the wording of the plans to make them more client -centered. Rahastajate poolsest järelevalve aktist ilmnes, et individuaalsed plaanid peaksid olema põhjalikumad ja üksikasjalikumad. Mõnel juhul kirjeldatakse spetsialisti tegevusi klient ide eesmärkide asemel. Mitmel juhul korrati samu eesmärke/tegevusi, kuid oleks soovinud näha muudatusi. Keskenduda endam plaanide sõnastam isele, et need oleksid kliendikesksemad. 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 26  Strengths Improvem ent & developments The clients’ individual needs and expectat ions are wr itten down in the individual plans. The individual plans involve all the inf ormation set by the criter ion and are agreed by the persons ser ved, which was verif ied by examples of client documentation seen during the site visit. Interviews were conducted with persons ser ved that ver if ied that the clients were knowledgeable of their objectives and related activities . The individual plans were agreed with the customers. 36. The social service provider identif ies, documents, and maintains the key servi ce deli 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 main social ser vices of the rehabilitat ion cent er are: inpatient treatment, outpat ie nt treatment and rehabilitat ion ser vice. The service deliver y processes are descr ibed in the ser vice deliver y procedures. The main ser vice deliver y pr ocesses are in line with t he rehabilitation 27 center ’s vision, mission and qualit y principles. 37. The so cial service provi der review s this delivery process and maintains control over the deli very of t he servi ce. 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 Procedures f or conducting internal audits have been descr ibed in the Organization’s Manual. The service deliver y processes are reviewed once a year dur ing the internal audit. They are also discussed during meetings and improvements are pr oposed. 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 The rehabilitat ion center ensures that the persons served can access a continuum of services as needs of persons ser ved are evaluated and descr ibed in individual plans. According to the individual plans, necessar y ser vices are provided. The continuation of service deliver y is monitored and evaluated regular ly. 28  39. The social service provi der develops a seamless continu um 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 & develop ments Annual act ivit y reports are composed, which address the continuum of services. The ser vices, that are part of the individual plan, are provided to the customers. 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 s erved. 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 Rehabilitation cent er 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 in individual plans. FI M/FAM instrument is used in the 29 rehabilitat ion center f or measurement. The criterion was verif ied f ulf illed by also explor ing the client work 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 of the reha bilitation center. These are evaluated annually during employees’ perf ormance evaluations. Trainings are provided to employees, which was conf irmed by the employees. 42. The social service provider identifies its business results and provides formal peri odic 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 The rehabilitation center has Turn attention to setting more developed perf ormance indicators t o specif ic indicators and target values 30 measure the results of its activit ies. and present the results in the annual The goals, act ivities, perf ormance report. indicators and expected results are descr ibed in the annual plans. Pöörata enam tähelepan u spetsiif iliste indikaatorite ja Results are r eported in the annual soovitavate sihttasemete reports. määratlem isele ning esitada vastavad tulemused Checks have been made by the tegevusaruandes. Estonian Social Insurance Board and the Health Insurance Fund. 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 The rehabilitation center gathers and More f ocus should be paid on t he documents inf ormation regarding registering outcomes and benef its f or results of pr oviding ser vices (bot h on persons ser ved (of the received individual and collective basis). ser vices) on collect ive basis. Individual plans are assessed Enam tähelepanu tuleks pöörata regularly. Conclusions are dr awn and teenuse kasutamisest saadud kasu summaries are made on collect ive dokumenteerim isele kollektiivsel basis annually. tasandil. The summary is presented in the annual reports. 44. The social service provider evaluates i ts business results in order to determine best value for purchasers and funders ( ‘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 vi ce pr oviders does meet this crit erion of the EQUASS Assurance certif icat ion program 31  Strengths Improvem ent & developments Rehabilitation cent er evaluates the Clarif y the understanding of the best results of its work during regular value (and the met hodolog y on how meetings and through surveys, f .e to evaluat e it) f or evaluat in the meeting with PERH. organizat ion’s results in delivering this kind of value. The added value is summarized also in the annual report, which is Täpsustada, mida mõistetakse available to the publicit y through the lisaväärtuse all (ja metoodika, mille web page of the organization. alusel seda hinnatakse) asutuse tegevuse läbi lisaväärtuse pakkumisel. 45. The social service provider evaluates the indi vidual and collecti ve satisfact i on of persons 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 & developm ents The rehabilitation center organizes regular sur veys to r eceive f eedback f rom the persons served. Also the satisf action of other stakeholders is evaluated by using diff erent means like meetings, questionnaires etc. 46. The social service provider pr ovides 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 32  Strengths Improvem ent & developments The records on outcome are There should be more c onscious communicated to stakeholders, staff approach towards adding inf ormation and persons served. F.e to reports concerning personal presentat ions are made to the staff . percept ions and achievements. At the moment this seems more Annual r eports include personal random, than systematic conscious percept ions and achievements to activit y. some extent. Soovitatav on teadlikumalt lisada inf ormatsiooni personaalsete arusaamade/kogemuste kohta aruandesse. Hetkel on see pigem juhuslik kui teadlik süsteemne tegevus. 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 se r vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Rehabilitation cent er reports its perf ormance to f unding bodies, staff and ser vice users. Related inf ormation is also available on the hom e page of the rehabilitat ion center. Inf ormation is disseminated through the home page, staff meetings, cooper ation partners’ meetings etc. 48. The social service provider has a standard procedure for continuous improvement on the basis of an improvement cycle. 33 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 t he Organization’s Manual. Annual plans are drawn up and are reviewed. The results and perf ormance of the rehabilitat ion center is measured and descr ibed in reports. Qualit y improvement projects are descr ibed in the annual plans and are documented. 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 The improvement program s of the The service provider is encouraged rehabilitat ion center ar e to present more of its activit ies as document ed, they include goals and improvement projects, as many of its respect ive perf ormance indicators. activities would qualif y as such. This was verif ied through inspecting Teenuseosautajal on soovitatav the documentat ion during the site esitada enam oma erinevaid tegevusi visit. parendusprojektidena, kuivõrd mitmedki neist sobiks sellek s. 50. The servi ce provider introduces and manages innovative w ays of w orking that have been identified based on the needs of stakeholders. 34 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 Rehabilitation center f inds ways of being innovative, taking into account the needs and expectat ions of stakeholders. For example: Neur ogological Music Theraphy; Using FI M/FAM instrument f or measurement; et c. The innovation projects related inf ormation was ver if ied to be document ed. 4. Agreed additional development / improvements The applicant decided on the f ollowing improvement actions and/or additional developm ent f or the period of two year s: Cr it e Sho rt d es c ri ptio n of the a cti on s rio n ( in clud ing SM ART ob je ctiv es ) 2 Dra w u p a n e w dev elo pm ent pl an ( inc l ud i n g l on g t erm go a ls ) f or th e org a n i za t io n an d s t ar t to r e vi e w a nd u pd at e th e d e ve l o pm ent p la n a n nu a l l y. T he im por ta nc e of t he d e v e lo pm en t p la n s t an ds i n t he i nc l u s i on of th e org a n i za t io n ’s l o ng t er m goa ls . K oos ta d a or g a n is a ts i oo n i are n guk a v a (m i s s is al d a b or g an is at s i oo n i pik a - aj a l is i e es m är k e) ni n g e das p i di v a ad at a ü l e j a u ue n d ad a ar e n guk a v a i g a - aas t as e l t. 3 Co n duc t a p er so nn el su rv e y an d t a rg et g roup s ’ f ee dba c k su r v e y i n ne ar f utur e to g a in f ee d b ac k and i nf orm at i on t o g a in f ee d bac k o n t h e s at is f ac t io n of th e m en ti o ne d gr o u ps a n d t o f i nd o ut th e ne w aris i n g ex p ec t at i o ns . A l an yze th e f ee d bac k , b es i d es s um m ari zi n g i t. V i ia p e ats e lt l ä b i per s on a l i n in g t eis t e hu v i g rup p i de s e as u ur in g ud , et s a ad a 35  ta g as is i d et n in g inf o r m ats i oo n i n im et at u d gru p p id e r ah u l ol u k oht a n i ng s e lg i ta d a v älj a u ue d ü les k erk i nu d o ot us e d . L is ak s k ok k uv õt te k oos t am is e le an a l üüs i da s aa d ud inf ot . 6, 4 2 In t h e a nnu al pl an : m ak e a s ep ar at e c ol u m n f or du e d a tes ; m ak e dif f er enc e be t we en o bj ec t i v es a n d ac t i v it i es (s ep ar at e c o lum ns ; wo rd o bj ec t i v es no t as ac t i v it i es ) ; tur n a tt e nt i on to s et ti n g m ore s p ec if ic i n d ic a to rs a nd t arg e t v a l ues an d pr es en t t he r es u lt s i n t he an n ua l re p ort . A as t ap l a an is : l uu a t ä ht a eg a de j a ok s era l d i t ul p ; k aj as ta d a e es m ärgi d j a te g e vus e d er a l di t ul p a de n a (s õ n as t a da e es m ärg i d m it te te g e vus t en a); p öör a ta en am tä he l ep a n u s p ets i if i l is t e i nd ik aa t or i te ja s o o v it a v at e s i ht tas em et e m äär at l em is e l e n in g e s it a da v as t a va d t u lem us e d t eg e v us a ru a nd es . 9 A ddr es s t he st af f r et ent ion pr in cip l es a n d th e p ri nc ip le s of e qua lit y and non- d is c ri min at ion m or e prof ou n dl y i n t h e p ers o n n el po l ic y. P öör a ta r ohk em täh e le p an u t öö t aj a te a m etis h o idm is e põ h i m õtet e n i ng v õr d us e ja m itt ed is k rim in e er im is e põ him õt t et e k irj el d am is e l e per s o n al i p ol i i tik as . 10 , Mak e s ur e t h at t h e he alth and s af et y r el at ed r is k a s se s sm ent wi l l b e 22 c on d uc t e d as s o on as pos s i b le . T aga d a, et tö ö ter v i os ho i u j a - o h ut us e g a s eo t ud r is ik i an a lü üs v i i ak s e l äb i es im es e l v õ im al us e l . 11 P ut i n p l ac e annu a l t ra in ing pl an a n d a dd t her e tr a in i n g op p ort un i t ies t h at ar is e in t im e. A n a l yze th e f ee d bac k o n tr a in i ngs . P an n a p a ik a k oo l it us k a va n i ng l is a da s i n na aj a j o ok s ul l is an d u va d k ool i tus e d. A na l ü üs i d a k o ol i tus t e k oht a s aa d ud t a gas is i d e t. 18 , Ma i nt a i n th e re co rd s of t he fol low ing ev al uat ion s : a n n ua l s e lf - as s es s m e nt 19 , on r es pec t in g th e r i gh t t o s elf - de te rm in a ti o n; pe rf orm anc e i n f ac i l it at i n g 20 per s o ns s er ve d i n ha v i ng ac c es s t o a d voc at es an d /or s u pp or t in g p ers o ns ; pre v e nt i o n ac t i v it i es f or th e p h ys ic al , m en t a l a nd f i n anc i a l a bus e o f us ers S äi l i ta d a j är gm is t e e n es e h i nd am is t e k oht a t õe n d id : h i nn a ng te e n us e s aaj a te en es em äär at l em is e õ i gus es t k inn i p id am is e k oht a; h i n na n g om a k äit um is e l e te e nus e s aaj at e ab is t am is e l e es tk os tj a /t u g i is ik u l e i dm is e l; hi n n a ng te e n us e s aaj at e f ü üs i l is e, va im s e ja m aj an d us l ik u ärak as u t am is e 36  en n et am is t eg e v us t e le ; 20 T he p ri nc ip le s / me ch ani sm s , w hi ch p r ev ent th e p h ysi c al , ment a l and fin anc i al ab us e of us er s s h ou l d b e d es c r ib e d i n a m or e de t ai l e d m an n er. As t h e or g a n i za t io n e v a lu at es it s , th e r ec o rds of th is e v al u at i o n s ho u l d b e m aint a i ne d . K äs i t le d a t ee n us e s a aj a te f ü üs i lis e , v a im se j a m aj an dus l ik u är ak as u tam is e en n et am is e t em aat ik at as ut us e d ok um ent ats i on is d e ta i ls em alt . 26 Dra w u p a p la n of c oope r ati on p art ne r s, in d ic a t in g wh at is t h e c om m on po i nt of i nt er es t , r el at e d ac t i vi t ies a nd des ir e d o utc om e. Us e i t wh en e va l u at i ng th e a dd e d v a lu e of pa rt ne rs h i p. P a y m ore at te nt i o n t o an a l yzi n g th e a d de d v al u e from partn ers hi p ( an d doc um en t t he r es ul t s of s uc h an a l ys is ) . K oos ta d a k oos t öö p ar tn er it e k oh t a p l a an , m ill es tu u ak s e vä lj a ü h is e d hu v i p unk t id , s e ot u d t e ge v us ed j a o o da ta v a d tu l em us ed . Se d a s a a b k as ut a da k oos t öö lis a v ää r t us e h i nd am is e l . P öö ra ta e n am tä he l ep a n u p art n er lus es t tu l en e v a le l is a v äär t us e h in d am is e le ( ni n g d ok um en te er i da s e l l is e an a l üüs i tu l em us e d) . 34 T he wor d i n g of th e i n div idu a l pl an s s h ou l d be m ore t h or ou g h a n d d et a i le d . Foc us o n th e wor d i ng of t he p l ans to m ak e t h em m ore c li e nt - c en t ere d an d bas e d o n c l ie n ts ’ obj e c ti v es . In d i v id u aa ls e d p l aa n i d pe ak s i d ol em a põ hj a l ik um alt ja ük s ik as j a lik um al ts õn a s ta tu d . Kes k e nd u da en am p la a n id e s õ nas tam is e l e, e t ne e d o lek s i d k l e i nd ik e s k s em ad n i ng b as ee ru k s id k l ie n ti d e e es m ärk i de l e. 43 P a y m or e f oc us o n t he re g is t er i ng out co me s and be nef it s f or pe r son s se rv ed ( of t h e r ec e i ve d s er v ic es ) on col l ect i v e b as i s . P öör a ta en am tä he l e pa n u t ee n us e k as utam is es t s a ad u d k as u dok um en te er im is e l e k o ll ek ti i vs e l tas a n di l . 44 Cl ar if y th e und e r st a n ding of th e b est v a lu e (a n d th e m eth o do l o g y o n h o w t o e va l u at e it) f or e va l u at i n t h e org a n i za t io n ’ s res u lts i n de l i v er in g th is k i n d of v a lu e. T äps us ta d a, m i da m õ is t e tak s e l is a v ä ärt us e a ll (j a m et oo d ik a, m ill e al us e l 37  s ed a h i nn a tak s e) as ut us e t e ge v us e l äb i l is a v äär t us e p ak k um is el. 46 T her e s ho u l d be m or e c o ns c i o us a pp ro ac h to wa rds ad d i ng inf orm at io n t o rep or ts c o nc er n i ng p e rs on al p er c ept ion s a nd ac hi ev e me nts . A t th e m om ent th is s e em s m or e r an d o m , th an s ys t em at ic c o ns c io us ac ti v i t y. S oo v i ta ta v on te ad l ik um al t l is ad a inf orm ats i o on i pers o n aa ls et e arus a am ad e/k og em us t e k oht a aru a nd es s e. He tk el on s e e p i gem j uh us l ik k ui te a dl ik s üs t eem ne t e g e vus . 5. Closing remarks North-Estonian Rehabilitation Center is the f ounder of the modern neur o - rehabilitat ion in Est onia. Many rehabilitation hospitals Denmark, Finland, Canada and England have been as an example in devel oping the center. In patient treatment we f ollow evidence -based methods and practices. North-Estonian Rehabilitation Center has been established in 1995 and is the second largest inpatient rehabilitat ion services provider in Estonia. Their main partner in f inancing the ser vices is Estonian Health I nsurance Fund. North-Estonian Reh abilitation Center is a residenc y base f or both doctors and rehabilitation prof essionals (physio and occuptional therapists, speech therapists and rehabilitation nurses). Their main area of competence is neuro -rehabilitation. North-Estonian Rehabilitation Cent er provide s comprehensive inpat ient rehabilitation programmes to patients who present with head injur y, spinal cord injur y, stroke, neuropathy and other complex disabilities. They also treat patients with orthopedic and cardiac condit ions. North-Estonian Rehabilitation Center has already once gained EQUASS Assurance certif icat e (in 2013). The improvement areas that were brought out in the previous EQUASS audit report have been addressed by the organizat ion. The or ganizat ion has continued to implement EQUASS qualit y principles and was able to show results and evidence of doing so. The auditor experienced on site that t he social ser vice provider North- Estonian Rehabilitation Cent er perf orms in compliance wit h the EQUASS Assurance cr iter ia. The inter viewed representatives of partners, f inancing bodies, employees of North-Estonian Rehabilitation Cent er and persons 38 ser ved conf irmed this, which was ref lected in their sat isf action. The whole staff was kind and cooperative in introducing the work of North- Estonian Rehabilitat ion Center, f inding necessar y evidential materials and sharing inf ormation about f ulf illing EQUASS crit eria. For the per iod of following two years, some improvemen t actions were agreed that are brought out in part 4 of the audit report. An over view of suggestions f or improvement that are mentioned under the specif ic cr iter ia is given as well in part 3. The improvement ar eas included in general drawing up a developm ent plan f or the organizat ions, conduct ing per sonnel sur vey and target groups’ f eedback survey, car rying out the health and saf ety related risk assessment, improving (and com plement) the content of the annual plan, annual report and some of the policy docu ments of the organization, making the individual plans more person centered and maintaining the results of various evaluat ions and self -assessments (summaries and analysis). 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 that North-Est onian Rehabilitat ion Center is devoted t o qualit y assuranc e and improvement in its work and delivers ser vices of high qualit y. I want to t hank the personnel of North -Estonian Rehabilitation Center f or good cooperat ion and f or helping the auditor in the course of the audit process. *** Põhja-Eesti Taastusravikesk us on kaasaegse taastusravi suuna rajaja Eestis. Keskuse loom isel ja arendamisel on olnud eeskujuks paljud taastusravi haiglad Taanis, Soomes, Kanadas ja Inglismaal. Organisatsioon lähtub ravipr otsessis ja patsiendi käsit luses tõenduspõhistest meetoditest ja praktikatest ning rakendame kaasaaegseid ravimetoodikaid. Põhja-Eesti Taastusravikeskus on asutatud 1995. aastal ning on suuruselt teine statsionaarse taastusravi teenuste osutaja Eestis. Tema peamiseks 39 partneriks teenuste f inantseerimisel on Eest i Haig ekassa. Põhja -Eesti Taastusravikeskus on praktika ja residentuuribaasiks nii taastusarstidele ja neuroloogidele kui teistele spetsialistidele (f üsio - ja tegevusterapeudid, logopeedid, taastusr avi õed). Põhja-Eesti Taastusravikeskus on kord juba EQUASS Assu r ance kvaliteedi sertif ikaadi saanud (2013. aastal). Põhiliste parendusvaldk ondadega, mis toodi välja eelmise auditi käigus, on asutuses tegeletud. Organisatsioon on kvaliteedisüsteemi põhimõtete rakendamist jätkanud ning näitas ette sellkohaseid tõendeid ja tulemusi. Kohapeal koges audiitor, et sotsiaalteenuse osutaja Põhja -Eest i Taastusravikeskus tegutseb vastavuses EQUASS Assurance kriteeriumit ega. Intervjuud huvigruppide ja rahastajate esindajat ega, Põhja -Eesti Taastusravikeskuse t öötajatega ja teenuse saajatega samut i kinnitasid seda, mis väljendus nende rahulolus. Kogu asutuse töötajaskond oli lahke ja koostööaldis Põhja -Eesti Taastusravikeskuse töö tutvustamisel, vajaliku tõendusm aterjali leidm isel ning inf ormatsiooni jagamisel EQUASS - i kriteeriumit e täitmise kohta. Järgnevaks kaheks aastaks lepiti kokku mõned parendustegevused, mis on välja toodud aruande 4 -ndas osas. Ülevaade par endussoovit ustest konkreetsete kriteeriumite lõikes on esitatud ka aruande 3 - ndas osas. Parendusvaldk onnad hõlmasid üldi ses plaanis organisatsiooni arengukava koostamist, personali ning teiste huvigruppide seas uur ingute läbiviimist, tööter vioshoiu ja -ohutusega seotud r isikianalüüsi läbiviimist, aastaplaani, aastaaruande ning mõnede töökorraldust reguleer ivate kordade täie ndam ist (inf o lisamist), individuaalsete plaanide kliendikesksemaks muutmist ning erinevate ülevaatuste ning enesehindamiste kohta tulemuste säilitamist (kokkuvõtted ja analüüsid). Pärast indikaator itele vastam ise tõendamist, tutvudes dokumentatsiooniga ning viies läbi inter vjuud, oli audiitor veendunud, et kriteeriumid Eur oopa kvaliteedimärgi jaoks sotsiaalteenustes on täidetud. Audiitor sai veendumuse, et Põhja -Eest i Taastusravikeskus on pühendunud oma töös kvaliteedi tagamisele ja täiustam isele ning osut ab kõrge kvaliteediga teenuseid. 40 Tänan Põhja-Eest i Taastusravikeskuse t öötajad hea koostöö eest ning auditi käigus osutatud abi eest. Tallinn, 29. 12.2015 Mar iliis Männik -Sepp EQUASSi audiitor / EQUASS auditor 41