EQUASS ASSURANCE APPLICATION
ADDITIONAL INFORMATION
1. Short information about the organisation in the nati ve language
S A Pär n u H a ig l a m is s i oo n ik s on t o et a da i ni m es te t er v is t j a e luk v a li t ee t i n i ng l is ak s
ter v is ho i u te e nus te l e os u t at ak s e tu g i is ik u te en us t , re h ab i l it a t s i oo n it e en us t j a
er ih o o lek a nd et e en us e i d.
P ärn u h a i g la ps ü h h ia a tr i ak l i in ik u am bu l at o or s e os ak on n a a l la k uu l ub P äe v ak es k us .
P äe v ak es k us es os ut a t ak s e er i h oo l ek an d et e e nus e na ig a pä e v a el u t o et am is e t ee n us t
(50 k oh ta k uus ) j a t o et at u d tö öt am is e t e en us t ( 5 k o ht a k u us ) n in g t ug i is ik u te e nus t.
Ps üh h i aa tr iak l i i nik u am bu l at oo rs e o s ak on da ja s is e ha i g us t e k l i in ik u
ta as t us r a v i os ak on d a k uu lu v a d r e ha b il i ta ts io o n iük s us ed , m is os ut a v ad
s ta ts io n aar s e lt j a am bu la to or s e lt re h ab i l i ta ts i oo n it e en us t .
2. Short informat ion about the organisation in English (acti vities,
clients, etc.)
T he m is s io n of Fo u nd a ti o n P är nu Hos p it a l is to s u p p ort h um an h e a l th a n d q ua l i t y of
l if e, a n d bes i des m ed ic al c ar e Fo u nd at i o n P ärn u Hos p it a l pr o v id e s s pec i a l c are
s er v ic es , r e ha b i l it at i o n s er v ic e an d s u p por t pers o n s er v ic e.
T he D a y C e nt er is a par t of o ut - p at i en ts ’ d ep ar tm ent of T he Ps yc h ia tr ic C l i nic i n
P ärn u Hos p it a l. T h e D a y C e nt er of T he Ps yc h ia tr ic C l i nic i n P är n u H os p it a l of f ers
s er v ic e of s u p por t pe r s on a n d s p ec i al c ar e s er v ic es : As s is t a nc e i n e v er yd a y l if e
(f or 50 p er s o ns per m on t h) an d As s is t anc e i n wor k i n g (f o r 5 p ers o ns p er m on th ) .
Re h ab i l it at i o n U n its ar e a p ar t of o ut - p at i e nt s ’ de p artm en t of T he Ps yc hi a tr ic C l i nic
an d T he I n ter n a l D is eas e C l i nic i n P är nu Hos pi t al . R eh a b il i ta t i on s e r vic es a re
pro v i d ed in r e ha b i li t at i on an d af t erc ar e in - p at i en t u n it a n d in re h a bi l i ta t io n
am bu la t or y un i t.
3. Name of the organisation as you w ould w ant it to appear on the
EQU ASS Assurance certificate
S A P Ä RN U H AIG L A
4. Name of services / departments of the organi sation i n the scope of
the application as you w ould w ant it to appear on the EQU ASS
Assurance certificate :
S A P är nu H a i gl a Ps ü h h ia atr i ak l i in ik u P ä e vak es k us
Ig a pä e v ae l u to e tam is e t ee n us
T ööt am is e t oe t am is e t ee n us
T ugi is ik u t ee n us
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SA P är nu Ha i g l a Ps üh h i aa tr iak l i i n ik u ja S is e h a i gus t e k li in ik u
reh a b i li t ats i oo n iük s us ed
Re h ab i l it ats i o on i te e nu s ed
5. Organisation’s logo
Information to be published on EQUASS website:
Name of the organisation: S A P ÄR NU H AIG L A / Foundation Pärnu
Hospital
Post address: Risti ku 1, Pärnu, Estoni a, 80010
Director: Urmas Sule
Contact person: Ol ga Sumbajeva
Email:
[email protected]
Web: w ww.ph.ee
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EQUASS ASSURANCE
ASUTUSE KÜLASTUSE
ETTEVALMISTAMISE VORM
Asutuse külastus: 8.-9.12.2015
SA Pärnu Haigla
Triin Kraavi
© 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 nc 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 (max. 10 küsimust)
1. M i l li n e on t ei e or ga n is ats i oo n i k v al i te e d ij u ht im is s üs t eem n in g k ui d as s e e o n
i nt egr e er it u d EQ U A SS As s ur a nc e n õ ue t eg a ?
2. M i l li s e i d ar e n dus - j a in n o va ts io o n ipr oj ek te t e o le t e v iim as e k ahe a as t a j ook s u l
e ll u vi i n ud ?
3. K as j a k u id as te o le t e om a te e nus e i d v i im as e k ah e a as t a j o ok s u l ed as i
are n d an u d?
4. M i l lis e d o n te i e or ga n is ats i oo n i hu v i gr u p id , k ui d as t e ne n de v aj a d us t e k oh ta
ta g as is i d et s a at e n i n g k as j a k u id as k aas at e ne i d t ee n us t e ar en d a m is s e ?
5. K u id as t o im ib or ga n i s ats i oo n i p ar en d us s üs te em , m il l is e d o n s e l l e t u lem us e d ?
6. M il l i n e o n t e ie or ga n is a ts io o ni i ga - a as t a n e t eg e v us t e p l a ne er im is e j a ar u a nd l us e
pro ts es s i ?
7. K u id as t o im ib p er s o na l i vär b am is e, are n d am is e j a h i nd am is e pr ots es s ?
8. K ui d as t o im ub k li e nd i i nd i v i du a als e te te ge v us k a va d e e es m ärk i de j a tu l em us t e
m õõtm in e?
9. Ku i das Te m õõ d at e as ut us e tu l em us l ik k us t? K ui d as a nn at e s e l le k oh ta
i nf orm ats io o n om a h u v i gr u p p id e le ne i l e s o bi v a l v i is il ?
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1. Kvaliteedi põhimõtetele ja EQ U ASS Assurance kriteeriumitele
vastavuse küsimused / teemad:
Te en us e s a aj a d
Kv al i te e d i ju ht
J uh t/ dir ek tor
Huv i gr up i d
P er s o n a l
Juht im in e 1. Mi l l is ed on as u tus e v is i oo n , m is s io o n
x x x
j a v äär t us e d ?
2. M i da s is a ld a b as u tus e
k va li t ee d is t a nd ar d /- e e s k iri, k as j a k ui das x x x
on s ed a t ut v us t at u d?
3. K as o l et e t ea d l ik as u tus e p o o lt
pak u ta v at es t t e en u s tes t? Kus t Te
as u t us e k o ht a i nf or m ats io o n i s aa te ja x x
k uid as a nn a te t a gas is i de t te i e s o o v id e j a
v aj a d us t e k o ht a te e n u s e le ?
4. K u id as t o im ub a s ut us e a as t a p la a ni
k oos t am in e j a k as s e l le pr o ts es s i os as x x x
on v i im as te l a as t a te l m ida g i m uu tu n ud ?
5. M i l lis t l is a v ä ärt us t o n as u tus a nd n ud
om a k oguk o nd a j a l a i em alt ü h is k on da ?
x x x x
K as ja k uid as te hi nd a te s el l is te
te g e vus te t u l em us l ik k us t ?
P er so na l 1 Kas as u tus h i nd a b tö ö ti n g im us i, k as
ne n de os as on v i im as te l a as t at e l x x x
r ak en d at ud m in g ei d m uu d at us i?
2 M i l l is e d on nõ u de d tö öt aj at e
k om pet e nts i l e, k us t ne e d on
x x x
k ättes a ad a v ad , k ui d as on v õ im al ik
v aj a d us e l t eh a m uud a t us i?
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3 K as , k u i das j a k u i t ih t i v i iak s e l äb i
te e nus e s a aj at eg a ots es e l t k ok k u
x x x
pu u tu v a p ers on a l i h in dam is t , m i l l is e d o n
s e ll e t u lem us e d ?
4 Ku i das t oim ub p ers on a l i vär b am in e j a
x x x
tu n nus tam i ne ?
5 K as ja k u id as h in d at e p ers o n a li
x x
k ool i tus te ef ek ti i vs us t ?
Õ igu se d 1. K u i das t o im ub pers o na l i ja
v ab a ta ht l ik e i nf orm eer im i ne te e nus e x x x
s aaj at e õ i gus t es t j a k ohus t us t es t ?
2. K as t e e nus e s aaj a d o n te a d l ik ud om a
õ ig us t es t j a k oh us t us t es t ? K u id as t oim u b
x x x x
te e nus e s aaj at e t ea v i tam i ne n en d e
õ ig us t es t j a k oh us tus t es t ?
3. Ku i das t o im ub t ee n us e s aaj at e
en es em äär am is õ ig us e p õh im õt te
ar ves t am in e ig a pä e v as es t eg e v us es ? x x x x
K ui d as h in d at e s e ll is e te g e vus e
tu l em us l ik k us t i g a - aas tas e lt ?
4. K ui d as t o im ib k ae bus t eg a t e ge l em is e
x x x x
s üs t e em ?
E et i k a 1. K as T e o le t e t e ad l ik ee t ik ap ol i i t ik as t
( põ h im õt et es t) ja k äit um is p õ h im õte tes t
x x x
te e nus e os ut am is e l ? K us te
v aj a d us e l s e l l e i nf o l e i at e ?
2. Kas , k u id as j a k ui ti h ti hi n na t ak s e, et
m eeto d i d, m i da rak e nd a tak s e te e nus e
s aaj at e f ü üs i l is e, v aim s e j a m aj an dus l ik u x x x
är ak as ut am is e e nn e tam is el , on
ef ek ti i vs ed ?
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3. K ui d as o n t a ga t u d t ee n us e s a aj a te
k onf id e nts i aa ls us ja kui s ag e l i
s e ll ek oh as e id põ h im õtt ei d üle
v aa d at ak s e? K as s e l l e ü l e va at am is s e on x x x
k aas a tu d ka t ee n us e s a aj a d ? Ku i d as
te e nus e s a aj a i d n en des t p õh im õt et es t
te a v it at ak s e?
4. Kas T e t e at e, m i ll is ed ül es a nd e d o n
as u t us e t ö öt aj at e l? K us Te v aj a d us e l x x x x x
s e ll is t i nf ot s aa te ?
5. K u id as on t a ga t ud tu r va l i ne
x x x
tö ök es k k ond te e nus e os u t am is e l?
Koo st öö suh t ed 1. K as , k el l e ga ja k uid as t eh ak s e
te e nus te os u tam is e l ja par en d am is e l x x x x x
k oos t öö d ?
2. K u i das T e h i n da t e, k as te i e k o os t ö ö x x x x
on ol n ud ed uk as j a e e s m ärgi pä ra n e ?
3. K as j a k u id as as u t u s on k üs in u d inf ot x x x x
k oos t öö p art n eri t e v aj a dus t e k oh t a?
4.
5.
O s al em in e 1. K as te e n us e s aaj a d os a le v a d x x x
te e nus te p la n e erim is e l ja h i n dam is el
n in g k ui d as s e e t o im ub? K as j a k u id as
te h i nd a te e n da t e ge v us te e d uk us t
os a l em is e os as ?
2. Ku i d as T ei d o n k aas a tu d t ee n us t e x
ar e n d am is s e j a k as T eie et te p an ek ut e
a lus e l o n te h tu d k a m uu d at us i? K as T e
te at e , k ui d as te i l on õ i g us k aas a
r ääk i d a?
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3. K as /k ui d as ai t ab as ut us k a as a x x x
te e nus e s a aj at e j õ us t am is e l e? K as
per s o n al i o n s e l l ek s k oo l i ta tu d ?
Is ik uk e sk su s 1. Ku i d as o l et e v ä lj a s e l g it a nu d x x x
o lem as o l e v at e te e nus e s a aj a t e
v aj a d us e d (k es k p ik as p ers pek t ii v is ) j a
po t en ts ia a ls e t e te en us e s a aj a te
v aj a d us e d ?
2. K as t ee n us t pak ut ak s e v as ta v a lt x x x x
te e nus e s aaj a v aj a d u s e le j a ta l l e k õi g e
s ob i v am as as uk o has ? K as t ee n us e
s aaj a lt k üs it ak s e t em a ar v am us t j a k as
na d o n t ee n us e g a r a h u l?
3. K u id as a r ves ta t ak s e ra h as t aj a t e j a x x
m uude h u v i gru p p id e v aj a d us i , k as n ei d
uur i tak s e /k üs i tak s e ?
4. Mi d a s is a l da b i n di v i d ua a l ne x x x x
te g e vus p la a n n in g k as see
k oos k õl as t at ak s e te e n us e s aaj ag a ?
Lai ah a ar de li su s 1. N im et ag e om a a s ut us e pe am is e d x x x
pr o ts es s i d . K as , k uid as , m il l es t
tu l en e v a lt j a m il l is e r eg u l aars us eg a T e
ne i d ül e v aa t at e? K a s T e aru ta t e om a
as u t us e pr ots es s e om a te en us t e
r ah as taj a(t e) g a?
2. K ui d as te t ag a te , et t ee n us e x x x
os u t am in e t o im ub v as t a va l t p la n eer i tu l e
n in g i lm a tak is tus te t a ?
3. K u id as te ta g at e k õ ig i x x x
i nd i v i du a a ls es s e p l aa n i m ärg i tu d
te e nus te os u tam is e?
4. K u id as j a k e l le p oo lt o n m äära t le t ud x x x
te e nus e s a aj at e e l u k va li t ee t? K u id as
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h in d at e, et e l uk v a li t e ed i ees m ärg i d o n
tä i de t ud ?
5. K as ja kui s a g e li a n a lü üs it ak s e x x x
per s o n al i os k us e i d te e nus e s aaj a
e luk v a l it ee d i p ar an d a m is el ?
T ulemu st el e 1. K ui d as t e p l an e er it e j a m õõ da te i ga - x x x
ori en t e e rit u s aas t as e l t om a e em ärk id e t ul em us i ?
M il l is e id m õõ d ik ui d te k as ut at e?
2. K as T e ie te a te , m il l is e d ol i d as u t us e x x x
te g e vus e d ja t u l e m us ed e e lm is e l
aas t al ? Kas t e at e, k us t v aj a d us e l s el l is e
i nf o s a ak s it e?
3. K u id as t oim u b er i ne v a te h u v i po o lt e x x x
r ah u l o lu h i n dam i ne ?
Pi dev a r eng 1. Ku i d as to im ub te ie as u tus es x x x
te g e vus te pl a n ee rim in e, ne n de
tu l em us te h i n dam i n e ja v aj a dus e l
m uuda t us t e s is s e v i im in e? Kus t
v aj a d us e l s e l l is ed p õ h im õtt e d l e iak s i te ?
2. T o og e nä i te i d p ar en d us p roj ek ti des t. x x x
K ui d as on proj ek ti p la n e erim is e l
m äär at l et u d, k u i das s e ll e e duk us t h i lj em
m õõta ?
3. K as os k at e t u ua m õn e nä i te , k ui d as x x
te i e v aj a d us i on as u t us om a t eg e v us t e
p la n eer im is e l ar ves ta n ud ?
4.T o og e nä i te i d x x x
i nn o v ats i oo n i proj ek ti d es t .
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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. Ha i g la a r e n guk a v a , h a i gl a t eg e v us k av a , a as t ara am at ud , ür i tus te k a us t
2. J uh t im is k äs ir aam at
3. T ulem us j u h tim is e pr ots e du ur , H a i gl a t u lem us k aar t, S tr uk tuur i ük s us e
tu l em us p la a n , t ö öp l aa n j a n en d e tä i tm is e t ul em us ed
4. K l ie n d it ee n i nd us e s t a nd ar d, k orr a ld am is e pro ts ed u ur, h ea ta v a j uh e nd ,
aru a n ne .
5. P ers o n a li t öö g a ( v är b a m is e, k oo l it us e , ar e ng u - j a t u lem us ves t lus e , h in d am is e
j a tu n nus tam is eg a) s e ot u d pro ts ed u ur id j a a rua n d ed
6. Ra h uo l u- uur i n gu te t u l em us ed ( pe rs o n al , k l i e nd i d, par t ner i d j a r a ha s taj ad )
7. Re h ab i l it ats i o on i te e nu s te , i ga p äe v a e lu t oe t am is e te e n us e , t öö tam is e
to et am is e te e nus e, t ug i is ik u te e n us e os u tam is e g a s e ot u d pr o ts e d uur i d,
j uh e nd i d j a ar ua n de d .
8. T agas is i de j a k ae b us t e k äs it l em is e j u he n d id n i ng aru a nd e d .
9. K l ie nt i d e i nd i v i du a a ls e d te g e vus p l aa n i d
10 . K l ie nt i d e, p er s o n a li j a ük s us t e k oos o l ek ute p rot ok ol l i d
11 . T ööt er v is h o i u j a – oh ut us e al a ne dok um en ta t s i oo n
12 . T öös is ek or r a e es k ir i , d e l ik a ats et e is ik ua n dm ete t ö öt l em is e j uh e n d ,
ar vu t i võ r g u k as ut am is e j uh e nd
13 . Am et ij u h en d id , j uh at u s e r e g l em ent , j u h at us e li ik m ete ha l d us a l ad e j a ot us j a
pä d e vus e s t at u ut
14 . Le p i ng u d r a has taj at e g a, m ei l i va h et us r a h as t aj a te j a k oos tö ö pa rt ne rit e ga
15 . T eg e vus p l aa n i de tä i tm is e k var ta a ls ed aru a n de d, t e ge v us ar u an n e , a ru a nd l us
S K A le
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16 . S K A j är e le v a l v eak t , v ä lis a ud i t id
17 . S is ea u d it i te s üs t e em i d ok um en di d j a ar u an d ed
18 . Mu u d vaj a l ik ud dok um en d id , m is o n v aj a l ik ud a ud i t i lä b i v i im is e ees m är gi l
tu l en e v a lt m ude l is t.
3. Personali, teenuse saajate ja teiste 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 u h at us e l i ig e 1 tu n d
Personal Kestvus
1.T e en us te k v al i te e d i ees t v as tu ta v 30 m in ut i t
tö öt aj a
2. P äe v ak es k us e j uht ja 1 tu n d
rehabilitatsiooniteenuste üldkoordinaator
3. P ä e vak es k us e j a t ug i is ik u t e en us e 1 tu n d
pers o n al – er i n e va d s pe ts ia l is ti d v a j u ht
(k uni 5 t ö öt aj at)
4. R e ha b i l it ats i oo n i ük s us e per s o na l – 1 tu n d
er in e v ad s pe ts ia l is t i d ( k uni 5 t ö öt aj at)
Teenuse saajad Kestvus
1. P ä e vak es k us e er i ne v at e te e n us t e 1 tu n d
k lie n d id (k un i 5 k li e nt i )
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2. Re h ab i l it a ts i o o ni ük s us e k l ie n d id (k un i 1 tu n d
5 k l i en t i)
Teised huvigrupid Kestvus
1. Ra h as t aj a es i n d aj a 1 tu n d
2. K oos t öö p ar t n er it e e s i nd aj a d ( k un i 4 1 tu n d
i nim es t)
4. Asutuse kül astuse ajakava formaat
As ut us e k ül as tus pe ak s o l em a k orra l da t ud v as t a v al t j är gn e v at e le j uh is te l e:
a. As ut us e k ül as tus pe ak s o l em a k av a nd a tu d k ah e l e tö ö pä e v a le ( = 1 6 tu n d i)
b. Dok um en ta ts io o ni g a t ut v um in e p e ak s olem a p l an e er it ud es im es e 3 h s is s e
k ülas tus e es im es e l p ä e va l .
c . P äe v ak a vas pe ak s ol em a s ag ed as ed pa us i d (1 5 – 3 0 m inu t it) , et a u d ii t or
s aak s in d ik aa to r i t e tõ e nd e i d ü le va a d at a j a k orr as t ad a .
d. In ter vj u ud j uh tk on n a, per s o na l i j a t e is te g a ( vä l is ed hu v i gr up i d/ par tn er i d)
pe ak s k es tm a m ax 30 - 5 0 m in ü h e in ter vj uu k oh t a . I n ter vj u u d t ee n us e
s aaj at e ga pe ak s id ol em a k orra l da t u d gr u p ii n ter vj u ud e na ( m ax 5- i n im es t
k orr ag a)
e. J uh i g a/ d ir ek tor ig a i n ter vj uu p e ak s ol em a p la n ee ri t ud as ut us e k ülas t us e
te is e le p ä e va l e ( s o o v it a va l t p ea l e lõ u na l) .
f. Lõ p l ik as ut us e k ül as t us e pr ogr am m peak s o lem a t ao t lej a j a au d i it or i va h e l
k ok k u le p it u d j a s a ad e tu d EQ U A S S k o ha l ik ul e es in d aj a l e .
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Asutuse külastuse ajakava
kuup ä ev P äev 1
Ae g T egev us ( l üh ik e k irj e l dus )
9: 0 0- 9 .3 0 A v ak oos o lek , k es k us e ga t u t vum in e
9. 3 0- 1 2. 3 0 Dok um en ta ts io o ni g a t ut v um in e
12 . 30- 1 3. 0 0 Lõ u na p aus
13 . 00- 1 4. 0 0 In ter vj u u p äe v ak es k us e p ers o n a li g a
14 . 00- 1 4. 3 0 P aus
14 . 30- 1 5. 3 0 In ter vj u u p äe v ak es k us e k l i en t id e ga
15 . 30- 1 6. 0 0 P aus
16 . 00- 1 7: 0 0 In ter vj u u k o os t öö p art n er it e es i nd aj a t eg a
kuup ä ev P äev 2
Ae g T egev us ( l üh ik e k irj e l dus )
9: 0 0- 9. 3 0 In ter vj u u te e nus t e k v a l it e ed i e es t v as t ut a v a tö öt aj ag a
9. 3 0- 1 0. 3 0 In ter vj u u r e ha b i l it ats i o on i ük s us e k li e nt i d eg a
10 . 30- 1 1. 0 0 P aus
11 . 00- 1 2. 0 0 In ter vj u u r e ha b i l it ats i o on i ük s us e p ers o na l i ga
12 . 00- 1 2. 3 0 Lõ u na p aus
12 . 30- 1 3. 3 0 In ter vj u u r a has taj a es i nd aj ag a
13 . 30- 1 4. 3 0 In ter vj u u p äe v ak es k us e j uh i j a r eh a bi l i ta ts io on i te e nus t e
ü ldk o or d i n aa to r i g a
14 . 30- 1 5. 0 0 P aus
15 . 00- 1 6. 0 0 In ter vj u u j uh a tus e l i ik m ega
16 . 00 Lõ p uk oos o lek
Version 1.0
11
Maarika Aro
Saatja: Maarika Aro
Saatmisaeg: 17. detsember 2015. a. 10:36
Adressaat: 'Guus van Beek'
Koopia: '
[email protected]'
Teema: Pärnu Haigla audit report
Manused: EQ-ASS_AUD_Audit Report.docx; EQUASS Assurance taotlusvorm 2015
märkmetega.xlsx; Additional Information Form Pärnu Haigla 2015.doc; Asutuse
auditi külastuse ettevalmistuse vorm_PH.docx
Dear Marie, Dear Guus,
Attached you’ll find an audit report and other documents of Pärnu Haigla EE2015-023.
Please let Keiu to know in case there are some comments about the report.
Maarika Aro
Sotsiaalteenuste kvaliteedi keskus
Arendusspetsialist
Astangu Kutserehabilitatsiooni Keskus
tel +372 687 7223
mob +372 521 3563
[email protected]
Astangu 27 Tallinn 13519
www.equass.ee
www.astangu.ee
1
EQUASS ASSURANCE
AUDIT REPORT
Site visit: 08.-09.12.2015
SA Pärnu Haigla
Triin Kraavi
© 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
Na me of th e s o ci al SA Pärnu Haigla - Foundation Pärnu Hospital,
se rv i c e p rov id er hereinaf ter PH
Ad d re s s: Rist iku 1, Pärnu 80010 , Estonia
Po st bo x: N/A
P er so n re sp on sib le Urmas Sule, chairman of the board
(C EO ):
Cont ac t p e rs on: Olga Sumbajeva, coordinator of rehabilit ation
ser vices
Pho ne: (+372) 5341 6543
Fa x: N/A
E- m a il:
[email protected]
W eb s ite: www. ph.ee
Na me of Au dit o r: Triin Kraavi
Dat e s of aud it : 08.-09.12. 2015
Cli en ts: Number of person served: 255
As of (date): 09.12.2015
St aff: Number of Full time staff : 12
Number of Part time staff : 43
Number of Contracted staff : 4
Number of volunteer s: 0
S erv ic e s: Day Center of Pärnu Hospital Psychiatric
Clinic:
1. Assistance in ever yday lif e
2. Assistance in working
3. Support person
Rehabilitat ion Units of Pärnu Hospital
Psyciatric Clinic and Internal Disease Clinic
4. Rehabilitat ion ser vice
2
2. Audit program
3. kuup ä ev P äev 1
Ae g T egev us ( l üh ik e k irj e l dus )
9: 0 0- 9 .3 0 Av a k oo sol e k, k e s kus eg a tu tv umi ne
( G 3 30 I lm i, O l ga , E st er , K ad ri , Kr i sto, Epp )
9. 3 0- 1 0. 1 5 Int erv j uu t e enu st e kv al ite ed i e est v a stut av a t ööt aj ag a
( G 3 30 I lm i L e es m an )
10 . 15- 1 0. 3 0 P aus
10 . 30- 1 2. 3 0 Dok um en ta ts io o ni g a t ut v um in e ( O l g a G 3 30 )
12 . 30- 1 3. 0 0 Lõ u na p aus
13 . 00- 1 4. 0 0 In ter vj u u r a has taj a es i nd aj ag a
Sot si a al ki ndl ust us am et , e r ihoo l ek and et e e nust e
juht u mi ko r ra ld aj a Lin da Li ll em a a
14 . 00- 1 5. 0 0 In ter vj u u r e ha b i l it ats i o on i ük s us e p ers o na l i ga
( G 3 30 : E st er R e in sa l u , Ka j a Ra nd , J an ne T amm , An u
M art šu k, M er it S ini jä rv )
15 . 00- 1 5. 1 5 P aus
15 . 15- 1 6: 4 5 Dok um en ta ts io o ni g a t ut v um in e ( O l g a G 3 30 )
kuup ä ev P äev 2
Ae g T egev us ( l üh ik e k irj e l dus )
9: 0 0- 9. 4 5 In ter vj u u p äe v ak es k us e p ers o n a li g a
( P äe v ak es k us : Kad r i E en ra id , Di an a V ain o nen , L a ine T ag am ,
M eril i Rõõ m, E pp Jü r is son )
9. 4 5- 10 . 30 In ter vj u u p äe v ak es k us e k l i en t id e ga + K a dr i
10 . 30- 1 1. 0 0 (PPaus
äe v ak es k us : e i t äps us t a n im es i d e tt e)
11 . 00- 1 1. 4 5 In ter vj u u p äe v ak es k us e j uh i j a r eh a bi l i ta ts io on i te e nus t e
ü ldk o or d i n aa to r i g a
( G 3 30 K r ist o Ka ukv er , O lg a Su mb aj ev a )
11 . 45- 1 2. 3 0 Lõ u na p aus
3
12 . 30- 1 3. 1 5 In ter vj u u r e ha b i l it ats i o on i ük s us e k li e nt i d eg a (G 3 30)
13 . 15- 1 4. 0 0 In ter vj u u k o os t öö p art n er it e es i nd aj a t eg a
1. M T Ü Hing e r ahu ju hat us e li ige I nd re k Li nn ust e
2. P är nu T oi me tul e ku ko oli e s ind aj a K ri stj an Õ unpuu
3. P är nu Ko ll edž i sot si a alt öö ko r ra ldu s e o s a konn a
juh at a j a An n e Rä hn
14 . 00- 1 4. 3 0 P aus
14 . 30- 1 5. 3 0 In ter vj u u j uh a tus e l i ik m ega
( V ei ko Vah ul a )
15 . 30- 1 5. 4 5 Lõ p uk oos o lek
( G 3 30 I lm i, O l ga , Ka d ri , K ri sto , Epp )
4
4. Detailed feedback on performance
1. The social ser vice provider def ines documents and implements its
vision and mission values on ser vice 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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH has d oc um ent e d i ts v is io n, m is s i o n Cri t er io n is m et bu t it is a d v is a b l e t o
an d v al u es . It is p u b lis h ed i n var i o us up d at e t he d e v e lo pm en t p l an of P H s o
doc um en ts , f or ex am pl e i n de v e lo pm en t its t i t le a n d c o nt en t c orr es p o nds t o t he
p la n, hos p it a l we bs i te , ye a r b ook etc . c urr en t p er io d of tim e.
Dur i n g i nt er v i e ws it was v er if i e d t ha t t he Kr it e er ium on t ä i d et u d, k u id on
pers o n ne l is a wa r e of PH m is s i o n, s oo v i ta t a v u ue n da d a PH ar en g uk av a, et
v is io n a n d v a lu es . s e ll e pe a lk ir i ja s is u vas tak s
k äes o l e va l e p er io o d il e .
2. The social ser vice provider def ines, documents, and implements its
qualit y policy by determining long term qualit y goals, and its
commitment to cont inuous improvement.
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS As surance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
5
PH h as d oc um ent e d its lo n g t erm
qu a l it y g oa ls a nd c om m itm ent to
c on t in u ous im pr o v em ent in d e v e lo pm en t
p la n an d m an ag em en t h a nd b ook . L o ng
term g oa ls ar e c o n nec t ed wi t h th e
an n ua l p l a n ac t i v i ti es .
PD C A- c yc l e is us ed in t he h os p i ta l
proc e d ures a nd p er s o nn e l d em ons tr at ed
its a wa re n es s of t he q u a li t y go a ls
dur i n g i nt er v ie ws .
3. Persons ser ved, family members and ser vice user organisations are
able to give f eedback on their individual and collective experience of
programmes and ser vices.
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
6
T here ar e pr oc e d ur es i n p lac e f or g i v i n g
f ee db ac k e it h er via we b pa g e, via
s ur ve ys , on p a per a t th e hos p it a l, i n
m eeti n gs , d ir ec tl y t o t he p er s o nn e l etc .
Fe ed b ac k is doc um en t ed , a na l ys e d,
ans we re d , s um m ar i ze d a n d d is tr ib ut e d
reg u l ar l y wi t hi n t h e or ga n is at i on .
T his was v er if i e d by i n s p ec t in g th e
doc um en ta t io n and dur i ng th e
i nt er v ie ws wit h t he c l i en ts , c o - o p era t io n
par t ners , re pr es en ta t i v e of f un d in g bo d y
an d p ers on n e l th at t he y ar e a war e of
th e d if f ere n t p os s i b i l i ti es h o w to gi v e
f ee db ac k .
4. T h e s oc i a l s er v ic e pr o v i d er inf o rm s al l s tak e ho l de rs a b ou t t h e of f er ed
pro gr am m es a n d s er v i c es a v ai l a bl e .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
St ak eh o l der s ar e inf or m ed a bo u t th e
pro gr am m es a nd s er v ic es via PH
hom ep a g e, inf or m at i on l eaf le ts ,
c us t om er , p er s o n n e l a nd p ar tn er
m eeti n gs , e - m ai l etc .
T his was c o nf ir m e d dur i n g i n ter v i e ws
th at s tak e ho l d er s ar e a war e of th e
pro gr am m es a n d s er v i c es a v ai l a b l e .
5. T he s oc i a l s er v ic e pr o v i der m an ag em en t es t a bl is h es a nd d oc um ents an
an n ua l p l a nn i n g an d r e v ie w pr oc es s .
7
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T here ar e s e ver a l pr oc e d ur es i n p lac e
f or an n ua l p la n n in g a n d r e v i e w pr oc es s .
PH is us in g B SC m etho d. A nn u a l
p la n ni n g is l ink e d wi t h d e ve l o pm ent
p la n an d a n n ua l ac t i on p la ns .
Im plem e nt at i on is f o l lo we d
e lec tro n ic a ll y thr o ug h ou t t he ye a r a n d
th e proc es s an d r es u lts ar e r e v i e we d
an n ua l l y b y m an a ge m ent an d qu a l it y
un i t.
T his was c o nf i r m ed b y ex am in i ng th e
an n ua l p l an n i ng d o c um ent at i o n an d
i nt er v ie ws wit h t he per s on n e l a nd
m anag er s .
6. T he p l a n i nc lu d es :
an n ua l o u tc om es / tar ge ts
th e ac ti v i t ies t o b e u n der t ak en i n ac h ie v i n g th e a nn u a l tar g ets
m onit or i ng of th e pe rf orm anc e of t he or g an is at i o n i n m eet in g its
an n ua l t ar ge ts
tim e- s c al es a n d pr oc e dur es f or r e v i e w a n d r e v is i o n.
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
8
A nn u a l plan is we ll s tr uc t ur e d – it Cri t er io n is m et bu t it is a d v is a b l e t o
c ons is ts of o bj ec t i ve s , k e y ac t i v it i es , re v ie w t he tar g ets us e d i n a n nu a l p l ans
de t ai l e d ac t i ons , e x pec t ed r es u lts , so th at they c orr es po n d to SM A RT
res p o ns ib l e p er s ons . Im plem e nt at i on is c rit er i a or a na l ys e t he p os s i bi l i t y to
f ol l o wed el ec tr o n ic al l y t h r o u gh o ut t he de v e l op an d i m plem en t Key
ye ar an d s um m ar ies ar e do n e onc e a P erf orm anc e In d ic at or s .
ye ar dur i n g pe r f or m an c e i nt er v i e ws .
Kr it e er ium on t ä i d et u d, k u id on
A nn u a l p la n is a ppr o v e d by th e s oo v i ta t a v ü le v a ad at a a as t a p la a n is
m anag em en t. k as ut at a va d m õ õd ik ud , et n ee d v as tak s
S M ART - k rit eer i um it el e või an a l üüs i d a
v õ im al us t t o im iv us e v õtm ei n d ik aa tor i te
v ä lj a tö öt am is ek s ja k as ut us e l e
v õtm is ek s .
7. T h e s oc i a l s er v ic e p r o v i der d em ons tr at es org a n is a t io n ’s s uc c es s i n
s at is f yi n g th e n e eds a nd ex p ec t a ti o ns of t h e s oc i et 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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH c o l l ec ts f e e d bac k f r om the d if f ere nt
s tak e ho l de r s - c l i e nt s , p er s on n el , c o -
op er at i o n par t ner s .
Dur i n g the i nt er v i e ws it wa s
dem ons tr at e d b y s t ak eh o l der s t ha t PH
is ac t i v e l y c o n tr ib ut i ng t o s at is f y t he
ne e ds a n d ex p ec t at i o ns of t he s oc ie t y
by or g an is i n g and par t ic ip at i n g in
v ar io us ac t i v it i es wi t h c o - o per a ti o n
par t ners , c l i en ts a nd p er s o n n el .
9
8. T h e s oc i al s er v ic e pr o v i d er dem o ns tr at es or ga n is at i on ’s s oc i a l res p o ns ib i l it y
thr o ug h ac t i vi t ies c on t r i bu t in g t o th e s oc i et 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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH c arr i es o ut m an y c om m uni t y b as ed
ac t i v it es , f or ex am pl e or ga n i zes f a irs ,
th e atr e, c om pet i ti o ns , c om m uni t y
gar d e n, ex c ur s io ns e tc .
T his was ve r if ie d t hr o u g h in t er v ie ws
wi t h s t ak eh o ld er s a nd r e v i e wi ng
org a n is e d e v e nts d oc u m enta t io n.
9. T h e s oc i a l s er v ic e pr o v i d er h as a s t af f rec r ui tm ent a nd r e te n ti o n p o l ic y
th at pr om otes t he s e lec t io n of q ua l if i e d pe rs o n ne l b as e d o n r eq u ir ed
k no wle d ge , s k i l ls a n d c om pet e nc es .
Remark from the auditor: The ser vices of the social ser vice pr oviders mee t
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH has doc um en te d s taf f r ec r u itm en t
an d re t en t io n p o lic y wh ic h inc l u des
def in e d k no wl e d ge , s k il ls a nd
c om pet e nc ies .
10
10 . T h e s oc i al s e r vi c e pr o vi d er o per a tes i n c om pl i a nc e wi th m anda t or y
na t io n a l le g is l at i on , pr o v id i ng a p pr opr i at e w ork in g c o nd i t io ns , a d e qu a te a n d
agr e e d s t af f le v el a n d s t af f rat io , a n d a p p rop ri a te r e war d in g f or s taf f an d
v o lu nt e er 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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH pr oc e d ur es ar e i n c om pl i a nc e wi t h
th e n at i on a l l e g is l a ti on an d t he y are
re v ie we d wh e n th e l e gis l a ti o n is
c ha n ge d .
PH has pr oc e du r e s in p l ac e f or
rec o g n is in g s t af f ac h i e v em ents .
T he work i ng c o n d it i o ns ar e e v a l ua te d
via s taf f s at is f ac ti o n s ur v e ys th a t
c on t ai ns t hes e s p ec if i c q u es t i ons .
11. The social ser vice trains all staff based on a plan f or lea r ning and
development and evaluates the eff ectiveness of the training.
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
11
A nn u a l tr a i n in g p l an is a na l ys e d
reg ur ar l y a nd f e ed b ac k is d is tr ib u te d i n
org a n is a t io n . A l l tr a i n i ngs ar e r ec or de d
an d p ar t ic i pa n ts e v a lu at e t he
ef f ec t i ve n es s of th e tr a i n in g e i th er in
th e pers o n ne l m e et i ngs or wit h
e va l u at i on f or m s .
T his was v er if i ed by e x am i n in g the
doc um en ta t io n a n d b y i n te r vi e wi n g t he
pers o n ne l .
12 . T he s oc ia l s er vic e pr o v i de r a pp l i es re q u ir em ents f or c om pet e n c e i n t h e
i de nt if ie d r o l es a nd f u nc t i ons of s t af f a nd e v a lu at es t hem o n a n nu a l b as is .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Com pe te nc e r e q u ir em en ts of t h e s t af f
are d oc um ent e d in the work
des c r i pt i o ns . P er s o n ne l is e v a l ua te d
an n ua l l y d ur i n g de v e l opm en t
d is c us s i ons . A ls o c l i en t f e e db ac k
s ys tem an d p er s o n n e l m eet in gs ar e
us e d f or p er s o n ne l e v a lu at i o n.
13 . T he s oc i a l s er v ic e pr o v id er r ec o g n is e s th e s taf f as a r es ourc e f or
f ee db ac k on or ga n is at i on a l perf orm anc e , s er v ic e d e ve l o pm ent an d s taf f
de v e l opm en t
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
12
Str e n gt hs Im pro vem e nt & de v e lo pm ents
St af f i n v ol v em en t an d f e e db ac k f rom
s taf f is r ec or d e d in m in ut es of th e
m eeti n g, s a t is f ac t i o n s ur ve y.
It was c onf ir m ed dur i ng i nt er v i e ws th at
d if f ere nt s taf f pr o pos a l s t o m od if y or
im pro v e th e s er v ic e s or to d e v el o p th e
pers o n ne l wer e im pl e m ente d.
14. The social ser vice provider has mechanisms in place to enhance
satisf action and mot ivat ion 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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
P ers o n ne l s at is f ac ti on s ur ve ys are Cri t er ia is m et b u t i t is a d vis a b le to
c arr ie d o ut an n ua l l y. an a l ys e if th e a ns wer in g r at e i n t h e
s at is f ac t io n s ur ve y is s uf f ic i e nt to
T here ar e m e as ur es an d pr oc e d ur es in
e va l u at e th e p ers on n e l s a tis f ac t i on .
p lac e f or r ec o gn is i ng an d m ot i v at i ng t he
s taf f – le tt er s of ac k no wl e dg em en t, Kr it e er ium on t ä i d et u d, k u id on
org a n is in g e v en ts , inc en t i ve pa y e tc . s oo v i ta t a v an a l üüs i d a, k as ra h u lo l u
k üs it l us e v as t am is e m äär on p i is a v
pers o n al i ra h u lo l u h i n dam is ek s .
15 . T h e s oc i a l s e r vi c e p ro v i de r as s ur es th e r i gh ts of p ers o ns s e r ve d
ou t l in e d in a Ch ar ter of R ig h ts wh ic h is bas e d on t he E U C har t er of
Fu nd am en ta l Ri g hts , t he E ur op e an C on v e nt i on f o r t he Pr ot ec t io n of Hum an
Ri g hts a n d Fu n dam e nt a l Fre e dom s of the Cou nc i l of E uro p e an d o th er
i nt er n a ti o n al h um an r i gh ts c on v e nt i ons , es p ec ia l l y t h os e e l ab or at ed u nd er
th e U ni t ed N at i o ns .
13
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he ri g hts of t he pe r s ons s er v ed are
doc um en te d i n s e v er a l d oc um ents (f or
ex am p le i n t h e R u les of th e D a y C e nt er ,
th e R u l es of t h e H os p i ta l , C us t om er
S er v ic e St a n dar d) an d t he y c or r es p o nd
to t h e i nt er n a t io n al hu m an r ig hts .
It was c onf ir m ed dur i ng i nt er v i e ws th at
pers o n ne l is a war e of th e r i g hts an d
du t ies of t he per s o ns s er ve d .
16 . T h e s oc i a l s er v ic e pr o v i d er inf orm s th e pers o n s er ve d a bo ut h is / h er
ri gh ts a nd d ut i es es pe c i al l y t o eq u a l tre atm e nt o n gr ou n ds of a g e, d is a b i li t y,
ge n de r , r ac e , r e l ig i o n or be l i ef an d s ex u al or ie nt a ti o n b ef or e rec e i vi n g t he
s er v ic es .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
14
T he r ig h ts a n d du t ie s of t he p ers ons
s er ve d ar e i nf or m e d to the c l ie nts at t he
be g i nn i ng of th e s e r v ic e. E it h er t he
c l ie n t or t he ir r e pr e s en t at i v e c o nf irm
wi t h the s i g na tur e t ha t th e y have
un d ers t o od t he d oc u m ent. T h e r ig hts
an d d ut i es ar e a ls o o n th e inf or m at i o n
bo ar ds o n t he wa l ls an d ar e r e g u lar l y
d is c us s e d wit h t he c li en ts a t th e c li e nt
m eeti n gs .
It was c onf ir m ed dur i ng i nt er v i e ws th at
th e c l i e nts wer e a wa r e of th e ir r ig hts
an d d u tes an d k ne w wh er e t o f in d t he
i nf orm at io n wh e n n ec e s s ar y.
17 . T he s oc i a l s er v i c e pr o v id er h as ac c es s ib l e c om pl a i nt m ana g em ent
s ys tem wh ic h r e gis t e r s f ee d bac k o n perf orm anc e f rom pers o n s s er v ed ,
purc h as er s an d o th er r e le v a nt s t ak eh o ld ers .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH h as a do c um en t ed c om pl a in t
ha n d li n g s ys tem . St ak eh o ld er s h a ve
d if f ere nt p os s i b i l it i e s to is s ue a
c om pl a in t ( o n p a per , thr ou g h webs i te ,
v i a e- m ai l) . Com p la i nts a r e a n a l ys e d ,
ans we re d and r e v i e wed r e gu l ar l y.
S um m aries of th e c o m pla i nts ar e a ls o
pu b l is h e d at t h e h os p i ta l ye ar b o ok s .
15
18 . T h e s oc i a l s er v ic e pr o vi d er res p ec ts t he f u nd am en ta l r ig h t t o s e lf -
de t er m in at i on of t h e per s o n s er ve d . T he y f ree l y de te rm ine t he ir po l i t ic a l
s ta tus an d f r ee l y p ur s ue t h e ir ec on om ic , s oc i al an d c u lt ur a l d e ve l o pm ent .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Cl i e nts ar e pr es en t wh en t h e ir i nd i v i d ua l
p la ns ar e d o ne a n d t he y de te r m in e th e
ac t i v it i es a nd obj ec t i v es th e y wa n t t o
reac h . T hes e p la ns a r e r e v i e we d e ve r y
qu ar ter wi t h t he c l i en t s to e va l ua t e wha t
has b e en ac h ie v e d, wh a t wer e the
obs t ac l es an d wh at ne e ds to be
c ha n ge d .
P er s o n ne l d em on s tr a te d d ur in g
i nt er v ie ws hi g h a p pr e c i at i on to t he r i g ht
to s e lf - de t er m in at i on of th e p ers ons
s er ve d .
19 . T he s oc i a l s er v ic e pr o v i der f ac i l i ta t es th e pers o n s er v e d in c ho os i ng
an d h a v in g ac c es s t o ad v oc at es a nd / or s u pp ort i ng pers o ns .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
16
W hen in d i v id u a l p l a ns ar e p r e p are d
pers o n ne l i nf or m s c l ie n ts ab o ut t he
pos s i b i li t y of a d v oc a tes or t he y are
d irec te d to s up p or t p e r s on s er v ic e whe n
th e ne e d is dis c o v er e d . Ac c es s to
s up p ort pe r s o n s er v ic e is e va l ua t ed
an n ua l l y wi t h t h e f u nd i n g b o d y Pär n u
Ci t y G o v er nm ent . T h is was v erif ie d
dur i n g p er s on n e l a nd f u n d in g body
i nt er v ie ws .
20 . T h e s oc ia l s er v ic e pr o v i d er def in es a n d doc um en ts its p o l ic y o n et h ic s
th at r es p ec ts a nd as s ur es th e d i gn i t y of th e p ers o ns s er v e d, pro tec ts th em
f rom un du e r is k an d pr om otes s oc i a l j us t ic e
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance cert if ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH h as d oc um ent e d pr oc e d ure of
org a n is in g t h e c l i en t s er vic e an d t h e
i ns tr uc t i o n of the go o d c on d uc t in
c us t om er s er v ic e . T hes e pr oc ed ur es
an d or ga n is at i on va l u es ar e k no w n t o
th e pers o nn e l . T his w as ve r if ie d d uri n g
pers o n ne l i n ter v i e ws .
21 . T he s oc ia l s e r vic e pr o v id er op er at es m ec han is m s wh ic h pr e ve n t th e
ph ys ic a l, m ent a l a nd f i na nc i al ab us e of u s ers .
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
17
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Me as ur es to pr e v e nt th e p h ys ic a l ,
m enta l a nd f i na nc ia l a bus e of us ers ar e
doc um en te d i n th e h os p i ta l pr oc ed ur es
th at is s i gn e d b y c l i e nts . T hes e to p ic s
are a ls o r eg u l ar l y d is c us s e d at th e
c us t om er m eet i ngs . M i nu tes of the
m eeti n gs ar e d oc um ent e d a nd pu t o n
th e inf o rm ati o n b o ar d . T his was ver if ie d
b y s t ud yi n g th e d oc u m enta t io n a n d b y
i nt er v ie wi n g t he per s o nn e l.
22 . T he s oc i a l s er v i c e pr o v id er pr o v i des s erv ic es i n a s af e s ys tem of
work i n g wit h in a s af e e n v iro nm en t t o e n s ure th e ph ys ic a l s e c ur it y of
pers o ns s er v ed , t he ir f am il i es a nd c ar e tak ers .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH has s e v er a l pr oc e dur es f or e ns ur i n g
he a lt h y an d s af e e n v ir o nm en t, pl a ns
ho w to ac t in c r is i s or em er ge nc y.
T hes e pr oc ed ur es an d r es u lts ar e
re v ie we d a n nu a l l y, tr ai n i ngs and
s im ul at i o ns ar e c ar r i ed ou t. Per s o nn e l
was a wa re of th e pr oc e d ur es , a ls o
re le v a nt d oc um ent at i o n was ins p ec t e d.
23 . T h e s oc i a l s er v ic e pr o vi d er d ef i nes , doc um ents , m on it ors a nd e va l u at es
a s e t of pr inc i p les , v a l ues a nd pr oc e d ur es t ha t go v er n b e ha v i o ur i n s er v ic e
de l i v er y c o nt a in i n g as p ec ts of c o nf i d en ti a l it y, ac c u rac y, pr i v ac y an d
i nt egr i t y.
18
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Et h ic al pr i nc i pl es ar e doc um en te d i n t h e
i nt ern a l wor k i ns tr uc ti o ns a nd in t h e
i ns tr uc t i o n of the go o d c on d uc t in
c us t om er s er v ic e .
It was v er if i e d d ur i n g in te r vi e ws t h at
pers o n ne l was a war e of th e et h ic a l
pr inc i p les .
24 . T h e s oc i a l s er v ic e pr o vi d er d ef i nes , doc um ents , m on it ors a nd e va l u at es
proc e d ur es f or as s ur i n g c o nf i d en t ia l it y of d at a re g ard i n g t he pe rs o ns s er v e d
an d t he s er v ic e pr o v i d ed t o t hem .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH h as d oc um e nt ed pr oc e d ur e h o w t o
ha n d le de l ic at e p er s on a l i nf or m at i o n
an d h o w to us e c om pu ter n et wor k i n th e
hos p it a l whe r e t h e d e l ic a t e i nf or m at io n
is s t ore d.
Co nf i d en t ia l it y is s u e s ar e d is c us s e d
reg u l ar l y wi t h c l i en t s at th e c l i e nt
m eeti n gs a nd in per s o nn e l m e et i ngs .
It was c o nf ir m ed d ur i ng i n ter v i e w wi t h
c l ie n ts an d p er s o n n e l t h at t he y ar e
a war e of th e c o nf i de nt i a li t y r u l es a nd
th at it was d is c us s e d wi t h th em .
19
25 . T h e s oc ia l s er v i c e pr o v i d er def in es th e r o les a n d r es po ns ib i l it i es ,
au t hor i ti es a nd t he i nt er r e la t io n of a l l p ers o n n el wh o m a na g e, d es ig n,
de l i v er , s up p or t a n d e v a lu at e t he s er v ic e pr o v is i o n to pers o n s er v ed .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Ma n ag em en t r o les a nd r es p ons i b i li t i es
are d ef i n ed i n t h e d oc um ent at i o n t h at is
a va i l ab l e in t h e h os pi ta l in tr an et . R o les
an d r es po ns ib i l it i es of th e f u nc t i o ns
d irec t l y i n vo l v ed wi th s er v ic es ar e
doc um en te d in j ob des c r i pt i o ns and
s oc ia l s er v ic e pr oc ed u r es .
26 . T h e s oc i a l s er v ic e pr o vi d er work s i n p art ners h i p wi th o th er or g an is at i o ns
i n th e pr o v is io n of s er v ic es .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH has c o - o p er a t i on wi th S oc i a l
Ins ur anc e Fu n d, Pä r n u c i t y go v er nm en t
as f u nd i n g ag e nc ies a nd s e v er a l c o -
op er at i o n p ar tn er s a s s oc i al p ar tn ers .
A l l c o - op er at i on par tn er s ar e l is t e d a nd
th e ir f e ed b ac k is a s k ed r e gu l ar l y at
l eas t o nc e a ye ar .
20
27 . T h e s o c i a l s er vic e p r o v i de r work s i n p art n ers h i p wi t h p ers o ns s e r ve d,
purc h as er s an d o th er s tak e ho l de rs i n th e d e v e lo pm en t of s er v ic es .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
It was c o nf ir m ed d ur i ng i nt er v i e ws wi t h
c l ie n ts an d c o - op er at i on p ar t n er s th at
th e f e e db ac k ab o ut th e s er v ic e
de v e l opm en t is as k ed an d s e v er a l i de as
are a ls o im pl em en te d ( “ m en ho ur ” at th e
Da y Ce n ter , r e h a bi l i ta ti o n t eam is go i n g
ou ts id e t h e h os p i ta l to t h e s c h oo l t o
pro v i d e th e s er v ic e et c .) .
28 . The s oc i a l s er v ic e p ro v i de r inc l ud e s p ers o ns s er v ed as ac t i v e
par t ic ip a nts in p la n n in g a nd h a ve s et u p ap pra is a l m ade up of on - go i n g of
an o n- go i ng s tr uc t ur e d d i a lo g u e pr oc es s in th e m an ag em en t of t h e s er v ic e ,
i nc l u d in g th e d ef i ni t io n of th e n ee ds , t h e d ef i n it i on of t h e s er vic es , as we l l
as of t h e e v al u at i on of q u al i t y.
Remark from the auditor: The ser vices of the social ser vice pr ovide rs meet
this cr iterion of the EQUASS Assurance certif ication program
Str e n gt hs Im pro vem e nt & de v e lo pm ents
21
Dif f er en t s oc i a l s er v ic e pr oc e d ur es
s ta te h o w per s o ns s e r v ed ar e inc l ud e d
i n as s es s i n g th e ir n ee ds , p l a nn i ng wh at
s er v ic es they wi l l g et and how th e
f ee db ac k ab ou t t he s er v ic es is
ga t her e d.
It was ver if ie d d ur i n g i nt er v i e ws an d
ex am i n in g t he d oc um en ts t ha t p ers o ns
s er ve d a re inc l u de d i n a bo v em en t io n ed
ac t i v it es .
29 . T he s oc i al s er v ic e pr o v id er i ns t it u tes an a nn u a l e v a l ua t io n of
par t ic ip a ti o n of per s o n s s er v e d bo t h o n i nd i v i du a l a nd / or gr ou p b as i 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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
In d i v id u al pl a ns ar e s i gn e d b y th e c l i en t
or c l ie n t r epr es e nt at i v e. Ser v ic e
par t ic ip a ti o n r ul es ar e dis c us s ed a n d
agr e e d wi th t h e c l ie nt s at t h e m ee ti n gs .
T his was v er if i ed by s tu d yi n g the
doc um en ta t io n an d m inut es of th e
m eeti n gs .
T here is a pr oc e du r e in p lac e f or
re v ie wi n g a l l pr oc ed ur es a nn u al l y.
30 . T h e s oc i a l s er v ic e pr o vi d er o pe ra tes s pec if ic i ns tr um ents f o r us ers t o
im pr o v e t he ir pe r s o n a l em po werm e nt a n d pers o na l s it u at i on a nd . t ha t of
th e ir c om m un it 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
22
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Im pro vem e nt of per s o na l em po werm en t
is on e p ar t of the s oc i a l s er v ic e
obj ec t i v es . T h e r es u lt s ar e d oc um ent e d
i n th e in d i v i du a l p l an e va l u at i on . I t was
v er if i ed b y s t ud yi n g e x am pl es of c l i en t
i nd i v i du a l p l ans a n d e v a lu at i o ns .
31 . T he s oc i a l s e r v ic e pr o v id er o p er a tes s pec if ic m ec h a n is m s f or
es t a bl is h in g a n em po w er in g e n v iro nm en t.
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Em po wer i n g e n v ir onm en t is c r e at e d b y
tra i n in g t h e p er s on n e l a n d d is c us s io ns
i n pers o n ne l m eet i ngs .
T his was v er if ie d dur i n g pe r s o n ne l
i nt er v ie ws .
32 . T he s oc i al s er v ic e pr o v i der s e lec ts pr ogr am m es wh ic h are bas e d o n a
ne e ds as s es s m ent at th e l oc at i on wh ic h i s m os t c o n ve n i en t f o r th e p ers on
s er ve d , f am i l y a nd c a r e tak er 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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
23
T he l oc at i on of th e h os p it a l is
c on v e n ie nt f or t he c l i en ts a n d m ak es
pos s i b le to h a ve v er y go o d c o - o per a t io n
an d i nt egr a ti o n wi t h o th er h os p i ta l
s er v ic es . T his was ve r if ie d d ur i ng
i nt er v ie ws wit h c l i e nts an d c o - op er at i o n
par t ner s .
33 . T he s oc i a l s er v i c e pr o v id er of f ers p rog ram m es c ons is te n t wit h t h e
i de nt if ie d n ee ds of i ts c us t om ers an d o bj ec t i v es f or t h e pr ogr am m e.
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Fu nd i n g bo d ie s h a ve s ig n ed an
agr e em ents wi t h P H t ha t c or r es po n ds t o
th e ir n ee ds . O t her s tak e ho l de r ne e ds
are d et erm in e d b y s ur v e ys . T h e r es u l ts
of th e obj ec t i v es ar e s um m ar is e d in
ye ar b ook s , a n nu a l p l an r e por ts , c l ie n t
i nd i v i du a l p l an e v a l ua t i on d oc um ents .
34 . T he s oc i a l s er v ic e pr o v i der o per at es in d i v i du a l pr oc es s es t h at are dr i ve n
b y th e n e eds of t he p e r s on s er ve d .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
24
In d i v id u al p l ans of c l i en ts ar e dr a wn u p
ac c or d i ng to their i nd i v i du a l n ee ds .
Id e nt if i e d n e eds a nd ex p ec ta t io ns are
doc um en te d in t h e i n d i vi d ua l p la n. It is
pos s i b le f or a c l ie n t to r ec e i v e m ore
th a n on e s er v ic e a t th e s am e t im e.
35 . T h e s oc i al s e r vic e pr o v id er d oc um ents t he p l a nn i n g of s er v ic e s b as e d o n
th e id e nt if ic a ti o n of in d i vi d ua l n ee ds an d ex pec t at i ons of p ers ons s er ve d i n
an I n d i vi d ua l P la n.
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
In d i v id u al pl a n c o ns is ts of t he d es ir ed
s it u at i on , o v er al l obj e c ti v es , m eas ur ab l e
obj ec t i v es , m eth o ds a nd t ec hn i qu es t ha t
are pl a nn e d to us e a nd r es p o ns i b l e
pers o ns wh o wi l l c ar r y o ut t h e ac t i v i ti es .
In d i v id u al p la ns a r e s i gn e d b y c li e nt or
c l ie n t r e pres e nt at i v e.
36 . T he s oc i al s er v ic e pr o v i d er i d e nt if i es , d oc um en ts , a nd m a in t ai ns t he k e y
s er v ic e d e l i ver y pr oc es s es t o th e p ers o ns s er v ed in l i n e wi th its vis i o n,
m is s io n s ta t em ent a n d q u al i t y p ol ic 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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
25
All s oc i a l s er v ic e pr oc es s es ar e
i de nt if ie d, d oc um ent ed and r e v ie we d
an n ua l l y or m or e of t en if c ha n ges ar e
ne e de d . The pr o c es s es are in
ac c or d a nc e wit h PH v i s i on , m is s io n a nd
qu a l it y p o l ic y an d c o nt r ac ts wi th f un d i ng
bo d i es .
37 . T h e s oc i a l s er v ic e pr o v id er r e vi e ws th is d e l i ver y p roc es s a n d m ain t ai ns
c on tr ol o ver t h e d el i v e r y of th e s er v ic e.
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Pr oc es s es ar e m on it or e d a nd res u lts
e va l u at ed r e gu l ar l y. I nt er na l au d its are
c arr ie d o ut ac c or d in g to the an n ua l
au d it p l a n. F in d i ngs a r e r e por t ed i n t he
org a n is a t io n and c or r ec t i v e ac t i o ns
im pl em ent e d.
38 . T he s oc i a l s er v ic e pr o v id er e ns ur es th at the pers o n s er v ed c a n ac c es s a
c on t in u um of s er v ic e s th at s p a n f rom ea rl y i n ter v e nt i o n to s u pp or t a nd
res p o n d t o c h a ng i n g r eq u ir em ents o v er t im e .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
26
PH of f ers m an y s er vi c es f or th e c li e nts
th at c a n b e us e d wh en th e ne e ds ar e
c ha n ge d . A l l i nf or m at i on is doc um en te d
i n th e i n di v i d ua l p l a ns .
PH h as c o ntr ac ts wi t h f u nd i n g b o d ies
th at ens ur e th e c o nt i n uum of s er v ic es .
39 . T he s oc ia l s er v ic e pr o v i d er d e ve l o ps a s eam l es s c o nt i n uum of s er v ic es a nd
red uc es b ar r ier s i n a m ult i - d is c i p li n ar y or m u lt i - ag e nc y s et t in g .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
A nn u a l re p or ts h a ve i nf or m at io n ab o ut
th e s er v ic e q ue u es .
S er v ic e pr o v id er has v er y g oo d co-
op er at i o n wi t h ot h er h os pi t al s er vic es
th at a l l o ws to of f e r s er v ic es wi t h
m ult id is c i p li n ar y a ppr o ac h .
40 . T h e s oc i a l s er v ic e pr o vi d er o pe ra tes s er v ic es f rom a h o l is t i c a p pro ac h
bas e d o n t he ne e ds a nd ex p ec ta t io ns of t h e p ers o n s er ve d wit h th e a im of
im pro v i ng t h e qu a l it y of lif e f or t h e pe rs o n s er ve d .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
27
Q u al i t y of lif e of t h e p er s on s er v e d is
e va l u at ed in the in d i v i du a l p l a n,
m eas ur es f or im pr o v em en t a re
de t erm in ed an d the r es u l ts of th e
ac t i ons are e va l ua t ed r eg u l ar l y.
41 . T h e s oc i al s er v ic e pr o vi d er i d en t if i es t he ne e de d c om pe te nc es , s k il ls
an d s u p por t f or s taf f t o e nh a nc e t h e qu a l it y of lif e f or p ers o n s er v ed .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
P ers o n ne l s k i l ls an d c om pet e nc ies th a t
he l p t o im pr o v e t he q ua l i t y of l if e of th e
pers o ns s e r ve d ar e d oc um en t ed i n t h e
j ob d es c r ip t io ns and per s o nn e l is
e va l u at ed a nn u a ll y d ur in g de v e lo pm en t
d is c us s i ons .
42 . T h e s oc i a l s er vic e pr o vi d er i de nt if ies i ts bus i n es s r es u l ts a n d pr o vi d es
f orm al p er io d ic a n d i nd e pe n de n t re v i e w a nd pr oc e d ures to ac h ie v e t h e
tar g et ed r es u l ts .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
28
Res u lts of t he a n nu a l pl a ns a re
m eas ur ed a nd r e v ie w ed r e gu l ar l y. T h e
res u l ts are d oc um ent ed i n a nn u al p l a n
rep or t a nd PH ye ar b o ok .
PH s oc i a l s er v ic e d ar e a ud i te d a ls o b y
i nd e pe n de nt ex t er n a l b od y ( Soc i a l
Ins ur anc e F u nd , Q u a li t y N e t work f or
Com m unit y C A M H S)
43 . T h e s oc i al s er v ic e pr o vi d er i d en t if i es an d re g is t ers t he ou t c om es a n d
be n ef i ts f or p er s o n s er ve d of th e rec e i v e s er v ic es on in d i v i du a l a nd
c o ll ec ti v e b as is .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
In d i v id u al p la n r es u l ts ar e m eas ur e d
an d doc um en te d in t he i nd i v i d ua l p la n
re v ie ws .
Co l l ec t i v e r es u lts ar e s um m ar is e d in
ye ar bo ok an d d is c u s s ed i n pe r s o n ne l
an d c l i e nt m eet i ngs .
44 . T he s oc i a l s er v ic e pr o v id er e v a l ua tes its bus i n es s res ul ts i n or der to
de t er m in e b es t va l u e f or purc h as ers an d f u nd ers ( ‘b es t v a lu e ’ c a n a ls o be
ex pr es s e d i n r e la t io n to t h e i nc re as ed qu a l i t y of lif e of f ere d t o th e p ers o n
be i n g s er v ed) .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
29
T he a d de d v a lu e f or pur c h as e r s a n d
f un ders is e va l u at ed i n i nd i v i du a l p la ns
b y th e res u lts of t he q ua l i t y of lif e.
45 . T h e s oc i a l s er v i c e pr o v i d er e va l ua t e s th e i nd i v i d ua l a nd c o l lec t i ve
s at is f ac t io n of pe r s o n s s er ve d an d ot h er s tak e ho l de rs b y i nt er n a l a n d/ or
ex t er na l e v a l ua t io n.
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH c o nd uc ts r e g u lar c l ie n t and c o-
op er at i o n p ar t n er s a t is f ac ti o n s ur v e ys
(s ep ar at e l y f or r e ha b il i ta t io n s er v ic e
par t ners an d Day Ce nt er p ar tn ers ) .
Res u lts ar e a na l ys ed , s um m ar is ed a n d
d is tr i bu t ed wi th i n th e or g a n is a t io n .
46 . T he s oc i a l s e r v ic e pr o v id er p ro v i des ac c es s i b le an d e as il y
un d er s t a nd a b le r ec or ds on o utc om e, i nc l ud i n g p ers o na l p erc e pt i on a n d
ac h i e v em ents
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
30
Re p orts a bo u t PH ac t i v it i es an d r es u lts
are pu b l is h e d i n P H we bs it e, pr in te d in
broc h ur es , d is c us s e d in m ee ti n gs ,
doc um en te d i n in d i v i du a l p l ans . T he y
i nc l u de p er s o n a l a c h ie v em en ts a nd
perc e pt i o n ( f or ex a m ple m in ut es of
c l ie n t m eet i ngs , i n d i v i du a l p l an r es u lt
e va l u at i on r ep or t ) .
47 . T h e s oc i a l s er v ic e pr o v i d er ac t i v el y d is s em in at es org a n is a t io n perf orm anc e
am ong its s t af f , s er v ic e us er s an d ex t ern a l s tak e ho l de rs .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Inf orm at i o n a bo ut or g an is at i o n ac t i v i t i es
are d is tr ib u te d i n v a r i ous wa ys – v i a
we bs it e, d if f er en t r ep or ts , m ee t in gs ,
broc h ur es etc . E v er y ye a r an an n ua l
rep or t is c r e at e d.
48 . T h e s oc ia l s er v i c e pr o v i d er has a s ta n dar d pr oc e d ur e f o r c o nt i nu o us
im pro v em ent on t h e b as is of a n im pr o vem en t c yc l e.
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
31
PH has im pl em ent e d a pr oc e dur e t o
c arr y o u t im pr o v em e nt ac t i v it i es t h at
f ol l o w PD C A - c yc le . O bj ec t i ves are s et ,
im pro v em ent ac t i vi t ie s ar e c a r r i e d ou t,
res u l ts ar e e va l u at ed an d c o r r ec te d if
nec es s ar y. PH h as a r e gis t er of
c orr ec t i v e ac t i on .
49 The s oc i a l s er v i c e pr o v i der i d en t if i e s perf orm anc e i n d ic at ors f or
m eas ur in g t he r es u l ts of t h e im pro v em ent ac ti o ns .
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
Str e n gt hs Im pro vem e nt & de v e lo pm ents
PH h as d oc um ent e d pr oc e d ur e f or
im pro v em ent pr oc es s . I np u t f or th is
proc es s c a n c om e f r om var io us s ou rc es
(i nt er na l a ud i ts , d e v e lo pm en t p l a n,
l eg is l at i on c h a ng es etc ) . Im pr o v em ent
proc es s i nc lu d es d ef i n in g im pr o v em ent
pos s i b i li t ies , p l an n i ng the im pr o v em ent
ac t i ons , im p lem e nt i ng th e ac t i o ns a nd
re v ie w.
50 . T h e s er v ic e p r o v i der in tr od uc es an d m an a ges in n o va t i ve wa ys of work i ng
th at ha v e b ee n i d en t if i ed bas e d on t h e n ee ds of s tak e ho l d ers .
Remark from the auditor: The ser vices of the social ser vice pr oviders meet
this cr iterion of the EQUASS Assurance certif ication prog ram
Str e n gt hs Im pro vem e nt & de v e lo pm ents
32
PH h as im p lem en t ed m an y in n o va t i ve
i ni t ia t i ves ( f or ex am p le H am et work
c ap a b il i t y e v a l ua t io n tes t p i l ot proj ec t ,
gre e n ho us e pr oj e c t, ex p er ie nc e
c ou ns e ll i n g p i lo t pr oj ec t) . T hes e
proj ec ts ar e f o l lo we d and r es u lts of
th es e p roj ec ts ar e doc um en te d ye a r
bo ok .
33
5. Agreed additional development / improvements
T he a pp l ic an t d ec i d ed on th e f o l lo wi n g im pro v em ent ac t i on s an d/ or
ad d it i o na l d e v e lo pm e n t f or t h e pe ri o d of t wo ye ars :
Sho rt d es c ri ptio n of the a cti on s
( in clud ing SM ART ob je ctiv es )
1 Up d at e t he de v e l opm en t p l an of PH s o i ts ti tl e a n d c o nt e nt
c or r es p o nds t o t he c u r ren t p er io d of t im e.
Uu e nd a da P H ar e ng u k ava , e t s el l e p e a lk ir i j a s is u vas tak s
k äes o l e va l e p er io o d il e .
De ad lin e /tä hta eg : 3 1 . 12 . 20 1 6
2 Re v i e w th e tar g ets us e d in a n nu a l pl a n s so t h at th e y
c or r es p o nd to S M AR T c riter i a or an a l ys e th e p os s ib i l it y to
de v e l op a n d im pl em en t K e y P erf orm anc e In d ic at ors .
Ül e v a ad at a a as t ap l a an is k as ut at a v ad m õõd ik u d, et n e ed
v as t ak s S M ART - k rite er ium it e l e võ i a na l ü üs id a v õim a lus t
to im i vus e v õtm e in d ik a at or it e v ä lj a t öö tam is e k s j a k as ut us e l e
v õtm is ek s .
De ad lin e /tä hta eg: 3 1 . 12 . 2 0 1 7
3
4
5
6
34
35
6. Closing remarks
P ärn u Hos p it a l ’s m is s i on is t o s up p ort h um an h ea l th a nd q ua l it y of l if e. B es id es
m edic a l c ar e Pä r n u H os p i ta l pr o v i des s pec i a l c are s er v ic es , r e ha b il i ta t io n s er v ic es
an d s u p por t p er s o n s e r v ic e.
Curr e nt EQ U A S S As s u r anc e a u d it is t h e s ec on d a u di t f or P är nu H o s p it a l .
PH h as we l l im pl em ent e d q u a li t y s ys tem t ha t f o l l o ws P DC A - c yc l e . Pr oc es s es ar e
doc um en te d an d r eg u lar l y r e v ie we d . An n ua l p la n n in g c yc le is perf orm in g we ll .
Cl i e nts i n di v i d ua l n ee ds ar e t ak en i nt o ac c ou n t. T h er e is go o d c o - o p er at i on wit h
d if f ere nt c o - o p er a t io n par t ner s i n or der t o of f er b et ter s er v ic es . P er s on n e l is va l ue d
an d t he y a r e s at is f i e d wi t h th e ir j o b.
T here wer e d if f er e nt i nt er v ie ws wi t h c l i en t s , pers o nn e l, m an ag e rs , f u n di n g b od y
an d c o- op er at i o n pa r tn er s d ur in g th e a ud i t. I nt er v ie w p art ic i pa nts wer e co -
op er at i v e a nd ex pr e s s ed t h eir s a t is f ac t i on wi th P är n u H os p it a l’s ac t i v it i es .
Re q ui re d d oc um e nt at i on was we ll pre p ar ed an d s uf f ic i en t.
Dur i n g th e v is it au d i tor f o u nd v er if ic at i on m ateri a l f or a l l EQ UA S S As s ura nc e
c rit er i a.
A ud i tor pr es e nt ed o ne r em ar k s ta t ed in c r it er i a 14 and t wo im pr o vem en t
s ug g es t i ons :
Cri t er ia 1 : U p da te t h e d e ve l opm e nt p la n of P ärn u Hos p it a l s o its ti t le a n d c o n te nt
c orr es p o nds t o t he c u r r en t p er io d of t im e.
Criteria 6: Review the targets used in annual plans so that they correspond to
SMART criteria or analyse the possibility to develop and i mplement Key
Performance Indicators.
Af t er v er if ic at i on of t he i n d ic a t or s dur i n g t he s i t e v is it , r e vi e wi n g doc um en ta t io n,
c on d uc t i ng s e v er a l i nt er v ie ws wi t h pers o ns s er ve d , s t af f a nd ex t e rna l s t ak eh o ld ers
(pa rt ners , f u nd er s ) , t he a ud i tor r e ac h e d t o c onc l us io n t h at Pär n u H os p i ta l m ee ts
f ul l y t he c r it er ia f or E Q U A SS As s ura nc e c er tif ic a t io n pr o gram m e.
P ärn u ha i g la m is s io o n ik s on t o et ad a in i m es te t er v is t j a e l u k va li t ee t i. Lis ak s
ter v is ho i u te e nus te l e os ut a tak s e re h ab i l it ats i o on i , er ih o o lek an d e (t öö tam is e
to et am in e j a i g ap ä e va e lu t o et am in e) j a tu g i i s ik u te e nus e id .
36
K äes o l e v EQ U AS S as s ur a nc e a ud i t o l i P ärn u h ai g l al e t e is tk or dn e.
P ärn u h a ig l a l o n hä s ti j u ur ut at u d k v a l it e ed ij uh t im is s üs te em , m is j äl g i b P DC A -
ts ük l it . Pr ots es s id on k ir j e ld a tu d ni n g reg u l aars e lt ü l e va ad a tu d. A as t as e
p la n eer im is e ts ük k el o n h äs t i t o im iv . K l i en t id e le lä h en e tak s e i n d i vi du a a ls e l t s i lm as
p id a des ne n de v aj a d us i. T ee n us t e p ar em ak s os ut am is ek s to i m ub he a k oos t ö ö
er in e v at e k oos t öö p ar t ner i te g a. Pers o na l i v äär t us t at ak s e ni n g na d on om a t ö ög a
r ah u l.
A ud i ti l äb i v i im is e l t o im us i d er i ne v a d i nt e rvj uu d k li e nt i de , p er s on a l i, j u h ti d e,
rah as taj a j a k oos tö ö par t ner i te g a. I nt er vj u ud es os al ej ad o l i d k oos t öö a lt i d n in g
v ä lj e nd as i d om a r a hu l o lu P är n u h a i gl a t e ge v us e g a. K on tro l l i ta v d ok um ent ats i oo n
o li häs t i e t te v a lm is t at u d n in g am m enda v .
A ud i ti l ä b i v iim is e l le i d is a u d ii t or t õ en d us m aterj a l i k õ ik id e EQ UA S S As s ur a nc e
k rite er ium i te k oh ta .
A ud i it or es i tas üh e m ä r k us e 14 . k ri te er i um is j a k ak s p are n dus e tt ep an ek ut :
Kr it e er ium 1: Uu e nd ad a PH ar en g uk av a , et s el l e p ea lk i r i ja s is u v as t ak s
k äes o l e va l e p er io o d il e .
Kr it e er ium 6 : Üle vaadata aastaplaanis kasutatavad mõõdikud, et need vastaks
SMART -kriteeriumitele või analüüsida võimalust toimivuse võtmeindikaatorite
väljatöötamiseks ja kasutusele võtmiseks .
P ea l e as ut us e k ül as t u s t, d ok um ent a ts i o o ni ü le v a at us t n in g in te r v j uu d e l ä bi v i im is t
te e nus e s a aj a t eg a, t öö t aj a te j a v ä lis t e h u v ip o ol t eg a (p ar tn er i d j a ra h as t aj a d) ,
j õu d is a u d i it or ots us e le , e t P är n u ha i g l a tä i da b tä i e l ik ul t EQ UA S S As s ur anc e
s ert if ik a a di nõ u d e i d.
Ta l li n n, 15 .1 2 .2 0 15
Tri i n Kr a av i
37