EQUASS ASSURANCE
AUDIT REPORT
Site visit: 27.10 -28.10.2015
SA Viljandi Haigla
Elo Tuppits
© 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.
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1. Information of the social service provider
Na me of th e so ci al
S A V i lj and i H aig l a /V i lj and i Ho spit a l
se rv i c e p rov id er
Ad d re s s: Pärna tee 3, Jämejala küla, Viljandi vald
Po st bo x:
P er so n re sp on sib le P ri it T a mp er e , C E O
(C EO ) :
Cont ac t p e rs on: Ka ja K og er , di re cto r of N ur s ing C ar e C ent re
Pho ne: + 37 2 4 3 5 20 2 2 ( g en er a l)
+ 37 2 4 3 5 42 5 0 ( K aj a K og er)
Fa x: -
E- m a il: G e ner a l e - m ai l : vm h @ vm h. ee
K aj a Ko g er: k aj a.k o ge r@ vm h. ee
W eb s ite: ht t p: / /v mh .e e/ ( Vi lj an di Ha ig la / V il ja ndi
Hos pit al )
ht t p: / /oh k.v m h. e e/ ( Õ endu s- h ool du sk e sk u s/
Nu rs ing a nd C ar e C e ntr e ( NC C) )
Na me of Au dit o r: El o T upp its
Dat e s of aud it : 27 . 10 – 28 .1 0 .2 0 15
Cli en ts: Num ber of p ers on s er v ed a s of 2 0 14 an d 2 0 1 5
r eh a b i li t at i on s e r vic e s : 95 0 / 9 0 0
c ar e s er v ic es : 6 0 / 75
s pec i a l c ar e s er v ic es : 43 / 75
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St aff p rov id ing s oci a l Num ber of Fu l l t im e s t af f : 9 5
se rv i c es i n NC C :
Num ber of P ar t t im e s t af f : -
Num ber of C on tr ac t e d s taf f : 38
Num ber of vo l un t eers : 2 (c o n trac t ed) a n d
tr a i ne es f rom s c h oo ls i n Es t o n ia an d N et he rl an ds
S erv ic e s:
The scope of audit: rehabilitation services, care services
and special care services provided by Nursing Care
Centre of Viljandi Hospital
Rehabilitation services and programmes:
s er v ic e f or m ak ing re h ab i l it a ti o n p la ns (a ls o p la ns
i ns tr uc t i o n s er v ic e a n d res u lt m eas urem en t
s er v ic e) , p h ys io t h er a p y, s oc ia l c o u ns e l i ng , f am il y
an d gr o up c ou ns el i n g, s p ec ia l e d uc a t io n
s er v ic es , a ls o s pec i a l ed uc at i on f am i l y an d g rou p
c ou ns e li n g, ps yc h o lo g i c a l s er v ic es ( als o f am il y
an d gr o up c ou ns el i n g) , s pe ec h th er a p y s er v i c es
( a ls o f am il y a n d gr o up c o u ns e l i ng) ; a nd
ac c om m odat i o n s er v ic e i n th e f ram e wo rk of
r eh a b i li t at i on s e r vic e . 5 s p ec i a l pr o gram m es .
Ca r e s erv i c es and p r ogr am me s :
24 ho ur c ar e f or e ld er l y,
i nt er va l c are f or e l der l y,
da y c are f or e l de rl y,
ho ur c ar e f or e l der l y;
an d ac c om m oda t i on f o r f am il y m em bers of
per s o ns g et t in g s er v ic e.
2 s p ec i a l pr o gram m es .
Sp e ci al c a re se rv i c es an d p ro gr a mm es :
s er v ic e of as s is t a nc e i n e v er yd a y l if e ,
s er v ic e of s u p por te d l i v i ng ,
24 ho ur c ar et ak i ng f or p ers ons wi th perm an e nt
m enta l d is or der wi th u ns t a bl e rem is s io n .
3 s p ec i a l pr o gra m m es .
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2. Audit programme
27 . 10 .2 0 15 Da y 1
T ime Ac t iv it y
9: 0 0- 9 :1 5 O p en i ng m ee ti n g
9: 1 5- 1 2: 1 5 Doc um en ta t io n r e v i e w
12 : 15- 1 3: 0 0 In ter v i e w wi t h K aj a Ko ger , m a na g er (r es po ns i bl e f or
im pl em ent a ti o n of t h e EQ U AS S in N CC )
13 : 00- 1 3. 3 0 Lu nc h br eak
13 : 30- 1 4: 0 0 V is it of th e N CC ro om s f or c ar e s er v ic es
14 : 00 – 14 :1 5 Doc um en ta t io n r e v i e w, u p - da t in g f i les
14 : 15 – 15 :0 0 In ter v i e w wi t h pers o ns s er v e d ( r e ha b i l it at i on s er v ic es ) :
1 child with accompanist
1 person with mental illness
2 adults with accompanist/interpreter
1 retired person
15 : 00 – 15 :1 5 Doc um en ta t io n r e v i e w, u p - da t in g f i les
15 : 15 – 15 :4 5 /5 5 In ter v i e w wi t h s t af f :
Mai Tuuksam (social worker, rehabilitation of children, elderly),
Meelike Poplavski (social worker, rehabilitation of children, persons with mental
illness),
Asti Kallissaar (social worker, rehabilitation of children, persons with mental
illness),
Estri Kruus (doctor),
Pille Jõerand (care worker, care services),
Erika Perko (hostess, special care),
Siret Tamm (coordinator, care service and rehabilitation)
15 : 45 – 16 :0 0 Doc um en ta t io n r e v i e w, u p - da t in g f i les
16 : 00 – 16 :3 0 In ter v i e w wi t h pers o ns s er v e d (c ar e s er v ic es a n d s pec i a l c ar e
s er v ic es ) :
2 customers of 24 hours special care service and
1 customer of supported living service
(accompanied with activity supervisor),
1 customer of care service,
3 family members of persons served (care services)
16 : 30 – 17 :0 0 Doc um en ta t io n r e v i e w, u p - da t in g f i les
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28 . 10 .2 0 15 Da y 2
T ime Ac t iv it y
9: 0 0- 9 :4 5 V is it t o 2 4 ho ur s s p ec i a l c are un i t ( p ers o ns wi t h m en ta l d is or der
wi t h uns t ab l e r em is s io n ) , m eet i n g wi t h s taf f ( ac t i v it y s up er v is ors )
Urmas Murumäe, Ene Arak, Evi Aavik, Laine Talp, Marika Tali,
Raivo Heinrichen
9: 4 5- 1 0: 0 0 Doc um en ta t io n r e v i e w, u p - da t in g f i les
10 : 00- 1 0: 3 0/ 45 In ter v i e w wi t h f i n anc i n g b od y – N a ti o na l Soc i a l Ins ur anc e B o ar d:
Margit Laurson,
Linda Lillemaa
10 : 30 /4 5- 1 1: 00 Doc um en ta t io n r e v i e w, u p - da t in g f i les
11 : 15- 1 2: 0 0 In ter v i e w wi t h c oo p er a ti o n p art n er s :
Livia Kask, director of Social Board, Viljandi City Government,
Luule Vitsur, chief specialist of social care, Viljandi County Government
Sirje Fedjuk, project manager of Sakala Cultural Centre
Leho Tamvere, director of Vändra Health Centre
12 : 00- 1 2: 4 5 Lu nc h br eak an d v is i t to t h e r eh a b i li t at i on u n it of t he N CC
12 : 30- 1 3: 0 0 Doc um en ta t io n r e v i e w, u p - da t in g f i les
12 : 45- 1 3: 3 0 In ter v i e w wi t h m an ag e rs of th e N CC`s u n its :
Kaja Koger, head of the NCC,
Elena Erm, head of the Social Care Unit of the NCC,
Moonika Pukk, head of the Special Care Unit of the NCC.
13 : 30- 1 4: 0 0 In ter v i e w wi t h Pr i it T a m pere, c ha irm an of t h e B oa rd of V i lj an d i
Hos p it a l
14 : 00- 1 6: 3 0 Doc um en ta t io n r e v i e w, u p - da t in g f i les
16 : 30- 1 7: 0 0 Cl os i ng m eet i n g
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3. Detailed feedback on performance
1. The social ser vice provider def ines documents and implements its
vision and mission values on ser vice provision.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he m is s i o n, v is io n an d v a lu es ar e
s ta te d in th e Q u a l it y St a nd ar d of N CC ,
Inf orm at i o n Br oc hur e f or c l i en ts ,
i nf orm at io n s t a nds , an d on NC C`s
we bs it e h tt p :/ /o hk .vm h .e e/ . T he m is s io n
an d v is i on of th e NC C is f urt h er
de v e l op e d f r om H os p i ta l` s m is s i on a n d
v is io n ( VH s tr at e g y d o c um ents ) .
T he m is s i o n of NCC is to pr o v id e
s er v ic es f or p eo p l e wi th d is a b i l it i es ,
wh ic h ens ur e s af e a nd u n der s t an d in g
l if e e n v ir onm en t, im pr o v em en t of l if e
qu a l it y, a n d b e in g va l ue d as a m em ber
of s oc i et y.
T he em p lo ye e s of N CC dem ons tr at e d
thr o ug h i n ter v i e ws t h at t h e y ar e a war e
of th e NC C` s m is s i o n , v is i o n a n d c or e
v a lu es .
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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
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Str e n gt hs Im pro vem e nt & de v e lo pm ents
Lo n g- t erm qu a l it y g oa ls a nd
c om m itm ent t o c o nt i n uo us im pr o vem en t
are s ta t ed in th e Fu nc t i o na l
De v e lo pm en t P l an 2 0 1 4- 2 0 2 0 of V i lj an d i
Hos p it a l. R es p ec ti v e go a ls a nd
c om m itm ent of NC C ar e s ta t ed in N CC`s
Q u al i t y St a nd ar d 2 0 1 5- 20 1 8 an d
im pl em ent e d th r o u gh an n ua l p l a ns .
It was va l i da t ed dur i ng th e i n ter v i e ws
th at t h e s t af f of NC C is a war e of t h e
Q u al i t y S ta n d ar d an d c ons i der s it as
qu i d el i n es o n t h e ir wo r k .
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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he NC C of V i lj an d i H os p it a l has
de v e l op e d dif f er en t m et h ods t o as k an d
rec e i v e f ee d bac k f r o m per s o ns s er v ed ,
s taf f a n d s tak e ho l d er s .
For pers o ns s er v e d in NC C a n d f or t h eir
f am ili es t he m os t im por t an t an d
pref erre d wa y f or g i v i ng f e e db ac k is i n
f ac e t o f ac e m eet i ngs on o ng o in g bas is .
For m ore a no n ym o us f ee d bac k s pec i a l
c l ie n ts f ee d bac k s h ee ts and C l i en ts
B oar d M e et i ngs ( 4 t i m es a ye ar) ar e
im pl em ent e d.
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In ter n a l a ud i t an d C l i en ts B o ar ds ha v e
c o ll ec te d d ir ec t f e ed b ac k f orm pers o ns
s er ve d t hr o ug h in t er v i e ws . Fe e db ac k
c o ll ec ti o n us i ng p ho n e p o l ls h a ve be e n
rec e n tl y im pl em ent ed in V i lj a nd i
Hos p it a l ( h e al t h care s er v ic es and
r eh a b i li t at i on s er v ic e s ) . T h e c om pl a in t
m anag em en t s ys t e m ( box es for
c om pl a in ts a n d pr o po s a ls i n e ac h u n it
of th e hos p it a l , c om pl a in ts a re
d is c us s e d i n m an ag e m ent) is us ed i n
wh o le hos p it a l.
Co l l ec t i ng f e e db ac k f r om f und i ng bo d y
an d m a in c o o per a t i on p ar t n er s is
org a n i ze d t hr o u gh m eeti n gs , p h on e
c a lls , e - m ai ls a nd i n d i vi d ua l f ee d bac k -
qu es ti o nn a ir es . Pr o toc o ls of the
m eeti n gs , e - m ai ls an d r es u lts of
s ur ve ys wer e pr es en te d.
From f und in g b o d y f e ed b ac k is r ec e i v ed
tro u gh s u r ve i l la nc e/ a u d its .
Em pl o ye es have a c ha nc e to give
f ee db ac k on on g oi n g bas is an d a ls o
f ee db ac k is as k e d dur i n g s t af f
perf orm anc e r e v i e ws . R eg u la r s t af f
m oti va t io n a nd s a t is f a c ti o n s ur ve ys ar e
c on d uc t e d as we l l .
Dur i n g t he i n ter v i e ws was v a l id a te d t h at
th e s tak e ho l de r s h a v e gr ea t op p ort u ni t y
to g i v e f ee d bac k .
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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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
V i lj a n di Hos p i ta l / N CC inf or m s al l
pos s i b le s t ak eh ol d er s ab o ut i ts s er v ic es
us in g a v ar i et y of m etho ds a nd
ap pr o ac h es .
T he web p ag e of NCC is v er y
i nf orm at i ve on s er v ic e s pr o v i de d an d o n
ho w to get s e r v ic es / f u nd i n g
(i nf orm at io n f or p ar t ner s an d f ut ur e
c l ie n ts ). A ls o i nf or m ati o n on e v e nts is
pro v i d ed on we b pa g e. NC C h as
i nf orm at io n br oc hu r es f or eac h of it `s
s er v ic e gr o ups . F or p er s o ns c om in g t o
th e s er v ic e inf or m at i on f o ld er is
pro v i d ed f or c om pr e h ens i v e o ver v i e w of
th e s er v ic es a n d inf or m atio n s ta n ds f or
c l ie n t inf o r m ati o n ar e i n eac h u ni t. Al l
nec es s ar y inf or m at io n is pr o v i de d o n
e ver y d a y b as is b y s taf f as we l l. T o
ens ur e th at o n l y p er s ons wh o c ou l d ge t
s er v ic es wo u ld a p p l y to NC C a nd t o
as s is t t h em in pr e pa r i ng pa p er work to
bec om e a s e r vic e us e r of N CC , s p ec i a l
c oor d i na t or s wor k in N CC pr o v i d i ng
i nf orm at io n b y p h on e an d e - m a il .
For N CC`s s t af f inf o r m atio n o n s er vic es
an d pr o gr am m es , pr oc es s es and
proc e d ures , d e ve l op m ent of s er v ic es ,
ab o ut e v en ts and p os s ib i l it i es to be
i n vo l v ed is pr o v id e d i n h om ep ag e ,
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i ntr an e t ( i nc l all pr oc es s es and
proc e d ures ) , A nn u al Ac t i o n Pl a n,
i nt ern a l f o ld er s a n d i nf or m at io n s t a nd .
A ls o v ar i ous m e as ur es h a ve b e en
de v e l op e d f or i nf or m i ng and f or th e
par t ic ip a ti o n of s t af f , f .e. tr a in i n gs s t af f
m eeti n gs . St ak eh o l d er s ar e a war e of
th e s er v ic es of N CC a nd ex pres s
s at is f ac t io n on ho w NC C s pr e ads
nec es s ar y i nf or m at i o n. pr o toc o ls we re
pres e nt e d as pr o of th at a ll r e l e va nt
i nf orm at io n was pr es e n te d to all
i nt eres t ed par t ies .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he p l a nn i ng pr oc ed u r e is d oc um ent e d
i n t he Q u a l it y S ta n d ar d . T h er e is th e
pro of t h at a n nu a l p l an n i ng pr oc es s is
im pl em ent e d an d r e v ie we d ( t eam s `
an n ua l p la ns of dif f er en t ye ar s , m inu t es
of m eet i ngs ) .
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.
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Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v i c e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he an n ua l p l a nn i n g pr oc es s of N CC T o d e ve l o p t h e a nn u al p l an f orm f urth er
has c yc l ic c ha r ac ter . so t ha t dur i n g t he e va l u at i on it is
pos s i b le t o ad d i nf orm at i on o n ac t i v it i es
A nn u a l ac t io n p l ans of N CC` s u n its i n a d d it i on t o f i n is h ed o n es (t o a dd
pro v i d i ng s oc i a l s er v ic es inc l u de
i nf orm at io n: on p erf orm anc e/ no t
obj ec t i v es , m eas ur es an d ac t i v i ti es ,
s tar te d / p os tp o ne d) + i nf orm at io n on
ta n gi b l e res u lts , d e ad l in es an d p ers o ns pos s i b le pro b l em s if n ec e s s ar y. S o, t he
res p o ns ib l e .
an n ua l pl a n c o u ld g i v e f ul l o ver v i e w of
th e s it u at i on in im pl em ent i ng annual
A nn u a l ac ti o n p l a ns ar e a p pr o v e d b y t he
p la n a nd wh at a re t h e c ha n ges .
m anag em en t of V i lj a n d i Hos p it a l.
Ar en d ad a tö ö p la a ni v orm i e das i
s e ll is e lt , et t ö öp l a an i ü le v a at us t e l s a ab
l is ak s ü l e v aa tus e aj ak s lõ p et at u d
te g e vus te l e l is ad a s e ll es s e k a he tk el
e ll u v i im is e l v õi a l us tam at a t e ge v us t e
s ta at us e ( lis a d a i nf o : t äi tm is e l / p o le
a lus ta t ud / ed as i l ük at ud) n i n g vaj a dus e l
v õ im al ik ud pr ob l e em id. S e l l is e l moel
an n ak s ta be l tä i e l ik u p il d i s el l es t , k u i
k aug e le ol l ak s e j õ ut ud k ogu a as t a pl a an i
e ll u v i im is e ga ja m ill is ed on
m uuda t us e d .
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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
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T he NC C an d V i lj an d i Ha i g la as a wh o le
is v er y ac ti v e i n s a t i s f yi n g th e n ee ds
an d ex pec t at i ons of t he s oc i et y, a nd i n
dem ons tr at i ng s oc i a l r es p ons i b il i t y
c on tr ib u t in g t o th e s oc i et y.
In it `s s tr at e gic p l an n in g pr o c es s ,
V i lj a n di H os p i t al ha s a na l ys e d da t a
a va i l ab l e ( s t at is t ic s , i nf or m at io n
ga t her e d i n wor k i ng g r ou ps ) to arr an g e
its s er v ic es r es pec tf u l l y to t he n e eds of
th e s oc ie t y ( i nc lu d i ng p l a nn i n g ne w
s er v ic es wi t h hi g h dem an d – f .e .
tre atm e nt an d r eh a bi l it a ti o n of a d dic ts ,
c are f or d em ent e d e l d er l y, s p ec ia l c ar e
f or p ers o ns wi t h m e nt a l d is or d ers or
reg u l at i ng th e v ol um e of i ts s er v ic es
f lex i bl y etc ) . Var i o us pr oj ec ts ( i nc lu d i ng
p la n ni n g of n e w hos p it a l bu i l d in g a nd
ne w bu i l d in gs f or s p e c i al c ar e s er vi c es
to p ro v i de s er v ic es in c o n t em po rar y
en v ir o nm ent ) ar e in i t i at e d t o m eet th e
ne e ds of s oc i e t y.
V i lj a n di H ai g l a c o nt r i b ut es t o am end i n g
th e m en ta l he a lt h s er v ic es r e l at e d
l eg is l at i on , le a ds wor k ing gr ou p to j o i n
d if f ere nt p ar t ies d ea l i ng wi t h a nd
i nt eres t ed in be tt er r e gu l at i on and
de v e l opm en t of s er v i c es f or d em ent e d
e ld er l y.
T he c l ear pr o of f r om c oo p er at i on
par t ners ` r e pr es en ta t i v es of f un der h as
be e n go t d ur i n g th e in t er v ie ws th at
V i lj a n di H os pi t al s uc c es s f u l l y a r ra n ges
its s e r vic es ac c or d in g to t h e ne e ds of
s oc ie t y a nd is pr o ac t i v e t o f in d s o l ut i o ns
f or dif f er e nt pr o b lem s in t h e ir f ie l d of
ac t i v it i es .
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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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
NC C dem ons tr at ed c l ear l y t he s uc c es s
i n c on tr i bu t in g t o th e s oc ie t y.
V i lj a n di H os p i ta l h as be e n in i t ia to r a n d
ac t i v e p ar t ic i pa nt of dif f ere nt
c om m uni t y- bas e d e v e nts an d ac t i vi t ies .
B ot h NC C` s s t af f a nd s er vic e us ers
ha v e do n e vo l u nt ar y wo r k in loc a l
e ve n ts ( c l e an i ng s ur r ou n di n gs and
are as i n V i lj a n d i C i t y) . Se r vic e us ers
par t ic ip a te in ye ar l y l oc a l f a ir s to s e ll
th e ir ha n d ic r af t a n d l oc a l s oc i et y g ets
ac c es s t o us ef u l pr o du c ts .
T here ar e s e ve r a l e v en ts ar r an g ed i n
c oo p er at i on wi t h p ar t ner s . F .e . c h i l dr en
c o ll ec ti v es f r om V ilj a nd i c u lt ur al c e ntr e
g i ve c o nc er ts i n NC C h a vi n g pos s i b i l it y
to p erf orm , B ot h c h i ldr e n a nd el d er l y
i n c are e nj o y s uc h e v en ts a nd c o n tac ts .
Sc ho o l c h i ldr e n v is it c h il dr e n in hos p it a l
to g et ex per i e nc e wi t h c h il dr e n d if f er en t
f rom them
All t h es e ac t i v it i es ar e r eg u lar and
p la n ne d ye ar l y. A ls o s e ver a l “ Le tt ers o n
gra t it u de” f r om dif f er en t or g a n is a t io ns
wer e pr es en te d .
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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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
V i lj a n di H os p it a l h as doc um en te d S t af f
Rec r u itm en t an d S e le c ti o n Po l ic y. T he
po l ic y c o ns is ts of pr i nc i p l es f or
rec r ui tm ent a n d d es c r i bes t he pr oc es s
of rec r ui tm en t. C r i t er i a f or r ec r u i tm ent
an d p ri nc i pl es of eq ua l op p or t u ni t i es
an d n o n- d is c r im in a ti o n ar e d es c r i b e d i n
NC C S oc ia l Car e un i t` s P er s o nn e l
P ol ic y S t a nd ar d.
St af f is c h os en bas e d on t h ei r
c om pet e nc es , s k i l ls , k no wl e dg e a nd
pre v i o us wor k ex p er i e nc e .
All em pl o ye es have i n di v i d ua l j ob
des c r i pt i o ns , wh ic h i nc l u de r e q uir e d
k no wle d ge , s k i l ls a n d c om pet e nc es .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
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T he hum a n r es o ur c e m ana g em ent a n d
work p l ac e r e l at ed doc um en ta t io n of
V i lj a n di H os p i ta l m eets le g a l
req u ir em ents an d is r e v i e wed t o d o t his .
T he s t af f le v e l is k ep t a t o p tim um an d
th is is r e vi e we d r eg u lar l y. T o e ns ure
th at t h er e ar e a l wa ys nec es s ar y s t af f to
pro v i d e N CC ` s s er v ic es t h e f l ex ib l e j ob
m anag em en t is us e d
In r ec e n t ye a r s NC C h as em pl o ye d
v o lu nt e ers a nd h as e l ab or at e d s pec i a l
c on tr ac t f or t hem .
T he pr inc i p les f or s h o wi ng r ec o g n it i on
to em pl o ye es ar e des c r i b ed in
hos p it a l` s J ob M an a g em ent Ru l es an d
NC C Soc i a l Car e Un i t` s P er s o n ne l
P ol ic y S t a nd ar d.
T he work i ng c o n d it i o ns ar e e v a l ua te d
( work p l ac e r is k as s es s m ent s ys t em is i n
p lac e a nd r e v i e we d p er io d ic a l l y by
hos p it a l`s he a lt h an d s af e t y
rep res e nt at i v e) a nd nec es s ar y ac ti o n
p la ns a re dr a wn u p . B es i d es , th e work -
re la te d s tre s s a n al ys is has b e en c arr i ed
ou t.
11. The social ser vice trains all staff based on a plan f or leaning and
development and evaluates the eff ectiveness of the training.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
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St af f d e ve l o pm ent a nd tr a in i n g ne e ds
are as s es s e d a nd pr io r it is e d a n nu a l l y in
th e u n i ts of Vi lj an d i Hos p it a l b as ed o n
an n ua l per f o r m anc e r e v ie ws of th e s t af f
m em bers , a nd pr es e nt e d t o P er s o n ne l
De p artm en t t o c om pi l e th e T r a i ni n g P la n
f or t h e wh o l e or g a n is a ti o n.
Inf orm at i o n o n p l a nn ed a nd at t en d ed
tra i n in gs is r ec or d e d in i nf or m at io n
s ys tem . Us i n g s p ec i a l e v a lu at i o n s he e t,
f ee db ac k o n tr a i n in gs f r om par tic i p an ts
is c o l l ec t e d a bo u t al l tr a i n in g s to
m eas ur e th e r es u lt a n d ef f ec t i v en es s of
tra i n in g .
Inf orm at i o n ob t ai n ed f r om tr a i n in gs is
s har e d i n s t af f m eeti n gs an d is r ec o rd e d
i n m in ut es of m ee t in gs .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he c om pe t enc e r eq u ir em ents f or
em pl o ye es ar e des c r i be d i n t h ei r j ob
des c r i pt i o ns a nd a r e r e v ie we d a n nu a l l y.
T he perf or m anc e of s t af f is r e v ie we d i n
v ar io us wa ys . R eg u lar p er f or m a nc e
re v ie ws , s up er v is i ons , m eth od o lo g ic al
i ns tr uc t i o ns an d wo r k gui da nc e ar e
c arr ie d o ut wi t h s t af f m em ber s , d ur i ng
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wh ic h they ar e i ns tr uc t e d and
s up er v is ed t o d o t he i r wor k ef f ec ti v e l y
an d ef f ic i en t l y, a n d t he ir c om p et enc es
are e va l u at ed .
T he pr oc es s is d es c r i be d in N C C`s
P ers o n ne l P o l ic y St a n dar d a nd r ec or de d
i n an n ua l ac t i v it y p l a n s of u ni ts .
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
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Pr i nc i p l es of i n v ol v em en t of s t af f in t h e
p la n ni n g an d e va l u at i on of s er v ic es is
des c r i b ed i n h os pi t al ` s Pe r s o n ne l Po l ic y
an d in N CC S oc i a l C ar e U n it`s
P ers o n ne l P o lic y S ta n dar d. NC C
rec o g n is es s taf f as a us ef u l s o urc e t o
ga i n i nf orm at i on .
Re g ul ar s t af f s at is f a c ti o n s u r v e ys ar e
c arr ie d o ut in Vi lj a nd i H os pi t al and
perf orm anc e r e v ie w s ( doc um ent e d)
wh ic h pr o v id e i nf or m a ti o n f or per s o n ne l
p la n ni n g a nd de v e lo p m ent .
M in ut es of r e g u lar s taf f m eet in gs to
d is c us s s er v ic es an d p ol ic i es of NC C
wer e pr es en te d as p r o of .
17
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14. The social ser vice provider has mechanisms in place to enhance
satisf action and mot ivat ion of staff
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Re g ul ar s t af f s at is f ac t i on s ur v e ys (o nc e
a ye a r), ye ar l y p er f or m anc e r e v ie ws /
de v e l opm en t i nt er v ie ws a nd
qu es ti o nn a ir es ( f .e . wor k s tr es s s ur v e y)
are us ed to ga i n f ee d bac k on
s at is f ac t io n a nd m ot i v at i on of t he s t af f .
Me as ur es to e n ha nc e s a ti s f ac t i on an d
m oti va t io n ar e des c r i b ed i n R u l es of J o b
Ma n ag em en t an d N CC S oc i al C ar e
Un i t`s P ers o n n el Po l ic y S t a n d ar d .
T he pr in c i p l es of m oti v a ti o n a nd
rec o g n it i on of em plo yees ar e des c r i b ed
i n t he Ru l es of J ob M an a gem e nt of th e
hos p it a l a nd i n N CC s oc ia l c ar e u n it`s
P ers o n ne l P o l ic y St a nd ar d. St af f
m em bers ar e r ec o gn is ed i n e l ec t i ng T h e
Co l l ea g ue of th e Ye a r ( f r om eac h c l in ic
an d s u pp or t u n its ) a n d T he N CC` s B es t
Co l l ea g ue of th e Ye a r . A ls o t he Ac t of
th e Ye a r is e l ec t e d.
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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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
B as e d o n i nt er na t io n a l H um an R i gh ts
Co n v en t io n a nd ot h er r e l e va nt
i nt ern a ti o n al a nd E u r op e a n r e g ul a ti o n
NC C has d e v el o pe d th e r i g hts and
du t ies of p er s o ns s er v ed as a p art of
th e ir Q u a l it y S t an d ar d. R ef er e nc es t o
th e in t ern a ti o na l c o n v en t io ns a nd ot h er
re le v a nt re g u la t io ns ar e g i ve n .
T he s t af f d em ons tr a te d t h e ir k no wl e d ge
of t he r ig hts and d ut i es t hr o ug h
i nt er v ie ws .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
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T he ri g hts an d d u t ies ar e i ntr o duc e d t o In NC C`s we bs it e t h e ri gh ts a n d d u ti es
th e p ers ons s er ve d b y s t af f dur in g t he of s erv ic e us ers ar e s om e wh at d if f ere nt
f irs t e va l u at i on a nd p la n ni n g m eet i n g. i n c as e of eac h s er v ic e. S t i ll , i n c as e of
T he i nf orm at io n o n t he c l ie nt ` s ri gh ts ri gh ts t her e ar e m in or d if f ere nc es i n
an d du t ie s is i nc l ud e d to th e i nf or m at io n c on t en t wh ic h d oes n`t s eem to be
f ol der f or s er v ic e us e r s . T he d oc um ent reas o n ab l e. T her ef or e the re is n ee d t o
is a v a il a b le in i nf o s ta n ds of al l u n its re v ie w r i g hts a n d d ut i es .
an d loc a ti o ns of pr o v is i o n of N CC`s
Õ H K k od ul e he l to o du d t ee n us e s a aj a te
s er v ic es f or e v er yb o d y t o s e e . A ls o, th e
ri gh ts a nd d u t ies ar e a va i l ab l e i n N CC`s õ ig us ed ja k o hus t us ed on v as t a v a lt
te e nus te l e ja k li e nd i gru p p id e le p is ut
we bs it e.
er in e v ad / er i ne v a lt s õn as ta tu d . P arak u
T he p ers o ns s er v e d a nd th e ir f am i l y es in e b õ ig us te pu hu l ka s is u lis i
m em bers dem o ns tr at e d th e ir k n o wl ed g e er in e v us i, mis ei tu n du o l e v at
of th e r i g hts an d d ut i es t hr ou g h t h e põ hj en d at ud . Sel p õhj us el va a da ta
i nt er v ie ws . õ ig us ed j a k oh us t us ed ü l e .
A ls o , in t er n a l a u d it in c l ud i ng th e is s ue
of t h e i ntr od uc t io n o f th e r i g hts a n d
du t ies t o th e p er s on s s er v ed a n d o n
tak i ng i n to ac c o un t th e ne e ds of t hem .
has be e n c on d uc t e d i n N CC r ec e nt l 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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
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T here is c om pr e he ns i v e an d ac c es s ib l e Un l ik e in V ilj a nd i H os p i ta l`s m ai n
c om pl a in t m ana g em en t s ys t em in we bs it e, t h e we bs it e of NCC d oes n ` t
V i lj a n di H os p it a l. i nf orm abo ut a l l p os s i bi l i ti es t o s u bm it
c om pl a in ts a n d pr op o s a ls ac c ord i n g t o
T here ar e pr oc e d u r e f or h an d l in g
th e hos p it a l`s “ Pr oc ed ure of Com p la i nts
c om pl a in ts th at is i n d ic a te d i n NC C`s
an d Pr o pos a ls ” (f . e. us in g r es pec t i ve
Q u al i t y S t an d ar d a nd d es c r i b e d in box es i n u n it or s ub m it th e c om pla i n t
hos p it a l`s “ P r oc e dur e of C om pl a in ts a nd
ora l l y) ref err in g only to the b od y
Pr op os a ls ” . Ac c or d i n gl y, i t is pos s i b le to
m anag i n g c om p la i nt s (m ana gem en t).
c om pl a in us i ng t he b o x es of c om pl a in ts T heref ore , t h ere is pr op os a l t o pr o v id e
an d pro p os a ls in e v er y u n it of t he
s hor t i nf orm at io n i n NC C`s we bs i t e o n
hos p it a l, s en d i ng an e - m ai l or le tt er , or
d if f ere nt a nd m o re us er - f r i en d l y
v i a f orm i n h os pi t al ` s we bs it e. pos s i b i li t ies t o s u bm it c om p li a nc e ( in
ad d it i o n to t he d oc um en t of th e
All c om pl a in ts ar e d ea l t wi t h an d
“Pr oc e d ur e of Com pl a i nts a nd
ans we re d dur i n g c er ta i n p er i od . T he
Pr op os a ls ”) .
proc e d ure s t a tes r es p ons i b i li t i es
c onc er n in g t he c om p l a in t ha n d l in g. An d
Er i ne v a lt V i lj a n d i Ha i g la v e eb i
th er e is a r e g is t er f or c om pla i nts i n t h e
pe a l eh es t , ei k irj el d a ÕHK v ee b i le h t
hos p it a l. ha i g la „ K a eb us te ja e tt e pa n ek ute
k orras “ t oo d ud v õ i m alus i k li e nt i d el t
Dur i n g t h e i nt er v i e ws i t was c o nf i rm ed
k aeb us t e k og um is ek s , j ät tes m u lj e , e t
th at s t ak eh o ld er s ar e a war e of t he r ig ht
k aeb us e es i t am is ek s o n a i n us v õ im al us
to s u bm it a c la im in c as e of a ne e d b ut
pö ör d ud a ots e ha i g l a j u ha t us e või
s er v ic e us er s an d th e ir f am i l y m em bers
k aeb us e la h en d us e g a r a hu l o lem at us e
pref er s o l vi n g pr ob l em s thr o ug h
pu h u l te is tes s e i ns t i tu ts io o ni d es s e .
d is c us s i on as t he y f in d the
S ee p äras t e tt e pa n ek k aj as ta d a l ü h id a lt
c om m unic a ti o n wi th s er v ic e pr o v i der
ka Õ HK ve e bis li hts am ai d ja
eas i er.
k lie n d is õ br a lik um ai d v i is e k ae bus t e j a
T he NC C`s we bs it e i n f or m s the s er v ic e et te p an ek ut e es it am is ek s .
us ers a bo ut ot h er i n s ti t ut i ons t o s e n d
th e c om pl a in t in c as e n ot s at is f ie d wi t h
s o lu t io n of th e c om pl a i nt in t h e hos p it a l.
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 .
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Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he s e lf - d et er m in at i on r e la t ed
pr inc i p les ar e d es c r i b ed in t h e Q u a li t y
St a nd ar d a nd i n c as e of e ac h s er v ic e
us ers in t h e ir i nd i v i d u a l p la ns .
E v al u at i o n on s e lf - de t er m in at i on is
c arr ie d o ut t hr ou g h i n di v i d ua l p l a ns ,
s er v ic e us er s a t is f a c ti o n s ur v e y an d
m onit or i ng of c om p la i n ts . D is c us s i o n o n
Hos p it a l h as l au nc he d as p ar t of
In d i v id u al P l an s p ec ia l s h e et f or
m eas ur in g l if e qu a l it y of p er s o ns s er v ed
(he a lt h , s oc i a l b ac k gr ou n d, m oo d, f re e
tim e, i nt er es ts .. ..) a n d i t is e v a l ua te d
per i o d ic a l l y.
It b ec am e e v id e n t t hr ou g h th e
i nt er v ie ws th a t t h e s t af f s up p or t e d th e
ri gh t to s e lf - de t er m in a ti o n of c l ie nts an d
th e p ers ons s er v ed wer e h a nd l e d wit h
res p ec t.
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
22
Sh
T he n ee ds of s up p or t ar e d et ec t e d i n
i nd i v i du a l m ee ti n gs wi t h the pers o n
s er ve d and the ne e ds ar e as s es s e d
c on t in u ous l y i n t he i nd i v i du a l p l an n in g
proc es s . NC C` s s t af f a ls o c oo p era t e s
wi t h l oc a l g o v er nm e nt s i n t ha t m at te r.
P ers o ns s er v ed ar e i nf or m ed th a t t h e y
ha v e r ig h t to ap p l y f or r e p lac em en t of
s up p ort p er s o n.
T he is s u e is c o v er ed i n “ L it t le H e lp er”
m anua l .
T he p erf or m a nc e i n f ac il i ta t in g p ers o ns
s er ve d i n h a v in g ac c es s to a d v oc a t es
an d / or s u pp or t in g p er s ons is e v a lu at e d
an n ua l l y an d r e p or t e d in the a nn u a l
ac t i v it y r ep or t of N CC .
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
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he p ri nc i pl es to r es p ec t a nd as s ur e t h e
d ig n it y of th e p er s on s s er ve d, pr ot ec t
th em f rom und u e risk and pr om ot e
s oc ia l j us t ic e ar e d oc um ent e d in P o l ic y
on Et h ic s .
M in ut es of m ee t in gs wher e t h is p ol ic y
23
Sh
has b e en p r es e nt e d to s t af f an d
d is c us s e d wh er e s ho wn ( i nc lu d i ng
s i gn at ur es of eac h s taf f m em ber on
be i n g a war e of t h e P o l ic y of Et h ic s ) .
P ol ic y of Et h ic s is a ls o pr es e nt e d i n
NC C`s we bs it e a n d i nf o s ta n ds .
An im por t an t m eas ur e t h at is
em phas i ze d is t h e p a r t ic ip a ti o n of f am il y
m em ber or n e utr a l pe r s o n in all
ac t i v it i es wi t h u nd er ag e c l i e nts and
“d if f ic u lt ” c l ie n ts .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he po l ic y an d pr oc ed ur e t o pre v e nt
ph ys ic a l, m en t a l a n d f in anc i a l ab us e of
pers o ns s er v e d is s t at ed i n t he P o l ic y of
Et h ic s .
NC C e va l u at es th e ef f ec t i ve n es s of its
pre v e nt i o n ac t i v it i es us i ng s pec i a l
f ee db ac k s h ee ts ( s a tis f ac t i on s ur v e y)
f or pers o ns s er v e d a n d f am il y m em bers /
s up p ort i n g p er s o ns , dr a ws up a
s um m ar y an d r ef l ec ts th e r es u l ts in t he
an n ua l ac t i v it y r e p or t .
T he r es ul ts of s ur v e ys ar e d is c us s e d i n
24
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s taf f m eeti n gs a nd in C li e nt Bo ar ds
m eeti n gs .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Ye ar l y r is k as s es s m en ts of t he wo rk
p lac e h a ve be e n c on d uc t e d, re l at e d
ac t i on pl a ns c r e at e d , an d r e gu l ar f ir e
dr il ls in V i lj a n d i H o s p it a l have be e n
c on d uc t e d. D ue to s e ver a l b u il d i ngs
th er e ar e m an y p la ns , r e g ul a ti o ns a n d
proc e d ures t o e ns ur e t he s af e t y of s taf f ,
s er v ic e us er s a n d th e i r f am il y m em bers .
S af et y r ul es and pr i nc ip l es ar e
i nt egr a te d i n t he s er vi c e pr oc e d ur es .
Dur i n g t he i n ter v i e ws was v a l id a te d t h a t
he a lt h a n d s af et y i s e ns ur e d a n d is
im por ta nt t o p ic i n th e or g a n is a t io n .
B es i d es , V i lj a n di Hos p it a l tr a ins i ts s t af f
work i n g wi t h per s o ns wit h a g gr es s i v e
be h a v io ur t o ac t in no n v i ol e nt wa y i n
c rit ic a l s i tu a ti o ns , to e nh a nc e bo th
s af et y of em pl o ye es , p er s o ns s er v ed
an d th e ir f am i l ies a n d c ar e tak er s , an d
d ig n it y of p er s o ns s er v e d ( V ER G E
proj ec t ).
25
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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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he pri nc i p les , v a lu e s a nd pr oc ed ur es
in s er v ic e d e li v er y ar e d es c r ib e d in
P ol ic y of Et h ic s an d p r es e n te d i n N CC`s
we bs it e an d i t` s un i ts inf or m ati o n
s ta n ds .
Pr i nc i p l es a nd va l u es of s er vic e d e l i ver y
are als o d is c us s e d i n s taf f m eet i ngs
(m inu tes wer e pr es e n t ed) .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
26
Sh
T he p o l ic y a n d pr oc e dur es f or as s ur in g
c onf id e nt i a li t y r eg ar d i ng th e pers o ns
s er ve d an d s e r vic e pr o v id e d t o th em are
ge n er al l y d ef i ne d in NC C` s Q u a l it y
St a nd ar d and m or e s pec if ic a l l y in
NC C`s Co nf i d en t ia l i t y Po l ic y, an d in
hos p it a l`s P r oc e dur e o f De l ic at e Da t a.
T he pr i nc ip l es a r e r e v i e wed wi t h s t af f
an d s er v ic e us er s r e g u lar l y.
In th e i nt er v ie ws t he s er v ic e us ers
i nd ic at e d t h at t he y a r e a war e of t he ir
ri gh ts , inc l u d in g r i g ht f or c onf i d en t ia l it y
of d a ta .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he nec es s ar y r o l es a nd r es p o ns ib i l it i es To s u pp or t po t en ti a l a nd new
are def in e d i n V i lj an d i Hos p it a l`s a n d c l ie n ts / th e ir f am il y m em bers in f i n d in g
NC C`s s t a tu tes , J ob M a na g em ent th e ri g ht pers o n t o c o nt ac t wi t h i n c as e
Ru l es , N CC S oc i a l C ar e Un i t`s of c er t a i n is s u es , i t`s a d v is a b l e to
P ers o n ne l P o lic y S ta nd ar d, an d in j ob i nd ic at e r o les a nd r es po ns i bi l i ti es of a l l
des c r i pt i o ns of em pl o yees c on t ac t p ers ons bro u gh t o ut in N CC `s
we bs it e . S o f ar, t h e r es p o ns ib i l it i es ar e
T he re l at e d r o l es an d r es p ons i b i l it i es
s ho wn o nl y in c as e of s om e s taf f
are pr es e nt e d i n de ta i l in N C C` s s er v ic e m em ber.
de l i v er y pr oc es s es .
S el l ek s , et te e nus e l e s oo v ij at e l j a uu te l
k lie n ti d e l v õ i n en d e l ä he d as t e l o lek s
27
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Re l e va n t i nf or m at io n i s a v a il a b le in t h e v õ im al ik s el ge l t ar u s aa d a, k el l e p o o le
NC C`s we b pa g e. B es id es , t wo m ill is te k üs im us t e ga p öö rd u da , on
c oor d i na t or s f ac i l it at e p ot en t ia l s er v ic e s oo v i ta v n äi d at a ära k õ i gi ÕHK
us ers in f i nd i n g a p pr o pr i at e s er v ic e v ee b i le h e l v ä lj a t o od ud t ö öt aj at e ro l l id
pro v i d er ( a nd e ns ur i ng t h at t he y ar e (m ill is te k üs im us t eg a k el l e po o le
e li g i bl e f or s er v ic es N CC pr o v i des ) . pö ör d ud a). S e n i o n t ö öt aj a t e ro l l i d vä lj a
to o du d os ad e am et ik o ht a de p u hu l .
In f irs t m e et i ng b et we e n c li e nt a nd
s pec i a l is t e v er y c l i e nt g ets c on tac t
pers o n (s u p por t in g p er s o n) wh o h e lps
h im /her d ur i ng t h e s er v ic e per i o d.
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 o f s er v ic es .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
V i lj a n di H a ig l a an d i t ` s NC C work s i n
c l os e c o o per a t io n wi t h m an y p ar tn ers .
Pr i nc i p l es of p ar t n er s h i p ar e
doc um en te d i n N CC` s Q ua l it y St a nd ar d.
In s er v ic e pr o v is io n t h e y c o o per a te wi t h
l oc a l m un ic i pa l it i es , ot h er s oc i a l c a re
s er v ic e pr o v i der s , un e m plo ym e n t of f ic e ,
f un di n g a ge nc y ( m os t l y wi t h loc a l c as e
m anag er) , l oc a l s c h o o ls , d a y c en tres ,
c u lt ura l ins t it ut i o ns , c hur c h es etc .
V i lj a n di H ai g l a h as c on tr ac ts wi t h
f in anc i n g b od i es f or s er v ic e pr o v is i on
an d in s om e c as es c o ntr ac ts wi t h o t her
i ns t it u ti o ns a gr ee i n g in c oo p era t i on
us ef ul f or b ot h s id es .
28
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W ith c oo p er at i on par t ner s v ar i ous
ac t i v it i es ar e or g an is ed to pr o v i de
be tt er s er v ic es a n d e nr ic h t he d a ys of
pers o ns s er v e d. T he s e ac ti v i t ies a ls o
s er ve t h e ne e ds an d ex p ec ta t io ns of
s oc ie t y.
NC C s er ve s a ls o as th e tr ai n i ng bas e
f or s tu d en ts f r om the H ea l t h Ca re
Co l l eg es of T ar t u a n d T al l in n , T al l in n
Un i v ers it y and T ar tu U ni v er s i t y, and
a ls o f rom Mon dr i aa n Co l l eg e of L eu v e n,
Ne th er l an ds ( r es pec t i v e l y, NC C` s s t af f
m em bers ha v e pos s i b i l it y to p ar tic i p at e
i n s tu d y v is i ts to N et h er la n ds ) .
B es i d es , N CC s h ar e s it`s k n o wl ed g e
an d ex p er ie nc es wi th o t her s oc ia l
s er v ic e p ro v i de r s .
A dd e d v al u e of its p ar t n er s h i p is
e va l u at ed by m ee t in gs wit h p art ne rs
an d wi th s taf f , and f eed b ac k s he ets
(an n u al l y) , a nd r ef l ec t e d in a nn u a l
ac t i v it y r ep or t.
27 . T h e s oc 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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
29
Sh
T he pr i nc ip l es of in v o l v em ent ar e
des c r i b ed i n N CC ` s Q u al i t y St a nd ar d.
T he pers o ns s er ve d , p ur c h as er s an d
ot h er s t ak eh o ld er s ar e in v o l ve d i n t h e
de v e l opm en t of N CC ` s s er v ic es thr o ug h
m eeti n gs a nd s ur ve ys .
In N CC , f ee db ac k s he e ts of s er vic e
us ers an d f am il y m em ber s ar e us e d t o
ge t i n pu t t o t he s er v ic e d e ve l opm e nt
proc es s . Bes i d es , input is c o l l ec t e d
thr o ug h c li e nts m ee ti n gs a nd c l i en t
bo ar ds (5 bo d i es ac c or d i n g t o s er v ic es
an d c l i e nt gr o ups ) m eet i ngs .
In d e v e lo p i ng s e r vic e s the y c oo p era t e
wi t h f u nd i n g bo d i e s , m un ic ip a l it i es ,
un i v ers it i es , a n d c o l l eg es , o t her s oc i a l
s er v ic es p r o v i de r s , f or e ig n p ar t n ers .
F.e . V i lj a n d i H a i gl a is l e ad i n g the
s er v ic e d e v e lo pm en t pr oc es s r e g ard i n g
dem en t ed el d er l y i n Es t on i a, hos t in g
res p ec ti v e r o u nd t ab l es of d if f er en t
s er v ic e pr o v id er s an d ot h er
s tak e ho l de r s to d is c us s n e eds a nd
m etho d o lo g y of s er v ic e pr o vis i o n, e tc .
T he p ar tn er s s h o we d h ig h a ppr ec i at i on
on N CC ac t i v i ti es a nd f l ex i b i l it y, a n d
i nn o v at i on in pr o v i di n g s er v ic es
nec es s ar y f or t he i nh a b it an ts of
s urr ou n di n g c om m unit i es and wh o l e
Es t o n ia .
Co o per a ti o n r e l at i o ns an d ac t i v it i es a re
ref l ec t e d i n th e a n nu a l ac t i vi t y r e po rt .
30
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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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he pr i nc i p l es a nd p r oc e d ur es f or th e
i n vo l v em ent of p er s o ns s er v e d in th e
s er v ic e m a na g em ent ar e d es c r i be d i n
NC C`s Q u a li t y S t an d ar d, s er v ic e
de l i v er y p r oc es s es , an d in “L i tt l e
As s is t a nt” m an ua l .
T he m ain m eth o d f or i nc l u d in g p ers ons
s er ve d is in d i v id u a l p l a nn i n g (i nc l
i de nt if yi n g c l i en t` s n ee ds , pl a n ni n g
s er v ic es , a nd e va l ua t i on of s er v ic es ).
T he c r it er io n wa s ve r if i e d as s a t is f i ed
a ls o t hr ou g h ex p l or i ng c l i e nt wo rk
doc um en ta t io n a n d t hr o u g h i nt er v ie ws
wi t h s taf f a n d c l i en ts a n d th e ir f am i l y
m em bers .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
31
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T he m eas ur es , ac t i vi t i es a n d p o l ic y f or
c l ie n t p ar t ic i p at i o n ar e a gr e ed wi t h
pers o ns s er v ed a n d/ or t he ir f am il y
m em bers . The c li e n ts r i g hts to be
i n vo l v ed in t he m an ag em ent of s er v ic es
are d es c r i be d i n t h e r i gh ts an d d ut i es of
th e pers o ns s er ve d a nd N CC` s Q u a li t y
St a nd ar d.
T he e va l u at i on of pa r tic i p a t i on p o l ic y,
proc e d ures a n d ac t i v it i es ar e c arr i ed
ou t a nn u a ll y bo t h on i n di v i d ua l
(f ee db ac k f or m s / s atis f ac t i on s ur v e y)
an d on c o l lec t i ve bas i s ( doc um en te d in
th e m i nu tes of c l i e nt b oar d s m eet i ngs ).
In t h e f ram es of s atis f ac t i on s ur ve y,
s at is f ac t io n l e v e l wit h par tic i p at i on an d
i n vo l v em ent ar e m eas ur e d .
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
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Em po werm en t of p er s ons s er v ed is a n
i nt egr a l p ar t of s er v ic es de l i v er y.
Re l at e d ac t i v it i es wer e e v i d enc e d in
s er v ic e d el i v er y pr oc e s s es a n d br o ug h t
ou t i n in ter v i e ws wit h s taf f an d p ers ons
s er ve d . NC C` s Q u a l it y St an d ar d pro v i d e
f ram ework f or em po we r m ent of s er vic e
32
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us ers . C AR e ( Com pr e he ns i v e Ap pr o ac h
of Re h ab i l it a ti o n) m et ho d o lo g y is us e d
i n NC C.
B es i d es p ar t ic i pa t io n in i n di v i d ua l
p la n ni n g and e v a lu at i o n, an d
par t ic ip a ti o n i n c l ie n t bo ar ds , c l i en ts ar e
pro v i d ed dif f er e nt op p or t u n it i es to
de v e l op t h e ir s k il ls an d p ar t ic i p at e i n
c u lt ura l or o th er c om m unit y e v e nts , t o
do ac t i v it i es s im i lar t o wor k , e tc .
One ex p er ie nc e ad v is or is pr o v i d i ng
s up p ort to s er v ic e us er s a n d 5 s u p po rt
gro u ps f or d if f er e n t c l ie n t gr ou ps m eet
i n NC C (l e ad e d b y pe r s ons wi t h s im i lar
ex p er i enc es o n v o l un t ar y b as is ) .
NC C h as d e ve l o p ed p er f or m anc e
i nd ic at ors to m eas ur e t he r es u lts in
em po werm en t of per s o ns s er v ed .
Ac hi e v e d ta n g ib l e r es u l ts on
em po werm en t ar e pr es e n te d in an n ua l
rep or ts of NC C, f . e. da ta on pers o ns
s er ve d wh o ge t an d m aint a i n j o b, o n
c h il dr e n wit h b eh a v i our a l dif f ic u lt i es
wh o c o nt i nu e t h eir s tu d ies in norm a l
s c ho o l, r es u l ts r e l at e d to i nd e pe n de nc e
of s er v ic e us er s .
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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
33
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Str e n gt hs Im pro vem e nt & de v e lo pm ents
Em po werm en t of p er s ons s er v ed is a n
i nt egr a l p ar t of s er v ic es de l i v er y.
Pr i nc i p l es of em po we r m ent are
reg u l at e d i n NC C` s Q u al i t y S ta n dar d .
Re l at e d ac t i v it i es wer e e v i d enc e d in
s er v ic e d el i v er y pr oc e s s es a n d br o ug h t
ou t i n in ter v i e ws wit h s taf f an d p ers ons
s er ve d .
T hrou g h in d i v id u a l p la n n in g an d
e va l u at i on pr oc es s ( e v a lu at i o n/f e e db ac k
s he e ts ) th e a ppr o pr i at e em po werm en t
m eas ur es ar e de te r m in e d .
Em po werm en t of c l ie n ts is als o
m onit or e d in c o l lec t i v e le v e l t hr o ug h
e va l u at i on s h e ets an a l ys i s .
St af f m em ber s ar e t r a in e d t o s u p p ort
th e em po wer m en t of s er v ic e us ers a nd
th e s ubj ec t is d is c us s ed d ur in g NC C`s
s taf f m eeti n gs . F .e . C AR e m eth o do l o g y
tra i n in g, tr a i n in g of em po wer i n g
c om m unic a ti o n.
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
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
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NC C has an o ver v i e w of th e n ee ds of In t h e l oc a t io n m ap i n NC C`s we bs it e o n
th e p ers ons s er v ed an d t h e n ee ds of th e loc a t io n of NC C un i ts ` bu i l d in gs
po t en t ia l pe r s o ns s er v ed ( wa i t i ng l is ts , (an d t he b u il d i ngs of Ps yc hi a tr y C l i n ic )
c l ie n ts ` f e e db ac k , m eet i ngs wi th i n J äm ej a la Park t h e s tr ee t n am es ar e
c oo p er at i on par t ner s , m inu tes of m is s in g, a ls o in d i c at i ons to the
m eeti n gs of c l i e nt bo ar ds , i n d i vi d u al bu i l d in g s wh er e c ert a in s er v ic es ar e
p la ns of p er s o ns s er ve d , i nc lu d in g of f ere d are m is s i ng . T o f ac i l it at e th e
c on t in u it y n e eds , g en er a l po p u la t io n f in d in g of p l ac es in J äm ej a la p ark it is
s ta t is t ic s ). ad v is a bl e t o ins ta l l s im pl e s c hem e to
th e dr i v e wa y. S im i la r s c h em e c o u ld b e
V i lj a n di H os pi t al of f e r s i ts s er v ic es a t
pu b l is h e d in N CC`s an d h os p i ta l ` s
d if f ere nt bu i l d in gs of th e h os p it a l.
we bs it es . T h e l ink to th e h os p it a l m a i n
Curr e nt l y, the l o c at i on of th e bu i l d in g`s s c h em e an d b us s c he d u le in
reh a b i li t at i on s er v ic e pr o v is i o n a n d t wo
m ain we bs it e c o ul d b e ad d ed / li nk ed t o
un i ts of s pec i a l c ar e ar e s i tu at e d i n
NC C`s webs i te to pro v i d e l oc at i on
l arg e m a in b u i ld i ng of th e h os p i ta l , th e i nf orm at io n m or e us e r - f rie nd l y.
res t of th e N CC ` s s e r v ic es is pr o v id e d
ne ar b y t he m a in bu i l d i ng bu t in s m al l er J äm ej a la p arg i s as u va te
bu i l d in g s a n d p e ac ef ul en v ir o nm ent t h at ps ü h h ia at ri ak l i in ik u ja ÕHK ük s us t e
is m ore s u it a bl e f or c ar e a n d s p ec ia l as uk o hak a ar di l Õ H K v ee b is pu u du v a d
c are s er vic es . All bu i l d in gs of the tä n a va n im ed ja v i it ed k o nk ree ts e te
V i lj a n di H os p i ta l ( ex c ep t the N CC `s te e nus te p ak k um is e
bu i l d in g f or s oc i a l c ar e a nd n urs in g k oht ad e le / ho o ne t el e . S e l lek s , et
s er v ic es ) ar e r e l a t i ve l y o u t da t ed b ot h in es m as e l k ül as t aj a l ol ek s s el l es
term s of be i n g g oo d work in g as uk o has o l e va i d ük s us i l i hts am le i d a,
en v ir o nm ent , an d l oc at i on and on s oo v i ta v p a i ga l d ad a t err it o or ium i
en v ir o nm ent f or g et t in g s e r vic es ) . s is s es õ i du t ee l e h o on et e s k eem ni ng
T heref ore , t he h os p i t a l h as s t ar t e d th e l is a d a t ä ie l ik s k eem ka ve e b il e he l e.
p la n ni n g p r oc es s f or ne w m ai n b u i ld i n g L is ak s võ ik s Õ HK v ee b i l is a da li n g i
i n m ore ac c es s ib l e l o c at i on in Vi lj an d i ha i g la p e ah o on e s k e e m ile , m il l e l on i nf o
Ci t y to pr o v id e h ea l th c ar e a nd os a d e Õ H K ük s us t e p a ik nem is e k oh ta j a
reh a b i li t at i on s er v ic es . Bes i des , a n o th er bus s i d e s õ i d up l a an i l e. S e l lis e lt o l ek s
de v e l opm en t pr oj e c t h as b ee n in i ti a te d, Õ H K t e en us t e p ak k um is e as uk oh a inf o
to ha v e c o nt em por ar y s m all b u i l di n gs i n l ei t a v üh es t k oh as t.
J äm ej a la th at c o ul d s up p or t be tt er ,
c om m uni t y b as e d s er v ic e pr o v is i o n .
In s om e c as es if c li e nt is no t a b l e t o
c om e to th e or ga n is at i on t h en
s pec i a l is ts ar e vis i t in g t hem a t th e ir
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hom es . A ls o if c l ie nt n ee d
tra ns por t at i on , t h en i t is or g an is e d b y
s er v ic e p ro v i de r .
O n t he NC C` s we bs i t e a g oo g l e p ho t o is
pres e nt e d s h o wi n g the l oc at i o ns of
d if f ere nt u n its . I n h os p it a l m ain we bs i t e,
th e s c hem e of t he h os p i ta l` s m a in
bu i l d in g ( loc at i o n of u n its ) , i ns tr u c ti o ns
to c om e a n d p u b lic tr ans p or t s c h ed u l es
are pro v i d ed .
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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
V i lj a n di H a ig l a c o op er at es wi t h f u nd i n g
bo d i es a n d has d et e r m ine d t h e ne e ds
an d ex p ec ta t io ns of th em . Co ntr ac ts
ha v e b e en s ig n ed wi th f un d i ng b o d ies .
T he n e eds of d if f er en t s t ak eh o l ders
ha v e b e en d is c us s e d dur i ng m ee t in gs
an d da i l y c oo p er at i on ( thr o ug h e - m ai ls ,
ph o ne ).
B es i d es , t he n ee ds a nd ex p ec t at i ons of
f un der an d o t her im po r ta nt s tak e ho l d ers
are as c ert a i ne d us in g s pec i a l f e ed b ac k
qu es ti o nn a ir es an d ar r an g in g ye a r l y
rou n dt a b le - m ee t in gs wit h p ar t n er s .
T he s uc c es s an d r es u l ts of t he ex is t i ng
36
Sh
s er v ic es h a ve b ee n d et er m in e d a n d ar e
des c r i b ed in A n n ua l R ep or ts and in
i nd i v i du a l l e ve l i n i n d i vi d ua l p l ans of
pers o ns s er v ed .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
A l l re l at e d i nf or m at i o n is d oc um ent e d i n
i nd i v i du a l p l ans of per s o ns s er v ed
wh ic h was v er if ie d b y ex am p les of c l i en t
doc um en ta t io n s e en d ur in g th e s i te
v is it .
Ne e ds of p er s o ns s er v ed ar e d is c us s ed
an d a gr e ed f r om th e m om ent c li e nts are
en t eri n g t he s er v ic e an d a r e m on it or e d
c on t in u ous l y d ur i ng t h e s er v ic e pr oc es s .
S er v ic e us er s h a ve I nd i v i du a l Pl a ns –
Q u al i t y of Lif e m ea s ur em e nt (C A R E
m etho d o lo g y) , c l i en t` s pr of i l e
des c r i pt i o n an d c l i en t´ s s p ec if ic g o als
(des ir e d s it u at i ons , overall g oa ls ,
s pec if ic m eas ur ab l e obj ec t i v es ,
m etho ds ) . T he c l ie n t an d/ h er s up p ort
pers o n s i g n th e i n di v i d ua l p l a n.
T he proc es s i ts e lf is d es c r ib e d i n t h e
NC C`s s er v ic e de l i v er y p r oc es s es .
37
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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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e p ro v i d e rs m eet t h is
c rit er i on t h e EQ U A S S As s ur a nc e c er tif ic a t io n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
S er v ic e us er s of N CC ha v e an i n d i vi d ua l
p la ns th a t c on ta i n th e d es ir e d s i tu at i o n
of t he per s o ns s er v e d, g o als ,
m eas ur ab l e o bj ec t i v es , in te r ve nt i o ns ,
an d p ers on n e l r es po ns i bl e .
E ac h In d i v id u a l P l a n is a gr ee d b y t he
pers o n s er ve d or h is / her g u ar d i a n a n d
s up p ort i n g per s o n.
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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he m ai n s er vic e d e li v er y pr oc es s es are
i de nt if ie d a n d wr i tt en in NC C` s Q u a l it y
St a nd ar d an d m or e s p ec if ic proc es s
des c r i pt i o ns f or NC C` s r eh a bi l i ta t io n,
s oc ia l c ar e a n d s pec i a l c ar e s er v ic es .
T he m ai n s er vic e d e li v er y pr oc es s es are
reg u l ar l y r e v ie we d in t he f r am es of
38
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i nt ern a l a ud i t pr oc e s s es an d in the
NC C`s s taf f m eet i n gs .
T he m ai n s er vic e d e li v er y pr oc es s es are
i n l in e wi t h NC C` s v i s i on , m is s io n a nd
qu a l it y p ri nc i pl 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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
V i lj a n di H os pi t al r ef v i e ws t he s er v ic e
de l i v er y pr oc es s es t hr o u gh r eg u l ar
i nt ern a l a u di ts . C or r es p o n di n g a ud i t
rep or ts ar e c om pos ed . In c as e of n e ed
ex t er na l a u d its ar e d e l i ver e d
(m ana gem en t d ec is i o n ) .
Res u lts ar e d is c us s e d dur i n g t h e a nn u a l
p la n r e v ie wi n g pr oc es s a nd r ef lec t ed i n
an n ua l r ep or t of t he N CC .
Re g ul ar m ee ti n gs , c h ec k s and r e v i e ws
are c on d uc t e d to a s s ur e m ai n ta i n in g
c on tr ol o ver t h e d el i v e r y of s er v ic es .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
39
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Str e n gt hs Im pro vem e nt & de v e lo pm ents
V i lj a n di H ai g l a e ns ur e s th at t he p ers o ns
s er ve d can ac c es s a c on t in u um of
s er v ic es as n ee ds o f per s o ns s er v e d
are e v a lu a te d an d d es c r i be d in
i nd i v i du a l p l a ns . Also c l i e nt bo ar ds
d is c us s t he is s u e in t h e ir m ee ti n gs
(m inu tes ) .
In c as e t h er e is n o p lac es /r es o urc es
im m ed ia te l y a v a i la b l e, NC C h e lps t h ei r
c us t om ers b y p u tt i ng t hem i n wa i t in g l is t
an d he l ps t o f i n d a c t i v it i es / c ar e o u ts id e
of hos p it a l. I n c as e o f tem por ar i l y f ree
p lac es in NC C, th e y pr o v i d e c ar e or
s pec i a l c ar e s er v ic es t o p er s o ns wa it i ng
p lac e to o th er s oc ia l c ar e i ns t it ut i on . In
c oo p er at i on wi th ot h er s tak eh o ld ers an d
par t ners , NC C a ls o t a k es c ar e t h at th e ir
pers o ns s er ve d c ou l d get n e c es s ar y
s er v ic es a nd s u pp or t af ter th e en d of
NC C`s s er v ic es .
T he m eas u r es to e ns ur e c o nt i nu i ng
s er v ic e de l i v er y ar e d es c r ib e d i n N CC `s
Q u al i t y St an d ar d. E v al u at i on of
c on t in u i ng s er v ic e d e li v er y is c arr i ed
ou t by a n nu a l p la n ni n g/r e v i e wi ng
proc es s a n d t he is s ue is r ef l ec te d i n
an n ua l r ep or ts of N CC .
F.e . i n c as e of n ee d f or h ea l th c are
s er v ic es , c l i en ts of N CC ar e e as y to g et
he l p in ot h er d e par t m ents of V i lj an d i
Hos p it a l. As th e h os p it a l pr o v i d e s wi de
ran g e of h i g h - l e ve l ps yc h i atr y
tre atm e nt , t h e m os t im p or ta nt h er e is
th at t h e s er v ic e of ps yc h ia tr is t is eas i l y
40
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a va i l ab l e f or s oc i a l c ar e c li e nts , if
ne e de d .
.
In c as e of a n e ed th er e is a l wa ys
op p ort u n it y to c oo p er a t e wi th loc a l
s c ho o ls , m un ic ip a l it y, d a y c en tr es an d
un em pl o ym e n t of f ic e t o m ak e it pos s i b le
f or th e c l i en ts t o ge t a ll t he s er v ic es
th e y n e ed . L o ng - t er m c oo p er a t io n wi th
th es e o rg a nis a ti o ns en s ur e t h e e as i nes s
of c om m unic at i on an d f in d in g s o l ut i ons .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
NC C us es c l ie nt - c en tr ed h o l is t ic As th er e ar e on l y f e w ( 4) s p ec ia l is ts in
ap pr o ac h , wh ic h aims to im pr o ve th e or g a nis a ti o n wh o ha v e p as s ed f ul l
c l ie n t`s q ua l it y of lif e. As a p art of tra i n in g of C A Re m etho d o lo g y an d
i nd i v i du a l p l an , N CC us es s p ec i a l f orm th er ef or e h a ve t h e f u ll c om pet e nc e t o
bas e d on C A Re m eth o do l o g y to c on d uc t e v al u at i on s wi th C AR E
m eas ur e qu a l it y of l if e ( i nc l t h e is s ues m etho d o lo g y, to c ont i n ue tr a i n
of he a lt h , f r ee t im e, f in anc i a ls , f am i l y, ad d it i o na l s pec i a l is ts i n a l l N CC`s un i ts
s e lf - es t e em , ac ti v i t ies ) . pro v i d i ng s oc i a l s er v ic es .
T he pr i nc ip l es t o de t er m in e lif e q u al i t y K un a or ga n is a ts i oo n is o n a i n ul t ük s ik ud
are d es c r ib e d in NCC` s Q u a li t y (4) s pe ts i al is t id , k es o n lä b i nu d m ee t od i
St a nd ar d. tä i e lik u k oo l it us e, s u u da v a d l äb i v ii a
41
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T he q ua l i t y of l if e i n it i at i v es ` CA R E m et oo d ik al p õ h i ne v a i d h i nd am is i,
ef f ec t i ve n es s is m e as ur e d a n d r e por te d s i is k o ol i ta d a tä i e nd a va l t s p ets i al is te
i n i nd i v i du a l p l a ns . I n c o l lec t i ve l e ve l , k õig is ÕHK s ots ia a lt e en us e i d
th e qu a l it y of l if e is a ls o m on it or ed a nd os u t a va tes ük s us tes .
rep or te d i n a n nu a l r e p or ts .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he n ec es s ar y s k il ls an d c om pe t enc es
are d es c r i be d i n j o b d es c r ip t io ns . T hes e
are e v a lu a te d a nn u a ll y d ur in g
em pl o ye es per f or m an c e r e v i e w s a nd i n
s taf f s up er v is io n m ee ti n gs , a ls o dur i n g
work m eth o do l og y i ns tr uc ti o ns .
T rai ni n gs ar e pr o v id ed t o em p lo ye e s ,
wh ic h w as e v i d enc e d b y tr a in i n g re p orts
of NC C, i nt er v ie ws an d s t af f m eet in g
m inut es ( t hos e s taf f m em ber s wh o h a ve
par t ic ip a te d i n t r a i n in gs r ec e n tl y, s h are
th e ir k n o wl ed g e wi t h o th er s ) .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
42
Sh
V i lj a n di H os p it a l` s NCC s e ts i ts
obj ec t i v es i n A n nu a l P l ans of t he u n its .
Res u lts a r e r ep or te d i n an n u al ac t i v it y
rep or ts .
Ex t er n al r e v ie ws ar e m ade by t he
f un di n g b o di es in th e f r am es of
s up er v is i on .
Ex t er n al a u d its ar e a ls o c a r r ie d o ut i n
c as e of a n e ed .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
NC C g at h er s a n d d oc u m ents i nf or m at i on
reg ar d in g r es u lts of pr o v i d i ng s er v ic es
bo t h on in d i v id u a l a nd c o l l ec t i v e bas is .
T his i nf or m at i on is av a i la b l e in
i nd i v i du a l ac t i on p l ans , l if e q ua l it y
e va l u at i on s he e ts a n d f in a l e v a l ua t io n
rep or ts .
On c o l l ec t i v e l e ve l , the s um m ar y of
ac h i e v ed r es u lts a n d b en ef i ts of t he
rec e i v e d s er v ic es ar e als o m eas ur e d
(onc e a ye a r ) a nd pr es e n te d i n a n nu a l
ac t i v it y r ep or ts .
43
Sh
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) .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
NC C e v a l ua tes t he r es u l ts a n d ad d ed
v a lu e of i ts wor k dur i ng m ee t in gs a nd
thr o ug h s er vic e u s er s and o th er
s tak e ho l de r s ` s ur v e ys .
S er v ic e c o n tr ac ts wi t h f u nd er is
d is c us s e d an d e v a l ua t ed an n ua l l y.
In d i v id u al p la ns of s er v ic e us e rs ar e
reg u l ar l y e va l u at ed in c l ud i ng l if e qu a l it y
is s ue ( l if e q ua l it y e v a lu at i o n s h e e ts ,
i nd i v i du a l ac ti o n p l an s , f in a l e v al u at i on
rep or t) wh ic h e ns u r es th at a dd e d va l ue
of th e s e r vic es f or qu a l it y of l if e is
m onit or e d.
Inf orm at i o n o n bes t v a lu e f or s er v ic e
us ers a nd p ur c h as er s is a ls o
c om m unic a te d i n N C C` s we bs i te (t h e
reas o ns wh y t o c h o os e NC C` s s er v ic 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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
44
Sh
Str e n gt hs Im pro vem e nt & de v e lo pm ents
S at is f ac ti o n e v al u at i on in N CC is
c om pre he ns i ve . Q u a l i t y S ta n dar d s e ts
th e pr i nc ip l es f or as s ur in g a p pr o pr i at e
an d o bj ec ti v e m eas ur em ent of
s at is f ac t io n of s tak e ho l der s .
NC C or g an is es r e g u lar s ur v e ys to
rec e i v e f e e db ac k f r om the p ers o ns
s er ve d an d t h e ir f a m ili es ( i n c as e of
s er v ic es no t f u nd e d b y S oc i a l I ns u ra nc e
B oar d th e y ar e p ur c has er s ) . Sp ec i a l
f ee db ac k f or m s ar e d e ve l o pe d f or e ac h
tar g et gr o up .
T he is s u e of s at is f ac ti o n e va l u at i on is
d is c us s e d o n c l i e nt b oar ds m ee ti n gs i n
ord er to as s u r e a p pr opr i at e
m eas ur em ent .
In c as e s e r vic e us er s ar e n ot a b le t o f i l l
f ee db ac k s he ets , th e y ar e i n ter v i e we d
b y p ers o nn e l of NC C. A ls o i n ter v i e wi n g
of pers o ns s e r ve d b y th e m em bers of
c l ie n t bo ar ds ar e us ed .
T o g et o bj ec ti v e f ee d b ac k , af t er th e en d
of s er v ic e , in q u ir ies by p h on e wi th
s er v ic e us er s of h e a lt h c ar e s er vic es
an d r eh a b il i ta t io n s er v ic es ar e
c on d uc t e d in V i lj an d i H os p i ta l us i n g
ran d om s am pli n g ( c ur r en t l y in p i lo t
ph as e). B es id es , t her e is p os s ib i l it y to
s en d f e ed b ac k us i ng in te r n et f orm in
hos p it a l`s web p ag e .
A ls o t he s a t is f ac ti o n of ot h er
s tak e ho l de r s is e v a lu a te d b y us i ng
45
Sh
d if f ere nt m ea ns l ik e m eeti n gs , a n nu a l
rou n d- t a b le of p ar t n er s , and
qu es ti o nn a ir es .
T he is s u e is r ef lec t ed i n N CC` s a nn u al
rep or ts .
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 en ts
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
T he rec or ds on outc om e are
To in tr od uc e s h ort er and s im p ler
c om m unic a te d to s t ak eh o ld er s , s t af f
v ers io n of a nn u al re p o rt t o c om m unic at e
an d p ers ons s er ve d.
th e ac t i v it i es a nd r es u lts wi th p art n ers
NC C c om pl i es o nc e a ye a r a n nu a l an d s er v ic e us er s / t h ei r f am il y
rep or ts wh ic h is i ntr od uc ed in c li e nt m em bers , a nd to s h a re it thr o ug h th e
bo ar ds ` m ee t in gs ( m inu t es ) , s t af f NC C`s we bs i t e (a n a lt ern a ti v e c o ul d b e
m eeti n gs ( m i nu te s ) a nd o t her r el e v a nt pro v i d i ng t h e c or e res u l ts of NCC i n
s tak e ho l de r s ( ye a r l y par tn er s r o un d - we bs it e). T o i l lus tr at e th is i nf orm at i o n,
ta b le m eet i ng ) . NC C s e n ds an n u al it is ad v is ab l e t o inc l ud e c l ie nt s to ri es /
rep or ts to f un d er . R ep or ts inc l u de ex am p les t o dem ons t rat e NC C`s go o d
res um e of i n di v i d ua l ac h i e vem en ts of res u l ts (q ua l i ta t i ve da t a). T he las t
s er v ic e us er s . ap p l ies f or t he m ai n an n ua l re p orts , as
we l l.
O n i nd i v i d ua l l e v e l, l is t of d at a a n d f i n a l
e va l u at i on r e p or ts i nc lu d es pers o na l Et t ep a nek j a g ad a i ga - a as t as e lt i nf o t
perc e pt i o ns an d ac h ie v em ents . te e nus e s a aj a t e le / n en d e p er ed e le j a
par t ner i te l e ÕHK s aa v ut us t e ,
v ä lj ak uts et e j a ees m ärk id e k o ht a Õ H K
k odu l eh e l ja m uu d e k ana l it e k au d u,
k as ut ad es l üh em at ja l i hts am at
aas t aar u an d e v ers i oo n i. Se l l e
46
Sh
a lt ern a ti i v i n a t u ua k odu l e he l v ä lj a Õ H K
o lu l is im ad t u l em us e d . N im et at ud i nf o
i l lus t re er im is ek s on s oo v i ta v l is a da k a
k lie n d il u g us i d / n ä it e i d, m is n ä it a va d
ÕHK he a d t öö d, t ee n us e k as u ja
v äär t us t (k va l i ta t i i vn e i nf o) . V i im an e
k eht ib ka ÕHK nn pe am is e
aas t aar u an d e k o ht a.
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
NC C re p or ts i ts per f o r m anc e to f un d in g T he r ep or ts on NC C`s perf o rm anc e
bo d i es , s t af f , s er v ic e us e r s an d s ho u l d b e a v a i la b l e i n its we bs it e. ( S e e
purc h as ers s e nd i n g inf or m ati o n ( inc l a ls o c r it er io n 4 6. )
an n ua l re p or ts ) a n d d is c us s i ng r es u l ts
Õ H K k od u l eh e l e t u l ek s l is a da ar u an d e d,
i n m ee ti n gs ( m i nu t es ) .
et er in e v at e l hu v i ta tu d os a po o lt e l o lek s
O n a n i nd i v i du a l b a s is , ac h i e vem e nts v õ im al ik ne nd e ga tu t v ud a . (V t k a k rit.
an d p erc e pt i ons of s er v ic e us e rs ar e 46) .
d is c us s e d on i n d i vi d ua l bas is . On a
c o ll ec ti v e le v e l r es u l t s ar e d is c us s e d i n
reg u l ar c l ie n t b o ar ds ` m eet in gs a nd i n
m eeti n gs wi t h par t n er s . M i n ut es of
m eeti n gs ar e pr es e n te d.
Hos p it a ls a nn u a l r ep or t s ( i nc lu d i ng
ac t i v it y r e po r ts ) ar e a ls o a va i l a bl e on
hom ep a g e.
47
Sh
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.
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Co nt i n uo us im pr o v e m ent pr oc es s is
des c r i b ed i n N CC ` s Q u al i t y St a nd ar d.
T here ex is ts a P D A c yc l e in a n nu a l
p la n ni n g of im pr o v e m ent ac t io ns an d
it`s r e v ie wi n g pr oc es s .
T he m ai n im pr o vem en t p r oj ec ts wi t h
th e ir g oa ls an d r es u lt s ar e r ef lec t ed in
an n ua l p l a ns a nd r e p o r ts .
Q u al i t y im pr o v em en t pr oj ec ts ar e
doc um en te d .
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
Im pro vem e nt pr o gr am s ar e doc um en te d,
th e y i nc l ud e g o als an d r es pec t i ve
perf orm anc e i nd ic at or s . T h is was
v er if i ed thr o ug h ins p ec t i ng few
ex am p les dur i n g s it e v is it .
48
Sh
F.e . “I nt ro d uc t i on an d im pl em ent a ti o n of
th e V E RG E m eth o ds ( s p ec i a l
i nt er ve n t io n m eth o ds f or d ea l i ng wi t h
ag gr es s i ve b eh a v i our f or pr of es s io n als
work i n g wit h p eo p l e wit h s p ec i al ne e ds )
20 1 5- 20 1 7” , “ Saf et y an d H yg i e ne ”
proj ec t .
T he V i lj a n d i Hos p it a l´ s An n ua l Pl a n h as
s pec i a l s ec t i on f or im pr o v em ent
proj ec ts a nd p er f or m anc e i nd ic at ors f or
m eas ur in g th e r es u l ts of a ll
im pro v em ent pr oj ec ts .
Im pro vem e nt pr oj ec t s obj ec t i v es ar e
def in e d a nd r es u l ts m eas ur e d.
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 .
Rem ark f rom th e au d it or : T he s er vic es of th e s oc i a l s er v ic e pro v i d e rs m eet t h is
c rit er i on of t he EQ UA S S As s ur anc e c er t if ic a ti o n pr ogr am
Str e n gt hs Im pro vem e nt & de v e lo pm ents
V i lj a n di H os pi t al a n d i ts N CC f i nd wa ys
of be i ng in n o va t i ve , t ak in g i nt o ac c o un t
th e ne e ds and ex p ec ta t io ns of
s tak e ho l de r s . Bes t pr ac tic es an d
c on t em pora r y ap pr oac hes f r om d if f ere nt
c ou n tri es ar e us ed in de v e l op i n g
s er v ic es .
NC C p art ic i p at es in d if f er e nt pr oj ec ts
bo t h i n l oc a l a n d i nt er na t io n a l l e ve l .
49
Sh
F.e . “I nt ro d uc t i on an d im pl em ent a ti o n of
V ER G E m et ho ds ( s p ec ia l i n ter v e nt i on
m etho ds f or d e al i n g wi t h a g gr es s i v e
be h a v io ur f or pr of es s i on a ls wo r k in g wi t h
pe o p le wi th s pec i a l n ee ds ) 2 0 15 - 2 0 17” ,
“S af et y an d H yg ie n e” pr oj ec t ,
“De v e l opm en t of ex per i e nc e a d vis or
s er v ic e 2 01 5 - 20 1 7” . T he pr oj ec t on
us in g a n im al t her a p y 2 0 13 - 2 01 5 h as
bro u g ht ex c e ll e nt o u tc om es an d wi l l
c on t in u e.
A l l re l at e d inf or m ati o n was v er if i ed t o
be doc um en te d ( pr oj e c t d oc um en t at i on ,
m inut es of m eet i ngs of loc a l on es ) .
In n o va t io n pr oj e c ts ar e r ec or d e d in
an n ua l p l a ns a nd r e p o r ts .
50
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4. 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 :
1: Fu rt h er a r r ang em e nt / si mp lif ic at ion of NC C`s Q u al it y St and ar d and oth e r
ins tr uct ion s
Pr ob l em : N CC` s Q ua l it y S t a n d ard an d o th er NC C`s i ns tr uc t i o ns / d o c um ent at i o n
f or p ers o nn e l ar e r e l at i v el y v o l um in o us a nd o ver l a pp i n g i n s om e p arts . B es id es ,
th er e ar e v er y g en er a l p ar agr a phs no t c o nn e c te d t o NC C. T her ef or e, it m ak es
th e us i ng of d oc um e nt s t im e c o ns um in g f o r p ers o n n el .
G o al : us er - f r ie n d l y d o c um ent at i o n f or pers o nn e l t o ens ur e t he q u a l it y of
s er v ic es .
Ac t i v i ti es :
- to a n a l ys e t h e c o nt en t an d s tr uc t ur e of doc u m ents c om par i ng t h e a ppr o ac hes
i n us e t o b es t pr ac t ic e s of ot h er s uc c es s f u l EQ U AS S us ers ;
- to r ear r a ng e a n d s im p lif y d oc um e nt at i on wher e n ec es s ar y.
2: Dev el op st af f co m pet en ci es and qu al ifi cat ion
Pr ob l em : i n t h e c on d it i ons of im p lem en t in g E Q U A SS in ne w s er v ic e s , t h e
c om pet e nc ies a n d u nd er s t a nd i n gs r e la te d t o c l ie n t work c ou l d b e d i f f eren t.
A ls o , t her e ar e o n l y f e w ( 4) s p ec ia l is ts wh o ha v e p as s ed t h e f u l l tr a in i ng of
CA R e m et ho d o lo g y a n d c o ul d s u p er v is e o t he rs if n ec es s ar y.
G o al : T o p r o v i de v ar io us h ig h - q ua l it y s er v ic e s t o p ers o ns s er v e d, i nc lu d in g
ra is i n g s p ec ia l is ts ` qu a lif ic a t io n i n re l at i o n t o c l i en ts ` n ee ds e v a lu at i on an d
s et t in g g oa ls wi th c li e nts in c as e of a l l s oc ia l s er v ic es pr o vi d e d b y NC C .
Ac t i v i ti es :
- tra i n in gs o n l if e q u a l it y a n d em po werm en t ( i nc l CA R e m et ho d o lo g y) f or a l l
s pec i a l is t s d e al i n g wi t h c l i en ts .
51
Sh
Kokkulepitud täiendavad parendused/arendused järgnevaks
kaheks aastaks
1: Õ HK Kv al it ee di st a nda rd i ja t ei st e juh en dmat e rj a lid e ko r r ast a min e/
liht su st am in e
Pr ob l e em : Õ H K K v a l it ee d is t a nd ar d j a m u ud Õ H K j uh e ndm at erj al i d pers o n al i l e
on v õrd l em is i m ah uk ad j a k o ha t i du b l eer i v a d ük s te is t , s am ut i es i n eb v äg a ü l dis i
j a m it te k onk r e ets e lt Õ HK g a s e ot u d l õik e , m i s t ee b d ok um ent i de k a s ut am is e
pers o n al i l e a eg a nõ u d v ak s .
E es m är k : l i hts a l t k as ut at a v d ok um ent ats i o o n p ers o n a li l e t ee n us t e k va l it e ed i
ta g am is ek s
T ege v us ed :
- an a l üüs i d a dok um en t i de s is u j a s tr uk tu ur i v õrr el d es k as ut at u d l äh en em is v iis e
k a te is te ed uk at e EQ U A S S i r ak en d aj a te p ar i m ate pr ak tik at eg a ;
- k orras t ad a j a li h ts us t ad a d ok um ent ats i o on k us v aj a l ik .
2: P e rs ona li kom pet e nt s ide ar en da min e j a kv al ifi ka ts ioon i tõs t min e
Pr ob l e em :
s eos es E Q U A S S i r ak e nd am is e g a u ut e le s o ts i aa l te e nus te l e, v õ i va d k lie n d it öö g a
s eo t ud k om pet en ts id j a ar us a am ad o l l a or ga n is a ts io o nis er in e v ad . L is ak s o n
Õ H Ks a in u lt ük s ik ud ( 4) s p ets i a lis t id , k es o n l ä b in u d C AR e m ee t od i t äi e l ik u
k ool i tus e j a s u ud a v a d v aj a d us e l t e is i s pe ts ia l is t e j u he n da d a.
E es m är k : k li en t id e le m itm ek ül gs e k v a l it ee ts e t ee n us e os u tam i ne , s ea l h ul g as
k lie n ti d e h in d am is ek s j a ne n de g a k o os e es m ärk id e p üs t i tam is ek s v aj a l ik e
os k us t e ar e n d am in e k õ ig i Õ H K os u ta ta v a te s ots i aa l te e nus t e p uh u l .
T ege v us ed :
- k li e nd i e l uk v al i te e d i j a j õus t am is te em al is e d k oo l it us e d (s h C A Re m etoo d ik a)
k ogu k li e nt i de g a te g e l e va l e p ers on a l il e .
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Closing remarks
V i lj a n di H os pi t al is o ne of th e l ar ges t ge n era l h os p it a ls in Es t o n ia . T h e H os p it a l
c ons is ts of 4 c l i n ic s , 2 c e n tr es , m ed ic a l a nd n o n - m ed ic a l s up p ort s er v ic es :
O ut p at i en t T r ea tm ent an d D i ag n os t ic s C l i n ic , Su rg er y C l i n ic , I nt er na l Me d ic in e
Cl i n ic , Ps yc h i atr y Cl i n ic , N ur s in g Car e C e ntr e ( NC C) , an d De p en d e nts
Re h ab i l it at i o n C en tr e . Vi lj a nd i H os pi t al is th e l ar g es t em p lo ye r of the V i lj a n di
c ou n t y ( ap p 7 2 0 p eo p l e wor k in t h e h os p i ta l) .
In J äm ej a la v i l l ag e, w her e V i lj a n di H os p i ta l is loc at e d, ps yc h ia tr i c as s is t anc e has
be e n pr o v i de d al r e a d y ne ar l y 1 2 0 ye ars . C u rre nt l y, V i lj a n d i H os p i ta l is o n e of t h e
l arg es t pr o v id er s of p s yc h ia tr ic tr ea tm ent a nd de v e l ops its s oc ia l s er v ic es us i n g
th is a d v an t ag e. I t is th e o n l y i ns t i tu t io n i n Es t on i a pr o v i di n g 2 4 ho ur c ar et ak i ng
s er v ic e f or p er s on s wi t h pe r m ane n t m ent a l d is or d er wit h u ns ta b le r em is s i o n
(s pec i a l c ar e s er v ic e) . A ls o, V ilj a nd i H os pi t a l is t he on l y h os pi t a l i n Es to n ia wh ic h
pro v i d es in v o l un tar y t r ea tm en t f or m en ta l l y i l l of f e nd ers a nd i n v ol un t ar y tr e atm en t
f or m ent a l l y i l l T B pa t i en ts .
T he m os t im por ta nt obj ec t i v es of t he h o s p it a l ar e t he de v e l o pm ent of ac t i v e
tre atm e nt s er v ic es , es t a bl is hm en t of c o m pete nc y c e n tr e of re ha b i l it at i on f or
pers o ns wit h m ent a l d is or d er a nd dr ug ad d ic ts , a nd de v e lo pm e nt of n urs i ng an d
s oc ia l c ar e s er v ic es .
T he s c o pe of th e c ur r en t a u di t was re h ab i l it at i on s er v ic es , c ar e s er v ic es (f oc us in g
on dem en t ed e l d er l y) a n d s pec i a l c ar e s e rv ic es pr o vi d ed b y N urs in g a n d Car e
Ce ntr e (N CC) . T he r eh a b il i ta t io n s er v ic es pro v i de d b y N CC h a ve onc e a lr ea d y
ga i n ed EQ U AS S Q u a li t y As s ur anc e c e rt if ic at e (i n 20 1 3). V i lj a nd i H os p i ta l pro v i d es
d if f ere nt r eh a b i li t at i o n s er v ic es ap pr ox im ate l y t o 9 0 0 c li e nts p er ye ar . Bo t h c ar e
an d s pec i a l c ar e s er v i c es ar e pr o v i d ed f or 7 5 c l i e nts ( a lt og e th er 1 50) . T he n um ber
of s t af f wor k in g wi t h c l i en ts of ab o v e m en t io n ed s oc i a l s er v ic es is 1 33 .
T he b u i l di n gs of t he V i lj a n d i H os p it a l a r e s it u at ed i n J äm ej a l a v il l a ge n e arb y
V i lj a n di C it y. T he s er v ic es i n s c op e of t he au d it is pr o v id e d b o th i n lar g e m ai n
bu i l d in g of t he h os p i ta l an d i n s m al l er b u i ld i ngs i n o ld p ark , i nc l ud i ng n e w b u il d i ng
of NC C wi th i t s c on te m por ar y an d c om f orta b le e n v iro nm en t f or p ro v id i n g s er v ic es
of c ar e a nd n ur s i ng . De v e lo pm en t of n e w bu i l d in gs ar e p la n ne d t o pro v i d e be tt er
s er v ic es .
NC C of f er s to its c l ie n ts c om pr eh e ns i ve s u pp ort im pl em ent i ng ps yc h os oc i a l
reh a b i li t at i on pr i nc ip l es an d C AR e ( Com p reh e ns i ve A p pr oac h of R eh a bi l i ta t io n)
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m etho d o lo g y. I n its s er v ic e pr o v is io n NC C tak es i nt o ac c o u nt p res e n t a n d f u tur e
ne e ds of bo th s er v ic e us er s an d t he s oc i e t y i n g en er a l.
T he s t af f of NCC is pr of es s i o na l , wit h r e le v a nt ed uc at i on a l bac k gr o un d and
c on t in u ous l y tr a i ne d. St af f is hi g h l y v a lu e d b y m an a gem en t.
As i n c as e of c ar e a n d s p ec i a l c ar e s er v ic e s t he tr a ns it i on t o t he E Q U A S S s ys tem
has to ok par t o n l y th i s ye ar , s e v er al pr ac t ic es ar e s t i l l n e w an d h a ve n` t b ee n f u l l y
im pl em ent e d ( f .e . t h e wor k of c l i en t b o ar d s in c o l lec t in g f e e db ac k f rom s erv ic e
us ers , t he r e g u lar ( do c um ent e d) r e v ie wi n g of t he proc es s es a nd ap pr o ac h es , e tc ) .
B y t h e o p i ni o n of t h e au d it or th er e ar e a ll p rec o n d it i ons f or t he f u l l ( d oc um ent e d )
im pl em ent a ti o n of PD CA c yc le in a l l ar eas as th e d ir ec t or of t he NC C has b e en t h e
l ea d er of t he EQ UA S S im pl em ent at i o n a nd th ere ar e m an y p os s i bi l i ti es t o le ar n
f rom eac h ot he r be t wee n t he t e am s pro v i d i ng N CC`s s er vic es . A ls o, i n t he N CC
th er e is a n ex pe r i e nc e of b e nef its f rom th e E Q U A S S i m pl em ent at i on i n c as e of
reh a b i li t at i on s e r vic es .
Dur i n g l as t t wo ye a r s ( 20 1 3- 2 0 15) NC C h a s m ad e s e v era l im pro v em ents . S im p ler
an d pr op er an n u al p l an n in g a nd e v a lu at i on is us ed . T h e ra n ge of f e ed b ac k
c o ll ec ti o n m et h ods h a s i nc r eas e d to ens ur e t ha t a l l s tak e ho l de r gro u ps wo u l d be
c o ver e d c om pr e h ens i v e l y a nd t ak i ng in t o ac c ou n t th e ir a b i l i t ies to gi v e f ee d bac k .
T he NC C` s webs i te has bec om e thr o ug h ou t a n d i nf orm at i ve , al th o ug h s om e
im pro v em ents c ou l d be m ad e in a d d it i on . M or e s ys tem at ic i n v o l vem en t of
v o lu nt e ers t o th e s er v ic e pr o vis i o n of NC C is pr ac tic e d (es pe c i al l y in c as e of
ex p er i enc e ad v is i ng b ot h o n an i n di v i d ua l an d gro u p b as is , b ut als o i n c as e of
ot h er ac t i v it i es ) .
T he t wo - d a ys a ud i t w as we l l or ga n is ed b y NC C. Au d it or wa s h os t e d wi th g re at
hos p it a l it y. D oc um e nt s wer e we l l pr es e n t ed a nd wh o le s taf f was k in d an d
c oo p er at i v e i n i nt r o d u c i ng t h e work of NCC, f ind i n g n ec es s ar y e vi de n ti a l m ater i a ls
an d s h ar i ng inf or m at i o n a bo ut f u lf i l l in g of EQ UA S S c r it er i a.
T he au d it or ex per i e n c ed o n s i te t ha t th e s oc ia l s er v ic e pr o vi der p erf orm s i n
c om pl i anc e wi th th e E Q U A SS As s ur anc e c r i ter i a. T h e i n ter v i e we d repr es en t at i v es
of par t ners , f i na nc in g bo d ies , em p lo ye e s o f NCC a n d p ers o ns s er ve d , a nd th e ir
f am il y m em ber s c o nf i r m ed th is , wh ic h wa s ref l ec t ed i n t he ir s at is f ac t io n. T h e
pers o ns s er v ed an d t h e ir f am il y m em bers we re es pec i a l l y s at is f i e d wi t h th e p ers on -
c en tr ed a p pr o ac h, wi d e r an g e of ac ti v i t ies i n N CC , f lex i b il i t y of s er v ic e pr o v i der ,
p le as an t an d c ar i ng p er s o n n el , a nd t he n e w b u il d i ng of NC C . P ar t ners a n d f u n ders
ex pr es s e d t he ir s a t is f ac t i on wit h pr of es s io n a l s er v ic es pr o vi d ed b y N C C, f lex i b i li t y
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i n f i n di n g s o lu t io ns , an d v er y g o od c o o pe rat i on . M ee t in gs a n d i nt er v i e ws wit h
em pl o ye es an d m an a gem en t ga v e g re at c onf id e nt of c om m itm ent an d m ot i va t io n
to war ds t he ir wor k .
Dur i n g of th e au d i t, s e ver a l im pr o vem en t pro p os als aros e , s om e of th em wh er e
m inor a n d s om e m or e im por t an t. F or t h e per i od of f ol l o wi ng t wo ye a rs , t wo
ad d it i o na l im pr o v em e nt f ie l ds wer e a gre e d th a t a re br o ug ht o ut i n par t 4 of t he
au d it r e por t. Br i ef l y, t he i ns tr uc t i o na l m at er i a ls a nd p ol ic y doc um e nt s f or pe rs o n ne l
c ou l d be r e v i e we d an d s hor te n wh er e pos s i bl e i n ord er to b e m ore us er - f r ie n dl y
(th e i d e as c o ul d be s eek als o f rom oth er s im i la r or ga n is at i o ns im p lem en t in g
EQ U AS S) . A ls o, c o nt i nu at i o n of tr ai n i ngs f or p ers o nn e l on e m po werm e nt a nd
s up p ort i n g c l ie n ts ` l if e q u al i t y ( i nc l C AR e m e th o d) is n ec es s ar y.
B es i d es , i n th e c o nt e x t of t h e hos p it a l as a wh o le , t h e im pl em ent i ng of EQ U A S S
s ys tem or it ` s c e ntr a l pr i nc i pl es ( inc l em po wer i n g s er v ic e us ers , im pro v in g t h eir
l if e- qu a l it y) c o u l d b e c ons i d er e d i n c as e of s er v ic es s om ewh at s im il ar b y i ts n at ur e
to t h e s oc ia l s er v ic e s ( f .e. tr ea tm ent an d re ha b i l it at i o n of a dd ic ts , lo n g - t erm
ps yc h i atr ic tr e atm en t) .
A n o v er v i e w of s u gg e s ti o ns f or im pro v em en t t ha t a re m en t io n ed u nd er th e s pec if ic
c rit er i a is g i v en in par t 3 of th e r e p ort . I n br i ef t h es e ar e as f o l lo ws :
Cri t er io n 6: T o d e ve l o p f ur th er th e A nn u a l P la n f orm s o th at d ur i ng t he e v a lu at i o n
of ac t i v it i es i n t h e p l a n, t h e i nf or m at i on o n s ta tus of th e ac t i vi t i e s an d c o m m ents
c ou l d b e a dd e d.
Cri t er io n 1 6 : T o r e v ie w th e r ig h ts a nd d ut i es of t he pers o ns s er v ed ( i n p art ic u l ar
th os e pr es en t ed i n NC C` s we bs i t e) in or d er t o e ns ur e t h at i n al l u n i ts / i n c as e of a l l
s er v ic es t h e s am e r ig h ts ar e ap p l ie d .
Cri t er io n 1 7 : B es i d es the s ug g es t i o n to t urn to t h e m ana gem en t i n c as e o f
c om pl i an t , t o des c r i b e i n N C C` s we bs it e s hor t l y a ls o s im pl er an d m or e c l ie n t -
f rie nd l y p os s i b il i t ies t o s u bm it c om pl i a nt or p rop os a l s .
Cri t er io n 2 5: T o d es c r i be t h e r o l es ( wh ic h a re t he pro b l em s thes e pers o ns s o l ve )
on t h e NC C` s we bs i te i n c as e of a l l em pl o ye es br ou g ht o u t i n th e we bs it e.
Cri t er io n 3 2: I t is a d v is ab l e to ins ta l l s im p l e s c hem e to t h e dr i ve wa y of J äm ej a la
park o n wh er e NC C ` s bu i l d in gs ( an d t h e bu i l di n gs of Ps yc h i atr y C li n ic ) are
s it u at e d. Sim i l ar s c h e m e c oul d b e p u bl is h e d i n N CC`s a n d h os p i ta l`s we bs i t es to
pro v i d e l oc a t io n i nf or m atio n m or e us er - f ri e n d l y.
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Cri t er io n 4 0: T o c on t i nu e tr a in i ngs of C AR e m eth od f or a l l th e p e rs on n e l pr o vi d i ng
s oc ia l s er v ic es i n NC C .
Cri t ero n 4 6: To i n tr od uc e s hor t er an d s im pl er v ers io n of an n ua l re p ort to
c om m unic a te t h e ac t i v it i es a nd r es u l ts . T o il l us tr at e a nn u a l r ep or t s , it is ad v is ab l e
to inc l ud e c l i e nt s t or ie s / ex am p les t o d em on s tra te N CC `s g o o d r es u lts .
Cri t er io n 4 7: T h e r e p or ts on N C C`s p erf or m anc e s h o ul d b e a v a i la b l e i n N CC`s
we bs it e t o be a va i l ab l e f or in t er es t ed s t ak eh o ld ers .
Af t er ver if ic a t io n of i n d ic a tor s b y r e v i e wi ng doc um en ta t io n , c o n d uc t i ng i nt er v i e ws
an d p erf or m in g s i t e v is it , th e a ud i tor is c onf irm ed th a t t h e c r it er i a f or q u a li t y
as s ur a nc e of t h e E ur o pe a n Q u a li t y f or S oc ia l s er v ic es wer e f u lf i l le d.
S ih t as u tus V i lj a n d i H ai g la on E es t i s uur em ai d ü l dh a i gl a i d, m il l e k oos s e is u k uu l u va d
am bu la t oor s e ravi ja d ia g nos t ik a k li in ik , k ir urg i ak l i in ik , s is ek l i i nik ,
ps ü h h ia at ri ak l i in ik , õe n dus - h o ol d us k es k us ni n g s õ l tu v us ha i ge t e ra v i - ja
reh a b i li t ats i oo n ik es k us . H ai g l a o n s uur i m töö an dj a p i irk on nas (u 7 20 t ö öt aj a t).
J äm ej a las o n ps ü hh i a atr i l is t a b i p ak ut ud j u ba l i g i 1 2 0 a as t a t j a pra e g un e V ilj a nd i
Ha i g la on E es t i s u u r im ai d ps ü h hi a atr i l is e ra v i p ak k uj ai d. P s üh h i aa tr i lis e ab i
k ättes a ad a v us es t l äh t u va l t ar e n da t ak s e k a om a s o ts i a a lt ee n us ei d . H a ig l a o n ai n us
eb as ta b i ils e r em is s i oo n ig a ps üü h ik ah ä ir et eg a is ik ut e l e ö öp ä e var i n gs e t
er ih o o ld us t e en us t os u ta v as ut us Ees t is . L i s ak s on V i lj a n di H ai g l a a i nuk e ha i g la
E es t is , m is v õt ab v as t u k o ht um äär us e a lus e l r a v i le s u u na t ud ps ü hh i a atr i l is i
pa ts ie n te j a os u ta b s u ndr a v i ps ü üh ik ah ä ir et e ga t u berk u l oos i h a i g et e l e.
Ha i g la o l u l is im ad e e s m är gi d on ak ti i vr a v i t ee n u s e a re n dam i n e, ps ü üh ik a - ja
s õ lt u vus h ä ir e g a is ik ut e r e h ab i l it a ts i o on i k o m pete nts ik es k us e l oo m ine j a õe n dus -
ho o l dus te e nus t e ar en d am in e .
A ud i ti v a at e v ä lj as o li d ha i g la õ en d us - ho o l dus k es k us es ( Õ HK ) os ut a ta v a d
reh a b i li t ats i oo n it e en us ed , m i da h a i gl a os ut ab a l at es 2 0 03 . a , ho o l dus te e nus e d
(s pe ts ia l is e er um is eg a dem en ts et e le v a nu ri t e l e) j a er ih o o ld us te e nu s ed , m id a ha i g la
os u t ab a l at es 2 0 04 . a. Re h ab i l it a ts i o o ni te e nus e d on 20 1 3. aas t al EQ U A S S
As s ura nc e s er tif ik aa d i j u ba s aa n ud .
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V i lj a n di Ha i g l a p ak u b er i n e va i d re h a b i l i ta ts i o on i te e nus e i d um b es 9 0 0 k li e nd i l e
aas t as . N ii h o o ld us te e nus e id k ui er i ho o lek a nd et e en us e id p ak ut ak s e 7 5 - le
(k ok k u15 0 - l e) k l ie n d i l e. N im et at u d t ee n u s te r aam es t öö t ab k lie n ti d eg a 13 3
s pe ts ia l is ti .
Ha i g la h o on e d as u v ad J äm ej a l a k ü l as V i lj a n di l in n a l äh e da l. Au d it e er it a v ai d
te e nus e id pak u tak s e ni i h a i gl a s uur es pe a ho o nes kui v ä ik s em ates ho o n e t es
J äm ej a la p ar g is , sh ÕHK u u es , s pe ts i aa ls e lt õ en d us - ja ho o l dus te e nus t e
pak k um is ek s k ava n da t ud k aas a egs e s j a m u g a vas ho o nes .
Õ H K pak u b om a k l ie nt i de l e n en d e i nd i v i du a a ls et es t vaj a dus tes t l ä h tu v at ig ak ü lgs et
to et us t rak e n da d es p s üh h os o ts ia a ls e r eh a b il i ta ts io o n i e C A Re (Co m pr eh e ns iv e
A ppr o ac h o f Re h ab i l i ta t io n ) . O m a t ee n us t e pak k um is el v õ ta b Õ H K ar ves s e n i i
te e nus te s aaj at e k u i l a i em alt ü h is k on n a pr ae gus i j a t u le v as i v aj ad u s i.
Õ H K p ers on a l o n pr of es s io n aa l ne , as j ak oh a s e h ar i dus e ga j a p ers on a l i k oo l it at ak s e
j ärj e p id e v a lt . P er s o n a l o n j u htk on n a p oo l t k õ rge l t v ä ärt us t a tu d.
P äras t ee lm is t EQ U A S S au d it i t o n Õ H K t e i nu d m itm ei d p are n dus i. K as ut us el e on
v õe t ud l ih ts a m j a as j ak o has em aas t a s e pl a ne er im is e j a h i n dam is e s üs te em .
K as u ta t ak s e e n am er i ne v a i d ta g as is i d e k o g um is e m e et od e i d ta g a m ak s , e t k ae t ud
o lek s k õik Õ HK s i dus r ühm a d j a v õt tes ar v e s s e n e nd e v õim a lus i t ag as is id e t a n da .
ÕHK k od u le ht on s aa n ud p õ hj a l ik uk s ja i n f orm at ii vs ek s , k ui g i ru um i on ka
tä i en d a va t ek s par e nd us t ek s . Õ H K o n t ee n us t e os ut am is e l as un ud s üs t eem s em alt
k as ut am a v a ba ta h t l ik e abi ( e es k ätt i nd i v i d ua a ls e l ja gru p i v i is il is e l
k ogem us n õ us t am is e l , ag a k a m uu de t e ge v us te p u hu l ) .
K ui v õr d h oo l dus - j a e r i ho o l dus te e nus t e pu h u l t o im us E Q U A S S` i le ü lem i nek a l l es
k äes o l e va l a as t a l, o n ne n de t ee n us t e p uh u l m itm ed pr ak tik a d v ee l u ue d ( nt
k lie n d in õ uk og ud e t öö , r e gu l a arn e ( dok um en te er it u d) p rots es s id e ja
l äh e nem is v i is i d e ü l e v aa t us j ne ) . Au d i it or i h in n an g ul o n k õik ee l t i n g im us ed P DC A
ts ük l i t ä i el ik uk s ( d ok um ent eer i tu d) r ak en d am is ek s k õig is s ots i aa l te e nus t e
v a ldk o nd a des V i lj a n d i Ha i gl as ol em as , k un a Õ HK j uh t o n is ik lik u lt ol n ud EQ U A S Si
rak en d am is e ees t ve d a j ak s r eh ab i l it a ts i o o ni t ee n us t e pu h u l j a k u n a Õ H K t ee n us e i d
os u t a va t e m ees k on da de p u hu l o n p a lj u ük s te is e lt õ pp im is e võ i m alus i. S am ut i on
reh a b i li t ats i oo n it e en us te p u hu l s a a du d k og e m us EQ UA S S i rak e nd am is e k as u des t.
A ud i t k es tis 2 p äe v a, m ill e j o ok s ul k oh e l di au d i it or it v äg a s õ br a l i k ult . Dok um en d id
o li d h äs t i es it at u d ja k o gu pers o n al oli ÕHK töö tu t v us t a m is el äärm is el t
k oos t öö v a lm is , l e id es vaj a lik k e tões t us m aterj a le ni n g j ag a de s inf o t EQ U A S Si
rak en d am is e k o ht a.
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A ud i it or k o ges k o ha pe a l, e t s o ts ia a lt e en us t e os u taj a Õ H K t o im ib v as t a vus es
EQ U AS S As s u r a nc e k r it e er ium i de g a. I nt er vj ue er it u d Õ H K p art n er i d, f i na n ts e er ij a d ,
tö öt aj at e, t ee n us es a aj at e j a ne n de p er e li ik m ete es i n d aj a d an ds i d s el l e l e k in n it us t
n in g s ee p ee g el d us k a ne nd e r ah u l o lus Õ H K t öö g a. T e en us e s aaj a d j a ne n de
per e l i ik m ed ol i d er it i r ah u l t e ge v us te l a ia v a l ik ug a Õ H Ks , te e nus e os u taj a
pa i n dl ik k us eg a , k ena j a h oo l i v a p ers on a l i j a Õ H K u u e h o on e ga . Par t ner i te j a
rah as taj at e es i n daj a d v ä lj e n das i d om a rah u lo l u pr of es s i on aa ls e t ee n us e g a,
pa i n dl ik k us eg a l ah e n dus t e le i dm is e l n in g v ä ga h e a k oos tö ö g a. K o ht um is e d j a
i nt er vj u u d p er s o n a l ig a a nds i d t ä ie v ee n du m us e, et Õ H K tö ö taj ad on om a tö ös
pü h en d un u d j a m ot i v e er it ud .
A ud i ti k äi g us t ek k is a ud i i tor i l p ar a n d us e tt e p an ek u id , m õn e d ne is t v ä ik s ed j a p ig em
v orm il is ed j a ük s ik ud k aalu k am ad e tt e pa n e k ud. J är gm is ek s k ahe k s aas tak s le p it i
k ok k u k ak s täi en d a va t par e nd us v a ldk o nd a , m is on t ä ps em a lt v ä lj a to od u d r ap or ti 4.
os as . Se l l ek s , e t Õ HK k v a l it e ed is ta n da rd j a t e is e d pers o n al i j uh e ndm at erj al i d
o lek s i d t ö öt aj a t el e l i hts am alt k as ut a ta v a d, on s o o v it a v ne e d üle v aa d at a,
v õ im al us e l lü h en d a da , o ts id es id e i d ka teis t es t ed u k ates t EQ U A S S
k va li t ee d is üs t eem i r a k end a va t es t as u t us t e s t. S am uti o n vaj a l ik j ätk at a pers o na l i
k ool i tam is t k li e nt i d e j õ us t am is e ja e l u k va li t ee d i e de n dam is e a la l (s h C AR e
m etoo d ik a) .
K og u h ai g l a k on te k s tis võ ik s k aa lu d a t e is t e , ÕHK p o o lt os ut at a v at e
s ots i aa l t e e nus t eg a o l em us l ik ul t m õn e v õrr a s ar n as t e te e nus te ( n t s õl t u vus h ai g et e
ra v i j a re h ab i l it a ts io o n it e en us v õi p ik aaj al is t ha i g las v i i b im is t n õ ud e v ps ü hh i a atr i l i ne
ra v i) p u hu l EQ UA S S m ude l i v õ i s e l l e k es k s et e p õ h im õte te ( nt k l i en d i j õ us t am in e,
e luk v a l it ee d i p ar an d a m ine) r ak e nd am is t .
K õik par e nd us et te p an ek ud , m is 2 - p äe v as e au d i ti k äi g us tek k is i d , o n r a por t i 3.
os as k onk r e ets et e k r it eer i um id e a l l v ä lj a t o o du d . L ü h i da l t o n ne e d j ärgm is ed :
Kr it e er ium 6: A r e n da da t öö p l aa n i v orm i e das i s e l l is e l t, et t öö p l aa n i ül e v aa t us t e l
s aa b lis ak s ül e v aa tu s e aj ak s lõp e ta tu d t eg e v us t e le l is a d a s e l l es s e k a h etk e l
e ll u v i im is e l v õ i a l us t a m ata te g e vus t e s t a at u s e
Kr it e er ium 1 6: V a ad at a ül e k l i en t id e õ ig us e d j a k oh us t us e d (s h j us t Õ H K v ee b is
k uva t ud ver s i o on i d) n i ng t a ga d a , e t ük s us t es r ak en d at ak s e k l ie n ti d e le s ar n as ei d
põ h im õtt e i d.
Kr it e er ium 1 7: L is ak s Õ H K ve e b is t o od u d v õ im al us e l e es i t ad a k a eb us i ots e h ai g l a
j uh at us e le , k aj as t ad a s e a l l üh i da l t k a l i h ts am ai d j a k li e nd is õb ra lik um ai d vi is e
k aeb us t e j a e tt ep a n ek ut e es it am is ek s .
58
Sh
Kr it e er ium 25 : N ä i da ta är a k õi g i Õ H K v e eb i l eh e l v ä lj a to o du d tö öt aj at e r ol l i d
(m ill is te k üs im us t eg a k ell e p oo l e pö ör du d a) . S e n i o n tö ö taj at e r o l l id v ä lj a t oo d ud
os a d e am et ik oh ta d e p uh u l.
Kr it e er ium 3 2: Pa i g a l da d a J äm ej a la p ar g i te rr it oor i um il e h o o ne t e pa ik n em is e
s k eem nin g l is a d a t ä ie l ik s k eem (k oos tä n a va n im ed e ja er i ne v a te te e nus t e
pak k um is e k oh ta d eg a) k a ve e b il e he l e.
Kr it e er ium 40 : J ä tk ata CARe m eet od i k oo l i tus i k og u ÕHK s ots i aa l te e nus e i d
os u t a va l e p er s o n a li l e .
Kr it e er ium 4 6: K as ut a da lü h em at j a l i h ts am at a as t a aru a n de vers i oo n i h u vi p oo l te l e
i nf o j a g am is ek s . So o v it a v a lt l is ad a ar ua n n et e le j a k o du l e he l e k a k l ie n di l u gus i d/
nä i te i d, m is nä i ta v a d Õ H K he a d tö ö d, t e en u s e k as u j a v ää rt us t .
Kr it e er ium 47 : Õ H K k odu l eh e le t ul ek s l is ad a aru a nd e d / a ndm e id , e t er i n e va te l
hu v i ta t ud os a po o lt e l o l ek s v õ im al ik n en d eg a tu t vu d a.
P äras t in d ik aa tor i te l e v as t a vus e hi n dam is t dok um ent i d e va at l us e, i nt er vj u u de j a
te e nus e os u tam is e pa i k ade k ü las t am is e k a ud u o n a u d ii t or ve e n du n ud , et a ud i t i
v aa t lus e a l l o ln u d t ee n us t e os as v as t a b V i lj a n d i Ha i g la EQ UA S S As s ur a nc e
k rite er ium i de l e.
T al li n n, 10 . n o vem ber 20 1 5
E lo T u pp i ts
59
Maarika Aro
Saatja: Maarika Aro
Saatmisaeg: 11. november 2015. a. 15:21
Adressaat: 'Guus van Beek'
Koopia: 'Marie Dubost'
Teema: SA Viljandi Haigla audit report
Manused: SA_Viljandi_Haigla_2015_EQ-ASS_AUD_Audit Report.docx;
SA_Viljandi_Haigla_EQUASS 2015 Assurance Application Form.xlsx; EQUASS
Additional Information Form Viljandi Haigla.doc; Asutuse auditi külastuse
ettevalmistuse vorm_ViljandiMH2015.docx
Dear Marie, Dear Guus,
Attached you’ll find an audit report and other documents of SA Viljandi Haigla EE2015-014.
Please let Keiu to know in case there are some comments about the report.
Kind regards,
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
ASUTUSE KÜLASTUSE
ETTEVALMISTAMISE VORM
Asutuse külastus: 27.-28.10.2015
SA Viljandi Haigla
Elo Tuppits
© 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 ik s al us ta t i EQ U A S S i r ak en dam is eg a ja m id a on k v a l it e ed i s üs te em i
rak en d am is eg a s a a v ut at u d?
2. M id a o l et e t e i nu d t e e nus t e k va l it e ed i t a ga m is ek s j a tõs tm is ek s om a as u tus es
pär as t ee lm is t EQ UA S S i a ud i ti t ?
3. K ui d as o n k va l it e e di s üs t e em i rak en dam i n e m õj ut an u d as ut us e j uht im is t j a
pers o n al ij uh t im is t ? M il l is e d m uut us ed o n t o i m unud ?
4. K irj e l d ag e om a as ut u s e p õh i pr ots es s e: pl a ne er im is e pro ts es s i, k es tv a ar e ng u
pro ts es s i ( PD C A ts ü k li) j a t e en us t e os u t am is e pr ots es s i r ak end am is t om a
as u t us es .
5. M il l is e d o n as ut us e hu v i gr u p i d? Ku i d as o n v ä lj a s e l g it at u d h u v igr u pp i d e o ot us e d
j a v aj a d us e d ? K u id as k üs it ak s e ne n de l t ta g a s is id e t?
6. K el l e ga ja m ill is t k oos t öö d t ee t e n in g m il l is t l is a v ä ärt us t s ee l äb i o l et e
s aa v u ta n ud ?
7. K ui d as o n ta g at u d er in e va t e k l ie n d igr u pp i d e õ ig us ed j a e n es em äär am in e?
8. K ui d as r ak e nd at e oma tee nus tes is ik uk es k s us e ja te en us te p i d e vus e
põ h im õt et ?
9. K ui d as k aas at ak s e te en us e s a aj a i d, pe rs o na l i j a m ui d h u v i gru pp e t e en us t e
are n d am is s e?
10 . M il l is e id par e nd us pr oj ek te/ in n o va ts io o n ipr oj ek te o l et e e l lu v ii n u d?
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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. K ir j e l d ag e Teie as u tus e j uh t im is e
k or r al d us t ja a as tas e p la n ee rim is e X
k or r al d us t ?
2. K as o l et e t ea d l i k ud as u t us e
m is s io o nis t, v is i oo n is t ja
x
v äär t us h i n na n gu tes t ? Pa l un
s õn as ta g e.
3. M il l is e id on T ei e as u tu s e
x x X
k va li t ee d ip õ h im õtt ed ?
4. K ir j e l d ag e, m i l l is e id as ut us e
te e nus e id t e at e n in g k u id as o le t e x x
ne n des t t ea d a s aa n u d ?
5. K as T ei lt o n k üs it u d j a k ui das on T e i l
v õ im al ik a nd a t ag as is i de t p ak uta v a te x x
te e nus te k oh ta ?
6. K ui d as k og u te i nf ot ü h is k on na
v aj a d us t e k oht a n in g m il l is ei d
x
üh is k o nn a vaj a dus te l e / k oguk on n al e
s uu n at u d te g e vus i o l et e k orr a ld a nu d ?
P er so na l 1. K ui d as j ä lg i tak s e t ee n us e
pak k um is eg a ots es e lt te g el e v at e x x
tö öt aj at e te g e vus t (p er i oo d i lis e lt )?
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2. K ui d as k a as a t ak s e p er s on a l i te e nus t e
p la n eer im is s e, ar e nd a m is s e j a x x
h in d am is s e ?
3. K ui d as o n ta g at u d pe r s on a l ip o l i it ik a
x
k oos k õl a tö ös ea d us a n d lus e ga ?
4. K ui d as h i nn at ak s e tö ö taj at e
k om pet e nts us nõ u de i d n in g k u i das x x
tö öt i n gim us i?
5. K ir j e l d ag e as ut us e
m oti va ts io o n is üs t eem i j a k ui das x x
to im ub t öö t aj a te t u nn u s tam in e ?
6. K ui d as a na l ü üs i t ak s e
x
k ool i tus te g e vus e ef ek ti i vs us t ?
Õ igu se d 1 A. Se l g it a g e , k u id as T ei le o n s e l g it at u d
j a k u id as t un n et e „k l i e nt i de õi g us j a
k ohus tus i“ , tu u es m õn ed nä i te d ?
x x
1 B. Kas o l et e t ea d l ik (T eid on
i nf or m eer it u d) om a õi g us t es t j a
k ohus tus tes t t ee n us e s aaj a na ?
2 A. Ku i das on k orra l d at u d et te p an ek ut e
j a k ae b us t e m e ne t lem i ne ni n g ta g at u d
s e ll e pr o ts es s i as j ak ohas us j a
l äb i pa is t vus ? x x
2 B. Ku i das t e en us e s a aj a d s a a va d
es it ad a e tt e pa n ek ui d v õ i k ae b us i?
3. Ku i das a it ab t e en us e os ut aj a k aas a
te e nus e s a aj a te en es e m äärat l em is e l e j a x x
k uid as s e da ig a - a as t a s e lt h i nn a tak s e ?
4. Ku i das i nf orm eer it a k s e te e nus e s a aj a t
õ ig us es t s a a da e es tk os tj a t v õ i tu g i is ik u t x x
j a k u id as s e da ig a - a as tas e lt h i n na tak s e ?
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5. Ku i das T e h i nd at e , k uid as T e i d
X
k ohe l dak s e t ee n us e s aaj at e na ?
E et i k a 1. K ui d as T e i d o n i nf orm eer i tu d
ee t ik ak ood ek s is t j a k u i das t u nn et e
x x
v as t a v ai d p õ him õt t ei d (to o ge
nä i te i d) ?
2. K ui s ag e l i v a ad at ak s e ü le j a
an a l üüs i tak s e (k oos p ers o n a l ig a)
x x
k onf id e nts i aa ls us eg a s eo t ud n õ ud e d
n in g m i l l is e i d m uu d at u s i v i im at i te h t i?
3. M il l is e d on T e ie a s u tu s e te e nus t e
os u t am is e p õh im õt te i d n i ng x x
v äär t us h i n na n gu d ?
4. K ui d as p ääs e te li g i om a is ik l ik el e
x x
an dm et e le ? (k l i e nd i to i m ik )
5. K us on k l ie n ti d e tar v is k irj e ld a tu d
k lie n d il e p ak ut a v a te e nus e
os u t am is e ga s e o tu d r o l l id j a x x
v as t ut us a la d j a k u i das t o im ub
k lie n ti d e te a v it am in e n e is t ?
Koo st öö suh t ed 1. K el l e ga j a m il l is t k oos t öö d t ee t e
( s e lg i ta g e n äi d et e v ar a l, s h
x x x
s ots i aa l v a ldk o n na p ar t ner i d,
r ah as taj a d, t ee n us e k as u t aj a d) ?
2. K ui d as k a as a t ak s e t e e nus t e x x x
ar e n d am is s e te e n us e s aaj a id ( ne n de
es in d aj a i d), t e en us e o s tj a i d j a
ha nk ij a i d ?
3. K ui d as k a as a t ak s e (n e nd e) x x
v aj a d us t e v ä lj as e l gi t a m is e p ro ts es s i
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hu v i gr up p e?
4. K ui d as a na l ü üs i t e j a h i nd at e x
k oos t öös t tu l e ne v at l is an d v ää rt us t ?
5. K ui d as o l et e r a hu l k oo s tö ö ga ? x x
O s al em in e 1. K ui d as os a le v a d te e nu s e s a aj a d x x x
v aj a d us t e v ä lj as e l gi t a m is el ,
te e nus te pl a ne er im is e l j a
an a l üüs im is e l ?
2. K as j a k u id as o n p ers on a l i x x x
k ool i ta tu d t ee n us e s aa j at e
j õus tam is e te em al n i n g k u id as s e e
to im ub i g a pä e v as es e l us ?
3. K ui d as a it a b te e nus e os u t aj a k aas a x
te e nus e s a aj a te j õ us ta m is el e j a
m ill is e id m õõ de t a va i d tu l em us i o n
s aa v u ta tu d ?
4. K as j a k u id as o n t ee n us e s aaj at e x x x
os a l em is ek s vaj a l ik ud m eetm ed,
te g e vus e d j a k or d k oo s k õlas ta t ud
te e nus e s a aj a te g a v õ i ne n de
es in d aj a te g a?
5. K ui s ag e l i v a ad at ak s e ü le t e en us e x x
s aaj at e võ i n e nd e es i n daj at e
os a l em is e g a s eo t ud m ee tm ed n i ng
m ill is e d on ol n ud v i im as e d
m uuda t us e d ?
Is ik uk e sk su s 1. K ui d as o n k i nd l ak s t eh tu d x x x
r ah as taj at e vaj ad us ed n in g t eis t e
o lu l is t e h u v ig ru p pi d e v aj a d us e d j a
k uid as n en d eg a ar v es t at ak s e?
2. K ui d as o l et e r a hu l t e e nus e pak k uj a x x
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as uk o ha g a?
3 A. Ku i das on t a ga tu d , et t ee n us e x x
os u t aj a p ak ub om a t ee nus e i d v as t a v al t
te e nus e s a aj a vaj a dus te l e?
3 B. Kas in d i v id u aa l n e te g e vus p la a n
v as t a b T e ie v aj a d us t e l e j a o ot us t e le ?
4. Ku i das v aa d at ak s e as u t us e p o o lt x
pak u ta v a id t e en us e id ü le , ar v es t a des
s am as t ee n us e s aaj at e o od at a v at e
tu l em us te g a?
5. Kas in d i v id u aa l n e t eg e v us p l a an o n x x
k oos k õl as t at u d j a s e d a o n k orr ig e er it u d
v as t a v al t t ee n us e s a aj a ta g as is i d e le ?
Lai ah a ar de li su s 1. K ui d as ta g at e , et p ers on a l i l on x x
üh t ne ar us a am pe am is tes t te e nus e
os u t am is e pr ots es s id e s t j a en d a
v as t ut us es t n e nd es ?
2. K ui d as k as ut at e x
m ult id is ts ip l i na ars et lä he n em is t
k lie n d il e i n d i v id u aa ls e
te g e vus p la a n i k o os t a m is el j a
r ak en d am is e l?
3. K ui d as ta g at e , et t e en us e s aaj a x x
e luk v a l it ee t o n i n di v i d ua a ls el t
m äärat l et u d te e nus e s aaj a v õ i t em a
per ek o nn a p oo l t?
4. K ui d as ta g at ak s e te e n us e j ä tk u vus x x
j a k u id as s e da hi n n at a k s e i ga -
aas t as e l t?
5. K ui d as o n ta g at u d te e nus t e j a x
pr o gr am m id e os u t am is e l
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ü lem i nek ut e s uj u vus ?
T ulemu st el e 1. K ui d as v õrr e ld ak s e k l i en d i x
ori en t e e rit u s i nd i v i du a a ls e t e ge v us p la a ni t u l em us i
os u t at ud t e en us te t u le m us teg a e hk
k uid as i g a i nd i v i du a a l ne pl a an
pa n us t a b ü ld is es s e te en us e
tu l em us l ik k us es s e ?
2. K ui d as m õõ d et ak s e te en us e s a aj a te / x x x
ha nk ij a t e / te l l ij a t e j a r ah as taj at e
r ah u l o lu ?
3. K el l e l e j a m il l is t ü le v a ad e t an t ak s e x x x
as u t us e t e ge v us es t n i ng k as s ee on
s i htr ühm a de l e ar us a a d a vas k ee l es ?
4. K ui d as h i nn at ak s e as u tus e t eg e v us t e x x
tu l em us te l is a v ä ärt us t os tj at e le j a
r ah as taj at e l e ?
Pi dev a r eng 1. K ir j e l d ag e P DC A ts ük l i t o im im is t om a x
as u t us es ?
2. K ui d as o l lak s e k urs is hu v i gr up p i de x x
uu t e j a m uu tu v a te vaj a dus t eg a ?
T oog e n ä it e id hu v i gr u pp i d e
es il ek erk in u d v aj a d us t es t
3. T oog e n ä it e id in n o va a ti l is tes t x x x
tö öm eet o d it es t /
i nn o v ats i oo n i proj ek ti d es t (s h
v i im as e l 2 a as t a l) ?
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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. S ots i aa l h oo l ek an de ük s us e k v al i te e d is t a nd ar d 2 01 5- 20 1 8
2. S ots i aa l h oo l ek an de ük s us e pers o na l i po l i it ik a 2 0 15 - 2 01 8
3. S ots i aa l h oo l ek an de ük s us e pr o ts es s i d ja pro ts e d uur i d 20 15 - 2 01 8
(Re h ab i l it a ts i o on i te e n us ; Er ih o ol d us t e en us , Ho o ld us te e nus )
4. E et ik a po l i i t ik a 2 0 15 - 2 01 8
5. K onf id e nts i aa ls us po l i it ik a
6. S A V i lj a n d i h ai g l a tö ök or r al d us e r ee g l id
7. T ege v us k a va d 2013-2014 (re ha b i l it at s i oo n it e en us , ho o l dus t ee n us ,
er ih o o ld us t e en us )
8. A as t aa r u a nd e d j a p oo l aas t aar u an d ed 20 1 2 - 2 01 5
9. T agas is i de s üs te e m i dok um en di d (ra hu l o lu - u ur in g , ank e ed i d,
ta g as is i d el e h ed j n e)
S am uti pa l um e a ud i it o r i j a ok s va lm is p a nn a ta ot l us dok um en d is m ärg it ud ü lej ä än u d
tõ e nd us dok um en d id .
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. Ha i g la j u h t/ j u h at us e l i i ge 30 - 4 5 m i n
2.Õ e nd us - h oo l dus k es k us e j u ht 45 m in
(EQ U A SS k va li t ee d is üs t eem i
rak en d am is e e es t vas tu taj a) j a h o ol d us -
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j a r eh a b i li t ats i oo n it e e nus e ük s us t e j u h id
3. K v a li t ee d ij u h t/ EQ U A S S 45 m in
k va li t ee d is üs t eem i r ak en dam is e e es t
v as t ut a v t öö t aj a
Teenuse saajad Kestvus
1.G r u p ii n ter vj u u
reh a b i li t ats i oo n it e en us te s a aj a te g a (k un i
Kuni 45 min
6 in ( v aj a dus e l k l i en t k oos t u g iis ik u ga
v õ i l as t e p uh u l l a ps k o os v a nem ag a ) .
2.G r u p ii n ter vj u u h o o ld us t e en us te ja K un i 4 5 m i n
er ih o o ld us t e en us te s aaj at e või n en d e
per e l i ik m ete /e es tk os tj at e ga ( k un i 6 i n,
as u t us e es i nd aj a võ i b v aj a d us e l j u ures
v i ib i d a)
Teised huvigrupid Kestvus
1. As u t us e k oos tö öp ar tn er i d (1 - 3) K un i 4 5 m i n
as u t us e va l ik u l
2. As ut us e r a has taj a( d) K un i 3 0 m i n
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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 :1 5 A v ak oos o lek
9: 1 5- 1 2: 1 5 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
12 : 15- 1 3: 0 0 K v al i te e d ij u ht / EQ U A S S k v a l it e ed is üs t e em i r ak en dam is e e es t
v as t ut a v t öö t aj a
13 : 00- 1 3. 3 0 Lõ u na p aus
13 : 30- 1 4: 0 0 Õ e nd us - ho o l dus k es k u s e (Õ H K) ru um id e k ü l a s tus
14 : 00 – 14 :1 5 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
14 : 15 – 15 :0 0 In ter vj u u te e nus e s a aj at e ga (g ru p p 1)
15 : 00 – 15 :1 5 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
15 : 15 – 15 :4 5 /5 5 In ter vj u u p er s o n al i g a
15 : 45 – 16 :0 0 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
16 : 00 – 16 :3 0 In ter vj u u te e nus e s a aj at e ga (g ru p p 2)
16 : 30 – 17 :0 0 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
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 Ö ö pä e v ar in gs et e r i h oo l dus te e nus t os ut a v a ü k s us e ( eb as t a b i ils e
r em is s i o on i g a is ik ud) k ülas tus , i nt er vj uu per s on a l ig a
9: 3 0- 1 0: 0 0 Õ H K m aj j a s a ab um in e , dok um en ti d e ü l e va at us , vorm i de t ä itm i ne
10 : 00- 1 0: 3 0/ 45 In ter vj u u r a has taj a ga
10 : 30 /4 5- 1 1: 00 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
11 : 15- 1 2: 0 0 In ter vj u u k o os t öö p art n er it eg a
12 : 00- 1 2: 3 0 Lõ u na
12 : 30- 1 3: 0 0 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
12 : 45- 1 3: 3 0 In ter vj u u Õ e nd us - ho o l dus k es k us e j u h i ga j a k es k us e ük s us t e
j uh t id e ga ( ho o ld us te e nus e os ut am is e m ees k on n a j uh t j a
er ih o o ld us t e en us e os u tam is e m ees k on n a j u h t)
13 : 30- 1 4: 0 0 In ter vj u u h ai g l a j uh i ga
14 : 00- 1 6: 3 0 Dok um en ta ts io o ni ül e v aa t us , vorm i de t ä itm i n e
16 : 30- 1 7: 0 0 Lõ p uk oos o lek
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EQUASS ASSURANCE APPLICATION
ADDITIONAL INFORMATION
1. Short information about the organisation in the nati ve language
SA Viljandi Haigla põhieesmärgiks on tervishoiu – ja sotsiaalteenuse
osutamine. Sotsiaalteenused on peamiselt koondunud õendus -
hoolduskeskusesse. Meil osutatavad sotsiaalteenused jagunevad kolme suurde
rühama: rehabilitatsiooniteenus, hooldusteenus ja erihooldusteenus. Kõigi
sotsiaalteenuste ühiseks missioniks on pakkuda kvaliteetset taastumist ja
toimetulekut toetavat kliendikeskset teenust.
2. Short information about the organisation in English (activities,
clients, etc.)
The main objective of Viljandi Hospital Foundation is offering health and
social services . One part of the social services is the rehabilitation service.
The mission of the rehabilitation service is to provide qualit y customer -
driven recovery in a supportive rehabilitation.
Viljandi Hospital Foundation provides rehabilitation services for children,
disabled adults and persons with mental disabilities all over Estonia.
Rehabilitation service is intended onl y for persons with disabilities , we
provide service to about 1,000 people a year.
The care service is provided for the elderly, multi problematic and demented
individuals who need care round the clock, guidance and super vision and are
not maintainable in home conditions. The service is provided nationwide .
The special care services for the people with mental disabilities are provided
for the people with mental disabilities who cannot cope independent at home.
The service is provided nationwide in accordance with the guidance of a case
manager. The service is financed by the state and coordinated by the Social
Insurance.
Viljandi Hospital Foundation has more than 10 years of experience in the
provision of social cares .
3. Name of the organisation as you w ould w ant it to appear on the
EQU ASS Assurance certificate
SA Viljandi Haigla õendus -hoolduskeskus
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4. Name of services / departments of the organi sation in the scope of
the application as you w ould w ant it to appear on the EQUASS
Assurance certificate:
Õendus -hoolduskeskuse sotsiaalteenused:
• Hooldusteenus
• Erihooldusteenus
• Rehabilitatsiooniteenus
5. Organisation’s logo
Information to be published on EQUASS website:
Name of the organi sation : Viljandi Hospital Founda tion
Post address: Pärna tee 3, Jämejala küla, Viljandi vald, Viljandi
maakond, Estonia, 71024
Director: Priit Tampere
Contact person: Kaja Koger
Email: vmh@ vmh.ee
Web: w ww.vmh.ee
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