EQUASS ASSURANCE
ASUTUSE KÜLASTUSE
ETTEVALMISTAMISE VORM
Asutuse külastus: 08.12 - 09.12.2014
Põlva Haigla
Tiina Unukainen
© 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 ettev almistam ise küsimused
E QUA S S A s s uranc e t aot lus vormile ja ant ud lis ainformat s ioonile põhinedes palume
t eil et t eval mis t us ek s vas t at a järgne vat e le s elgit us t nõudvat el e k üs imus t ele:
Üldise d te e mad (max. 10 küsimust)
1. P alun andk e ülevaa d e rehabilit at s io o nit e en us e k orraldus es t t eie as ut us es
2. P alun k irjeldage aas t aplaa ni k oos t amis e prot s es s i?
3. P alun andk e ülevaade pers onali arendamis es t ja t agas is ides t amis es t t eie
as ut us es
4. P alun k irjeldage P õlva Haigla eet ik ak ood ek s i k oos t amis e prot s es s i?
5. P alun k irjeldage k oos t ööd rahas t ajat ega, s ot s iaalpart nerit ega, k lient idega,
huvirü h ma d e ga.
6. P alun k irjeldage, mis s ugus eid meet meid t e k as ut at e, et t agada oma as ut us es
k liendik es k s us ?
7. Mis s ugus ena t e näet e oma organis at s i o o ni aas t al 2020?
8.
9.
10.
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2
1. Kv alite e di põhimõte te le ja EQUASS Assurance krite e riumite le
v astav use küsimuse d/ te e mad:
Teenus e s aajad
J uht / direk t or
K v alit eediju ht
Huv igrupi d
P ers onal
Juhti m i ne 1. P alun k irjeldage, k uidas t eie
as ut us e vis ioon, mis s ioon ja
x x x
väärt us ed rak enduvad
igapäe vas es elus ?
2. P alun k irjeldage, mis s ugus ed
arendus projek t id t oimus id P õlva
x
Haiglas aas t a 2014 jook s ul ja
k uidas olit e t eie k aas at ud?
3. P alun k irjeldage, k uidas on
k valit eedik äs iraamat olnud t eile x
abik s igapäe vas es t öös ?
4. K uidas t eil on võimalik anda
t agas is idet P õlva Haigla t eenus t e x
k oht a?
5. K us t te peamis elt s aat e
informat s iooni P õlva Haigla x x
t eenus t e k oht a?
P e rsona l 1 P alun nimet age, mis on t eie as ut us e
pers onali (rehabilit at s ioonit eenus eid
x x
os ut ava pers onali) peamis ed
k ompet ent s in õ u de d ja mik s ?
2 P alun k irjeldage lühidalt , k as t e k äis it e
x
aas t a 2014 jook s ul mõnel k oolit us el ja
k uidas te hindat e k oolit us e mõju oma
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t ööle?
3 P alun s elgit age, k uidas t eil on võimalik
anda t agas is idet P õlva Haigla x
juht k onnal e ?
4 P alun k irjeldage, mis s ugus eid
ümberk orraldus i t e olet e t einud t eenus t e
x x
os ut amis e k orraldus es põhinedes
pers onali ja k lient ide t agas is idel e?
5
Õi guse d 1. P alun s elgit age, k es ja k uidas on
t ut vus t anud t eile t eenus el
x
viibimis el põhilis i õigus eid ja
k ohus t us i?
2. K ui t eil on mõni probleem t eenus el
viibides , s iis k elle poole t e s aat e x
pöördud a ?
3. P alun t ooge näit eid, k uidas te
olet e t aganud (s t mis s ugus eid
t egevus i t einud), et k lient ide x x
õigus ed t eenus el rak enduk s id
t eenus e os ut amis el?
4. Mis s ugus eid meet meid te olet e
k as ut anud t agamak s k lient ide x x
enes emää ra mis õi g us t ?
5.
Ee ti ka 1. Mis s ugus eid meet meid te oma
as ut us es k as ut at e, et t agada
x x x
k lient ide andmet e
k onfident s i a als us ?
2. P alun k irjeldage põhinedes x x x
näidet ele, k uidas rak endub t eie
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as ut us es eet ik ak ood ek s ?
3. P alun s elgit age t eie as ut us e
juht k onna vas t us t t agamak s x
k lient idele k valit eet ne t eenus ?
4.
5.
Koostöö s uh te d 1. P alun t ooge näit eid k oos t öös t
x x x x
s ot s iaalpart n e rit eg a ?
2. K uidas te olet e uurinud X x X x
huvirühmadelt , mis s ugus eid
t eenus eid nad vaja va d t ulevik us ?
3. K uidas te hindat e k oos t öös t x x x
t ulenevat lis avää rt us t ?
4. P alun k irjeldage, k uidas t eie x
k äes t k üs it ak s e t agas is idet
t eenus el viibides ?
5.
Osa l e m i ne 1. P alun k irjeldage, k uidas t eie x
s aat e k aas a rääk ida
rehabilit at s ioonit eenus e
os ut amis e prot s es s is ja k as t eie
s oove on arves t at ud ?
2. P alun t ooge näit eid, mis s ugus eid x x
t ulemus i te olet e s aavut anud
k lient ide jõus t amis el?
3. K uidas te analüüs it e t eenus e X X
s aajat e ja/ või nende es indajat e
os alemis ega s eot ud
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prot s eduu r e ?
4.
5.
I si kuke sk su s 1. P alun s elgit age, k uidas t eet e x x
k indlak s praegus t e k lient ide
vajadus ed ja nn pot ent s iaals et e
k lient ide vajadus e d ?
2. K uidas te hindat e rahas t ajat e x x
vajadus i?
3. P alun k irjeldage, k uidas t eiega x
k oos k õlas t at ak s e k oos t at ud
rehabilit at s iooniplaan ja
päevak a v a t eenus el viibides ?
4. P alun k irjeldage, k uidas on x
os ut at ud t eenus ed t eid aidanud ?
5. Millele põhinedes te olet e x x x
k oos t anud
rehabilit a t s i oo ni p r og r am mi d ?
La i a ha a rde l i sus 1. P alun s elgit age, k uidas t agat e, x x
et t eie t eenus e os ut amis e
peamis ed prot s es s id on
k oos k õlas rahas t ajat e
märk us t ega ?
2. P alun k irjeldage t eie as ut us es x x
k as ut at avat eluk valit eedi
mõõt mis e met oodik at ?
3. K uidas t e s aat e t eenus el viibides x
anda hinnangut oma
eluk valit e ed il e ?
4. P alun k irjeldage, mis s ugus eid x x x
t ak is t us i on es inenud t een us e
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os ut amis el?
5.
Tul e m uste l e
1. K as t e olet e t eadlik P õlva Haigla x
ori e nte e ri tus rehabilit at s ioonik es k us e t egevus e
t ulemus t es t ?
2. Mis s ugus eid t egevus i te x x
k avat s et e t eha põhinedes
rahuolu -u u ri n gut e t ulemus t ele ?
3. K uidas te olet e t ut vus t anud x x x
aruandeid k õigile huvit at ud
os apoolt el e ?
4. P alun t ut vus t age lühidalt x
k lient ide rahulolu-uuringu
t ulemus i.
5.
P i de v a re ng 1. P alun t ooge näit eid t egevus e x x
indik aat orit es t mõõt mak s
k valit ee di pr o jek t id e t ulemus i
2. P alun k irjeldage oma as ut us es x x x x
t oimunud k valit eediprojek t e
aas t at el 2013 ja 2014 ning t ooge
näit eid projek t ide t ulemus t es t ?
3. P alun t ooge näide (näit eid) x x x x
innovat s io o ni p ro j ek t i des t
4.
5.
Ve rs i o n 1 .0
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2. Nõutav dokume ntatsioon
E QUA S S A s s uranc e t aot lus es s e märgit ud infole ja lis adele põhinedes palume
vaat lus ek s et t e valmis t ad a järgne v dok ument at s io o n:
1. Kva l i te e di kä si ra a m a t
2. K innit at ud k orrad (eelk õige k orrad, mis on ot s es elt s eot ud
rehabilit at s ioonit eenus e os ut amis ega või mis mõjut avad
rehabilit a t s i oo nit e e nus e os ut amis t )
3. Lepingu d/ t a ot l us e d
4. K ont rollak t i d
5. Uuringut e k ok k uvõt t e d
6. A as t aplaani k oos t amis e juhend
7. A as t aplaan
8. Is ik uandm et e k ait s et regulee ri v dok ument at s io o n
9. Ris k ianalü üs
1 0. K aebus t e k ok k uvõt e
Ve rs i o n 1 .0
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1 1. Is ik lik rehabilit at s i oo ni pl a a n
1 2. Õendus lu gu
1 3. K oolit us t e analüüs
1 4. A met ijuhen di d
1 5. E et ik as t anda r d
3. Pe rsonali, te e nuse saajate ja te iste oluliste huv igruppide
inte rv jue e rimine
E QUA S S A s s uranc e t aot lus es ant ud vas t us t ele ja t õendit ele põhinedes palume
k orralda da int ervj u u d järgmis t e inimes t ega (funk t s ioo n ja k es t vus ):
Juhtkond Kestvus
1. P õlva Haigla juht 30 min
2. Rehabilit at s i o on ik es k us e juhat aja 30 min
3.
4.
5.
6.
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Personal Kestvus
1. P ers onali rühm 1 (k uni 5 inimes t ) 45 min
2. P ers onali rühm 2 (k uini 5 45 min
inimes t )
3.
4.
5.
6.
Teenuse saajad Kestvus
1. K lient ide rühm 1 (k uni 5 inimes t ) 30 min
2. K lient ide rühm 2 (k uni 5 inimes t ) 30 min
3.
4.
5.
6.
Teised huvigrupi d Kestvus
1. Rahas t aja 30 min
2. K oos t ööpart ner (või 35 min
k oos t ööpart n e ri d)
3.
Ve rs i o n 1 .0
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4.
5.
6.
4. Asutuse külastuse ajakav a formaat
A s ut us e k ülas t us peak s olema k orraldat u d vas t a va lt järgne vat e le juhis t ele:
a. A s ut us e k ülas t us peak s olema k avandat u d k ahele t ööpäe val e (= 16 t undi)
b. Dok ument at s iooniga t ut vumine peak s olema planeerit ud es imes e 3h s is s e
k ülas t us e es imes el päeval.
c . P äevak avas peak s olema s agedas ed paus id (15 – 30 minut it ), et audiit or
s aak s indik aat orit e t õendeid üle vaadat a ja k orras t ada.
d. Int ervjuud juht k onna, pers onali ja t eis t ega (välis ed huvigrupid/ part nerid)
peak s k es t ma max 30-50 min ühe int ervjuu k oht a. Int ervjuud t eenus e
s aajat ega peak s id olema k orraldat ud grupiint ervjuudena (max 5-inimes t
k orraga)
e. Juhiga/ direk t origa int ervjuu p eak s olema planeerit ud as ut us e k ülas t us e
t eis ele päeval e (s oovit a v al t pealelõun al ).
f. Lõplik as ut us e k ülas t us e programm peak s olema t aot leja ja audiit ori vahel
k ok k u lepit ud ja s aadet ud E QUA S S k ohal ik ule es indajal e.
Asutuse külastuse ajakava
kuupä e v Pä e v 1
Ae g Te ge vus (lühik e k irjeldus )
10. 30-11. 0 0 A vak oos o lek , audit i prot s es s i t ut vus t ami ne
11. 00-13. 0 0 Tut vum i ne dok ument at s io o ni g a
13. 00-13. 4 5 Lõuna ja võimalus el t ut vumin e as ut us ega
Ve rs i o n 1 .0
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13. 45-14. 3 0 Int ervju u k lient ide rühmaga 1 (aega on arves t a t u d k a hilis em
märk met e t egemine)
14. 30-15. 3 0 Int ervju u pers onali rühmaga 1 (aega on arves t at u d k a hilis em
märk met e t egemine)
15. 30-18. 0 0 A udit i dok ument at s i oo ni k oos t amine
kuupä e v Pä e v 2
Ae g Te ge vus (lühik e k irjeldus )
8. 30-9. 00 Dok ument at s io o ni g a t ut vumin e
9. 00-9. 45 Int ervju u rehabilit at s i o on ik es k us e juhiga
9. 45-10. 3 0 Int ervju u pers onali rühmaga 2
10. 30-11. 3 0 Int ervju u k lient ide rühmaga 2
11. 30-12. 3 0 Int ervju u P õlva Haigla juhiga
12. 30-13. 0 0 Lõuna(k u i es imes el päeval e k õik e vaadat a ei jõudnud, s iis k a
t ut vumin e as ut us ega)
13. 00-14. 0 0 A udit i dok ument at s i oo ni k oos t amine
14. 00-15. 0 0 Int ervju u k oos t ööpa rt n e rit e ga
15. 00-15. 3 0 Int ervju u rahas t aja g a
15. 30-1 6. 0 0 A udit i dok ument at s i oo ni k oos t amine
16. 00-1 7. 0 0 Lõpuk oos o lek
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EQUASS ASSURANCE APPLICATION
ADDITIONAL INFORMATION
1. Short information about the organisation in the native language
AS Põlva Haigla on üldhaigla, mille struktuuriüksusteks on teiste hulgas ka taastusravi osakond ja
Rehabilitatsioonikeskus.
AS Põlva Haigla taastusravi osakond loodi 1994. aastal, osakond taasavati kaasaegses käsitluses 2001 a. AS
Põlva Haigla taastusravi osakond osutab ambulatoorset ja statsionaarset taastusravi nii lastele kui
täiskasvanutele multidistsiplinaarse meeskonnatöö põhimõttel; igapäevatöös kasutame professionaalseid
teadmisi, oskusi ja kogemusi ning arvestame oma töös patsiendi individuaalseid eripärasid ja vajadusi.
Taastusravi meeskonna peamiseks eesmärgiks on taastada/ arendada/ säilitada patsiendi maksimaalset iseseisvat
toimetulekut igapäevaelus ning integreerimist ühiskonda.
Rehabilitatsioonivaldkonnas osaleb Põlva Haigla rehabilitatsioonimeeskond aktiivselt alates 2000.a. AS Põlva
Haigla Rehabilitatsioonikeskus asutati 2005.a. Osutame rehabilitatsiooniteenust erinevate probleemidega lastele,
tööealistele klientidele ja pensionäridele, sealhulgas psüühikahäirega isikutele. AS Põlva Haigla
Rehabilitatsioonikeskus osutab ka programmipõhist rehabilitatsiooniteenust, keskuses on praeguseks välja
töötatud kolm klientide poolt hästi vastu võetud jätkusuutlikku rehabilitatsiooniprogrammi. Kliendikesksel
meeskonnatööl põhinev töökorraldus annab hea lõpptulemuse, mida on olnud näha klientide tagasiside
uuringutest ning ka objektiivsetest rehabilitatsiooni tulemuslikkuse hinnangutest aastate lõikes.
2. Short information about the organisation in English (activities, clients, etc.)
Põlva Hospital is a general hospital, which includes (among others) the department of physical and
rehabilitation medicine and Rehabilitation Centre.
The physical medicine and rehabilitation department was first established in 1994 and reopened, at its current
state, in 2001. The Põlva Hospital physical medicine and rehabilitation department offers multidisciplinary
approach to out-patient and in-patient care – both children and adults. We combine professional knowledge with
skill, experience and personal approach as we take into consideration the patient’s individual needs and
characteristic traits. The main goal of our department is to re-establish, develop and preserve the patients’
maximum independence in order to cope in their everyday lives and achive integration into society.
Põlva Hospital Rehabilitation Centre was established in 2005, although the team of our rehabilitation
specialists has been actively involved in social rehabilitation field since 2000. already. Põlva Hospital
Rehabilitation Centre offers large variety of rehabilitation services to children, adults and elderly people with
various health situations, including psychiatric disorders. An important part of Põlva Hospital Rehabilitation
Centre´s work is to offer program-based rehabilitation services – we have three highly refined and sustainable
programs, all well received by client groups. The organization and job management of our client-oriented team
gives desirable results, which can be seen both from client feedback surveys and objective rehabilitation
productivity assessments over the years.
3. Name of the organisation as you would want it to appear on the EQUASS Assurance certificate
1
AS Põlva Haigla
4. Name of services / departments of the organisation in the scope of the application as you would
want it to appear on the EQUASS Assurance certificate:
AS Põlva Haigla taastusravi osakond (ingl.k. Põlva Hospital Ltd. physical and rehabilitation medicine
department)
AS Põlva Haigla Rehabilitatsioonikeskus (ingl.k. Põlva Hospital Ltd. Rehabilitation Centre)
5. Organisation’s logo
Information to be published on EQUASS website:
Name of the organisation: AS Põlva Haigla (ingl. k. Põlva Hospital Ltd.)
Post address: Uus 2, 63308 Põlva
Director: Koit Jostov
Contact person: Tiina Tammik
Email:
[email protected]
Web: http://www.polvahgl.ee/
2
3
EQUASS ASSURANCE
AUDIT REPORT
Site visit:08.12-09.12.2014
Põlva Haigla
Tiina Unukainen
© 2012 by European Quality for Social Services (EQUASS)
All rights reserved. No part of this document may be reproduced in any form or by any means, electronic, mechanical,
photocopying and recording or otherwise without the prior written permission of the EQUASS.
1. Information of the social service provider
Name of the social service
provider AS Põlva Haigla
Address:
Uus 2, Põlva 63308
Post box:
Person responsible (CEO): Margit Rikka
Contact person: Tiina Tammik
Phone: 7999152/ 7999153
Fax: 7999105
E-mail:
[email protected];
[email protected]
Web site:
Name of Auditor: Tiina Unukainen
Dates of audit: 08.12-09.12.2014
Clients: Number of person served:
Social rehabilitation- 568
Medical rehabilitation- 1254
As of (date):01.10.2014
Staff: Number of Full time staff: 40
Number of Part time staff:
Number of Contracted staff:
Number of volunteers (if applicable)
2
Services: Medical and social rehabilitation
3
2. Audit program
Esimene päev
10.30-11.00 Avakoosolek, auditi protsessi tutvustamine
11.00-13.00 Tutvumine dokumentatsiooniga
13.00-13.45 Lõuna ja võimalusel tutvumine asutusega
13.45-14.30 Intervjuu klientide rühmaga 1 (aega on arvestatud ka hilisem märkmete
tegemine)
14.30-15.30 Intervjuu personali rühmaga 1 (aega on arvestatud ka hilisem märkmete
tegemine)
15.30-18.00 Auditi dokumentatsiooni koostamine
Teine päev
8.00-9.00 Dokumentatsiooniga tutvumine
9.00-9.45 Intervjuu rahastajaga (SKA)
9.45-10.30 Intervjuu koostööpartneritega
10.30-11.00 Intervjuu rehabilitatsioonikeskuse juhiga
11.00-11.35 Intervjuu rahastajaga (Haigekassa)
11.45-12.30 Intervjuu Põlva Haigla juhiga
12.30-13.00 Lõuna (kui esimesel päevale kõike vaadata ei jõudnud, siis ka tutvumine
asutusega)
13.00-14.00 Auditi dokumentatsiooni koostamine.
14.00-15.00 Intervjuu klientide rühmaga 2
15.00-15.30 Intervjuu personali rühmaga 2
15.30-16.00 Auditi dokumentatsiooni koostamine
16.00-17.00 Lõpukoosolek
4
3. Detailed feedback on performance
1. The social service provider defines documents and implements its vision and
mission values on service provision.
Remark from the auditor: The services of the social service providers meet this criterion of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider has defined its
vision and mission values on service
provision in a quality handbook and made
publicly available also on webpage.
The tour and interviews with staff proved
these values are followed. The staff
described how they defined vision, mission,
values and set goals together.
There are practical examples how the
values observed in a daily life.
For example:
Professional- the staff is educated and
there is also a training plan;
The services are individual- the clients said
that service provider always considers their
needs and wishes.
5
2. The social service provider defines, documents, and implements its quality
policy by determining long term quality goals, and its commitment to continuous
improvement.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
In a quality handbook are defined long term
quality goals and its commitment to
continuous improvement. The service
provider has defined clients, staff,
organization and resources long term
quality goals and principles of quality.
The staff were awere of the quality
handbook. The employees analysed the
values and described how the values are
used in a daily life.
6
3. Persons served, family members and service user organisations are able to give
feedback on their individual and collective experience of programmes and
services.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The feedback system is described in a The quantitative questionnaire is not always
quality handbook. the best way to ask feedback.
There are once a year patients (medical The social provider should analyse is the
rehabilitation) and clients (social quantitative questionnaire statistically
correct when there are few respondents.
rehabilitation) satisfaction survey.
Alati ei ole parim viis tagasiside küsimisks
The clients and patients could give their kasutada kvantitatiivseid meetodeid. Kui
feedback also after the service. vastajaid on vähe, siis ole tulemused
üldistatavad.
The service user organizations feedback
questionnaire is used once a year.
The feedback has been documented.
In the course of the interviews, clients said
their feedback is taken into account in the
provision of services.
7
4. The social service provider informs all stakeholders about the offered programmes and
services available.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
On the service provider web page and also
on consortium web page is sufficient amount
of information about offered programmes
and services available.
The stakeholders were very satisfied with
the new rehabilitation programs. There are
some good examples how the intervention
changed clients life quality.
8
5. The social service provider management establishes and documents an annual planning and
review process.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has documented The service user could use technological
annual planning and reviewing process. resources for annual planning and
reviewing process.
The action plan for 2014 has been applied.
Most of the developments are based on The technological resources will help to
Equass quality system. use resources effectively.
Teenuse osutaja võiks kasutada
planeerimis- ja hindamisprotsessis
infotehnoloogilisi vahendeid.
Infotehnoloogiliste vahendite kasutamine
aitab ressursse kasutada efektiivsemalt.
9
6. The plan includes:
annual outcomes / targets
the activities to be undertaken in achieving the annual targets
monitoring of the performance of the organisation in meeting its annual targets
time-scales and procedures for review and revision.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has a plan (for 2015) The 2014 annual plan includes only actions.
which includes the following aspects:
The social service provider should think
1. Goals and actions;
what is a goal and what is an action. For
2. Expected results; example- a goal training the staff. Actually
training is an action. The goal could be- the
3. Time frame; staff have the necessary knowledge and
4. Analysis. skills.
Defined goals and actions will help to
The plan for 2015 is based on Equass analyze the results and make the future
criterias. plans.
The plan for 2014 is based on Equass Aasta 2014 tegevusplaanis on välja toodud
ainult tegevused.
actions. All actions are applied.
Teenuse osutaja võiks analüüsida, mis on
eesmärk ja mis on tegevus. Näiteks
personali koolitamine ei ole iseenesest
eesmärk, vaid tegevus. Eesmärkide ja
tegevuste selge sõnastus aitab analüüsida
saavutatud tulemusi ja teha paane
edaspidiseks.
10
7. The social service provider demonstrates organisation’s success in satisfying the needs and
expectations of the society.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider have a feedback
from local stakeholders how their needs and
expectations are satisfied.
There are good communication between the
social service provider and stake holders.
Because of the good communication one
client works on the open labor market. The
social service provider offers to the students
options for school practice.
11
8. The social service provider demonstrates organisation’s social responsibility through activities
contributing to the society.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider cooperates with
universities. The service provider offers
practical teaching programs for the students.
There are regular information days ( about
the rehabilitation sytem, preparation of
applications, healthy lifestyle).
We can say that most of the social service
provider activities are connected to local
community in one way or another.
12
9. The social service provider has a staff recruitment and retention policy that
promotes the selection of qualified personnel based on required knowledge, skills
and compentence
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The staff recruitment and retention policy is The service provider should analyse what
set up on consortium level and incudes are the clear staff competences. At the
necessary criteria’s for recruitment and staff moment the competences are too general.
retention. The analyse helps to plan the services future
vision.
The management described what is
important for selection of staff. Teenuse osutaja võiks analüüsida, mis on
täpsed personali kompetentsusnõuded.
Personali kompetentsusnõuete analüüs ja
täpsustus aitab luua teenuste
tulevikuvisiooni.
13
10. The social service provider operates in compliance with mandatory national legislation,
providing appropriate working conditions, adequate and agreed staff level and staff ratio, and
appropriate rewarding for staff and volunteers.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider operates in a
compliance with mandatory national
legislation.
The Social Insurance Board and Estonian
Health Insurance Fond has confirmed that
service provider operates in a compliance
with mandatory national legislation.
The service provider has a special
procedure for rewarding staff.
The staff was aware of the rewarding
procedure. The staff mentioned christmas
bonus and team events. The staff said that
the manager is very open minded and
helpful.
14
11. The social service trains all staff based on a plan for leaning and development
and evaluates the effectiveness of the training.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider has trained staff The are ohther ways to evaluate the training
based on a plan. The staff plan for learning effectivness. For example after the training
and development is reviewed once a year. the social service provider could analyze are
there any substantive changes provining the
After every training the social provider services. The feedback analyse is one
analyse feedback. criteria to evaluate the effectiveness of the
training. The accurate effectiveness analysis
After every traing the praticipant organizes
helps to plan the future trainings.
the information day.
Koolituste tagasiside analüüs võiks olla
täpsem. Täpne koolituste tagasiside analüüs
aitab planeerida võimalikke koolitusi
tulevikus.
15
12. The social service provider applies requirements for competence in the identified roles
and functions of staff and evaluates them on annual basis.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social provider has applied general There could create the system to evaluate
requirements for competence in the the staff compentence (who, when and
identified roles and functions. The staff roles, how). He system helps to achieve better
general competence and functions has results providing the services.
defined in a job descriptions and some of the
Some of the job descriptions are not
job descriptions are evaluated in a meeting. updated.These job descriptions should be
reviewed.
Teenuse osutaja võiks selgelt välja töötada
süsteemi, kuidas hinnata personali
kompententsusnõudeid- kes, kuidas ja millal
hindab.
Mõned ametijuhendid on uuendamata ja
need peaks üle vaatama
16
13. The social service provider recognises the staff as a resource for feedback on
organisational performance, service development and staff development
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider is organizing The staff could have an opportunity to give
regularly anonymous questionnaires. feedback during an individual progress
review. Durining the individual progress
Most of the staff gave the positive feedback. review the staff have a chance to give
individual positive and negative feedback.
Teenuse osutaja võiks kaaluda
arenguvestluste süsteemi loomist.
Arenguvestlusel on töötajal võimalik
edastada juhtkonnale oma soovid ja
juhtkond saab aidata töötajal tööalaseid
eesmärke seada.
17
14. The social service provider has mechanisms in place to enhance satisfaction and
motivation of staff
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has a special
procedure for rewarding staff. The staff was
aware of the document. The staff is also
motivated to plan team events.
18
15. The social service provider assures the rights of persons served outlined in a Charter of
Rights which is based on the EU Charter of Fundamental Rights, the European Convention
for the Protection of Human Rights and Fundamental Freedoms of the Council of Europe and
other international human rights conventions, especially those elaborated under the United
Nations.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider has a document
called “The client’s/patient`s fundamental
rights and restrictions”. The staff were aware
of the document. The staff was able analyze
why the document “The client’s/patient`s
fundamental rights and restrictions” is
important. There were many good examples
how how the staff is following the document
in a practical work.
19
16. The social service provider informs the person served about his/her rights and duties
especially to equal treatment on grounds of age, disability, gender, race, religion or belief and
sexual orientation before receiving the services.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
There is regular work ongoing to explain to
clients/patients their rights in an appropriate
way. The same is about duties – knowing
and remembering them is made very easy
clients and patients.
The person served said that the sevice
provider always explains (sometimes using
practical examples) their rights and duties.
20
17. The social service provider has accessible complaint management system which registers
feedback on performance from persons served, purchasers and other relevant stakeholders.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
Complains management system is
connected to the clients’ right awareness
and built up considering persons served
skills to communicate if they are unsatisfied.
There was a model to settle the complaint.
The clients/patients said that usually they do
not have complaints. They were worried
about the national system (they need more
services).
21
18. The social service provider respects the fundamental right to self-determination of the
person served. They freely determine their political status and freely pursue their economic,
social and cultural development.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The fundamental rights of clients and
patients are respected and supported by
staff.
Every year the service provider organizes
the feedback questionnaire. Durning the
rehabilitation process the clients/patients are
explaining their wishes and goals.
22
19. The social service provider facilitates the person served in choosing and having access
to advocates and/or supporting persons.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider has examples of
the rehabilitation plans how the
clients/patients are supported. The clients
said that service provider offers to them
support person when they need one.
23
20. The social service provider defines and documents its policy on ethics that respects and
assures the dignity of the persons served, protects them from undue risk and promotes social
justice
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider has
its own ethics policy. The policy
respects and assures the dignity of the
persons served, protects them from
undue risk and promotes social justice.
The staff were aware of the document. The
staff explained how they created
organization ethics policy. There were
regular workshops and the staff had
opportunity to comment.
24
21. The social service provider operates mechanisms which prevent the physical, mental and
financial abuse of users.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider
has its own ethics policy and a document
which is called “The specialist’s fundamental
rights and restrictions”. These two
documents are regulating mechanisms
which prevent the physical, mental and
financial abuse of clients.
Durining the meetings the service provider
has analyzed the ways to prevent the abuse.
25
22. The social service provider provides services in a safe system of working within a safe
environment to ensure the physical security of persons served, their families and caretakers.
Remark from the auditor:The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider environment is
adapted to needs of persons served
considering their safety and not limiting the
freedom to be active.
The social provider is oranizes regulary
organization's risk analysis.
26
23. The social service provider defines, documents, monitors and evaluates a set of
principles, values and procedures that govern behaviour in service delivery containing
aspects of confidentiality, accuracy, privacy and integrity.
Remark from the auditor:The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The social provider has documented
its own ethics policy.
The staff were aware of clients/patients
confidentiality, accuracy, privacy and
integrity.
There were practical examples how the staff
is following the ethics policy. During the
meeting the service provider discussed how
to resolve the complaint and follow the
ethics policy.
27
24. The social service provider defines, documents, monitors and evaluates procedures for
assuring confidentiality of data regarding the persons served and the service provided to
them.
Remark from the auditor:The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider has
defined a document “Confidentiality
requirements”. There are meetings
protocols which are proving that the social
service provider is monitoring and evaluating
procedures assuring confidentiality of data
regarding the persons served and the
service provided to them.
28
25. The social service provider defines the roles and responsibilities, authorities and the
interrelation of all personnel who manage, design, deliver, support and evaluate the service
provision to person served.
Remark from the auditor:The services of the social service providers meet this
criteria of the EQUASS Assurance certification program
Strengths Improvement & developments
Most of the roles and responsibilities are
defined in job descriptions.
The service provider has created the
document “The procedure of provding
medical and social service”. The staff were
aware of the document.
During the the tour I analyzed that procedure
is followed.
29
26. The social service provider works in partnership with other organisations in the provision
of services.
Remark from the auditor:The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The social provider works in
partnership with other organizations.
The social service provider has developed
with other organizations rehabilitation
programs.
The service provider organizes information
days about the services.
The service provider cooperates with
universities. The service provider offers
practical teaching programs for the students.
30
27. The social service provider works in partnership with persons served, purchasers and
other stakeholders in the development of services.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
There are meetings
protocols which are proving that the social
service provider works in partnership with
persons served.
There are regular meetings with purchasers.
Purchasers were satisfied with the quality of
services. AS Põlva Haigla could be one day
competence centre of medical service.
31
28. The social service provider includes persons served as active participants in planning
and have set up appraisal made up of on-going of an on-going structured dialogue process
in the management of the service, including the definition of the needs, the definition of the
services, as well as of the evaluation of quality.
Remark from the auditor:The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has created the
documents which are called “Rehabilitation
service (medical and social) procedures”.
Based on interviews, tour and documents
we can say that clients and patients are
included to the process.
32
29. The social service provider institutes an annual evaluation of participation of persons
served both on individual and/or group basis.
Remark from the auditor:The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The participation is documented and
evaluated (rehabilitation plans and case
reports).
At the beginning of the service the clients
and patients have a opputunity to describe
their excpectatitions. The service provider
prepares (with the client ) the action plan. At
the end of the sevice the service provider
evaluates the results with the clients.
33
30. The social service provider operates specific instruments for users to improve their
personal empowerment and personal situation and. that of their community
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The service provider is using instruments
evaluating life quality and there are a lot of
good results. For example one client was
able to walk at the end of the service. The
other client explained that after the service
she is emotionally stable.
34
31. The social service provider operates specific mechanisms for establishing an
empowering environment.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The environment supports persons served -
its safety, cosy and creative in a many ways.
Durning the tour i saw that the enviroment is
adjusted to clients and patients.
There is a system of ongoing external
(including international) and internal training.
The service provider also organizes
information days about the social and
medical rehabilitation service.
35
32. The social service provider selects programmes which are based on a needs assessment at
the location which is most convenient for the person served, family and care takers
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
On the webpage is an accurate information
about the service provider location.
During the rehabilitation process the social
service provider is analysing the clients and
patients needs.
36
33. The social service provider offers programmes consistent with the identified needs of its
customers and objectives for the programme.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
Based on interviews and feedback analyses
we can say that the service provider is
evaluating regularly partners needs.
The purchasers have analyzed the services
and submitted suggestions.
37
34. The social service provider operates individual processes that are driven by the needs
of the person served.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
Based on interviews and rehabilitation
plans/case reports the process is mainly
individual.
1. The clients/patients said that the sevice
provider takes account of their substantive
and formal proposals.
38
35. The social service provider documents the planning of services based on the identification
of individual needs and expectations of persons served in an Individual Plan.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
Based on interviews and rehabilitation
plans/case reports and clients interviews-
the social service provider reflects the clients
individual needs and expectations in a plan.
At the beginning of the service the clients
and patients have a opputunity to describe
their excpectatitions. The service provider
prepares (with the client ) the action plan.
Durning the process there are regular
meeting and clients can change their actions
plans. At the end of the sevice the service
provider evaluates the results with the
clients.
39
36. The social service provider identifies, documents, and maintains the key service delivery
processes to the persons served in line with its vision, mission statement and quality policy.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider is analysing
regularly are the service processes in line
with its vision, mission statement and quality
policy. There are meetings protocols which
are evidence material.
The main regulatory document is
“Rehabilitation service (medical and social)
procedures”.
40
37. The social service provider reviews this delivery process and maintains control over the
delivery of the service.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider is analysing
and controlling regularly the service
processes. There are meetings
protocols which are evidence
material.
41
38. The social service provider ensures that the person served can access a continuum of
services that span from early intervention to support and respond to changing requirements
over time.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has examples of the The service provider could create end of the
contracts with the purchasers and year the activity report. The document could
documents which are proving that the prove in a collective way how the services
service aspects are regularly evaluated. are evaluated and will help to plan the
future development.
Teenuse osutamise tulemuslikkuse
hinamiseks (asutuse tasemel) võiks
koostada aruandeaasta lõpus
tegevusaruande. Koostatud tegevusaruande
abil on võimalik planeerida järgmise aasta
arendustegevusi.
42
39. The social service provider develops a seamless continuum of services and reduces barriers
in a multi-disciplinary or multi-agency setting.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider informs the partners .
about service problems (examples of the
letters).
The social service provider has
defined a document which is called
“Rehabilitation service process”.
This document proves that service provider
develops a seamless continuum of services
and reduces barriers in a multi-disciplinary
setting. During the interviews the clients said
that the service provider is very
approachable.
43
40. The social service provider operates services from a holistic approach based on the
needs and expectations of the person served with the aim of improving the quality of life for
the person served.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The client/patient is involved in rehabilitation
processes (medical and social). When the
service ends the service provider evaluates
(with the client) changes of the client life
quality.
Durning the interviews the clients/patients
said that they are more active after the
service.
44
41. The social service provider identifies the needed competences, skills and support for
staff to enhance the quality of life for person served.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The social provider has applied general Some of the job descriptions are created in
requirements for competence in the the year 2002.These job descriptions
identified roles and functions. The staff roles, should be reviewed. Reviewed job
general competence and functions has descriptions will help to evaluate the
defined in a job descriptions and some of resources.
them are evaluated in the meetings. Mõned ametijuhendid on aastast 2002 ja
need peaks üle vaatama. Uuendatud
ametijuhendid aitavad hinnata teenuse
osutamiseks vajalikke ressursse.
45
42. The social service provider identifies its business results and provides formal periodic
and independent review and procedures to achieve the targeted results.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has created the The service provider should create end of
financial report at the end of the year. the year the activity report. Activity report
helps to evaluate the results. The report
There are regular meetings with purchasers. must be published. The activity report should
Purchasers were satisfied with the quality of be based on year plan.
services
Teenuse osutaja võiks iga aasta lõpus
koostada tegevusaruande, et hinnata oma
astuse tegevuse tulemusi ja põhinedes
tulemustele planeerida arendustegevusi.
46
43. The social service provider identifies and registers the outcomes and benefits for person
served of the receive services on individual and collective basis.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
When the service ends the service
provider evaluates (with the client/patient)
changes of the life quality.
The service provider has a statistical
summary of services.
44. The social service provider evaluates its business results in order to determine best
value for purchasers and funders (‘best value’ can also be expressed in relation to the
increased quality of life offered to the person being served).
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider has collected
feedback (in that analyse service provider
evaluates its business results in order to
determine best value for purchasers and
funders).
47
45. The social service provider evaluates the individual and collective satisfaction of persons
served and other stakeholders by internal and/or external evaluation.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The social service provider evaluates
the clients/patients needs.
The are regular regular meetings with the
Estonia Health Insurance Fond.
The Social Insurance Fond has evaluated
the service provider. The Social Insurance
Fond evaluated that AS Põlva Haigla offers
high quality medical service.
Purchasers were satisfied with the quality of
services.
48
46. The social service provider provides accessible and easily understandable records on
outcome, including personal perception and achievements
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
Every year the service provider organizes
the feedback questionnaire (for staff,
clients). The client`s survery results are
available on a homepage.
The staff was aware of the survery results
and the results reflect the reality.
49
47. The social service provider actively disseminates organisation performance among its staff,
service users and external stakeholders.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The reports are published .
on a homepage. There are meetings
protocols which are proving that the
social service provider actively disseminates
organisation performance among its staff,
50
48. The social service provider has a standard procedure for continuous improvement on the
basis of an improvement cycle.
Remark from the auditor: The services of the social service providers meet this criteria of
the EQUASS Assurance certification program
Strengths Improvement & developments
The service provider has a plan (for 2015) The 2014 annual plan could be more
which includes the following aspects: accurate. At the moment the plan includes
mainly actions.
1. Goals and actions;
1. The precisely targeted plan helps to achieve
2. Expected results;
results.
3. Time frame; 2.
4. Analysis. Aasta 2014 plaanis on peamiselt kirjeldatud
tegevused.
In 2014 the service provider has an action
plan. Teenuse osutaja peaks looma süsteemi
tulemuslikuma aastaplaani koostamiseks.
51
49 The social service provider identifies performance indicators for measuring the results of
the improvement actions.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
In the year 2014 the social provider has
implemented Equass quality system and
indetified inicator and analyzed the actions
results.
In the annual plan (2015) the service
provider has identified performance
indicators.
52
50. The service provider introduces and manages innovative ways of working that have been
identified based on the needs of stakeholders.
Remark from the auditor: The services of the social service providers meet this criteria of the
EQUASS Assurance certification program
Strengths Improvement & developments
The service provider offers new The social provider should use
rehabilitation programs. The programs are technological resources to manage the
disained for children. There are some good projects. The technological reources will
examples how the intervention changed help to save resources.
clients life quality.
Teenuse osutajavõiks kasutada
infotehnoloogilisi vahendeid projektide
juhtimisel.
53
4. Agreed additional development / improvements
The applicant decided on the following improvement actions and/or additional development for the
period of two years:
Short description of the actions
(including SMART objectives)
1 The quality of social service
The social service provider has developed a new rehabilitation
program for children by end of the year 2015
Uus rehabilitatsiooniprogramm laste sihtrühmale on välja töötatud
2016. aasta lõpuks.
2 The quality of medical service
By the may 2016 the service provider has implemented team
evaluating method (for stationary patients) to evaluate the functional
condition (team training, technical solutions).
Meeskonnapõhise hindamise meetodi sisseviimine statsionaarse
taastusravi patsientide funktsionaalse seisundi hindamisel ja
dokumenteerimisel (meeskonna koolitus, tehnilised lahendused)
2016.a. maikuuks.
54
3 The quality of the services
1. The service provider has updated the staff job descriptions
(physiotherapist, psychologist, nurse, administrator, occupational
therapist) by the may 2015.
AS Põlva Haigla on lõpetanud personali ametijuhendite
ülevaatamise ja uuendamise protsessi taastusravi osakonna ja
rehabilitatsioonikeskuse töötajate osas 2015.a. maikuuks
(füsioterapeudi, psühholoogi, taastusõe, administraatori ja
tegevusterapeudi ametijuhendi uuendamine)
55
5. Closing remarks
AS Põlva Haigla ” is an organization providing medical and social services. The aim is to
offer social and medical rehabilitation service to the clients/patients who want to have a good
health. Their services are available for persons with mental, physical or physical disabilities
of all ages.
The social service provider has defined his vision and mission. During the interviews I found
out that vision and mission came from practical life. The vision and mission is written down in
a Quality Handbook and we could find it from the homepage.
The social service provider has a document called “The client’s fundamental rights and
restrictions”. The staff and clients were aware of the document.
The social service provider has its own ethics policy. The policy respects and assures the
dignity of the persons served, protects them from undue risk and promotes social justice.
The staff was aware of the document.
The services process is designed (processes are based on clients/patients needs).
Purchasers were satisfied with the quality of services. AS Põlva Haigla could be one day
competence centre of medical service.
There are also some general developments what the service provider should consider
(detailed developments are written in a report):
1. The service provider should analyze what is the best way to ask feedback;
2. The service user could use technological resources for annual planning and reviewing
process;
3. The annual planning and reviewing process should be systematic (regular, targeted and
evaluated).
It was a very good cooperation between representative of the social service provider and
auditor. All requested documents were prepared for auditing.
In conclusion I can say that the social service provider generally meets criterias of the
EQUASS Assurance certification program. The services are individual and well-planned. The
staff is motivated to work with clients.
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Põlva Haigla on tervishoiuastus, kus pakutakse rehabilitatsiooni- ja taastusravi teenuseid.
Teenuseid pakutakse kõikidele klientide sihtrühmadele. Põlva Haigla soovib aidata oma
klientidel saavutada võimalikult head elukvaliteeti.
Põlva Haigla on defineerinud oma asutuse visiooni, missiooni ja väärtused. Personal oli
missioonist, visioonist teadlik ning oskas tuua praktiliseid näiteid igapäevases töös
kehtivatest väärtustest.
Põlva Haigla eetikakoodeks on loodud koos personaliga ja personal tõi intervjuude käigus
näiteid, missuguste eetiliste printiipide osas on tekkinud arutelu. Aantud aspekt viitab sellele,
et eetikakoodeks ei ole Põlva Haigla jaoks formaalne dokument.
Põlva Haigla teenuse osutamise protsessid on läbi mõeldud ja põhinevad klientide
vajadustel ning võimalikult säästlikul ressursikasutusel.
Rahastajad hindasid Põlva Haigla teenuste kvaliteeti kõrgelt ning leidsid, et Põlva Haigla
võiks kunagi olla kompententsikeskus.
Auditi läbiviimise käigus ilmnesid järgmised arendusvaldkonnad:
1. Oluline mõelda, mis oleks kõige efektiivsem viis sisulise tagasiside küsimiseks;
2. Infotehnoloogiliste vahendite kasutamine aitab optimaalselt ressursse kasutada;
3. Aastaplaani koostamine peaks muutuma süsteemsemaks (mõõdetavad eesmärgid ja
tegevused eesmärkide saavutamiseks, vastustajad ja tulemuste selge mõõdetavus).
AS Põlva Haigla rehabilitatsiooni- ja taastusravi teenus vastab Equass Assurance
kvaliteedisüsteemi kriteeriumitele. Põlva Haigla personal on motiveeritud osutama klientidele
isikukeskseid teenuseid.
Tallinn, 09.01.2015
Tiina Unukainen
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Maarika Aro
Saatja: Keiu Talve
Saatmisaeg: 10. jaanuar 2015. a. 12:15
Adressaat: Maarika Aro
Teema: FW: Audit report EST2014-006 Põlva Hospital Ltd. physical and rehabilitation
medicine department
Manused: Additional Information Form_Põlva haigla.doc;
Equass_auditi_raport_polva_haigla.docx; EQUASS_taotlusvorm_2014
_polva_haigla_audit.xls; 2014_polva_haiga_auditi_ettevalmistuse vorm.pdf
From: Keiu Talve
Sent: Saturday, January 10, 2015 12:05 PM
To: Marie Dubost (
[email protected]); Guus van Beek (
[email protected])
Subject: Audit report EST2014-006 Põlva Hospital Ltd. physical and rehabilitation medicine department
Dear Marie, Dear Guus,
Attached you’ll find an audit report and other documents of Põlva Hospital Ltd. physical and rehabilitation medicine
department (EST2014-006).
For some reason in the Application form criteria no 10 shows „partial compliance“ although all the indicators are
met.
Please let me know in case there are some comments about the report.
Keiu
EQUASS Eesti
Astangu KRK
Tel: +372 5682 9104
www.equass.ee
www.astangu.ee
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