Kiri välja Pärnu Haigla auditi raport Brüsselisse

EQUASS ASSURANCE APPLICATION ADDITIONAL INFORMATION 1. Short information about the organisation in the nati ve language S A Pär n u H a ig l a m is s i oo n ik s on t o et a da i ni m es te t er v is t j a e luk v a li t ee t i n i ng l is ak s ter v is ho i u te e nus te l e os u t at ak s e tu g i is ik u te en us t , re h ab i l it a t s i oo n it e en us t j a er ih o o lek a nd et e en us e i d. P ärn u h a i g la ps ü h h ia a tr i ak l i in ik u am bu l at o or s e os ak on n a a l la k uu l ub P äe v ak es k us . P äe v ak es k us es os ut a t ak s e er i h oo l ek an d et e e nus e na ig a pä e v a el u t o et am is e t ee n us t (44 k o ht a k uus ) j a t oe t at ud t öö tam is e t e en us t (1 1 k oh ta k u u s ) n in g t u g i is ik u te e nus t. Ps üh h i aa tr iak l i i nik u am bu l at oo rs e o s ak on da ja s is e ha i g us t e k l i in ik u ta as t us r a v i os ak on d a k uu lu v a d r e ha b il i ta ts io o n iük s us ed , m is os ut a v ad s ta ts io n aar s e lt j a am bu la to or s e lt re h ab i l i ta ts i oo n it e en us t . 2. Short informat ion about the organisation in English (acti vities, clients, etc.) T he m is s io n of Fo u nd a ti o n P är nu Hos p it a l is to s u p p ort h um an h e a l th a n d q ua l i t y of l if e, a n d bes i des m ed ic al c ar e Fo u nd at i o n P ärn u Hos p it a l pr o v id e s s pec i a l c are s er v ic es , r e ha b i l it at i o n s er v ic e an d s u p por t pers o n s er v ic e. T he D a y C e nt er is a par t of o ut - p at i en ts ’ d ep ar tm ent of T he Ps yc h ia tr ic C l i nic i n P ärn u Hos p it a l. T h e D a y C e nt er of T he Ps yc h ia tr ic C l i nic i n P är n u H os p it a l of f ers s er v ic e of s u p por t pe r s on a n d s p ec i al c ar e s er v ic es : As s is t a nc e i n e v er yd a y l if e (f or 44 p er s o ns per m on t h) an d As s is t anc e i n wor k i n g (f o r 11 pers ons per m ont h) . Re h ab i l it at i o n U n its ar e a p ar t of o ut - p at i e nt s ’ de p artm en t of T he Ps yc hi a tr ic C l i nic an d T he I n ter n a l D is eas e C l i nic i n P är nu Hos pi t al . R eh a b il i ta t i on s er vic es a re pro v i d ed in r e ha b i li t at i on an d af t erc ar e in - p at i en t u n it a n d in re h a bi l i ta t io n am bu la t or y un i t. 3. Name of the organisation as you w ould w ant it to appear on the EQU ASS Assurance certificate S A P ÄRNU H AIG L A / Foundation Pärnu Hospital 4. Name of services / departments of the organi sation i n the scope of the application as you w ould w ant it to appear on the EQU ASS Assurance certificate : Day Center of Pärnu Hospital Psychiatric Clinic  As s i s t a n c e i n e v e r y d a y l i f e  As s i s t a n c e i n w o r k i n g  Support per son Rehabilitation Units of Pärnu Hospital Psyciatric Clinic and Internal Disease Clinic  Rehabilitation service 1 5. Organisation’s logo Information to be published on EQUASS website: Name of the organisation: S A P ÄR NU H AIG L A / Foundation Pärnu Hospital Post address: Risti ku 1, Pärnu, Estoni a, 80010 Director: Urmas Sule Contact person: Ilmi Leesman Email: [email protected] Web: w ww.ph.ee 2 EQUASS ASSURANCE ASUTUSE KÜLASTUSE ETTEVALMISTAMISE VORM Asutuse külastus: 21.-22.11.2013 Pärnu Haigla Mariliis Männik-Sepp © 2012 by European Quality for Social Services (EQUASS)Tõrge! Järjehoidja nime pole antud. Kõik õigused kaitstud. Antud dokumendi elemente ei tohi paljundada, kopeerida ega muul elektroonilisel moel salvestada ilma EQUASS kirjaliku loata.  Asutuse külastuse ettevalmistamise küsimused EQUASS Assurance taotlusvormile ja antud lisainformatsioonile põhinedes palume teil ettevalmistuseks vast ata järgnevatele selgitust nõudvatele küsimustele: Üldised teemad (max. 10 küsimust) 1. Mida olete teinud teenuste kvaliteedi tagamiseks ja tõstmiseks oma asutuses? 2. Kuidas olete taganud asutuse personali pädevuse ja arendamise? 3. Kuidas olete asutuses korral danud teenuse saajate õiguste kaitsmise? 4. Millised on asutuse eetilised põhimõtted? 5. Kellega ja millist koostööd asutus teeb ning millist lisaväärtust seeläbi on saavutatud? 6. Kuidas saavad teenuse seejad osaleda teenuste arendamisel ? 7. Kuidas selgitatakse välja teenuse saajate vajadused ja kuidas neid arvestatakse asutuse tegevuste täiustamisel? 8. Kirjeldage asutuse teenuste osutamise protsessi ja holistilist lähenemist teenuse kasutajale? 9. Kirjeldage kestva arengu tsükli rakendamist oma asutuses. 10. Tooge näiteid innovaatilistest lahendustest oma asutuses. Version 1.0 2  1. Kvaliteedi põhimõtetele ja EQ U ASS Assurance kriteeriumitele vastavuse küsimused/ teemad: Kvaliteediteeni stuse juhataja Teenusesaaja ja juhatajad Huvigrupid Personal d Juht im in e 1. Kas olete teadlikud as utuse missioonist, visioonist ja x väärtushinnangutest? Palun sõnastage. 2. Milliseid on asutuse x x kvaliteedipõhimõtted? 3. Kuidas on Teil võimalik anda tagasisidet pakutavate teenuste x x kohta? 4. Kirjeldage, milliseid asutuse teenuseid teate nin g kuidas olete x x nendest teada saanud? 5. Milliseid kogukonnale suunatud tegevusi olete teinu d ja kuidas annate lisandväärtust x kogukonnapõhistesse tegevustesse? 6. Milliseid ühiskonna vajadustele vastavaid mõõdetavaid tulemusi x olete kogukonnapõhiste tegevuste kaudu saavutanud? P er so na l 1. Kuidas jälgitakse teenuse pakkumisega otseselt tegelevate x x töötajate tegevust (perioodiliselt)? Version 1.0 3  2. Kuidas kaasatakse personali teenuste planeerimisse, x x arendamisse ja hindamisse? 3. Kuidas on tagatud personalipoliitika kooskõla x tööseadusandlusega? 4. Kuidas hinnatakse juhtkonna, personali ja vabatahtlike x x töötingimusi? 5. Kuidas toimub töötajate x x tunnustamine? Õ igu se d 1A. Selgitage, kuidas Teid on informeeritud ja kuidas tunnete „klientide õigus ja kohustusi“, tuues mõned näited? x x 1B. Kas olete teadlik (Teid on informeeritud) oma õigustest ja kohustustest teenuse saajana ning olete andud vastava kinnitava allkirja? 2A. Kuidas on korraldatud ettepanekute ja kaebuste menetlemise kord ning tagatud selle asjakohasus ja läbipaistvus ? x x 2B. Kuidas teenuse saajad saate esitada ettepanekuid või kaebusi? 3A. Kuidas aitab teenuse osutaja kaasa patsientide enesemääratlemisele ja kuidas seda x x iga-aastaselt hinnatakse ? 3B. Kuidas teenuse osu taja aitab Version 1.0 4  kaasa teie enesemääratlemisele ? 4. Kuidas informeeritakse teenuse saajat õigusest saada eestkostjat või x x tugiisikut ja kuidas seda iga -aastaselt hinnatakse? 5. Kas teid on koheldud austusega? x E et i k a 1. Kuidas Teid on informeeri tud eetikakoodeksist ja kuidas tunnete x vastavaid põhimõtteid (tooge näiteid)? 2. Kui sageli vaadatakse üle ja analüüsitakse (koos personaliga) konfidentsiaalsusega seotud x x nõuded ning milliseid muudatusi viimati tehti? 3. Kui hästi tunnete teenuste osutamise põhimõtteid ning x väärtushinnanguid (tooge näiteid)? 4. Kuidas pääsete ligi oma isiklikele x andmetele? (klienditoimik) 5. Kus on kirjeldatud ja k as teate oma x rolli ja vastutusulatust? Koo st öö 1. Kellega ja millist koostööd tehakse (selgitage näidete varal, sh x x sotsiaalvaldkonna partnerid, rahastajad, teenuse kasutajad)? 2. Kuidas kaasatakse teenuste x x x arendamisse teenuse saajaid (nende esindajaid), teenuse ostjaid ja hankijaid? 3. Kuidas kaasatakse (nende) x x Version 1.0 5  vajaduste väljaselgitamise protsessi huvigruppe? 4. Kuidas analüüsite ja hindate x x koostööst tulenevat lisandväärtust? 5. Kuidas olete rahul koostööga? x x O s alu s 1. Kuidas osalevad kliendid vajaduste x x x väljaselgitamisel, teenuste planeerimisel ja analüüsimisel? 2. Kas ja kuidas on personali x x x koolitatud teenuse saajate jõustamise teemal ning kuidas see toimu igapäevases elus? 3. Kuidas aitab teenuse osutaja x kaasa teenuse saajate jõustamisele ja milliseid mõõdetavaid tulemusi on saavutatud? 4. Kas ja kuidas on teenuse saajate x x x osalemiseks vajalikud meetmed, tegevused ja kord kooskõlastatud teenuse saajatega või nende esindajatega? 5. Kui sageli vaadatakse üle teenuse x x saajate või nende esindajate osalemisega seotud meetmed ning millised on olnud viimased muudatused? Is ik uk e sk su s 1. Kuidas on kindlaks tehtud x x rahastajate vajadused ning teiste oluliste organisatsioonide huvigruppide vajadused ja kuidas Version 1.0 6  nendega arvestatakse? 2. Kuidas olete rahul teenusepakkuja x asukohaga? 3A. Kuidas on tagatud, e t teenuse x x osutaja pakub oma teenuseid vastavalt teenuse saaja vajadustele? 3B. Kas individuaalne tegevusplaan vastab Teie vajadustele ja ootustele? 4. Kuidas vaadatakse asutuse poolt x pakutavaid teenuseid üle, arvestades samas teenuse saajate oodata vate tulemustega? 5. Kas individuaalne tegevusplaan on x x kooskõlastatud ja seda on korrigeeritud vastavalt teenuse saaja tagasisidele? Lai ah a ar de li su s 1. Kuidas asutus tagab, et personalil x x on ühtne arusaam peamistest teenuse osutamise protsessides t ja enda vastutusest nendes? 2. Kuidas asutus hindab teenuse x osutamise protsessi, et tagada teenuse saajate vajadustele ja huvidele vastavalt sujuvust üleminekul? 3. Kuidas asutus kasutab x x multidistsiplinaarset lähenemist kliendile individuaalse tegevusplaani koostamisel ja rakendamisel? 4. Kuidas asutus tagab, et teenuse x x saaja elukvaliteet on Version 1.0 7  individuaalselt määratletud teenuse saaja või tema perekonna poolt? 5. Kas ja kuidas teenuse jätkuvust x x hinnatakse iga -aastaselt? 6. Kuidas on tagatud teenuste ja x x programmide osutamisel üleminekute sujuvus? T ulemu st el e 1. Kuidas võrreldakse kliendi x ori en t e e rit u s individuaalse tegevusplaani tulemusi osutatud teenuste tulemustega ehk kuidas iga individuaalne plaan panustab üldisesse teenuse tulemuslikkusesse? 2. Kuidas mõõdetakse teenuse x x hankijate / tellijate ja rahastajate rahulolu? 3. Kuidas on tagatud asutuse x tegevuse kooskõla seadusandlusega? 4. Kellele ja millist ülevaadet antakse x x asutuse tegevusest ning kas see on sihtrühmadele arusaadavas keeles? 5. Kuidas kogutakse huvigruppidelt x x tagasisidet aastaaruandes kajastatud tulemuste kohta? Pi dev a r eng 1. Kirjeldage PDCA tsükli toimimist x x oma asutuses? 2. Kuidas ollakse kursis huvigruppide x uute ja muutuvate vajadustega? Version 1.0 8  Tooge näiteid huvigruppide esilekerkinud vajadustest 3. Tooge näiteid innovaatilistest x x töömeetoditest? 4. Tooge näiteid x innovatsiooniprojektidest? 5. Millised olid viimase kvaliteedi x parendamise projekti tulemused? 2. Nõutav dokumentatsio on EQUASS Assurance taotlusesse märgitud infole ja lisadele põhinedes palume vaatluseks ette valmistada järgnev dokumentatsioon: 1) Haigla arengukava 2) Haigla ja teenuste tegevusplaanid ja tegevusaruanded 3) Juhtimiskäsiraamat 4) Põhitegevuse aruanne 5) Personalipol iitika juhend 6) Töösisekorra eeskiri 7) Kõikide EQUASSi kvaliteedisertifikaadi taotlemisega seotud teenuste protseduurid ja juhendid 8) Tulemusjuhtimise protseduur, tulemiskaart ja kvaliteedi tagamise protseduur 9) Sise- ja välisauditid 10) Klienditeeninduse korraldamise protseduur 11) Klienditeeninduse standard ja klienditeeninduse hea tava juhend 12) Klientide tagasiside käsitlemise protseduur ja kaebuste käsitlemise juhend 13) Töötervishoiu ja tööohutuse tagamise protseduur Version 1.0 9  14) Riskihindamise läbiviimise juhend 15) Asjaajamise juhend ja delikaatsete isikuandmete töötlemise juhend 3. Personali, teenuse saajate ja teiste oluliste huvi gruppide intervjueerimine EQUASS Assurance taotluses antud vastustele ja tõenditele põhinedes palume korraldada intervjuud järgmiste inimestega (funktsioon ja kestvus): Juhtkond Kestvus 1. juhatuse liige (intervjuu koos 45 minutit rehabilitatsiooniüksuse juhatajaga ) Personal Kestvus 1. kvaliteediteenistuse juhataja 60 minutit 2. päevakeskuse juhataja ja 45 minutit juhataja kt 3. päevakeskuse persona l 45 minutit 4. rehabilitatsiooniüksuse juhataja 45 minutit (intervjuu koos juhatuse liikmega) 5. rehabilitatsiooniüksuse personal 45 minutit Teenuse saajad Kestvus 1. kahes grupis 2-5 päevakeskuse 45 minutit erinevate teenuste saajad 1. grupis 2-5 rehabilitatsiooni 45 minutit Version 1.0 10  teenuse saajat Teised huvigrupid Kestvus 1. Vähemalt kaks erinevat 45 minutit (kokku) koostööpartner it 2. Rahastaja 45 minutit 4. Asutuse kül astuse ajakava 5. 21.11.2013 Päev 1 Aeg Tegevus (lühike kirjeldus) 9.00-12.00 Avakoosolek , dokumentatsiooni ülevaat us 12.00-13.00 Intervjuu kvalit eediteenistuse juhatajaga 13.00-14.00 Lõunapaus 14.00-14.15 Dokumentatsiooni ülevaatus, vormide täit mine 14.15-15.00 Intervjuu Pärnu Haigla juhat use liikmega ja rehabilitatsiooniüksuse juhataja ga 15.00-15.15 Dokumentatsiooni ülevaatus, vormide täit mine 15.15-16.00 Intervjuu rehabilitatsiooniüksuse personaliga 16.00-16.15 Dokumentatsiooni ülevaatus, vormide täit mine 16.15-17.00 Intervjuu rehabilitatsiooniüksuse teenuse saajatega (kaks gruppi erinevate teenuste saajatega) Version 1.0 11  22.11.2013 Päev 2 Aeg Tegevus (lühike kirjeldus) 9.00-10.00 Dokumentatsiooni ülevaatus, vormide täit mine 10.00-10.45 Intervjuu koostööpar tneritega ( vähemalt kaks erinevat partnerit) 10.45-11.00 Dokumentatsiooni ülevaatus , vormide täit mine 11.00- 11.45 Intervjuu rahastajag a 11.45-12.00 Dokumentatsiooni ülevaatus, vormide täit mine 12.00-13.00 Lõunapaus 13.00-13.15 Dokumentatsiooni ülevaatus, vormide täit mine 13.15-14.00 Intervjuu päevakeskuse juhataja ja juhataja kt -ga 14.00-14.15 Dokumentatsiooni ülevaatus, vormide täit mine 14.15-15.00 Intervjuu päevakeskuse personaliga 15.00-15.15 Dokumentatsiooni ülevaatus, vormide täit mine 15.15-16.00 Intervjuu päevakeskuse teenuse saajatega 16.00-16.45 Dokumentatsiooni ülevaat us, vormide täit mine 16.45-17.00 Lõpukoosolek Version 1.0 12 EQUASS ASSURANCE AUDIT REPORT Site visit: 21.-22.11.2013 Pärnu Haigla Mariliis Männik-Sepp © 2012 by European Quality for Social Services (EQUASS) All rights reserved. No part of this document may be reproduced in any form or by any means, electronic, mechanical, photocopying and recording or otherwise without the prior written permission of the EQUASS.  1. Information of the social service provider Name of the social SA Pärnu Haigla - Foundation Pärnu Hospital, service provider hereinafter PH Address: Rist iku 1, Pärnu 80010 Post box: N/A Person responsible Urmas Sule, chairman of the board (CEO): Contact person: Ilmi Leesman, qualit y unit manager Phone: (+372) 4473101 Fax: N/A E-mail: [email protected] Web site: www. ph.ee Name of Auditor: Mar iliis Männik -Sepp Dates of audit: 21.-22.11.2013 Clients: Number of person served: 76 As of (date): 21.10.2013 Staff: Number of Full time staff : 8 Number of Part time staff : 64 Number of Contracted staff : 9 Number of volunteer s: 0 Services: Day Center of Pärnu Hospital Psychiatric Clinic: 1. Assistance in ever yday lif e 2. Assistance in working 3. Support person Rehabilitation Units of Pärnu Hospital Psyciatric Clinic and Internal Disease Clinic 4. Rehabilitation ser vice 2 2. Audit program 21.11.2013 Day 1 Time Acti vit y 9.00-12.00 Opening meeting , documentation review 12.00-13.00 Interview with qualit y unit manager Ilmi Leesman 13.00-14.00 Lunch break 14.00-14.15 Documentation review, up -dat ing f iles 14.15-15.00 Interview wit h cooperation partners: Toomas Mihkelson (Pärnu Puuetega Inim este Koda) Linda Lillemaa ( Social Insur ance Boar d Pärnu bureau) 15.00-15.15 Documentation review, up -dat ing f iles 15.15-16.00 Interview with rehabilitat ion unit staff : Natalja I vanov ( social worker) 16.00-16.15 Documentation review, up -dat ing f iles 16.15-17.00 Interview with persons ser ved by the r ehabilitation units of : Pärnu Hospital Psyciatric Clinic and Internal Disease Clinic 22.11.2013 Day 2 Time Acti vit y 9.00-10.00 Documentatio n review, up-dat ing f iles 10.00-10.45 Interview with member of the board of Pärnu Haigla (Veiko Vahula) and head of r ehabilitation unit Ester Reinsalu 10.45-11.00 Documentation review, up -dat ing f iles 3  11.00- 11.45 Interview with f inancing bodies: Katrin Tsuiman ( local government ) Margit Laurson – (Social Insurance Board ) 11.45-12.00 Documentation review, up -dat ing f iles 12.00-13.00 Lunch break 13.00-13.15 Documentation review, up -dat ing f iles 13.15-14.00 Interview with manager (Indrek Linnuste) of Day Center and deput y manager ( Kadr i Eenraid ) of Day Center 14.00-14.15 Documentation review, up -dat ing f iles 14.15-15.00 Interview with Day Center staff - Kadri Melnits (activit y super visor ) 15.00-15.15 Documentation review, up -dat ing f iles 15.15-16.00 Interview with persons ser ved by Day Center 16.00-16.45 Documentation review, up -dat ing f iles 16.45-17.00 Closing meeting 3. Detailed feedback on performance 1. The social servi ce provider defines documents and implements its visi on and mission values on servi ce provision. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The mission, vision and values of PH are documented in the organization’s development plan and on its website 4 www. ph.ee. It was demonstrat ed through the inter views that the employees are well aware of the organization’s mission, vision and core values. 2. The social servi ce prov ider defines, documents, and implements its qualit y policy by determining long term qualit y goals, and its commitment to continuous improvement. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assura nce certif ication program Strengths Improvem ent & developments The qualit y standard of PH is document ed in the management handbook. The long -term goals of PH ar e descr ibed in the organizat ion’s development plan. PH has appr oximat ely t wo decades of perf ormance management exper ience. It appeared f rom the inter views that the staff is well inf ormed of the qualit y standard, is devoted to deliver qualit y ser vices and pursue f or continuous improvem ent. 3. Persons served, famil y members and servi ce user or ganisations are able to give feedback on their individual and collecti ve experience of programmes and services. Remark from the auditor: The ser vices of the social ser vice pr oviders meet 5 this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments PH has developed ways to ask and In order t o receive regular f eedback receive f eedback from the person f rom stakeholders (partners, ser ved, staff and stakeholders. The f inancing bodies, similar organizat ion uses various met hods t o organizat ions etc), it would be achieve this. advisable to develop ways f or gaining regular f eedback f rom these F.e ambulat or y patients’ satisf action interest groups. F. e using wr itten sur vey, employee satisf action sur vey. questionnaires. There is procedur e f or handling Also attent ion has to be paid, that customer f eedback and guidance f or the questionnaires are revised to handling complaints. give more inf ormative and necess ar y f eedback. All the meet ings are summarized in wr itten m inutes of the meetings . Huvigruppidelt (partnerid, rahastajad, sarnased organisatsioonid) regulaarse tagasiside saamiseks on soovitatav välja töötada regulaarse tagasiside saamise viisid. Nt kirjalike küsimustike kasutamine. Tähelepanu tuleb pöörata küsimutike ülevaatami sele, et anda inf ormatiivsemat ja vajalikku tagasisidet. 4. The social service provider i nforms all stakeholders about the offered programmes and services avai lable. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iteri on of the EQUASS Assurance certif ication program 6  Strengths Improvem ent & developments PH has inf ormed all stakeholder s about its ser vices. This was verif ied implemented through inter views wit h persons ser ved, staff and partners. Inf ormation about serv ices is available on the homepage of PH. There are brochur es available to promote the awareness of people. There are client meetings, staff meetings, hospital brief ing (weekly meetings). The hospital intranet is also a source of all kinds of inf ormation. Besides that, also Pärnu Hospital magazine is issued. The partners demonstrat ed awareness of the ser vices of PH. The opportunit ies f or involvement are descr ibed in the policies and procedures of the organizat ion. 5. The social service provider managemen t establishes and documents an annual planning and review process. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The annual planning and review process is well int egrated into the perf ormance management process of the organization. This is described in the perf ormance management 7 procedure, which is available to all of the staff through intranet . The process is reviewed annual ly by the qualit y unit. There are annual action plans and perf ormance plans , also annual reporting on the implementat ion of the plans. PH uses scorecar d methodolog y. 6. The plan includes:  annual outcomes / targets  the acti vities to be undertaken in a chieving the annual targets  monitoring of the performance of the organisation in meeting its annual targets time-scales and procedures for revi ew and revi sion. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of t he EQUASS Assurance certif ication program Strengths Improvem ent & developments The annual planning process of PH has a cyclic character. The annual action plan includes SMART objectives, key act ivities, tangible results and targets. The annual plan is approved by the management. 7. The social servi ce provider demonstrates organisation’s success in satisf ying the needs and expectations of the societ y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQ UASS Assurance certif ication program 8  Strengths Improvem ent & developments Feedback f rom staff and clients is More attent ion should be paid to the collect ed, summarized and analyzed collect ion of feedback f rom regularly. stakeholders. F.e Cust omer Ser vice Report is Also, the results in meeting needs drawn up. and expectations of the societ y could be more clear ly presented in f uture. PH Day Center does cooperat ion with nonprof it organizat i on Enam tähelepanu tuleb pöörata Hingerahu, organizes all kinds of tagasiside kogumisele events, is training base f or the huvigruppidelt. students of Tartu Universit y and Pärnu College, and participat es in Samuti tuleks täpsemalt esitada the activit ies of the Food Bank. It tulemus ed ühiskonna oot ustele also plans to issue a Year Book f or vastamise osas edaspidi. 2013. 8. The social service provider demonstrates organisati on’s social responsibilit y t hrough acti vities contri buting to the societ y. Remark from the auditor: The services of the social ser vice providers meet this criter ion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments PH is involved in communit y based It would be advisable f or PH to activities. present the evidence of its added value to the societ y more clear ly in The Day Center of PH organizes all f uture. kinds of events, is t raining base f or the students of Tartu Universit y an d Soovitatav on edaspidi täpsema lt Pärnu College, and participat es in esitada PH ühiskonnale lisaväärtust the activit ies of the Food Bank. It toovad tegevusad. also plans to issue a Year Book f or 9 2013. 9. The social servi ce provider has a staff recruitment and retention policy that promot es the selection of qualified personnel based on required know ledge, skills and compet ences. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Staff policy (including recruitment and select ion procedures) has been developed. There is al so job analysis and workf orce planning procedure. A value system of job posit ions and corresponding wage policy has been complied. For new employees there is a pr ocedure f or the f acilitation of their adapt ion. Also, the internal work procedur e rules apply to all employees. All employees have individual job descr iptions which include required knowledge, skills and competences. There is training policy and annual training plans. Each year employees’ assessments are car ried out. It appeared f rom the inter views wit h the personnel that t hey all are well aware of their roles, r ights and duties. It also came out that the employees are highly mot ivat ed, like their jobs and are devoted to 10 delivering high qualit y ser vice. 10. The social service provider operates in compli ance w ith mandator y national legislation, providing appropriate w orking conditions, adequate and agreed staff level and staff ratio, and appropriate rew arding for staff and vol unteers. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The documentation of PH meets legal r equirements and is reviewed to do this. The staff level is kept at optimum and this is reviewed also regularly. The principles f or showing recognit ion to employees are descr ibed in the staff policy and staff recognit ion policy. The working condit ions are evaluated regularly according to risk assessment procedure (risk assessments are carried out ) and necess ar y amendments are made. The work condit ions are also evaluated by staff through staff satisf action sur veys. 11. The social service provider trains all staff based on a plan for leaning and development and evaluates the effecti veness of the training. 11 Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Staff training policy regulates the It would be advisable to collect arrangement of trainings. Annual f eedback (and assessment of training plans are dr awn up based on eff ectiveness) prom ptly after ever y the needs of the employees and passed training (f .e using web based expectat ions of PH. applications) and then analyzing the inf ormation gained. The staff of PH is trained regular ly and all the inter viewed employees Soovitatav on koguda tagasisidet (ja showed high appreciation concer ning hinnanguid ef ektiivsuse kohta) the trainings received. koheselt pär ast igat koolitust (nt kasutades veebipõhist rakendust) Training needs are discussed during ning seejär el analüüsida saadud annual staff evaluations. inf ormatsiooni. Feedback on trainings is collected through annual staff satisf action sur veys, which is then analyzed. 12. The social servi ce provi der applies requirements for competence in the identified roles and functions of staff and evaluates them on annual basis. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certi f ication program Strengths Improvem ent & developments The competence r equirements f or employees are described in their job descr iptions. Annual staff evaluat ions are carried out, as descr ibed in the staff policy, where the before mentioned 12 requirements are assessed. It was ver if ied by the inter views and related documentation t hat perf ormance reviews of staff members who are directly involved in ser vice deliver y, are carried out. 13. The social servi ce provi der recognizes the staff as a resource for feedback on organizational perf ormance, service development and staff development Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developm ents The involvement of staff in the planning and evaluation of services is descr ibed in the corresponding ser vices’ deliver y pr ocedur es. PH recognizes staff as a usef ul tool f or gaining inf ormation. It has a well- developed system of regular meetings, where various levels and groups of staff meet. Minutes of meetings are prepared and are available f or all staff through the organization’s int ranet. Also annual staff questionnaires are used f or gaining f eedback. 14. The social service provi der has mecha nisms in place to enhance satisfaction and motivation of staff Remark from the auditor: The ser vices of the social ser vice pr oviders meet 13 this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Staff evaluatio ns, staff questionnaires and annual employees’ evaluat ions are used to gain f eedback on satisf action and motivat ion. Mechanisms to provide satisf action and mot ivat ion are described in staff recognit ion policy. 15. The social servi ce provi der assures t he rights of persons served outlined in a Chart er of Rights w hich is based on the EU Charter of Fundamental Rights , the European Convention for the Protection of Human Rights and Fundamental Freedoms of the Council of Europe and other int ernati onal human r i ghts conventions, especiall y those elaborat ed under the United Nations. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments PH has developed the rights and duties of persons ser ved, which conf orm to international human rights convent ions. The rights and duties of persons served are part of the client ser vice standard, which is available on the web page of PH. They are introduced to the persons ser ved by staff . Clients also sign the related documentation (contract). 14 The staff and clients demonstrated their knowledge of their rights and duties through the interviews. 16. The soci al service provider informs the person served about his/her rights and duties especiall y to equal treatment on grounds of age, disabilit y, gender, race, religion or belief and sexual orientation before recei ving the services. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The rights and duties of persons ser ved are introduced to the clients by the employees of PH. The rights and duties of persons ser ved are part of the client ser vice standard, which is available on the web page of PH. The staff and clients demonstrated their knowledge of their rights and duties through the interviews. Clients also sign the r elated documentation (contract). 17. The social service provider has ac cessibl e complai nt management s ystem w hich registers feedback on performance from persons served, purchasers and other relevant stakeholders. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments 15 Complaint handling procedures and associated documentation is document ed in PH’s management system policy. Ther e is a procedur e f or handling custom er f eedback and guidance f or handling complai nts. Inf ormation is available on t he web page of PH. Complaints and pr oposals may be communicated also through the mentioned web page. The system can be assessed as accessible and transparent. If was verif ied during the interviews that the persons served, purchaser s and other relevant stakeholders were aware of the ways of making proposals and complaining. 18. The social service provider respects the fundamental right to self-determination of the person served. They freel y det ermine their political stat us and freel y pursue their economic, soci al and cultural development. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments PH proce dures, instructions and Even though the cr iterion is met, it is f orms have been prepared, taking suggested to describe more clear ly into account the persons’ ser ved in the policies of the organizat ion: right to self -determination. - PH’s act ivities concerning the It became evident through the evaluat ion on respecting the right inter views that the staff was aware of to self -determinat ion with the 16 this issue and the persons ser ved persons ser ved on annual basis. were handled wit h respect. Kuig i kriteerium on tä idetud, on soovitatav täpsemalt kirjeldada organisatsiooni poliit ikates: - PH tegevusi hindamaks iga - aastaselt koos teenuse saajatega oma käitumist teenuse saajate enesemääratlemisõigusest lugupidam ise osas. 19. The social service provi der facilitates the person served in choosing and having access to advocates and/or supporting persons. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developm ents The need f or an advocate and/or Even though the cr iterion is met, it is support ing person is discussed wit h suggested to describe more clear ly the persons ser ved and related in the policies of the organi zat ion: inf ormation is presented in individual plans. - PH’s act ivities concerning the evaluat ion on f acilitating persons ser ved in having access to advocates and/or support ing persons on annual basis. Kuig i kriteerium on täidetud, on soovitatav täpsemalt kirjeldada organisatsiooni poliit ikates: - PH tege vusi hindamaks iga - aastaselt oma käit umist teenuse saajate abistamisel leidmaks eestkostjat ja/või tugiisikut? 17  20. The social service provi der defines and documents its policy on ethics that respects and assures the dignit y of the persons served, protects them from undue risk and promotes soci al justice Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Customer ser vice management procedure and client service pract ice guide include the ethical pr inciples. New members of staff (including volunteers) are intr oduced with the ethical principles of customer ser vice. 21. The social service provider operat es mechanisms w hich prevent the physi cal, mental and financial abuse of users. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Customer ser vice management Even thoug h the cr iterion is met, it is procedure and client service pract ice suggested to describe more clear ly guide include the ethical pr inciples in the policies of the organizat ion: (also policies to prevent physical, mental and f inancial abuse of person - PH’s act ivities concerning the ser ved). evaluat ion on PH’s policies’ eff ectiveness in preventing New members of staff (including physical, mental and f inancial volunteers) are intr oduced with the abuse of person ser ved. related principles. Kuig i kriteerium on täidetud, on soovitatav täpsemalt kirjeldada 18  organisatsiooni poliit ikates: - PH tegevuse ef ektiivsuse hindamine teenuse saajate f üüsilise, vaimse ja amajandusliku ärakasutamise ennetamisel. 22. The social servi ce provi der provides services in a sa fe system of w orking w ithin a safe environment to ensure the physical securit y of persons served, their families and caretakers. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif icatio n program Strengths Improvem ent & developments PH has pr ocedures f or ensuring the provision of saf e and healthy working conditions. F. e there are health and saf ety assurance procedur es, guidance on risk assessments etc. Risk are assessed regularly and related impr ovement activities ar e carried out. Related trainings are provided to staff . 23. The social service provider defines, documents, monitors and evaluat es a set of principles, values and procedures that govern behavi our in servi ce deli ver y con taining aspects of confidentialit y, accuracy, pri vacy and integrit y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program 19  Strengths Improvem ent & developments The princ iples, values and procedures in ser vice deliver y are descr ibed in the PH’s inter nal work procedures, ser vices’ deliver y procedures, client ser vice standar d etc. There is a manual f or processing delicate personal data. It was demonstrated through the inter views of staff that they ar e aware of the et hical principles related to their work. 24. The social service provider defines, documents, monitors and evaluat es procedures for assuring confidentialit y of data regardi ng the persons served and the service p rovided to them. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The principles, values and procedures in ser vice deliver y are descr ibed in the PH’s inter nal work procedures, ser vices’ deliver y procedures, client ser vice standar d etc. There is a manual f or processing delicate personal data. The policies are over viewed regularly according to the guidance 20 on the administ ration of the management handbook. 25. The social service provider defines the roles and responsibilities, authorities and the interrelation of all personnel w ho manage, desi gn, deli ver, support and evaluate the service provision to person served. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The necessar y roles and responsibilities are descr ibed in the job descript ions of employees. Job descr iptions are available to all employees through the intranet of PH. Related tasks are also descr ibed in the ser vices’ deliver y procedures. 26. The social service provi der w orks in partnership w ith other organisations in the provision of servi ce s. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments PH does a lot of cooperat ion wit h its It would be advisable to list PH’s partners. F.e there is tight cooper ation partners (and group cooper ation with Puuetega Inimest e them by the f ield of partnership ). Koda and the representation union of patients. To guarantee, that partnership and its added value is evaluated 21 PH has contracts with f inancing regularly, this should be laid down in bodies. the PH’s procedures . PH evaluates the cooperat ion related F.e annual questionnaires may be to the services delivered by contract used to evaluat e the satisf action of partners. partners ( concerning the value in the partnership with PH and how to make partnership more effective). Soovitatav on koostada nimekir i PH koostööpartner itest (ja grupeerida need partnerluse valdkonna alusel). Tagamaks, et partnerlust ja sellest tulenevat lisaväärtust hi nnatakse regulaarselt, on soovitatav see sätestada PH protseduur ides. Nt võib kasutada partnerite rahulolu uuring uid (seoses partnerit e rahuloluga koostööst saadava lisaväärtusega ning kuidas partnerlust veel ef ektiivsemaks muuta). 27. The social servic e provider w orks in partnership w ith persons served, purchasers and other stakeholders in the development of services. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The persons ser ved, purchasers and It would be advisable to present other stakeholders are involved in more clear ly in the documentat ion of the development of services of PH PH: through meeting s and sur veys. - how PH does cooperation with 22  persons ser ved, their representat ives, purchasers an f unders in the development of PH’s ser vices. - how relevant external stakeholders in are involved in the assessment of their needs (related to the ser vices of PH). Soovitatav on täpse malt kirjeldada organisatsiooni poliit ikates: - kuidas seotud väliseid huvigruppe kaasatakse nende vajadust e väljaselgitam isse. 28. The social service provi der includes persons served as acti ve partici pants in planning and have set up appraisal made up of on- going of an on -going structured dialogue process in the management of the service, incl uding t he definition of the needs, the definition of the services, as w ell as of the evaluation of qualit y. Remark from the auditor: The ser vices of the social ser vi ce pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The services’ delivery policies and procedures are regulated by diff erent ser vice management procedures and the client work documentatio n is regulated by diff erent client work procedures. The criterion was ver if ied sat isf ied through exploring client work documentat ion and through 23 inter views with staff and clients. 29. The social service provi der institutes an annual evaluation of partici pation of persons served bot h on indi vidual and/or group basis. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The measures, activities and polic y Even though the cr iterion is met, it is f or client participat ion ar e agreed suggested to describe more clear ly with the persons served or in the policies of the org anizat ion: representat ives of persons ser ved. - how PH reviews t he measur es, The policy is reviewed regular ly. activities and policy f or participation of persons ser ved or representat ives of persons ser ved on an annual basis. Kuig i kriteerium on täidetud, on soovitatav täpsemalt kirjeldada organisatsiooni poliit ikates: - kuidas PH analüüsib iga -aastaselt teenuse saajate või nende esindajate osalem ise poliit ikat, meetmeid ja tegevusi. 30. The social service provi der operates specific instruments f or users to improve their personal empow er ment and personal situation and that of their communit y. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments 24 Empowerment of persons ser ved is The criter ion is met, but it is an integral part of ser vice deliver y. suggested to def ine empowerment Related act ivities were evidenced in and the f acilitat ion of empowerment ser vices’ deliver y pr ocesses and also of the persons ser ved in the came out f rom the inter views wit h processes and procedures of the staff and persons served. organizat ion. It is also advisable t o bring out more clearly t he tangible results achieved in strengthening the empowerment of persons being served in the organizat ion’s report s. Kriteer ium on täidet ud, ku id soovitatav on def ineerida jõustamine ning selgemalt välja tuua mõõdetavad tulem used teenuste saajate jõustam ise tugevdamises asutuse protsessides ja protseduur ides . Samuti on soovitatav välja tuua selgemalt mõõdetavad tulemused teenuse saajate jõustamis e tugevdamisel. 31. The social service provi der operates specific mechanisms for establishing an empow ering environment. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication p rogram Strengths Improvem ent & developments Empowerment of persons ser ved is The criter ion is met, but it is an integral part of ser vice deliver y. suggested to bring out measures f or Related act ivities were evidenced in creating an empowering environment 25 ser vices’ deliver y pr ocesses and also in the organizat ion more clear ly in came out f rom the inter views wit h PH’s policies and pr ocedur es. staff and persons served. Kriteer ium on täidet ud, kuid The employees ar e trained about soovitatav on selgemalt välja tuua empowerment and the subject is meetmed, mis aitavad discussed dur ing organizat ion’s organisatsioonis luua jõustam ist meetings. soodustavat keskkonda. 32. The social servi ce provider sel ects programmes w hich are based on a needs assessment at the location w hich is most convenient for the person served, famil y and care takers Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & development s PH has an over view of the needs of the persons served (queues, meetings wit h cooperation partners, questionnaires). The locat ion of PH is pleasant, awa y f rom the Pärnu cit y center. All the ser vices are delivered at the sam e complex, which is convenient f or the clients. 33. The social service provider offers programmes consistent w ith the identified needs of its customers and objecti ves for the programme. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program 26  Strengths Improvem ent & developments PH is in t ight cooperation with the f unding bodies and has ascertain ed the needs and expectations of them. The needs of other stakeholder s have also been discussed dur ing meetings and during dail y cooper ation (though e -mails, telephone) . The success and results of the exist ing ser vices have been determined. 34. The social service provi der operates indi vidual processes that are dri ven by the needs of the person served. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments All related inf ormation is documented in the individual plan s of the persons ser ved, which was ver if ied by examples of client documentation seen during the site visit. The process itself is described in the organizat ion’s policies and procedures. 35. The social service provider documents the planni ng of services based on the ident ifica tion of indi vi dual needs and expectations of persons served in an Indi vidual Plan. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program 27  Strengths Improvem ent & developme nts The clients’ individual needs and expectat ions are wr itten down in the individual plan s. The individual plans involve all the inf ormation set by the criter ion and are agreed by the persons ser ved. This was ver if ied by examples of client documentation seen during the site visit. 36. The social service provider identif ies, documents, and maintains the key servi ce deli very processes to the persons served in line w ith its vision, mission statement and quali t y policy. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The service deliver y processes are descr ibed in the management handbook of the organization, which is a ver y well str uctured intranet based system of procedures and procedures covering the whole organizat ion. The key ser vice deliver y processes are in line wit h PH’s vision, mission and qualit y principles. All processes are regularly reviewed. 37. The social service provi der review s this delivery process and maintains control over the deli very of t he servi ce. 28 Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments PH reviews the ser vice deliver y process es. Perf ormance reports are composed by all units f or all of the ser vices. The perf ormance is summed up in the activit y reports. The processes t hemselves are reviewed per iodically. The processes and the deliver y of ser vices is also audited by the internal audit f unction (audit reports are issued) . 38. The social service provider ensures that the person served can access a continuum of servi ces that span from earl y int ervention to support and resp ond to changing requi rements over time. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments PH provides a large variet y of ser vices. Needs of persons ser ved are evaluated and accordingly necessar y ser vices are provided. Ser vices are linked with each other, rehabilitat ion and social ser vices are combined with healt h care ser vices. The continuation of service deliver y 29 is monitored and evaluated regular ly. 39. The social service provi der develops a seamless continuum of services and reduces barriers in a multi -disciplinary or multi -agenc y setting. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The barriers are discussed in meetings and report ed as necessar y. The criterion was verif ied f ulf illed by also explor ing the client work documentat ion, where evide nce was f ound about multidisciplinar y approach. 40. The social service provi der operates servi ces from a holistic approach based on the needs and expectations of the person served w ith the aim of improving the qualit y of life for the person served. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments PH uses client -centered holistic approach, which is aimed to improve client ’s qua lit y of lif e. The qualit y of lif e init iat ive’s eff ectiveness is measured and reported. The criterion was verif ied f ulf illed by also explor ing the client work 30 documentat ion, where evidence was f ound about measur ing the qualit y of lif e. 41. The social se rvice provider identif ies the needed competences, skills and support for staff to enhance the qualit y of life for person served. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif icatio n program Strengths Improvem ent & developments The necessar y competences and skills are described in job descr iptions. These are evaluated during annual employees’ perf ormance reviews. Trainings are provided to employees, which was evidenced by trainin g plans of PH and came out f rom inter views. 42. The social service provider identifies its business results and provides formal periodic and independent revi ew and procedures t o achieve the targeted results. Remark from the auditor: The ser vices of th e social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments Targeted results are measured and reported. PH has procedure named reporting arrangements, which gives a good over view of the reporting system. Also perf ormance 31 management procedure applies, according to which perf ormance conversations are held related reports issued. External audits have been carried out regularly concerning the activities of PH. 43. The social servi ce provi der identifies and registers the outcomes and benefits for person served of the recei ve services on individual and collecti ve basi s. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance cer tif ication program Strengths Improvem ent & developments PH gathers and documents inf ormation regarding results of providing ser vices (both on individual and collective basis). This was evidenced in client work documentat ion and in the reports of PH. 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 qualit y of life offered to the person bei ng served). Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments PH evaluates the results and added It would be advisable to disclose in 32 value of its work during meetings. the reports more precisely: This is also ref lecte d in related reports. - the added value of the business results f or f inancing bodies; - the added value to the qualit y of lif e of the persons served. Soovitatav on aruandluses täpsemalt avaldad a: - asutuse tegevuse tulemuste lisaväärtus rahastajale; - lisaväärtus teenuse saajate eluk valit eedile. 45. The social service provider evaluates the indi vidual and collecti ve satisfact ion of persons served and other stakeholders by internal and/or external evaluation. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments PH organizes regular sur veys to More attention has to be paid in receive f eedback f rom the persons gaining f eedback f rom other ser ved. stakeholders concerning their satisf action. The inf ormation is analyzed and necessar y improvem ent activities are Enam tähelepanu tuleks pöörata ref lected in the annual act ion plans. tagasiside saam isele teistelt huvigruppidelt nende rahulolu kohta. 46. The social service provider provides accessible and easil y understandable records on outcome, including personal perception and achievements 33 Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The record on outcome are It would be advisable to draw up an communicated to stakeholders, staff annual act ivit y report (including and persons ser ved. records on outcome), that would be disclosed on the web site of the The content and f ormat depends on organizat ion. the target group. Soovitatav on koostada iga -aastane tegevusaruanne (sisaldades tegevust e tulemusi), mis avalda takse asutuse kodulehel. 47. The soci al service provider acti vel y disseminates organization performance among its staff, service users and external stakeholders. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments PH reports its perf ormance to It would be advisable t o draw up an f unding bodies, staff and ser vice annual act ivit y report (including users using diff erent methods. organizat ion performance), that would be disclosed on the web sit e The content and f ormat depends on of the organizat ion. the target group. Soovitatav on koostada iga -aastane tegevusaruanne (sisaldades asutuse tegevusi), mis avaldatakse asutuse kodulehel. 48. The social service provider has a standard procedure for continuous improvement on the basis of an improvement cycle. 34 Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments The PDCA cycle is used and descr ibed in the perf ormance management procedure. There is also procedur e f or carrying out improvement activit ies. PH has a good system of internal audits. All the process and activit ie s are reviewed regular ly. The results and perf ormance of PH is measured and descr ibed in related reports. All qualit y improv ement projects ar e document ed. 49. The social service provi der identifies performance i ndicators for measuring the results of th e improvement actions. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments All improvement programs are document ed, include goals and respect ive perf ormance indicators. This was verif ied through inspecting f ew examples during site visit. 35  50. The servi ce provider introduces and manages innovative w ays of w orking that have been identified based on the needs of stakeholders. Remark from the auditor: The ser vices of the social ser vice pr oviders meet this cr iterion of the EQUASS Assurance certif ication program Strengths Improvem ent & developments PH f inds ways of being innovative, taking into account the needs and expectat ions of stakeholders. F.e the developm ent of regional mental health center s. All related inf ormation was verif ied to be docum ented. 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 (criteria 3, Make a l ist PH’s cooperation partners / stakeholders (and 7, 26) group them by the f ield of partnership). Develop ways f or gaining regular f eedback f rom f rom stakeholders (partners, f inancing bodies, similar organizat ions etc). F.e using wr itten questionnair es. Also attention has to be paid, that the questionnaires are revised in tim e to give more inf ormative and necessar y f eedback. Koostada nimekiri PH koostööpartner itest / huvigruppidest (ja grupeer ida need valdkonn iti). 36  Töötada välja regulaarse tagasiside saamise viisid huvigruppidelt (partnerid, rahastajad, sarnased organisatsioonid). Nt kirjalike küsimustike kasutamine. Tähelepanu tuleb pöörata küsimustike ülevaatamisele ajas, et saada inf ormatiivsemat ja vajalikku tagasisidet. 2 The policies and procedures of the organization have t o (criteria 8, be made more precise concerning diff erent EQUASS 18, 19, 21, criteria related act ivities, in order to guarantee their 26, 27, 29, sustainable implementation and leave a wr itten evidence 45) of implement ing the act ivit ies (see more precise recommendat ions f rom the text part of the report). Organisatsiooni poliitikaid ja protseduur e on soovitatav täiendada er inevat es EQUASSi kriteerium ides välja toodud tegevusteg a, et tagada nende jätkusuutlik rakendamine ja kirjalik jälg vastavate tegevuste elluviimisest (vt täpsemaid soovitusi aruande tekstiosast). 3 (criterion Collect f eedback (and assess the eff ectiveness) of 11) trainings promptly after ever y passed training (f .e using web based applications) and then analyz e the inf ormation gained. Koguda tagasisidet (ja hinnanguid ef ektiivsuse kohta) koolituste kohta koheselt pärast igat koolit ust (nt kasutades veebipõhist rakendust) ning seejärel analüüsida saadud inf ormatsiooni. 4 (criteria 30, Def ine empowerment of the persons ser ved as PH 31) understands this ter m. Also bring out the measures f or creating an empowering environment in the organization more clearly in the processes and procedures of the organizat ion. Bring out more clearly the tangible results achieved in strengthening the empowerment of persons being ser ved in the organizat ion’s reports. Def ineer ida jõustamine PH mõistes ning selgemalt välja 37  tuua mõõdetavad tulemused t eenuste saajate jõustamise tugevdamises. Sam uti tuua selgemalt välja meetmed jõustava keskkonna loom iseks organisatsioonis asutuse protsessides ja protseduur ides. Täpsemalt välja tuua mõõdetavad tulemused teenuse saajate jõustamise t ugevdamisel asutuse aruandluses . 5 (criterion Disclose in the repor ts more precisely: 44) - the added value of the business results f or f inancing bodies; - the added value to the qualit y of lif e of the persons ser ved. Täpsemalt esitada ar uandluses: - asutuse tegevuse tulemuste lisaväärtus r ahastajale; - lisaväärtus teenuse saajate elukvaliteedile. 6 (criteria 46, Besides the reports drawn up today (that are not 47) disclosed to the public ), and besides “ Pärnu haigla raamat 2013” and annual “Pärnu haigla teatmik”, draw up an annual act ivit y report (including activities and records on outcome), that would be disclosed to the public f .e on the web site of the or ganizat ion. The purpose of this report would be inf orm the publicit y of the activities and outcom es that EQUASS criteria see as important to be communicated to the stakeholders. Lisaks tänasel päeval olemasolevale aruandlusele (mida ei avaldata avalikkusele) ning lisaks “ Pärnu haigla raamatule 2013” ja iga-aastasele “Pärnu haigla teatmik ule”, koostad a iga-aastane aruanne tegevustest - tulemusest, mis avaldatakse avalikkusele nt asutuse veebilehel. Nimetatud aruandluse eesmärk on avaldada huvigruppidele teavet tegevustest ja tulemustest, mida EQUASSi kriteer iumid peavad oluliseks avalikkusele teavitada. 38  5. Closing remarks The mission of Foundation Pärnu Hospital (PH) is to support human health and qualit y of lif e, and besides medical care PH provides special care ser vices, rehabilitation ser vice and support person ser vice. The Day Center is a part of out -patients’ department of The Psychiatric Clinic in PH. The Day Center of The Psychiatric Clinic in PH offers ser vice of support person and special car e ser vices: Assistance in ever yday lif e (f or 44 persons per month) and Assistance in working (f or 11 persons per month). Rehabilitation Units are a part of out -patients’ department of The Psychiatric Clinic and The Internal Disease Clinic in PH. Rehabilitation ser vices are provided in rehabilitation and aftercare in -pat ient unit and in rehabilitat ion ambulator y unit. PH implements and develops continuously its organization wide qualit y management system. PH has f ew decades exper ience in perf ormance management, which ensur es the qualit y of work arrangement and management. It enables to achieve targeted results with f irm methodolog y and to eliminate subjective assessment methods. To guarantee prof essionalism and qualit y ser vice, PH has developed intranet based management handbook; it uses system of internal audits and carries out the satisf action sur veys of its clie nts. The preparations f or EQUASS enabled to improve the qualit y management system of the organizat ion f rom the aspect of the requirements set to socia l sector ser vice pr ovider s. The existing functioning qualit y system was used as much as possible, adding the specif ic elements arising f rom EQUASS qualit y principles. The corresponding additions were added to the procedures and guidance notes of the organization and the activities of the organizat ion were improved in or der to respond to the ten qualit y princi ples of EQUASS. The auditor experienced on site that the social ser vice provider PH perf orms in compliance with the EUQASS Assurance crit eria. The inter viewed representat ives of partners, f inancing bodies, employees of PH and persons ser ved conf irmed this , which was ref lected in their satisf action . Also the qualit y management system and the documentation of the organizat ion wer e impressive. 39 During the audit the organization showed many examples of best practice that would be usef ul also f or other organizati ons. The whole staff was ver y kind and cooperat ive in introducing the work of PH, f inding necessar y evident ial materials and sharing inf ormation about f ulf illing EQUASS criter ia. For the period of f ollowing two years, some improvement actions and additional developm ents were agreed that are brought out in part 4 of the audit report . A more detailed over view of suggestions f or improvement that are ment ioned under the specif ic criter ia is given in detail in part 3. The improvement areas included in general t erms paying more at tention to asking regular and concr ete f eedback f rom stakeholders, complement ing the processes and pr ocedures of the organizat ion and also drawing up a more thorough annual report, that would be disclosed to the public. After verif icati on of the indicators by r eviewing documentation, conduct ing inter views and performing site visit, the auditor was conf irmed that the criteria f or qualit y assurance of the European Qualit y f or Social ser vices were f ulf illed. The auditor was convinced entire ly that PH is devoted to qualit y assurance and improvement in its work and delivers services of high qualit y. *** SA Pärnu Haigla (PH) missiooniks on toetada inimeste ter vist ja elukvalit eet i ning lisaks tervishoiuteenustele osutatakse tugiisiku teenust, rehabilitatsiooniteenust ja erihoolekandet eenuseid. PH psühhiaatriakliiniku ambulatoorse osakonna alla kuulub Päevakeskus. Päevakeskuses osutatakse erihoolekandeteenusena igapäevaelu toetamise teenust (44 kohta kuus) ja toetatud töötamise teenust (11 kohta kuus) ning tugiisiku teenust. Psühhiaatriakliiniku ambulatoorse osakonda ja sisehaiguste kliiniku taastusraviosakonda kuuluvad rehabilitatsiooniüksused, mis osutavad statsionaarselt ja ambulatoorselt rehabilitatsiooniteenust. PH-s on välja töötatud ja ra kendatakse ning arendatakse pidevalt organisatsioonipõhist kvaliteedijuhtim issüsteemi. PH - l on paarkümne aastane tulemusjuhtim ise kogemus, millega tagatakse töökorralduse ja juhtimise kvaliteet. See võim aldab saavutada kindla metoodikaga eesmärgipärased tulemused ning kõrvaldada subjektiivsed hindamismeetodid. 40 Prof essionaalse - ja teenindamisk valiteedi tagamiseks on PH -s välja töötatud siseveebipõhine juhtimiskäsir aamat, kasutusel on siseauditi te süsteem ja toimub patsient ide rahulolu hindam ine. EQUASSi rak endamiseks ettevalm istamine võimaldas täiustada asutuse kvaliteedijuhtim ise süsteem i sotsiaalvaldkonna teenuseid osutava tele asutusteele esitat ud nõuet est lähtuvalt. Olemasolevat toimivat kvaliteedisüsteemi kasutati võimalikult palju ära, lisades sinna EQU ASSi kvaliteedi pr intsiipidest tulenevat eripär a. Vastavad täiendused viidi siise asutuse protseduuridesse ja juhenditesse ning täiustati oma tegevust, et see vastaks EQUASSi kümnele k valiteedi põhimõttele. Kohapeal koges audi itor, et sotsiaalteenuse osuta ja tegutseb vastavuses EQUASS Assurance kriteeriumitega. Intervjueer itud huvigruppide ja rahastajate esindaj atega , PH tö ötajatega ja teenuse saajatega samut i kinnitasid seda, mis väljendus nende rahulolus. Samuti olid mul jetavaldavad asutuse k valiteedi juhtimise süsteem ning dokumentatsioon. Auditi käigus oli asutusel ette näidata mitmeid häid näiteid ja saavutusi EQUASS- i põhimõtete täitmisel, mis on parima praktika näited ka teistele asutustele. Kogu asutuse töötajaskond oli väga lahke ja koostööaldis PH töö tutvustamisel, vajaliku tõendusmaterjali leidmisel ning inf ormatsiooni jagamisel EQUASS - i kriteeriumite täitmise kohta. Järgnevaks kaheks aastaks lepit i kokku mõned parendustegevused ja täiendavad arendused, mis on välja toodud aruande 4 -ndas osas. Detailsem ülevaade parendussoovitustest konkreetsete kriteeriumite lõikes on esitatud aruande 3-ndas osas. Parendusvaldkonnad hõlmasid laias laast us enam tähelepanu pööram ist regulaarse ja konkreetse tagasiside küsimisele huvigruppidelt, asutuse protsesside ja protseduuride täiustamist ning täielikuma aastaaruande koostamist, mis avaldatakse avalikkusele. Peale indikaator itele vastamise tõendam ist, tut vudes dokumentatsiooniga ning viies läbi inter vjuud, oli audiitor veendunud, et kriteeriumid Eur oopa kvaliteed imärgi jaoks sotsiaalteenustes on täidetud. Audiitor sai täieliku veendumuse, et PH on pühendunud k valiteedi tagamisele ja täiustam isele oma töös ning osutab kõrge kvaliteediga teenuseid. Tallinn, 27. 11.2013 Mar iliis Männik -Sepp 41 Kristi Reimets Saatja: Keiu Talve Saatmisaeg: 17. detsember 2013. a. 11:58 Adressaat: Kristi Reimets Teema: FW: Audit report- Pärnu haigla- EST2013-13 Manused: EQ-ASS_AUD_Audit Report_PH.doc; 130221 EQUASS_taotlusvorm.xlsx; Asutuse külastuse ettevalmistus_Parnu_Haigla.doc; Additional Information Form logoga.doc From: Keiu Talve Sent: Friday, November 29, 2013 11:10 AM To: Guus van Beek ([email protected]) Cc: Marie Dubost ([email protected]) Subject: Audit report- Pärnu haigla- EST2013-13 Dear Guus, Attached you’ll find audit documents of Pärnu Hospital’s social services. Please review the documents and let me know if any questions, comments! Keiu EQUASS Eesti Astangu KRK Tel: +372 5682 9104 www.equass.ee www.astangu.ee 1