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Evaluation of Hospital Audit Report

Paper Type: Free Essay Subject: Health
Wordcount: 3311 words Published: 21st Sep 2017

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Josefina B. dela Cuesta 

Executive Summary

This paper will critically evaluate the audit report of CHT St John’s Hospital which was conducted last September 2015 which is the Certificate of Audit under the Health and Disability Auditing New Zealand in accordance of the standard of the Health and Disability of the Health and Disability Services (Safety) Act 2001 for the compliance of the Ministry of Health. On this study it will tackle the key findings of the audit report of the CHT St John Hospital. The key findings will focus on six areas which are the consumer rights, organizational management, continuum of service delivery, safe and appropriate environment, restraint minimization and safe practice lastly the infection and prevention and control. As a result of the audit done in CHT St John Hospital they have fully attained the six areas that adhere to Health and Disability Services (Safety) Act 2001.

In addition, this paper study also discusses the four auditing principles, the consumer focus, outcome focus, system and process focus and transparency and openness. Furthermore, this paper report includes recommendation and conclusion for the organization.



Health is very important to every individual thus it is very vital to evaluate every program implemented to different organization, facilities, or a health program to view the effectiveness  and make necessary interventions for specific program. Health care audit is defined as the review of an existing practice against standards in any part of Health care and it includes clinical and non- clinical Audit. Furthermore the key purpose of a health care audit is to monitor to what degree of standards for any given health care activity are achieved or met (Daly, 2008).

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In New Zealand, heath care sector are basing from the Health and Disability Standard Service standard which is the Safety Act of 2001 which required auditing the different health programs in New Zealand. The major purpose of this Act are, first to promote the safe delivery of health and disability services to all New Zealanders, second establish a consistent and reasonable standard in giving health and disability services to the public safely, thirdly, reassure providers of health and disability service to take accounts for providing those services, lastly reassure providers of health and disability services to endlessly improved the quality of services (Ministry of Health, 2017)

Health and Disability Auditing New Zealand Limited conducted the auditing for Aged rest home, hospital and other residential facilities designated by the Health and Disability of the Health and Disability Services (Safety) Act 2001, for the compliance to the Ministry Of Health. The CHT St John and Hospital where I worked  as a part time care giver is the audit report to be used and it is located at Epsom Auckland which has 70 residents during the auditing last September 14-15 , 2015.

This paper report will discuss the audit report of CHT St John Hospital and to critically evaluate to its significance, methodology, contribution to topic and quality. Moreover, it will also tackle the four audit and evaluation processes and approaches.

Background of the Organization

Christian Health Trust (CHT) St John’s Hospital is an independent healthcare trust which caters residential care to aged people. The company is located at Epsom Auckland and it was established in the year 1962. Furthermore, CHT St John offers a calm and peaceful sense of home for residents. The facility is redeveloped in 1999 and second floor is added in the year 2003 which has 8 and 10 bed suites (Eldernet, 2017)

CHT St John concentrates all energy and resources into caring for residents and their respective families and communities. In addition, CHT St John have been serving over the fifty (50) years and leading provider of residential care in Auckland New Zealand. Furthermore, they have different amenities provided to their residents like Gardens, outdoor seating spaces, BBQ area, shared lounge spaces, Shared dining room, activities programme , organized outings. Moreover, the organization had opened their dementia unit in early 2016.

Auditing and Critical Evaluation of CHT St John Hospital

The Audit report of CHT St. John Hospital has conducted by the Health and Disability Auditing New Zealand which is the Certificate of audit surveillance that was done last September 2015 this is under the section of the Health and Disability Services (Safety) Act of 2001 ( Ministry of Health,2014). The auditing report comprises of review of their policies and procedures, interview and observation with the residents and staff.

Furthermore the certificate of audit also reviews the sustainability of the ten (10) suites that provide aged and hospital care to residents. Moreover, as result of their auditing report CHT St John Hospital the auditing in charge did not find any areas of improvement and they exceeded with the standard set by the Health and Disability Auditing New Zealand (Ministry of Health, 2014)

Continually, in conducting the audit of an organization or a health program it requires the different principles like with fair performance, ethical conduct, professional care and support, independence and an evidenced approach as required by the Ministry of Health. The different principles are consumer focus, outcome focus, system and process focus, openness and transparency (Ministry of Health, 2016).

The first principle is consumer focus, which concentrate on the care for patients, support services with updated standard of practice and being consistent with the consumer. The auditing committee will make use of technical and clinical skill to gather audit evidence straightly form the consumers, families , providers which includes the review of the care and support received both on the individual components of care and care of  patients ( Ministry of Health, 2016). In CHT St John Hospital auditing on consumer focus was done through face to face interview with the residents, families and the staff and the providers and this area was fully attained by the organization.

The second principle is the outcome focus that describes that outcome can be accomplished by several inputs, practices, and outputs in rendering service to the clients. Moreover, the audit evidence should comply with requirements of the Health and Disability Services Standards in providing care and services to the consumers. The CHT St John Hospital when it comes to outcome focus they have updated standard of care and risk management committee comprises of philosophy, goals and planners to continually serve their clients with outmost respect, dignity and best quality care.

Third principle system and process focus concentrates on how an organization is effective in terms of service delivered. In addition, on this principle the auditors consider the evidence of audit based on the standard of service and care and services do not rely on one person but on the system implemented and process (Ministry of Health, 2016).The CHT St John Hospital had competent staff and clinical manager who manage the system and they attained it well specially on the different policies and procedures.

Lastly, the openness and transparency principle describes as the gathered information is communicated effectively throughout the audit process and ensures the stakeholders are involved in the auditing process. Furthermore, organization should adhere to Health and Disability standard the quality of care and CHT St John Hospital has achieved this area of principle (Ministry of Health, 2016).

Method of Evaluation

The CHT St John used Certification of Audit as method of evaluation; this audit has been conducted by the Health and Disability Auditing New Zealand that is chosen under section thirty two (32) of the Health and Disability Services (Safety) Act 2001 for submission to the Ministry of Health. Certificate of Audit is  done every 1-4 years, after the audit, rest homes are certified for  a given set of time but it depends how the rest home performed during the  certification of audit and once expired the facility should again renewed and evaluated ( Ministry Of Health, 2014).

The audit happened last September 2015 and there were 65 residents and the service is overseen by the unit manager and supported by the clinical coordinator and the area manager. The clients and the resident physician shared their positive outlooks about the service. Furthermore the audit process comprises of examination of policies and procedures, to the residents and employees’ files, observation and interviews with the residents, staff and management. Moreover, as a result of this audit, the auditing team did not recognize any areas that require an improvement; their service was exceeded with the necessary standard (Ministry of health, 2014).

Key findings

1. Consumer Rights

The outcome audit of CHT St John as to consumer right contains thirteen (13) standards that support the outcome where clients obtain safe  services of an right standard that comply with consumer rights. The services offered in CHT St John are provided in way that is respectful of the client’s rights, facilities, informed choice, lessens harm and recognizes the cultural and individual values and principles. Moreover as to their audit report, staff of CHT St John do their best to ensure that their care is being provided that focuses on the individuals, values, maintaining the privacy of the patients and their own choices. Furthermore, their service functions conform to Health and Disability Commissioners (Ministry of Health, 2016) (Ministry of Health, 2015) (Ministry of Health, 2014)’ Code of Consumer Rights, their cultural needs of the patients is achieved. Continually, policies were implemented well to upkeep the resident’s rights. In addition, care plans includes their families and complaints and concerns had been accomplished and their complaints were maintained (Ministry of Heath, 2015)

2. Organizational Management

The CHT St John comprises of nine (9) standards that support the outcome where patients, receives services in accordance with the legislation and are achieved in a harmless, effective and well-organized manner. Moreover, they have fully attained their standards with exceeded some of their standards. Furthermore, CHT St John has a unit manager and a registered nurse, clinical coordinator, and health care staff support. Their quality and risk management comprises of service philosophy, goals and quality planner. In addition, quality activities were piloted and this produces improvements on their practice and service delivery (Ministry of Health 2014).

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The CHT St John conducting meetings to tackle quality and risk management process and resident’s meetings with their own families are conducted every year. Furthermore, health and safety policies, system and process are implemented to cope with risk. The incidents and accidents were conveyed and followed -up. There are also complete education and training program and it has been implemented well. Continually, precise employment processes are observed to and all employees have yearly appraisal and their rooster of staff were sufficient to meet the quality of service (Ministry of Health, 2014).

3. Continuum of Service Delivery

The CHT St John comprises of thirteen (13) standards that support the outcome of clients and receive appropriate assessment followed by their services that are well planned, organized and  conveyed in a timely and correct method with compliance to the current legislation and all standards suited on this service were fully attained with some standards exceeded ( Ministry of Health, 2014)

In CHT St John the clinical coordinator manages the services offered with assistance from the registered nurses. Moreover, first hand-in assessment were accomplishes by the nurse which includes the InteRAI assessment and complete the care plan evaluations within the mandatory time. In addition, care plans are centered on InteRAI findings and each of their patients or residents are being interviewed and involved in the care planning and review process (Ministry of Health, 2014).

Furthermore, medicines are kept and managed properly in accordance to legislation and guidelines. The resident physicians review the patients every three months and more frequently if needed. Continually, their meals were prepared on the site by a contracted agency under the direction of a dietitian, and menu are wide-ranging and appropriate, and patients were interviewed and they were satisfy about the food service offered by CHT St John (Ministry of Health, 2014).

4. Safe and Appropriate Environment

As to safe and appropriate environment CHT St John have achieved their service are fully attained which includes eight (8) standards that supports the outcome where their services are offered in a clean and safe environment that is applicable to the age or need of the residents, make certain physical privacy and it is well maintained. Sufficient space and amenities to conduct independence is appropriate to meet the needs of people with disabilities (Ministry of Health, 2014).

Moreover, the building of CHT St John has a up-to-date warrant fitness and emergency evacuation plan and ongoing maintenance problem are solve and being addressed. The facility has eight (8) suites that comprises of eight to ten patients and bedrooms are single occupant and they their own suite. Furthermore, there is enough space to permits residents to move around freely and the facility utilized mobility aids for the residents. In addition there is an open lounge and dining area in each suite, outdoors section is safe and certainly   accessible. The maintenance departments are able to provide the appropriate services and the employees of St John have planned and strategies in case of emergency and emergency system are in place in the event of a fire or exterior disaster (Ministry of Health, 2014).

5. Restraint Minimization and Safe Practice

The CHT St John comprises of three (3) standards that support outcomes where the clients received and experienced services in the least and safe way through restraint minimization and this standard of practice in the facility was fully attained. The CHT St John’s Hospital has a restraint minimization and safe practice policies and procedures wherein the employees received trainings on restraint for patients who have challenging behavior. During the audit last September 2015 there were six patients with restraint and three with an enabler. The restraint management procedures were applied (Ministry of Health, 2014).

6. Infection and Prevention and Control

The CHT St John has six (6) standards that minimize the risk of infection to their clients, service providers and visitor. The Infection Control Policy and procedures is practical, safe and appropriate for the type of service rendered that adheres to the legislative and accepted good practice. In addition, the facility offers significant education on infection control to all the service providers and clients and surveillance of the infection control is done as well. The standard of infection control of CHT St John service is fully attained (Ministry of Health, 2014).

Moreover, the documentation evidence that is related to infection control education is provided to the service providers as a part of the orientation and as a part of an ongoing in service education program. Furthermore, the type of surveillance carry out is suited for the organization as to its size and complexity and standardized definitions were utilized for the identification and classification of infection events. The results of the surveillance were acted upon, assessed and reported to the relevant person in a well-timed manner (Ministry of health, 2014).


In CHT St. John Hospital certificate of audit is done last September 2015 which they have fully attained the different areas conducted by the Health and Disability Auditing New Zealand. This shows that the organization had achieved a success in providing quality of care to their consumers. Nevertheless, it is recommended that CHT St John Hospital should expand more their services like putting up additional building so that it could cater more patients to care. Moreover, the organization should add more services like for emergency procedures and minor operations that will help the residents instead of referring to other facility.


In conclusion, CHT St John Hospital certificate of audit was done as a result they have attained or achieved the different standard set by the Health and Disability Services (Safety) Act of 2001. Furthermore, it is very fundamental in every organization to conduct an audit because it measures the effectiveness and accuracy of the services rendered and to measure the competency of the staff as well as the providers and stakeholders.

Moreover, auditing plays an important role especially in the delivery of care to the clients because this would determine the success of the organization through the feedback of the clients and family involved. Having a positive feedback of the organization can raised the confidence of the staff as well as the organization thus success of the organization will be visible.


Daly, M. (2008). Healthcare Audit Criteria and Guidance. Retrieved March 2017, from http://hse.ie/eng/about/Who/qualityandpatientsafety/resourcesintelligence/Quality_and_Patient_Safety_Documents/guid.pdf

Ministry of Health. (2013). Rest home Certification and Audits. Retrieved March 2017, from Ministry of Health: https://www.health.govt.nz/your-health/services-and-support/health-care-services/services-older-people/rest-home-certification-and-audits

Ministry of Health. (2014, April). Health and Disability Service Standards. Retrieved March 2017, from Ministry of Health: https://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/services-standards

Ministry of Health. (2015, September). Christian Health Trust St John. Retrieved March 2017, from Ministry of Health: https://www.health.govt.nz/sites/default/files/prms/audit_summaries/AuditSummary_PRMS_CommunicatePublish_000001594001.pdf

Ministry of Health. (2016, December). Designated auditing agencies. Retrieved March 2017, from Ministry of Health: https://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/information-providers-health-care-services/designated-auditing-agencies

Ministry of Health. (2016, July). Designated Auditing Agency Handbook. Retrieved March 2017, from Ministry of Health: http://www.health.govt.nz/publication/designated-auditing-agency-handbook

Ministry of Health. (2017, February 14). Health and Disability Services (Safety) Act. Retrieved March 2017, from Ministry of Health: https://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/health-and-disability-services-safety-act


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