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St Joseph's Hospital

2nd October 2006

St Joseph’s Hospital uses ISO 9001:2000 Healthmark to raise quality

St Joseph’s Hospital in Ennis, County Clare, is a 228-bed elderly care hospital operated by Mid-Western Health Board. Employing 300 staff, its services include acute rehabilitation, slow-stream rehabilitation, extended care, dementia care, physiotherapy, occupational therapy, speech and language therapy and podiatry.

To ensure quality of care and service to patients and to increase communication with staff and their involvement in drafting new policies and procedures, managers and unions at St Joseph’s Hospital established a Local Partnership Working Group in 2001.

In an important first step towards continual quality improvement in patient care and service, the working group decided to introduce the ISO (International Organization for Standardization) 9001:2000 Quality Management System (QMS).

ISO 9001:2000 encompasses eight principles of quality management: focus on the customer; leadership; involvement of people; a process approach; a system approach to management; continual improvement; a factual approach to decision making; and mutually beneficial supplier relationships. 

International Certification Body SGS carried out a pre-audit of St Joseph’s Hospital in November 2004, with hospital staff being familiarised with the standard at the same time. SGS audited and awarded St Joseph’s Hospital ISO 9001:2000 Healthmark certification in January 2005, with no non-conformities found at certification audit.

“We’re glad we chose SGS, which is well-known in Ireland,? says St Joseph’s Hospital Quality Management Representative, Noreen O’Regan. “Throughout the pre-audit and certification process, SGS was approachable, accessible, professional and supportive.?

Quality initiatives and assurance

As one element of its new ISO 9001:2000 Healthmark-based QMS, St Joseph’s Hospital has established a Quality Representatives’ Forum (QRF) comprising 38 quality representatives (QR) from all the hospital’s departments. These include nursing & attendants, catering, pharmacy, laundry, administration, portering, infection control, human resources, occupational therapy, physiotherapy, podiatry, and speech & language. 

This group meets every three weeks to review planned new hospital procedures and guidelines and to discuss suggested improvements. The QRs then discuss these with their
departments and bring staff feedback to the next meeting for incorporation in final guidelines and implementation.

In the case of procedures relevant only to a specific department, these are dealt with by staff in that department and do not go through the QRF.

As an example of recent improvements at St Joseph’s Hospital, there are now: set standards for nursing procedures such as dressing wounds; colour-coded cleaning programmes and increased staff training in infection control; HACCP (Hazard Analysis and Critical Control Point) procedures in kitchens; new procedures to reduce the risk of SRSV (winter vomiting bug) and MRSA infection; more nutritious meals; and patient satisfaction surveys and patient information booklets.     

As another improvement, different kinds of waste (such as glass, paper, and aluminium and steel cans) are collected at set times. Increased recycling has benefited the environment and greatly reduced landfill costs.

St Joseph’s Hospital’s QMS is assessed twice a year at a management review meeting attended by senior hospital and area healthcare managers. In addition, 16 hospital staff have completed their internal auditor training to help monitor the QMS and check that improvement requests have been followed through.

QMS success

“ISO 9001:2000 Healthmark has been a great success,? says Noreen O’Regan. “Running neatly alongside our other existing and planned quality initiatives, it shows we’re committed to the highest standards of patient care and service, increases our efficiency, reduces complaints and reassures our patients, staff and other stakeholders.
 
“Our staff’s ethos of ‘Quality Begins with Me’ can now be clearly seen throughout the hospital and in every aspect of patient care and service.?

St Joseph’s Hospital’s QMS has attracted much interest from other hospitals and it is proposed to replicate the system in two community nursing units in County Clare. 

 

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