Centre for Patient Safety and Service Quality

Reducing patient harm by supporting clinicians to provide best/safe care.


Whanganui DHB’s patient safety and quality team supports clinicians to provide safe care by providing expertise and experience to ensure patient harm is managed and that, systems and processes to support safe care delivery are in place. Our goal is to move organisational thinking towards a safety first approach. Rather than focussing on what went wrong our core approach is to ask ‘why did this work’ and ‘what went right’. In order to understand these questions we analyse data such as patient transfer, mishap reporting and the adult inpatient experience. We commend staff who speak up for safety or report near misses. Essentially if we understand why things went right we can prevent a similar incident from going wrong for another patient.


Key work areas:




Speaking up for safety (SUFS)

With the support of the Board WDHB is implementing the speaking up for safety programme provided by the Cognitive Institute to help prevent unintended patient harm.

Adult inpatient experience survey (HQSC)

A 20 item adult inpatient survey runs quarterly in all DHBs and covers four key domains of patient experience: communication, partnership, co-ordination and physical and emotional needs. Data is collected and accessed via the internet for download and analysis. Action is then taken to improve these domains.

Health Quality & Safety Commission quality and safety markers [QSMs]

QSM’s are intended to evaluate the success of HQSC programs and determine change and harm reduction. QSM’s have included: falls, healthcare associate infections (hand hygiene, surgical site infection), safe surgery and medication safety. Pressure injury and opioid quality markers are being rolled out in 2018.

Data is often collected manually before being submitted to HQSC. The markers chosen are processes that should be undertaken nearly all the time, so the threshold is set at 90 percent in most cases.

Patient tracer audit programme and Hospital Surveillance

The tracer methodology uses information from the organization to follow the experience of care, treatment or services for a patient through the organization’s entire health care delivery process.

We coordinate the tracer program and the tracer methodology that follows an actual patient’s journey, mapping both the good aspects of care and areas for improvement. Support is provided to the teams and we monitor and report on outcomes and activities.

A patient tracer audit is also required by the DAA group as part of hospital certification/surveillance auditing.

Customer Relations, Event reporting & investigating

The WDHB values patient/consumer feedback, whether it is positive, negative or simply a suggestion. We use many methods for gathering patient feedback but one of the most useful tools is the insight and information we gain from dealing with patient complaints.

If you make a complaint, the WDHB’s customer relations and complaints coordinator will listen to your concerns, record the details and initiate a complaint investigation. Our complaints management process will be explained to you and you will be kept informed on the progress of your complaint.

Since 2006 WDHB has used the RiskMan system for event reporting and audit and complaint management. We administer the use of RiskMan undertaking event analysis, data reporting and audit/complaint records and reporting.

We are also responsible for the Sentinel Event reporting process including the initial daily rating meeting, commissioning investigations, working with patients and their families, reporting to HQSC and monitoring agreed actions/activities.

The process of feedback to the patient and their family after a serious harm incident is called Open Disclosure. This is offered to all patients and their families with a copy of the report and the findings.

We work closely with the members of Te Pukaea (the trumpet) our consumer partnership and engagement group.

Emergency Management

Whanganui DHB needs to be well prepared for emergencies or unexpected incidents. In the event of a major disaster that affects the community or a simple in-house emergency such as an IT outage, the DHB still needs to function and provide care. At its most basic, emergency management is simply making sure that the WDHB is able to do this.

We work with departments to develop and update department specific emergency management resource material including business continuity plans created to enable departments to carry on with ‘business as usual’ in the event of an unexpected incident.

If an emergency such as a major accident, earthquake, tsunami or pandemic occurs, we have plans in place to enable us to continue our business and provide care to our community. These plans link in with regional and national emergency plans.

We regularly test our plans with exercises to enable us to see how the plans work and improve them. We often run these exercises in conjunction with other agencies including Civil Defence, NZ Police, St John Ambulance, NZ Fire Service and the NZ Army. Some exercises are also held nationally to test all DHBs’ readiness to handle a national emergency.

We run the Emergency Operations Centre (EOC) when it is opened up and ensure resources for the EOC are maintained and checked on a regular basis.

We encourage the community and our staff to protect those they care for, and those who may depend on them, to complete a family emergency plan and be prepared at home. You can download your family planning form directly from the Civil Defence website: www.getthru.govt.nz

Infection prevention and control

Infection is one of the five areas of high harm - nationally and internationally. With this in mind, Whanganui DHB developed a robust infection control programme focusing on hand hygiene, hospital-acquired surgical site infections, antibiotic use and responding to outbreaks of infection within our community.

Hand hygiene is the most effective way to prevent the spread of infection. As a visitor or patient, you can play a key role in supporting the DHB to remain infection free by ensuring your hands are washed when entering the hospital.

Hospital-acquired infections are considered patient harm. When they do occur we follow up to ensure we understand the cause and how we may be able to minimise occurrences in the future. There is a ‘real time’ hospital infection surveillance programme in place for patients having surgery. Training in infection control practices is provided to all staff to maintain knowledge and to support safe practice.

More information about hand hygiene, in general, can be found at the Hand Hygiene New Zealand website: http://www.handhygiene.org.nz

Quality improvement

To improve the quality of services, it is necessary to understand where we are now and to measure the effectiveness of the care we give and the actions we take. To help us improve what we do, WDHB has embraced the Plan/Do/Act/Study (PDSA) methodology as supported internationally by the Institute of Healthcare Improvement,

By always looking at ourselves and listening to the feedback from patients and families, we can plan what to do next to improve the care we deliver. An example of such an approach is the ‘Releasing Time to Care’ programme which is supported by the Ministry of Health and championed in our wards. Staff work in partnership with patients and each other to improve the environment and processes of care to ensure the right care is delivered at the right time.