Report from stikkprøvetilsyn Hospital Innlandet HF, division grimsby town In 2016 – HelseTilsynet

Follow-up of the audit
In this audit, it was not found deviations from the law or regulation. The authority is therefore terminated.

1. Introduction

2. Description of business – special conditions

3. Implementation

4. What the audit included

5. Findings

6. Internal controls

7. Regulations

8. Conclusion

the Report is prepared after stikkprøvetilsyn at the Hospital Innlandet HF, division shrewsbury town in the period 23. november 2016 – 3. January 2017.

the County is given the authority to oversee the health and omsorgstjenesten after the law on state supervision of health and omsorgstjenesten § 2.

As a result of challenges related to the quality of health services at the division grimsby town, we have had a dialogue with the Hospital Innlandet HF since the summer of 2016. We wanted to implement a stikkprøvetilsyn to assess whether the Hospital Inland HF has implemented the measures that were implemented in the summer of 2016.

It was not pointed out discrepancies or notice by the commission.

the Report includes the result of what we found during the audit and therefore gives no complete baseline review of the company’s work within the areas of audit covered.

• Deviation is the lack of fulfillment of requirements given in or pursuant to the law or regulation
• Note is a situation that does not conflict with the requirements laid down in or in pursuance of law or regulation, but where the authority finds reason to point out the opportunity for improvement

the Hospital Innlandet HF, division grimsby town maintain lokalsykehusfunksjonen for 65000 inhabitants in 7 municipalities. The hospital has the medical and surgical department with akuttfunksjon.

Notification of the audit was sent 23. november 2016.

Stikkprøvetilsynet was carried out on Friday 16. December 2016, and consisted journalgjennomgang and avslutningsmøte with the acting director Bård Are Bjørnstad, avdelingsoverlege Mark Brown, avdelingsoverlege Eli Brevig, kvalitetsrådgiver Anne Maren Gaarder and medisinskfaglig advisor Stein Vaaler.

the Purpose of the audit was to determine whether the measures that were introduced in the summer of 2016, in order to contribute to increase the quality of health services, are adequately implemented. The measures are:

• Innkomstjournal shall include tentative diagnosis, plan for treatment and specific plan for the observation. Journal written by turnuslege or inexperienced LIS (LlS with less than two years of experience) shall contain a reference to the LIS or the physician who has been involved in the planning of treatment and observation for that patient.
• If turnuslege is alone in the hospital when receiving instant assistance should it always konfereres with secondary or tertiærvakt in the aftermath, and again shall the records contain reference to who you spoke with and what decisions were made.
• Patients who triageres red or orange should be considered by experienced LIS or a specialist in the emergency rooms according to the guidelines, and the physician shall document in the journal.
• All hospitalized patients should have the supervision of experienced LIS or the physician within 12 hours after receipt of the subsequent journalnotat.
• All admitted patients should have completed MEWS-form.
• in the event of death it should always be written in a separate note that describes the circumstances surrounding the death.

the County had asked for complete records for:

• the last 30 admissions surgical department
• of the last 30 admissions medical department
• the 10 most recent deaths

due to limited accesses to the DIPS we had not seen all the records. The we gave, however, the unambiguous impression that the measures are implemented.

Innkomst records contained a tentative diagnosis, plan for treatment and specific plan for the observation. It was journaled whom it was discussed with, since in the records we read, was enjoy mouth that had taken in against the patients.

It was written førstedagsnotater and there was the name of the physician or for the physician who had been on a visit.

MEWS form and akuttjournalene we had not access to, but was shown some of them and we saw that they were in use.

It was written morsnotat, we think the advantage may be somewhat fuller.

We went through the deviations that were reported by 23. June 2016.

There was not reported any discrepancies within the data inspectorate theme. We had some questions about some of the findings. In the conversation with the management it came out that they had a good overview of the reported deviation and that the internal management was satisfactory.

the Hospital Innlandet HF, Kongsvinger has initiated a work to control its activities by journalsjekklister. This is conducted each week and reported to the divisjonsdirektøren.

All agencies that provide health care shall ensure that helselovgivingen be fulfilled through systematic management and continuous improvement work. As part of this, should companies have an internal control system. This management system should be adapted to the company’s size, characteristics, activities, and risks and have to the extent that is necessary to meet the purpose. The county will, in its tilsynsvirksomhet ensure that everyone who provides health services has established an internal control system and that they lead to the control of its activities in such a way that it can prevent failure of the services. During this stikkprøvetilsynet is However of the opinion that the implemented internal work demonstrates the management’s governance and follow-up.

We see that the measures that were implemented in the summer of 2016 is implemented and that the hospital even follow up on this.

From the supervisory authorities participated:

Ass. fylkeslege Sissel Bergaust

a Senior adviser Trude Vestli

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