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NZS:8165 Rooms Office Based Surgery and Procedures

We are accredited by DAA Group for the above standard.

Self assessement document prior to completing the audit which gives an idea what this audit is about.

Standards Audited

    Standard 1: Consumer / Patient-Focused Services
  • 1.1 Consumer rights: The patient receives services in a manner that complies with the requirements of the Code of Health and Disability Services Consumers’ Rights (the Code)
  • 1.2 Cultural safety: Patients receive services in a manner that recognises their cultural, ethnic, religious, social and individual values

    Standard 2: Organisational management
  • 2.1 Governance: Patients receive services that are managed in a safe, efficient and effective manner, that comply with legislation,and minimize harm
  • 2.2 Organisational management: The organisation ensures effective management and co-ordination to maximise patient outcomes
  • 2.3 Advertising and marketing strategies: All advertising and marketing strategies are presented in a consistent and accurate manner, are socially responsible and do not mislead or deceive the patient.
  • 2.4 Human resource management: Human resource management processes are conducted in accordance with good employment practice and comply with legislation
  • 2.4 Quality and risk management: The organisation has an established, documented and maintained quality and risk management system that reflects continuous quality improvement principles

    Standard 3: Pre-entry to Services
  • 3.1 Patient selection process: When a need for the service has been identified, patients are considered for entry to the organisation in an equitable and timely manner
  • 3.2 Declining entry to services: Where entry to the service is declined, the immediate risk to the patient is managed
    Standard 4: Service Delivery
  • 4.1 Service provision requirements: Patients receive timely, competent and appropriate service provision in order to meet their assessed needs
  • 4.2 Clinical records management: Each clinical record is documented in a complete and accurate manner and complies with legislation
  • 4.3 Sedation and anaesthesia: Sedation and anaesthesia techniques used shall be safe and appropriate for the patient and the procedure, to enable the patient to recover and be discharged in less than 24 hours.
  • 4.4 Clinical emergency response: Safe care is provided in the event of a clinical emergency
  • 4.5 Exit, discharge or transfer management: Patients experience a co-ordinated exit, discharge or transfer from the organisation
  • 4.6 Referrals, relationships and links: The service provider demonstrates effective links with relevant health and community service providers

    Standard 5: Managing Service Delivery
  • 5.1 Medicine management: Patients receive medicines in a safe and timely manner that complies with legislative and regulatory requirements
  • 5.2 Infection control management: Patients, visitors, service providers and communities are protected from preventable exposure to transmittable disease as a result of service provision
  • 5.3 Management of waste and hazardous substances: Patients, visitors and service providers are protected from harm as a result of exposure to waste or hazardous substances generated during service delivery
  • 5.4 Management of surgically removed tissue/body parts: Body parts/tissue are managed in a safe and culturally sensitive manner

    Standard 6: Safe and Appropriate Environment
  • 6.1 Facility specifications: Facility layout and design is clinically appropriate, contributes to safe service delivery and maintains patient and service provider safety
  • 6.2 Environment management: The environment and equipment is maintained in reliable and safe working order