StHilaryCaseStudy.pdf - St Hilaryu2019s Private Hospital...

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St Hilary’s Private Hospital CASE STUDY
SAI GLOBAL LIMITED Document Name: AU 01 LAT Case Study 1 Participant Guide 01 0518 Document ID: SAI-EDAU CS1 PG LAT.01 0518 Date of Issue: 12 March 2018
ACKNOWLEDGMENTS SAI Global would like to acknowledge John Fawkner Hospital for kind permission to base this hypothetical case study on their hospital. In particular SAI Global would like to thank Catherine Willmont, Executive Nurse Manager. All staff named in this Case Study are entirely fictitious. Any similarities to real persons is unintentional.
ST HILARY’S PRIVATE HOSPITAL CASE STUDY www. saiglobal .com | 1 CONTENTS Introduction to the Case Study ............................................................................... 3 Structure of the Case Study ............................................................................................... 3 Background to the Audit ..................................................................................................... 3 Part One: About St Hilary’s Private Hospital ........................................................... 4 Mission ................................................................................................................................ 4 Services Offered ................................................................................................................. 4 St Hilary’s Private Hospital Organisation Chart .................................................................. 5 Staff .................................................................................................................................... 6 Site Plan ............................................................................................................................. 7 Location of Hospital Departments ...................................................................................... 9 Part Two: Integrated Management System Documents ......................................... 10 Quality Policy .................................................................................................................... 11 Health and Safety Policy .................................................................................................. 12 Environmental Policy ........................................................................................................ 13 Organisational Risk Register ............................................................................................ 14 Objectives and Targets ..................................................................................................... 18 Procedures for Identifying Legal Compliance Obligations ............................................... 21 Responsibility, Authority and Accountability Procedures ................................................. 23 Document and Data Control ............................................................................................. 24 Management Review ........................................................................................................ 26 Communication and Consultation Procedure ................................................................... 27 Hazard Identification, Risk Assessment and Control Procedure ...................................... 29 Process Control Procedure .............................................................................................. 33 Procurement and Change Management Procedures ....................................................... 35 Incidents and Emergencies .............................................................................................. 39 Training Procedure ........................................................................................................... 41 Contractor Pre-start Procedure ........................................................................................ 43 Workplace Inspection Procedures .................................................................................... 45 Internal Auditing ................................................................................................................ 47 Audit Schedule .................................................................................................................. 49 Monitoring and Measurement ........................................................................................... 50 Corrective Action Procedure ............................................................................................. 52 Management of Contractors ............................................................................................. 54 Management System Performance Evaluation ................................................................ 57 Workplace Inspection Instructions .................................................................................... 59 Workplace Inspection Schedule ....................................................................................... 61 Risk Assessment Form ..................................................................................................... 62 Corrective Action Report .................................................................................................. 66 Continual Improvement Record ........................................................................................ 68 Workplace Inspection Checklist ........................................................................................ 69 Appendix A: Core Management Audit Evidence .................................................... 71
ST HILARY’S PRIVATE HOSPITAL CASE STUDY 2 | www. saiglobal .com Appendix B: OHS Procedures and Audit Evidence ................................................ 91 Permit to Work Procedure ................................................................................................ 94 Work in Confined Spaces Procedure ............................................................................... 96 Safe Patient Handling Procedure ..................................................................................... 99 Manual Handling Procedure ........................................................................................... 101 Chemical Management Procedure ................................................................................. 103 Plant and Equipment Safety Procedures ........................................................................ 105 Handling and Disposal of Sharps Procedure .................................................................. 108 Health and Safety Issue Resolution Procedure .............................................................. 109 Injury and Incident Reporting and Investigation ............................................................. 111 Disposal of Sharps Work Instruction .............................................................................. 114 Plant Pre-Start Inspection Work Instruction .................................................................... 116 Plant and Equipment Authorisation Register .................................................................. 118 Incident Reporting and Investigation Form ..................................................................... 119 Appendix C: EMS Procedures and Audit Evidence ............................................. 136 Identification of Environmental Aspects .......................................................................... 138 Determination of Risk Exposure ..................................................................................... 140 Monitoring of Environmental Performance Instructions .................................................. 141 Groundwater Sampling ................................................................................................... 144 Solid Waste Control ........................................................................................................ 146 Effluent Sampling ............................................................................................................ 148 Extract: Register of Environmental Aspects ................................................................... 158 Appendix D: QMS Procedures and Audit Evidence ............................................. 159 Admissions Procedure .................................................................................................... 160 Cleaning Procedure ........................................................................................................ 162 Customer Complaints Procedure ................................................................................... 164 Invoicing Procedures ...................................................................................................... 166
ST HILARY’S PRIVATE HOSPITAL CASE STUDY www. saiglobal .com | 3

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