Centre for Patient Safety and Service Quality

Patient Safety, Quality & Innovation team      Te Pokapū Haumarie Turoro – Ratonga Whai Kounga


As part of Te Whatu Ora, our focus is to provide quality, safe care to the population we serve. Te Whatu Ora Whanganui’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.


The functions of the Patient Safety Centre include:

  •   quality improvement activities, initiatives and auditing
  •   infection prevention and control
  •   occupational health and safety
  •   emergency management
  •   customer relations and complaints management
  •   risk and incident management
  •   certification and legislative compliance
  •   education and training


Document management

All policies, procedures and guidelines are reviewed for accuracy and that they are evidence-based. The controlled document administrator ensures that all documents are current, and removes expired documents as notified.



Cgov is our risk, incident and consumer feedback management system. It is used to capture risks, incidents, consumer feedback, quality improvement, audits and hazards. The link to Cgov is available and staff can also link through to the Cgov App from the start menu and by viewing all Apps in Office 365. You will need to be on Microsoft Edge or Chrome for Cgov to work. Find training videos here.


Consumer relations

Te Whatu Ora Whanganui 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.


Patients have rights when accessing health or disability services which are described in the Code of Health and Disability Services Consumers’ Rights (insert text link to code). These service standards are what any one of us would expect if we were accessing a health or disability service in New Zealand. If you feel that one or more of your rights have been breached, you may make a complaint. Read more about your rights here.


If you make a complaint, Te Whatu Ora Whanganui’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.


Staff can lodge feedback using Cgov.


Emergency management

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


Health and safety

Te Whatu Ora Whanganui is committed to providing and maintaining a safe environment for all our employees, patients and visitors. Our robust programmes enable us to identify and remedy/minimise hazards. We encourage visitors and patients to advise our staff if they see or experience a hazard that needs to be remedied.


HQSC projects

PSQI lead several HQSC projects including:

  •  Mental Health Zero Seclusion and Connecting Care
  •  Kōrero Mai
  •  Shared goals of care

PSQI also collate data for the Quality Safety Markers and report this to HQSC for National benchmarking.


Incident management

“When things go wrong for patients and patient harm occurs, or when things were at risk of going wrong”


Te Whatu Ora Whanganui strives to provide safe care, and, for the majority of patients, this does occur. However, sadly, there are times when the care does not meet the patient/family expectations and a patient is harmed in our care. Whanganui Hospital is no different to other hospitals, nationally or internationally, in this regard and is committed to reducing preventable patient harm. All incidents are taken seriously and are investigated to understand what happened, why it happened and to make a plan to address the findings.


To support this approach, Te Whatu Ora Whanganui has developed systems and processes to enable electronic reporting of all incidents, investigation of all incidents and feedback to the patient, their families and to staff.


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.


Infection prevention and control

Infection is one of the five areas of high harm - nationally and internationally. With this in mind, Te Whatu Ora Whanganui 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 staff, visitor or patient, you can play a key role in supporting us 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)


Occupational health

Te Whatu Ora Whanganui provides an occupational health service for staff managing return to work programmes.


Privacy/Police and coroner liaison

Te Whatu Ora Whanganui recognises that patient’s health information is sensitive and must be handled with the utmost care. Our privacy officer is responsible for ensuring all staff are educated about their responsibilities under the Privacy Act 2020 and the Health Information Privacy Code 2020. The privacy officer maintains oversight of all incidents relating to privacy and health information.


This role also ensures that the Police and Te Whatu Ora Whanganui assist each other in fulfilling their obligations. Staff are supported with providing statements to the Police for criminal matters and the Police support Te Whatu Ora Whanganui staff when dealing with aggression and criminal event. The Police can request  copies of patient’s records but may require a formal statement using this template. Staff are to list their full name and qualifications and describe their involvement in the patient’s care paying attention to any injuries sustained, the assessment undertaken, and the treatment given. Any medical abbreviations or terms are simplified so that those lay people attending court can understand the statement. If staff need any assistance, please contact the clinical quality and risk advisor.



All research must meet organisational, professional, legal and ethical standards. The PSQI research advisor ensures that the correct documentation is provided, and that organisational approval is obtained.


Risk management

Te Whatu Ora Whanganui has an obligation to patients, staff, public and the Ministry of Health to manage risk effectively.


PSQI monitors compliance with Australian/New Zealand Standard [AS/NZS ISO 31000: 2009] where appropriate, and is supported by the risk management procedure to ensure all relevant parties:

  • understand actual and perceived risks within the organisation that could impede the achievement of the organisation’s strategic and operational objectives as defined in the Annual and Regional Plans.
  • understand their legal obligation to comply with legislation or contracts
  • identify, assess, prioritise, manage and monitor risks in a manner that complies with the WDHB legal obligations, policies and procedures.


VIP/child protection

Te Whatu Ora Whanganui’s Family Violence Intervention team aims to prevent intentional injuries to children and adults in the Whanganui district. Please refer to the Family Violence Intervention page.