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Quality Department

Short introduction of Quality Systems Division

An established quality system is essential for ensuring the quality of  health care services and guarantees efficient administration and management of hospital: procedures, instructions and other relevant documents help to harmonise hospital's activities. This allows managing risks, minimizing the number of accidents and checking all activities step by step, if necessary.
North Estonia Medical Centre has been engaged in teaching both patients and their relatives in order to enhance the treatment process. One of the most common methods in patient education are special information leaflets for patients and their relatives. All these materials are also available on hospital's web page.
In 2008, Quality System Division was established as a part of Quality Department in order to ensure all above mentioned quality requirements. Quality System Division coordinates and develops the comprehensive quality management system of the organization, including preparing and administering quality documents and ensuring availability of patient information leaflets.

Activities:

  • integrates the comprehensive quality management system of North Estonia Medical Centre and develops its structural unit based sub-systems and quality management systems by following national requirements and international accreditation standard Joint Commission International Accreditation Standards for Hospitals”.
  • administers the documents of North Estonia Medical Centre organization manual
  • composes patient education leaflets and distributes them through departments and hospital's web page
  • analyses patient feedback and results of customer satisfaction surveys and sums them up
  • develops quality and document systems for handling cells, tissues and organs; applies for and renews activity licences

Short introduction of Infection Control Division

Hospital infections are a significant problem in modern medicine. The number of infections has increased due to the increasing number of patients with reduced immunity; use of invasive diagnostics and treatment methods; extensive use of antibiotics and distribution of  microbial resistance.
In 2002, Infection Control Department was established as a part of Quality Department. The main objective of the department is to minimize the risk for hospital infections and create safer treatment and working environment for patients and staff.

Daily activities:

  • registration and analyses of hospital infections
  • monitoring resistant microbes and outbreaks in cooperation with microbiology laboratory
  • developing antibiotics policies; monitor and analyse the use of antibiotics and provide counselling regarding antibacterial treatment in co-operation with hospital pharmacy
  • develop hygiene requirements and regularly check if these requirements are followed
  • advise staff on preventing the spread of infectious diseases
  • register all incidents where staff has had contact with cuts and stick wounds, in cooperation with Work Safety Division
  • provide training on infection control issues, in cooperation with Training Division
  • consult with other medical specialists regarding infectious diseases

The department employs 3 doctors and 6 nurses.

Short introduction of Therapy Quality Division

Therapy Quality Department has important role in quality evaluation and professional therapy quality evaluation in North Estonia Medical Centre
Employees of Therapy Quality Department are responsible for arranging the proper issuing of medical documents; coding diseases and surgical procedures; preparing monthly; quarterly and annual reports as required by the Ministry of Social Affairs; and submitting health data to national registries and databases.
Therapy Quality Department draws up comprehensive charts of medical statistics indicators and summaries which allow the council, management and heads of sub-units to get an overview of  the results and volume of clinical activities; it also acts as a basis for evaluation of therapy quality; making necessary and knowledge-based management decisions; and developing strategies, forecasts and development plans. Our department draws up statistical information which is used to introduce the hospital to our partners and patients.
Collection and analyses of health data is made by the methods approved by the World Health Organization (WHO), international and TIS (Health Information Centre) classifiers and indexes.
In order to enhance the evaluation of therapy quality, we are participating in PATH project (Performance Assessment Tool for quality improvement in Hospitals) with Estonian Health Insurance Fund, Tartu University Hospital and central hospitals.

Clinical pharmacology

The only clinical pharmacologist in Estonia, PhD Toomas Marandi, works at North Estonia Medical Centre. As a result of his team's long term efforts, our hospital has become the competence centre of clinical trials. As the first hospital in Estonia, we have become the member of Sanofi premier site network which has allowed us to participate in large-scale clinical trials and be a part of planning process from the very first moment.
We also have good relations with our other partners: in 2012, North Estonia Medical Centre started 33 clinical trials (34 in 2011); by the end of the year there were 113 on-going trials (92 in 2011).
On 20 May 2011 North Estonia Medical Centre turned a new page in the history of clinical trials in Estonia. We launched series of  follow-up trainings teaching good practices and methods of clinical trials for doctors who have not participated in trainings for five or more years. The curator of the course is clinical pharmacologist Toomas Marandi and lecturers include specialists from Tartu University, State Agency of Medicines, Human Studies Ethics Committee of Tartu University, Sanofi Aventis Estonia OÜ and North Estonia Medical Centre. One-day course concentrates on the development in the methodology of clinical trials, also modern research ethics and introduces practical aspects of clinical trials at the example of our hospital. In addition to this unique training, we continue with traditional two-day basic courses for nurses, dispensing chemists and doctors.

The area of clinical pharmacology includes

  • ensuring coordinated development of clinical pharmacology in North Estonia Medical Centre
  • coordination of preparing and updating the list of medicinal products used in North Estonia Medical Centre in cooperation with hospital pharmacy; also participating in purchasing medicinal products.
  • participation in international cooperation projects;
  • preparing and updating clinical pharmacology documentation and medical instructions in cooperation with relevant sub-units.

Quality is never a matter of chance; it is always a result of high objectives, sincere effort, smart target and great implementation.

Marina Kaarna

Quality Department

Marina Kaarna

Head of Quality Department

+372 617 2145