Quality Assurance Coordinator
Pohnpei State Government
Department of Health Services
P.O Box 189 | Kolonia, Pohnpei FSM, 96941|
W (691) 320-2216 Ext. 168
M (691) 924-5378


A system for setting appropriate standards, monitoring performance & continually striving for improvement.



To ensure the Quality Assurance System implemented into PSDHSS is effectively managed so that quality of health care services and operating efficiencies will be maintained and improved.


• PSDHSS is committed to the Quality Assurance System and sees its maintenance as fundamental to the ongoing provision of quality health care services in both the Hospital and in Public Health areas.

• The success of the system depends on setting appropriate standards, the regular active review, monitoring performance and continually striving for improvement. The system is under the management of the Quality Assurance Coordinator, who is a senior employee and regarded as a specialist in this area. The incumbent will have a good working knowledge of every unit in PSDHSS and of the principles and practice of Quality Assurance.

• The QA System uses as its major maintenance tool the established Policy & Procedure Manuals and the related QA Audits, implemented into every PSDHSS unit.

• A copy of the Policy & Procedures Manual relative to each PSDHSS unit is kept in that unit as a ready reference and all staff of that unit will be familiar with its contents and observe the policies and procedures detailed in the Manual.

• The observance of these Policies & Procedures is measured in every unit each 3 months by the QA Coordinator, utilizing the QA Audits.

• Post-Audit meetings of staff are arranged and chaired by the QA Coordinator in each unit to address and rectify any deficits identified by the QA Audits.

• Random swabs are taken from specified areas of PSDHSS where infection control is important. These swabs are taken at a minimum of 3 monthly and are cultured by the Medical Laboratory for bacteria. Results are conveyed to the Director in the QA Coordinator's Monthly Report, including actions taken to correct any unacceptable swab results.

• The QA Coordinator prepares a Monthly Report for submission to the Director. The Report will contain a full summary of activities undertaken, Audits completed with associated ratings, swab/culture results and any other matters requiring attention or of concern.

• Every 2 years the QA Coordinator implements a review of the Policy & Procedures Manuals for each unit. These reviews will involve the staff of the respective units and the Division Chiefs.