Notification of a Proposed
Reconfiguration of Certified Services
DHB hospital services
Note: The self-assessment outlines the potential impact of:
a.
increasing patient/client capacity, or
b.
the transfer of current clinical services, or
c.
the provision of a new clinical service, or
d.
a combination of the above.
DHB reconfiguration is often the movement of existing clinical services to a new building or to an
existing building while renovations are completed. The criteria are sourced from the Health and
Disability Services Standards (NZS 8134:2008).
Note: Reconfiguration includes a DHB merging certificates which effectively adds services to one
certificate in favour of revoking another.
Use of this form
Use this form for the notification of a proposed reconfiguration of services where it is proposed to:

change bed use, and/or

increase in capacity, or

add services from one certificate to another.
The Director-General of Health must be satisfied that a reconfiguration will not negatively impact on
the provider’s ability to meet the relevant standards. An audit may be required to be undertaken by a
designated auditing agency, prior to utilisation of the reconfigured facilities, in order to demonstrate
that the provider will continue to meet the relevant standards.
A partial provisional audit will be required if this reconfiguration relates to the provision of a new
clinical service as defined by the Health and Disability Services (Safety) Act 2001. For example, the
DHB will now provide Hospital Services Geriatric in an existing building.
A partial provisional audit will not be required if this is a transfer from one building to another with
the same or similar number of beds. For example, a new mental health unit with three additional beds
or the transfer of four current AT&R wards to a new building on an existing DHB site with no change
in bed numbers.
Notification of a Proposed Reconfiguration of Certified Services: DHB Hospital Services
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A partial provisional audit may be required where services are being moved from one certificate to
another. The decision is dependent on a range of factors including the expiry date of certificates,
timing and results of recent audits.
Please return this form by:
Email to:
Fax to:
Mail to:
certification@moh.govt.nz
04 496 2343
HealthCERT, PO Box 5013, Wellington 6545
If you have any questions please contact the Ministry on 0800 113 813.
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Notification of a Proposed Reconfiguration of Certified Services: DHB Hospital Services
Notification of a Proposed
Reconfiguration of Certified Services
DHB hospital services
DHB name:
<Enter organisation's legal name>
Premises name:
<Enter name of premises where reconfiguration taking place>
Premises address:
<Enter address of premises>
Description of change
Proposed change:
<Enter a description of the change you propose to make>
Will there be a change in the number of beds?
Yes
No
If yes, state current bed numbers and proposed bed numbers. Be specific about the types of beds
(mental health, maternity, etc):
a.
Current beds:
<Enter current bed number>
b.
Proposed beds: <Enter proposed bed number>
Is this a transfer of existing bed numbers to a new building?
Yes
No
If yes, how many beds does this apply to: <Enter number of beds>
Are the clinical services currently provided at the DHB?
Yes
No
List the clinical services that are involved in this process:
<List clinical services involved>
Is this a request to merge existing certificates?
Yes
No
Is progress reporting against corrective actions up to date for all certificates involved?
Yes
No
Notification of a Proposed Reconfiguration of Certified Services: DHB Hospital Services
3
Transition plans – new or existing build
Complete this section if the notification relates to a new building or renovations to an existing
building.
Standard
1.2.8
1.3.13
Evidence
Must relate to the new or existing build
Service provider availability

There is a planned staff orientation and emergency
training for staff in the new clinical area (eg, copy of
plan, attendance to orientation and emergency training
for clinical staff).
<Click here to enter text>

If there is an increase in bed numbers, staff levels and
skill mix processes have been undertaken.
<Click here to enter text>
Nutrition, safe food and fluid management

1.4.1
1.4.2
1.4.3

Emergency management plan
<Click here to enter text>

HSNO management, particularly after hours, interface
with cleaning/orderly staff
<Click here to enter text>
Facility specifications

BWOFs and/or CPU for new and current facilities
(CPU to be submitted prior to transfer of
patients/clients)
<Click here to enter text>

Amenities, fixtures, equipment and furniture are
selected located installed and maintained for service
users, safety, needs and abilities
<Click here to enter text>
Toilet, shower and bathing facilities
On site visits to clinical areas completed – report on
issues
<Click here to enter text>
Comment on dedicated areas for service types, eg,
paediatrics, long-term care
Cleaning and laundry services

4
<Click here to enter text>
Communal areas for entertainment, recreation, and
dining

1.4.6
On site visit to clinical areas completed – report on
issues
Personal space/bed areas

1.4.5
<Click here to enter text>
Management of waste and hazardous substances

1.4.4
Evidence of current Food Safety Inspection Certificate
(eg, against HACCP) (eg, evidence that
kitchen/servery in the new build meets standards)
Processes for new services or increased capacity
have been planned and completed
<Click here to enter text>
Notification of a Proposed Reconfiguration of Certified Services: DHB Hospital Services
Standard
1.4.7
1.4.8
Evidence
Must relate to the new or existing build
Essential, emergency and security systems in respect
of the new build and/or services

Fire evacuation plans
<Click here to enter text>

Methods of keeping patients/public/staff aware of
environment hazards
<Click here to enter text>

Call bells functioning
<Click here to enter text>

Emergency responsiveness, including clinical teams,
specific earthquake response teams etc
<Click here to enter text>

Impact on security service report
<Click here to enter text>
Natural light, ventilation and heating

3.1.8
No internal rooms are used for overnight patient stays
<Click here to enter text>
Infection prevention and control standards

There has been a process of consultation and sign off
with infection control team for the new build/new
services
<Click here to enter text>
Notification of a Proposed Reconfiguration of Certified Services: DHB Hospital Services
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Declaration
I, <Enter full name of agent or employee of the company> of <Enter town or city of residence>,
<Enter occupation> solemnly and sincerely declare that the statements made in the above application
are true and correct.
Declared at <Enter town or city> this <Enter date of month, eg, 1st> day of <Enter month> <Enter
year>
Signature of applicant:
.....................................................................................................................
Before me:
Full name (please print):
.....................................................................................................................
Occupation:
.....................................................................................................................
A person authorised under section 9 of the Oaths and Declarations Act 1957 to take this declaration.
A declaration made in New Zealand must be made before:
a)
a barrister or solicitor of the High Court
b)
a Justice of the Peace
c)
a notary public
d)
the Registrar or a Deputy Registrar of the Supreme Court
e)
the Registrar or a Deputy Registrar of the Court of Appeal
f)
the Registrar or a Deputy Registrar of the High Court or a District Court
g)
some other person authorised by law to administer an oath
h)
a member of Parliament
i)
a person who is a fellow of the New Zealand Institute of Legal Executives and is acting in the
employment of a practising barrister and solicitor of the High Court
j)
an employee of the New Zealand Transport Agency authorised for that purpose by the Minister
of Justice or an employee of Public Trust authorised or an officer in the service of the Crown or
of a local authority authorised for that purpose.
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Notification of a Proposed Reconfiguration of Certified Services: DHB Hospital Services
Declaration
I, ...................................................................................................................... (full name of agent or employee of the company)
of .......................................................................................................................................................... (town or city of residence)
..................................................................................................................................................................................... (occupation)
solemnly and sincerely declare that the statements made in the above application are true and correct.
Declared at ...................................................................... this ....................... day of ....................................... 20............
Signature of applicant:
...................................................................................................................................................
Before me:
Full name (please print):
...................................................................................................................................................
Occupation:
...................................................................................................................................................
A person authorised under section 9 of the Oaths and Declarations Act 1957 to take this declaration.
A declaration made in New Zealand must be made before:
a)
a barrister or solicitor of the High Court
b)
a Justice of the Peace
c)
a notary public
d)
the Registrar or a Deputy Registrar of the Supreme Court
e)
the Registrar or a Deputy Registrar of the Court of Appeal
f)
the Registrar or a Deputy Registrar of the High Court or a District Court
g)
some other person authorised by law to administer an oath
h)
a member of Parliament
i)
a person who is a fellow of the New Zealand Institute of Legal Executives and is acting in the
employment of a practising barrister and solicitor of the High Court
j)
an employee of the New Zealand Transport Agency authorised for that purpose by the Minister
of Justice or an employee of Public Trust authorised or an officer in the service of the Crown or
of a local authority authorised for that purpose.
Notification of a Proposed Reconfiguration of Certified Services: DHB Hospital Services
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