Failure to address this issue could affect the hospital's ability to withstand any future large-scale infectious event, states the 54-page report All Protected or All at Risk?, containing 36 recommendations.
Hospital management says much work has been done to address major issues from the report.
The changes were successfully applied to the hospital's handling of the swine flu outbreak earlier this year.
Otago District Health Board chief operating officer Vivian Blake yesterday said it was important the review was seen as an opportunity to learn from both the positives and the mistakes during the norovirus outbreak.
It should not be seen as a witch-hunt.
Shortcomings highlighted in the report included the lack of a plan for managing hospital-wide infections and confusion over leadership, decision-making and communication.
Some aspects listed as key successes in the report, such as team-work, decision-making and communication, also came in for criticism by some contributors to the report.
The reviewers, whose work included interviews with about 60 groups and individuals associated with the event, heard that some staff, across all occupational groups, were rude to people posted on entrances to encourage compliance with the hand hygiene rules, and had refused to use sanitising gel.
"This attitude was remarked on by numerous door volunteers, who were stunned at the reactions of doctors and nurses."
Many staff did not have their identity cards and some refused to show theirs to security staff because they said wearing a uniform should be sufficient to allow them through.
Some disagreed with the infection control policies, and protocols were seen to be inconsistently applied.
Some doctors, nurses and students were observed going into isolation rooms without personal protection.
There were comments about staff wearing scrubs and uniforms outside, with "negative perceptions from the public".
Some of those interviewed said "medical staff thought infection prevention and control procedures did not apply to them", prompting chief medical officer Richard Bunton to issue a notice on the matter.
It was noted there was better compliance with use of personal protective equipment when senior staff were on the wards.
Mrs Blake said the behaviour of those unwilling to comply was disappointing and there was a need to ensure regular reinforcement of correct protocols.
Board chief nursing and midwifery officer Leanne Samuel said the protocols introduced for the norovirus outbreak were a change from usual practice.
The report congratulated cleaners for their work, saying they were widely admired for their extra work, , pointing out only one person from their service fell ill.
Concerns about the impact of the run-down state of the building on infection prevention and control were noted and a recommendation made about the need to address deferred maintenance.
One of the reviewers, public health physician Dr Marion Poore, said the efforts of staff and contracted staff during the outbreak had been outstanding.
Once the outbreak had been recognised, it was brought under control in a relatively short time.
"In some places, it can rumble on for weeks, if not months."
One of the difficulties in dealing with an outbreak was that its severity could be difficult to assess.
In connection with this, the report included recommendations about improving integration of illness surveillance systems across the health sector to help minimise infectious disease outbreaks.
The report noted some staff were reluctant to admit they had been or were unwell, and either returned to work early or did not take time off when ill.
Instructions to remain off work for 48 hours after symptoms abated were seen as problematic for staff levels.
Mrs Blake said people working in the hospital felt "a need to serve" and were keen to come back to work because they knew colleagues had a heavy workload.
Dr Poore agreed, saying it was challenging to get the message to staff of the importance of coming to work only when well.
The co-ordinated incident management system (CIMS) introduced following pandemic planning in 2006, was problematic initially, with confusion over who was taking the role of incident controller, which led to tension between staff.
Some staff said the lack of process created anxiety and uncertainty and was "disempowering and upsetting".
It was also noted there were no guidelines or "triggers" to prompt escalation of certain situations to a more senior level.
This has yet to be settled.
Because CIMS had not been used at the board before, and only a few staff had relevant training, staff were unclear what was required for certain roles.
"This resulted in poorly organised shifts, with ineffective handover at the end of shifts."
A roster of staff so they lasted the distance was important, the review said.
Mrs Blake said time had been taken since to identify staff in key roles and ensure they were well informed.
CIMS was used during the swine flu outbreak.
The report also states the clinical leadership structure did not provide a "robust way of engaging and communicating with senior or junior medical staff in the hospital".
A few senior medical staff attended incident response meetings intermittently.
An infectious diseases physician could have provided a liaison function in this role, but nobody was delegated to that role.
An appointment has since been made.
Communication was not consistent, with some staff receiving material more than once, while others missed out.
Some staff said the Otago Daily Times was the best source of information in the first few days.
The work done by staff to communicate with people affected by the "lock down" was commended by reviewers.
The review was led by board quality and risk manager Catherine Rae.
Also on the team were charge nurse manager infection prevention and control and emergency planner Jo Stodart, public health physician Dr Marion Poore, and board nurse director mental health and community services Heather Casey.
The recommendations from the report have been considered by the board's regional executive management team.
Norovirus outbreak
At Dunedin Hospital, August 15 to September 9, 2008:
About 143 patients and 383 staff affected.
More than 2000 appointments, procedures and planned surgeries postponed.
Hospital closed for 10 days for all except acute admissions.
Cost: At least $276,000.
Between July 9 and September 9, nine wards of Dunedin and Wakari Hospitals were affected by norovirus.
There were also eight other community outbreaks of the illness in Dunedin.
Recommendations
Some of the 36 review recommendations already achieved or partially achieved:Develop an outbreak management plan.
Appoint an infectious diseases physician.
Improve record keeping.
Support introduction of national programme to encourage good hand-washing hygiene.
Ensure all Otago District Health Board staff attend regular infection prevention and control courses.
Assess all clinical staff on infection prevention and control skills.
Review board illness surveillance systems.
Ensure senior medical staff promote good hand-washing hygiene.
Appoint infection prevention and control co-ordinator for community work.
