ACHS NEWS - Australian Council on Healthcare Standards

<strong>ACHS</strong>
<strong>ACHS</strong> <strong>NEWS</strong>
The official newsletter of the <strong>Australian</strong> <strong>Council</strong> on Healthcare Standards
ACN 008 549 773
Issue 14 – Autumn 2005
Standards
<strong>ACHS</strong> Standards
Performance Indicators
The Future Agenda for Quality
Will 2005 be as significant as it needs to be?
Programs
Evaluation and Quality
Improvement Program (EQuIP)
EQuIP In-depth Reviews
EQuIP Corporate
<strong>ACHS</strong> Certification Program
Services
Performance and
Outcomes Service
Education and Support Service
<strong>ACHS</strong> on the World Wide Web
Publications
Contacts
The <strong>Australian</strong> <strong>Council</strong> on
Healthcare Standards
5 Macarthur Street
ULTIMO NSW 2007
Australia
Telephone 61 2 9281 9955
Facsimile 61 2 9211 9633
E-mail achs@achs.org.au
Website http://www.achs.org.au
<strong>ACHS</strong>
<strong>ACHS</strong> accreditation is offered
through its Evaluation and Quality
Improvement Program (EQuIP).
safety, quality, performance
As this newsletter goes to press the
review of the future governance
arrangements for safety and quality
in health care has commenced consultation
meetings around Australia. The review is
being conducted under the auspices of the
<strong>Australian</strong> Health Ministers’ Conference
and will provide advice on the future of
the safety and quality agenda after the
<strong>Australian</strong> <strong>Council</strong> on Safety and Quality
in Health Care completes its program in
June 2006.
The importance of this major
undertaking to ensure a sustained
commitment to effective health care
delivery should not be under estimated.
The <strong>ACHS</strong> strongly believes that quality
must remain as a first-order governance,
both clinical and non-clinical, issue.
Around a hundred people attended the
national workshop conducted by the
Review Team in Sydney on 14 February.
The purpose of the workshop was given as
‘engaging stakeholders in considering the
issues, possible models and priorities for
national governance arrangements for safety
and quality in health care’. There was general
recognition that the priority areas for a
future agenda included:
• national data collection
• maintenance of a broad focus
on quality
• integration across safety and the other
quality dimensions
• cultural change
• workforce capacity
• increased focus on over, under and
misuse of resources and interventions
• reduction of inconsistency in practice
• strengthening of implementation
capacity and accountability.
Anyone interested in contributing is
strongly encouraged to take the opportunity
of attending one of the scheduled
consultation meetings.
The <strong>ACHS</strong> is committed to supporting a
continuation of this national issue and has
much to contribute towards both taking a
leading role at a national level and in the
In this issue …
Divisions of General Practice
accreditation program
National Accrediation Report
2005 Quality Improvement
Awards categories
EQuIP 3rd Edition review
process
development of nationally coordinated
standards and accreditation activities.
It is with great pleasure that I advise that
Maureen Robinson commenced in the
position of Executive Manager Development
17 January. Maureen brings a wealth of
experience both as a clinician and as an
expert in quality and health system
performance.
Previously Director, Quality and Safety,
NSW Health, she will retain membership of
the <strong>Australian</strong> <strong>Council</strong> on Safety and Quality
in Health Care. One of her major tasks will
be to lead the review of EQuIP that
commenced in the later part of last year.
I am also pleased to announce the
appointment of two full-time Surveyors to
the <strong>ACHS</strong> workforce.
Dr David McMaugh’s background
involves general dental surgery and specialist
prosthodontistry for 23 years in the private,
university and public health sectors. He has
held District management appointments in
Queensland Health in the coastal rural area
of Gympie, the central rural area of North
Burnett, as well as the Royal Brisbane and
Women’s Health Service District.
Mr John Hodge has been surveying with
the <strong>ACHS</strong> since 1999 and has a background
in nursing with extensive experience
gained as the Nursing Executive Officer at
Sydney Adventist Hospital. John also has
expertise in nursing education and clinical
nurse consulting in Cardio – Thoracic and
Acute Care.
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<strong>ACHS</strong> <strong>NEWS</strong> Issue 14 – Autumn 2005 • PAGE 2
continued from page 1
As previously announced the first edition of the publication
Improving Safety and Quality of Care with EQuIP – A
Clinician’s Guide has now been widely distributed. There has
been an overwhelming request for additional copies resulting in
all of the initial 10,000 print run being distributed.
Whilst this is an excellent response we would value your
feedback on how subsequent editions could be improved.
In this regard the views of clinicians would be highly valued.
The publication of our corporate history <strong>ACHS</strong> 30 Years has
received many positive reactions and has been widely
distributed. Author Glenda Banks has produced a fascinating
and entertaining publication and I commend it to you. Copies
are available from Sharon Tier at <strong>ACHS</strong> or via our website.
From time to time we receive requests to provide information
to state and territory governments as to the schedule of
planned accreditation surveys in the public sector for a
defined period.
The Board has determined a policy to cover such
instances. Information will be provided on a request basis.
The provision of this information is to respect our contractual
obligations regarding confidentiality and is to be confined to
the organisation’s name and membership number, the date
and nature of the survey, their current accreditation status
and its expiry date.
It is important that member organisations are aware of
this policy.
The <strong>ACHS</strong> is delighted to announce that we are now able
to offer a new program to Divisions of General Practice
across Australia. The program, Quality for Divisions
Network, is underpinned by a focus on continuous quality
improvement and incorporates standards, a full range of
support services and education. For further details, please
see the Products and Services column.
A very real example of the value of accreditation surfaced,
recently, when a major acute care provider was called to defend
an action in court. The organisation was able to demonstrate
a commitment to quality by long standing participation in
the <strong>ACHS</strong> accreditation program. Although the judgment went
against the organisation, the penalty imposed was a fraction of
the maximum with the concept of accreditation noted by the
judge in his summation.
The <strong>ACHS</strong> has been very conscious of certain anxieties arising
from organisations’ concerns as to the impact of mandatory
criteria on survey outcomes and therefore accreditation status.
Whilst it is early days the results of surveys conducted since
January this year generally look very promising; further details
are provided elsewhere in the newsletter.
I look forward to making contact with as many member
organisations as possible during the course of this year.
Products and services
Quality for the Divisions Network
The <strong>ACHS</strong> has developed a new quality improvement and
accreditation program for the Divisions of General Practice,
State-based organisations and the <strong>Australian</strong> Divisions of
General Practice. The Divisions Network Program has been
tailored to meet organisational responsibilities established to
support on-going professional development of General
Practitioners and their practices. It incorporates standards,
a full range of support services and education. The 2003
review, The Future Role of the Divisions Network, auspiced by
the Commonwealth Department of Health and Ageing, made
a strong case for the Divisions to focus on continuous quality
improvement through a recognised accreditation program.
Accreditation is evolving as a Commonwealth requirement
for all divisions. There are currently 123 divisions of general
practice nationally, as well as eight State-based organisations
and a national organisation. The Department has approved
three providers but the <strong>ACHS</strong> is the only one with a
program developed in consultation with representatives of
the Divisions and AGPAL (<strong>Australian</strong> General Practitioners
Accreditation Ltd). Modelled on the <strong>ACHS</strong> Evaluation and
Quality Improvement Program (EQuIP), the first function is
Program Delivery, with a focus on the special activities of
the Divisions. For more information please contact Heather
McDonald on (02) 9281 9955.
Coordinator workshops
The requirement for organisations to demonstrate evidence
based performance especially in respect of mandatory criteria
within the EQuIP survey process to achieve full accreditation
from January 2005, may put some organisations at risk. Failure
to maintain accreditation status can have major implications
for health organisations, including the loss of funding in
the private sector. Also, the impact of provision of an SA
rating or below on mandatory criteria, and subsequent failure
to achieve accreditation places considerable pressure on
survey teams. The <strong>ACHS</strong> now offers a one-day workshop
to enhance the development of skills enabling trained
co-ordinators to manage, in particular, division over provision
of an MA rating, and the consequences of failing to achieve
full accreditation status. Member organisations wishing
to participate are invited to contact Heather McDonald on
(02) 9281 9955.
New national report
Production of The <strong>ACHS</strong> National Report on Accreditation has
been approved by the Board and is currently in progress.
Publication is planned for June this year and consideration
is being given to the frequency of future editions. The report
is intended to be of value to consumers and will provide
high level strategic advice to health professionals concerned
with policy determination, organisational performance and
the delivery of care. This is the first time an organisation
has collected and collated evidence on the value of
accreditation specific to health care in Australia on a national
basis, and we will publish the resulting report in hard copy
and electronic format.
Brian Johnston
Chief Executive
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<strong>ACHS</strong> <strong>NEWS</strong> Issue 14 – Autumn 2005 • PAGE 3
Improvement to electronic reporting tools adds value
Recently the <strong>ACHS</strong> released two electronic tools; the Performance Indicator Reporting Tool (PIRT), which replaces the
Comparative Results Booklet (CRB), and the latest version of the Electronic Assessment Tool v3.5 (EAT). Both of these new
tools address many of the issues previously raised by member organisations. They are intended to make the collection of
information easier as well as incorporating other new features.
Both products have been supported by a program of free workshops; for details refer to the last paragraph.
An important new dimension is the provision for the collection of information in relation to sentinel event.
Electronic Tools
PIRT provides facilities for multi-users to collect and submit their indicator data. In addition, it incorporates the most recently
published national aggregated data and allows member organisations to generate a series of graphical reports for immediate
local use. As national trends usually only change slowly, using this information and report generating features can be of great
assistance in disseminating information to support the timely review of an organisation’s performance in any selected clinical
area against a specific indicator.
Future enhancements planned include the development of a set of more broadly based, non-clinical performance indicators
relevant to <strong>ACHS</strong> standards and criteria.
The changes in EAT are to the reporting function and a number enhancements requested by users. These changes include:
• A planning tool to be used for conducting a ‘gap analysis’ against the criteria and elements;
• A template for the preparation of the accreditation performance statement introduced last year to support increased
public disclosure of performance information;
• Improvements in the functions that support the printing of reports; and
• An improved ‘help’ file.
Sentinel Events.
The <strong>Australian</strong> <strong>Council</strong> for Safety and Quality in Health Care (ACSQHC) have published an agreed list of eight core sentinel
events. The <strong>Council</strong> defines sentinel events as “events in which death or serious harm to a patient has occurred”. It also
states such events signal catastrophic system failure and have the potential to seriously undermine public confidence in the
health care system. Sentinel events are a type of adverse event, or patient safety incident, that occur infrequently, but with
alarming consequences.
The wide ranging discussion as to the appropriateness of the ACSQHC’s list is acknowledged, but the consistent message
to <strong>ACHS</strong> has been that information does need to be collected and there are valuable lessons to be learned from developing a
national perspective.
As an independent organisation <strong>ACHS</strong> can play an important role in generating information in this area. We are seeking the
support of health care organisations in reporting only three aspects of sentinel events:
1. the number, if any, of sentinel events within each of the ACSQHC categories that have occurred during the reporting
period;
2. the number of events that underwent a root cause analysis (RCA) review process; and
3. whether practice changed as a result of the RCA; a yes/no answer only is requested.
Although there are a number of initiatives by states and territories to collect and report on sentinel events, for example
Victoria and New South Wales, this is the first attempt at a national collection program. Importantly, it will include the
private sector.
Initially, it is intended to report total numbers only. No reports will be generated for individual organisations from this
information at this stage, however, national aggregated data will be published, ensuring anonymity of sources and the
maintenance of confidentiality. Participation from as many organisations as possible can only improve the usefulness of the data
collected.
Comment on the list of sentinel events published by the <strong>Australian</strong> <strong>Council</strong> for Safety and Quality in Health Care would be
welcomed as would feedback on how the national collection program can progress. <strong>ACHS</strong> is also interested in receiving
comments on the merits of reporting information on the causes and strategies identified through any root cause analysis
conducted. The goal is to examine the feasibility and implications of developing a national de-identified database on the types
of sentinel events occurring and the lessons learned from root cause analysis processes.
For those events that do not fit in any of the eight core categories, an ‘other’ category has been provided together with a
text box for a brief description of the event, for example, consumption of a toxic substance which resulted in critical internal
damage, which may be reported as poisoning.
Instructions for submitting information are contained within the PIRT program.
The program of free workshops is currently being offered aimed at providing members with an overview of the recently
released Performance Indicator Reporting Tool (PIRT) and the latest version of the Electronic Assessment Tool v3.5 (EAT). The
highly successful workshops are being conducted in a number of locations including both capital cities and regional centres.
They have already been held in all States with the exception of Queensland and South Australia, where they will be provided
in March.
Please contact Kay Richards, Team Leader, Performance and Outcomes Service, on (02) 9281 9955 if you would be
interested in attending.
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<strong>ACHS</strong> news in brief
<strong>ACHS</strong> <strong>NEWS</strong> Issue 14 – Autumn 2005 • PAGE 4
<strong>ACHS</strong> News reaches
Federal, State and
Territory health ministers,
<strong>ACHS</strong> surveyors,
accredited <strong>ACHS</strong> member
organisations and other
stakeholders including
consumers and carers.
We value readers'
comments on issues and
items contained in this
publication – in
writing please, to:
The Editor,
<strong>ACHS</strong> News, <strong>ACHS</strong>,
5 Macarthur Street,
Ultimo, NSW 2007
Australia
or via email at
achs@achs.org.au
<strong>ACHS</strong>
<strong>ACHS</strong> Quality Improvement Awards 2005
Looking forward, we are pleased to announce the three categories for consideration in
preparing for the <strong>ACHS</strong> Quality Improvement Awards 2005.
The building blocks of quality clinical care. This category will look at projects and
programs that demonstrate improvements in the basic requirements of an organisation’s
capacity to provide high quality care. These include, but are not restricted to: documentation,
delineation of clinical privileges, safe work hours, clinical hand-overs, the use of data for
improvement, consumer focus and participation, teamwork and process re-engineering.
The appropriateness of healthcare. This category will look at projects and programs
that review whether the right care or service is being provided. Such projects and programs
will examine issues such as over-use and under-use of services and interventions eg surgical
utilisation rates, admission rates.
Non-clinical service delivery. This category will look at programs relating to
administrative processes and general customer service, for example, housekeeping,
HR management, engineering, info management, equipment, waste, catering. Note projects
which do not fit into the other categories should be submitted for the non-clinical service
delivery award.
The guidelines for submission, together with the application form have been distributed
to EQuIP Members, councillors and surveyors. Submission of applications will be take place
electronically this year. Please visit the <strong>ACHS</strong> website www.achs.org.au for further details.
PIRT/EAT workshops
Complimentary workshops aimed at
providing members with an overview
of the recently released Performance
Indicator Reporting Tool (PIRT) and the
Electronic Assessment Tool v3.5 (EAT) have
been held in all States with the exception of
Queensland and South Australia. The
workshops for the latter two States will be
conducted in March.
PIRT provides facilities for multi-users to
collect and submit their indicator data. In
addition, it allows importation of national
aggregated data and provides graphical
reporting. Future enhancements planned
include the development of a set of
performance indicators.
The changes in EAT are to the reporting
function and a number of enhancements
requested by users.
Clinician’s Guide
Such has been the demand for additional
copies of The <strong>ACHS</strong> Evaluation and
Quality Improvement Program (EQuIP) –
The Clinician’s Guide (10,000 have been
distributed so far) that we have had to go
into a second print run. Further copies are
now available, free of charge. Orders can
be placed with Sharon Tier via email at
stier@achs.org.au or call (02) 8218 2761.
Feedback, especially from clinicians, would
be most welcome and will greatly influence
any changes to be incorporated into the
second and subsequent editions. Comments
should be forwarded to Margaret Jackson at
mjackson@achs.org.au
Middle East market
In collaboration with Quality Healthcare
Australia (QHA), the <strong>ACHS</strong> participated in
the Arab Health exhibition held in Dubai in
February 2005.
The <strong>ACHS</strong> was represented by Dr “Taffy”
Jones who has identified the potential for the
<strong>ACHS</strong> to launch an international accreditation
program in the Middle East.
The exhibition has generated a number
of enquiries from organisations in the United
Emirates. The <strong>ACHS</strong> and QHA are following
up on these enquiries.
Review team candidates
The <strong>ACHS</strong> is preparing for its own
accreditation review conducted by the
International Society for Quality in Health
(ISQua) in late May 2005.
The <strong>ACHS</strong> is calling for expressions
of interest from surveyors to be part of
the assessment team. The requirement
will be for three days in Sydney from
25 May 2005. Details from Heather
McDonald, Executive Manager Customer
Service at hmcdonald@achs.org.au or call
02 9281 9955.
Surveys in 2005.
The year has commenced slowly with
no accreditation surveys in January
2005. February has also been slow with
only 15 organisations having a survey.
The anxiety around reaching the required
level within the Mandatory Criteria has
been high, so it is reassuring to see that
many of the organisations that have been
surveyed are pleased with the outcome of
their reviews.
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safety, quality, performance