ACHS News - Issue 40 - Autumn - Australian Council on Healthcare ...

The <strong>Australian</strong> <strong>Council</strong> on Healthcare Standards
<strong>ACHS</strong>NEWS
The official newsletter from <strong>ACHS</strong> to communicate to all member organisations and our stakeholders No. <strong>40</strong> <strong>Autumn</strong> 2012
ADDRESSING YOUR
ACCREDITATION
ASSESSMENT NEEDS
Welcome to <strong>Autumn</strong>, which so far isn’t feeling any different
from our Summer. For those of us in the Eastern states a
little less rain would be most welcome! We sincerely hope
no-one has suffered a catastrophic loss and those affected
are re-establishing themselves.
At <strong>ACHS</strong> we have been busy ensuring that all current and
potential member organisations have a full range of
options for accreditation available. Our product range has
been revised and our procedures streamlined. We are
ready to meet your accreditation service requirements.
The range of products now extends to:
EQuIP5
National Standards only
EQuIPNational which includes the National
Standards as well as the extension components
contained in EQuIP and not covered by the National
Standards; and
EQuIP5 Day Procedure Centres
EQuIP5 Corporate Health Services.
EQuIPNational has been designed to take the external,
independent assessment of your organisation’s
performance well beyond compliance.
We can advise you as to the product that best suits your
needs and there will be more exciting developments
released in the months ahead.
<strong>ACHS</strong> is also able to respond on your behalf to any
reporting requirements if your organisation will be
assessed against the National Standards. The exact
nature of those requirements is still being finalised, but our
electronic systems are structured to respond to any thirdparty
requirements. One requirement for being authorised
to undertake assessments against the National Standards
is to provide data to the <strong>Australian</strong> Commission on Safety
and Quality in Health Care.
Those requirements may extend in the future to all
jurisdictions, the newly established National Health
Performance Authority and the <strong>Australian</strong> Institute for
Health and Welfare.
St John of God Murdoch Hospital celebrated its 18 th birthday with a
certificate presentation recognising the hospital’s recent accreditation by
<strong>ACHS</strong>. On hand to present the certificate was CEO Brian Johnston
(centre).
From left to right: St John of God Health Care Group CEO Dr Michael
Stanford, Murdoch Quality and Risk Management Vanessa Unwin, and
on the right hand side, Murdoch CEO Peter Mott with Murdoch Quality
Manager Rita McIlduff.
We appreciate that there is a degree of frustration being expressed by
some that not all details of the requirements for those undergoing
surveys to the National Standards are known. The Commission’s staff
members are working to resolve those outstanding matters, and they are
consulting with the authorised accreditation agencies as part of this
process.
Meanwhile, Laurie Leigh and our Customer Service Managers have
been busy conducting a highly successful round of well-attended
education sessions focusing on EQuIPNational. These sessions have
included discussions on the National Standards. We have answered
those questions that we could and undertaken to provide information
once received from the Commission.
The good news is that from the initial sample of assessments against the
National Standards, more than 90% of the measures have been
achieved, so the stretch to fully comply is well within the reach of most, if
not all. Due to the very small sample size this is not statistically
significant, however more comprehensive information about performance
results will progressively be made available by us over the coming
months. <strong>ACHS</strong> will continue to offer these gap analyses free to all
members for the remainder of this year.
We look forward to continuing to work with you.
Brian Johnston
Chief Executive
CALL FOR ABSTRACTS CLOSE C.O.B. 30 APRIL 2012

ISQua Accreditation for EQuIP5 Day
Procedure Centres Standards
<strong>ACHS</strong> continues to demonstrate its commitment to accreditation at an
international level – with its own EQuIP5 Day Procedure Centres Standards now formally accredited by the
International Society for Quality in Health Care (ISQua). The endorsement in February 2012 by ISQua recognises
the strengths of the standards program as an important tool all <strong>Australian</strong> day procedure centres can utilise to
ensure their delivery of care is at the highest possible level. “The Day Procedures Centres Standards have been
developed to meet the needs of this important healthcare sector, and we are justifiably proud of this recognition from
ISQua,” said Linda O’Connor, Executive Director of Development. The accreditation of EQuIP Day Procedure
Centres is valid from February 2012 until January 2016.
National Conference Date Announced
The <strong>ACHS</strong>, along with its collaborators – the <strong>Australian</strong> Healthcare and Hospitals Association (AHHA) and the
Women’s Hospital and Children’s Hospitals Australasia – have announced the date for their national conference this
year. The conference will be held on Monday 24 September, concluding on Wednesday 26 September. The
Quantum Leap: Measurement: redefining health’s boundaries? will be this year’s theme. Put the dates in your
diary now. Register your interest at: admin@thequantumleap.com.au.
Farewell to a Loyal <strong>ACHS</strong> Supporter
A former <strong>ACHS</strong> Medal winner, and a long-time supporter of the <strong>ACHS</strong>, Dr John
Greenwell, passed away on 6 January.
Dr Greenwell made an important contribution to <strong>ACHS</strong> in its formative foundation years, and
will be remembered by many who worked in the public hospital sector in NSW for both his
wisdom and the friendship he extended to many. His interest in and involvement in health
industry matters was regarded as impressive by many, and his calm demeanour reassuring.
Appointed as the Medical Superintendent of the Royal Hospital for Women in 1951, he had a
long association with the hospital, subsequently becoming its General Medical
Superintendent in 1963.
Dr John Greenwell
Among his many career highlights, a notable one was establishing the Royal’s Birth Centre in 1983 as the premier alternative
birthing unit in NSW. Altogether, his contributions to health care spanned 41 years.
He was a <strong>Council</strong>lor to the <strong>ACHS</strong> representing the <strong>Australian</strong> College of Obstetricians and Gynaecologists for many years, at
one time the longest serving director of the <strong>Council</strong>, as well as serving the Standards Committee for many years. From
September 1990 until November 1991 he served as <strong>ACHS</strong> Vice President. Dr Greenwell is survived by his children Lisa
Greenwell and Robert Greenwell and grandchildren Jonathon, Jocelyn and Charles.
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There is continued interest in the introduction of the upcoming NSQHS standards
<strong>ACHS</strong> recently invited members to comment on the newly drafted EQuIPNational
Standards, as well as conducting free workshop sessions for members around Australia
throughout February 2012.
Here we explain what the new EQuIPNational Standards mean to our members.
Why were the National Safety and
Quality Health Service (NSQHS)
Standards Developed?
The <strong>Australian</strong> Commission on Safety and Quality
in Health Care (the Commission) commenced on
1 January 2006. The Commission was established
by the <strong>Australian</strong>, State and Territory Governments
to develop a national strategic framework and
associated work program to guide its efforts in
improving safety and quality across the healthcare
system in Australia.
In September 2011, <strong>Australian</strong> Health Ministers
endorsed a set of National Safety and Quality
Health Service (NSQHS) Standards. The NSQHS
Standards were developed by the Commission to
“provide a nationally consistent and uniform set of
measures of safety and quality for application
across a variety of health services”. In addition,
Health Ministers and regulators will receive
information on the results of accreditation of health
services to enable them to determine whether there
are systems in place to assure minimum standards
of safety and quality.
Following the planned full implementation in
January 2013, accreditation data from assessment
against the NSQHS Standards in all <strong>Australian</strong>
hospitals and day procedure services will be
provided to regulators and to the Commission for
reporting and review. Currently, the feedback and
results from accreditation are generally shared
between the health service and the accrediting
agency only.
Why has <strong>ACHS</strong> developed
EQuIPNational?
The content of the ten NSQHS Standards mirror
some of the components of <strong>ACHS</strong>’ established
EQuIP5 product. However, to allow members to
retain the organisation-wide evaluation and quality
improvement program that is EQuIP, without
duplication of assessment to the NSQHS
Standards, <strong>ACHS</strong> offers EQuIPNational to all its
members.
EQuIPNational will be presented in the same
format as the NSQHS Standards, to provide a
seamless product for organisations that want to
retain an organisation-wide perspective on their
health service. The program consists of the ten
NSQHS Standards, then provides a further five
Standards that focus on the performance of nonclinical
systems. They are designed for healthcare
organisations which would like to retain the robust,
comprehensive organisational approach that <strong>ACHS</strong>
products have historically had, and to complement
the ‘patient safety’ approach of the NSQHS
Standards. To assist in the seamless integration of
the NSQHS Standards and EQuIP, the rating scale
of EQuIPNational will also be aligned to the
NSQHS Standards.
<strong>ACHS</strong> currently offers member organisations a gap
analysis against the NSQHS Standards during their
EQuIP5 survey.
After the implementation of the NSQHS Standards
in January 2013, organisations can choose to be
assessed against either the NSQHS Standards
only, or to continue to benefit from the overall focus
on improvement across the organisation that
EQuIPNational will deliver.
Copies of the NSQHS Standards are available on the Commission’s website:
www.safetyandquality.gov.au
A draft copy of EQuIPNational is available to view on the <strong>ACHS</strong> website:
www.achs.org.au
For further information on EQuIPNational or the NSQHS Standards,
please contact your dedicated CSM at <strong>ACHS</strong> on (02) 9281 9955
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Research into Accreditation Programs
Strengthening organisational performance through accreditation research:
THE ACCREDIT PROJECT
<strong>ACHS</strong> continues to play a key research and
educational role in the field of accreditation.
Notably, the <strong>ACHS</strong> is a collaborator in the
Accreditation Collaborative for the Conduct of
Research, Evaluation and Designated
Investigations through Teamwork (ACCREDIT)
project. The ACCREDIT project partners include
<strong>Australian</strong> General Practice Accreditation
Limited, the Aged Care and Standards
Accreditation Agency, the <strong>Australian</strong>
Commission on Safety and Quality in Health
Care, and the New South Wales Clinical
Excellence Commission and Professors
Braithwaite and Westbrook and colleagues at
the University of New South Wales (UNSW).
Together, we are partners in an <strong>Australian</strong>
Research <strong>Council</strong> Linkage Grant. The
collaboration, across 2011 to 2015, is
implementing a multi-method, triangulated series
of studies to evaluate current accreditation
processes – see Figure 1.
WHY RESEARCH INTO
ACCREDITATION?
There is evidence that accreditation programs
can promote change and the standardisation of
services and organisational processes, including
how decisions about care are made. However,
Figure 1: Research strategy and studies
the research literature is either inconsistent or
does not support the contentions. Hence this project plans to produce results which will link with other similar studies
underway in Europe.
The ACCREDIT project builds upon research previously conducted by <strong>ACHS</strong> and Professors Braithwaite and Westbrook
and colleagues, who previously carried out four studies into accreditation between 2005 and 2008.
As the ACCREDIT project is implemented and results are produced, findings will be made available via the <strong>ACHS</strong> and
UNSW websites, and at national seminars and conferences. Questions and inquiries about the project can be directed to
<strong>ACHS</strong> executives or UNSW staff - Dr David Greenfield, who leads the research team (d.greenfield@unsw.edu.au), Dr Max
Moldovan (m.moldovan@unsw.edu.au) or Dr Reece Hinchcliff (r.hinchcliff@unsw.edu.au).
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National Report on Accreditation Released
<strong>ACHS</strong> has released the 4 th
biennial <strong>ACHS</strong> National Report
on Health Services
Accreditation Performance, for
the years 2009 – 2010.
The Report contains
aggregate information from
509 accreditation surveys of
<strong>Australian</strong> healthcare
organisations between 2009 –
2010, assessing their
combined performance and
emerging trends.
The healthcare organisations
participating in this survey are members of the <strong>ACHS</strong>
Evaluation and Quality Improvement Program (EQuIP) and
include hospitals, day hospitals, clinics, community and mental
health services.
<strong>ACHS</strong> President, Adjunct Associate Professor Karen Linegar,
said “The overall data suggest an ongoing consistent level of
improvement by organisations building on previous years’
efforts, across the spectrum of health care. There are some
positive trends throughout the Report and these developments
may have been supported by increased familiarity with the
EQuIP 4 Standards.”
Highlights include survey trends indicating four areas of marked
improvement in performance compared to the previous survey
period, namely:
- the rate of Advanced Completion in 60 day surveys
(AC60s) decreasing by 21%,
- the rate of High Priority Recommendations (HPRs)
decreasing by 23%,
- a 27% increase in the awarding of Extensive Achievement
(EA) ratings, and
- a 25% increase in the awarding of Outstanding
Achievement (OA) ratings.
Key areas identified as needing further improvement included:
- Emergency and disaster management systems,
- Organisation-wide risk management policies and systems,
- Processes for credentialling clinicians, and
- Infection control systems.
It is of note that six of the seven areas requiring further
improvement are classified as non-clinical.
The purpose of the Report is to establish broad national
comparisons for accreditation performance, to assist healthcare
organisations evaluate their own performance against the
aggregate.
“The Report includes information on the majority of healthcare
organisations in Australia and has three themed commentaries
(on infection control, credentialling and organisational systems)
as well as a report on accreditation performance research and
detailed summaries by criterion of organisations which attained
Outstanding Achievement (OA) ratings,” Adjunct Associate
Professor Linegar said.
For copies of the Report, access the website or contact Ian
McManus at imcmanus@achs.org.au for a print copy.
CLINICAL INDICATOR PROGRAM Update March 2012
Second Half 2011 Data Collection
Data for the first half of the 2011 collection was submitted on 20 February 2012. Comparative reports will be available
for all participating organisations in early April 2012. These can be sent directly to your email inbox by logging into
PIRT and selecting ‘Reports, General and Peer Comparison Reports’.
Working Party Activity
The Paediatric working party met at <strong>ACHS</strong>’s office on 16 February 2012. The working party consisted of 23 members
who represented the majority of States and Territories in Australia, including both regional and metropolitan areas.
Members reviewed the existing clinical indicators from the Paediatric, ICU and Surgical sets, and discussed a number
of potential new paediatric clinical indicators. The new Paediatric clinical indicator set is expected to be released in
2013.
A new set of clinical indicators for Domiciliary / Community nursing is to be added to the existing 22 indicator sets, with
a newly formed working party meeting in May 2012. The Infection Control clinical indicators are due to be reviewed and
the working party is scheduled to meet in June 2012.
Education
The Measurement in Health Care: How to Maximise the Benefits of Clinical Indicators workshops continue to be well
attended. Remaining scheduled workshops for 2012 include Melbourne (Thursday 3 May) and Sydney (Thursday 10
May). Customised workshops for individual healthcare organisations / districts / clusters / networks are also available.
Australasian Clinical Indicator Report 2004 - 2011
This annual publication is currently being compiled, and will be officially launched at the <strong>ACHS</strong> Conference The
Quantum Leap in September 2012. This 13 th edition will provide valuable analysis on the 350 indicators available
across 22 clinical streams.
Closing Date 20 July 2012
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Changes in EAT5 for
Self-Assessment (SASS)
FOR ORGANISATION MEMBERS
Organisations can now upload a copy of their risk register before survey submission. Please note
the following in relation to this new feature:
The file must be in a PDF file format
The file size must be no larger than 20mb
You will not be able to submit your SASS if you have not attached your Risk Register
Attaching your risk register is very simple. Please follow the instructions outlined below:
1. In your “In Progress” SASS Review phase, click on the menu item “Upload / View Risk
Register”
2. Click “Browse” to go to the file path of a PDF document
3. When you have located and opened the file, click “Save” in EAT
4. A link should then be available to access the file with the option to delete so that a different
file can be uploaded if so desired. Check that the file can be accessed from the link.
FOR SELF-ASSESSMENT READERS
Organisations will now upload a copy of their risk register as part of the submission for SASS
Review phases.
To view the Risk Register that the organisation has uploaded, please follow the instructions outlined
below:
1. Click on the left hand navigation menu item “Upload / View Risk Register”
2. Click on the file link provided.
A new feature called “SASS Summary” has been added to EAT5 SASS Review phases. In this
section SASS Readers should enter general comments regarding the organisation’s Member Details
section, which covers the organisation’s background information. This new section replaces the
need to enter feedback for SASS Review Phases into the Function Summary as previously advised.
If you have any questions regarding these new features or any other EAT related enquiries, please
do not hesitate to contact EAT support staff eat@achs.org.au or via AHCS Reception on
02 9281 9955.
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ISQua Geneva Conference
The annual ISQua Conference will be held in
Geneva in October 2012. More than 50 speakers
from 20 countries have already been confirmed,
and hundreds of papers have been submitted as
abstracts. The <strong>ACHS</strong> will wait to hear whether
their abstracts have been successful. Information
about attending the conference can be found at www.isqua.org
<strong>ACHS</strong> Surveyor Ms Manbo Man, who is the Director of Nursing Services at Hong Kong Sanatorium and
Hospital, was awarded the Medal of Honour by the Hong Kong SAR Government for her valuable
contribution to the regulatory work of Chinese medicine practitioners. The presentation ceremony was held
on 29 October 2011 at Government House in Hong Kong.
Manbo has been a member of the Chinese Medicine Practitioners Board and the Chinese Medicine <strong>Council</strong>
for six years and was the Chairman of the committee on assessment for the Chinese Medicine Degree
Course for Hong Kong and Mainland China.
Ms Manbo Man
Kowloon East Cluster Team
visit <strong>ACHS</strong>
<strong>ACHS</strong> welcomed a new delegation to its offices in a Leap Year.
On Wednesday 29 February 2012, a delegation from the Kowloon East Cluster, Hong Kong,
learnt firsthand about <strong>ACHS</strong> services and the <strong>Council</strong>’s knowledge of the <strong>Australian</strong>
healthcare industry as it met with staff in Ultimo.
Photo: K F Chung presents Brian Johnston from <strong>ACHS</strong> with a souvenir of thanks.
<strong>ACHS</strong> Education Update
Continued from Page 8
New in 2012:
Getting Started as a New Quality Manager
Presented by Cathy Balding, <strong>ACHS</strong> Surveyor. This program is
designed for newly appointed Quality Coordinators and
Managers and those considering moving into a quality
management role. This workshop will assist participants in
defining the key components of their role and understanding where
the role fits within their organisation and the broader quality
context. It will also help them to prepare for the challenges of the
role and to identify key quality and change tools.
http://www.achs.org.au/pdf/Getting_Started_as_a_New_Quality_M
anager.pdf
NEW INITIATIVE in 2012
<strong>ACHS</strong> now provides one discounted registration (cost = $120) to a
healthcare consumer on a ‘first come-first serve’ basis, in each full
day <strong>ACHS</strong> calendar workshop which runs from 1 January 2012
onwards. Click here for details:
Eligibility for Healthcare Consumer Space CLICK HERE to
access.
http://www.achs.org.au/pdf/Eligibility_for_Health_Care_Consumer_
Space.pdf
ONLINE LEARNING
Will soon be available to members to support the upcoming
introduction of the National Safety and Quality Health Service
Standards (NSQHSS). The eLearning will outline options for <strong>ACHS</strong>
members in organisations in which the standards will be
mandatory, and how this will fit with the EQuIP program. eLearning
is easy to access and user friendly. Once available, members will
be able to access from the link on the homepage of the <strong>ACHS</strong>
website.
eLearning for <strong>ACHS</strong> Members CLICK HERE to
access.
If you do not have a password, it is easy to go online and apply
via the <strong>ACHS</strong> website at: http://www.achs.org.au/memberregform
All the workshops are available as customised
on-site workshops in your own organisation.
<strong>ACHS</strong> also offers an on-site consultancy service.
Please do not hesitate to contact us if you
would like to find out more about these options.
<strong>ACHS</strong> Education Phone: +61 2 9281 9955
Email: Educate@achs.org.au
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<strong>ACHS</strong> Education Update
March 2012
The <strong>ACHS</strong> Education Workshop calendar for January to June 2012 is
available on the <strong>ACHS</strong> website at: http://www.achs.org.au/EduCalendarmonth/
UPDATE
EQuIP5 and the National Safety and Quality
Health Service Standards
Several short sessions have been held in February and March
2012 outlining the plans for the upcoming introduction of the
National Safety and Quality Health Service (NSQHS) Standards.
These sessions have outlined options for <strong>ACHS</strong> members in
organisations in which the Standards will be mandatory, and how
this will fit with the EQuIP program. The sessions have been well
attended and well received. To support the introduction of the
NSQHS Standards, several workshops are now running which
are designed to assist members in covering both the EQuIP5
and the NSQHS Standards. These include:
New in 2012:
Introduction to EQuIP and the National Safety and
Quality Health Service Standards
Presented by several experienced <strong>ACHS</strong> surveyors, this
workshop is designed to give participants understanding of the
EQuIP5 process, cycle, structure and ratings, including the 15
mandatory criteria. The workshop will cover how EQuIP
interfaces with the National Safety and Quality Health Service
Standards. It also allows participants to understand what is
needed in the summary of supportive evidence. The program is
suitable for all staff and volunteers in healthcare organisations,
Quality and Governance team members, health workers,
educators, project workers, consumer representatives, quality
coordinators and Board members.
http://www.achs.org.au/pdf/Introduction_to_EQuIP_National_Saf
ety_and_Quality_Health_Service_Standards_12A.pdf
New in 2012:
Prevention and Control of Healthcare Associated
Infection
Presented by David Gunderson, <strong>ACHS</strong> Surveyor.
This workshop is designed to give participants an
understanding of the intent and elements of the
new National Safety and Quality Health Service
Standard 3: Preventing and Controlling Healthcare Associated
Infections, together with the intent and additional elements of
EQuIP5 Criteria 1.5.2 / 1.3.2. This workshop is suitable for
anyone who is responsible for the prevention and control of
healthcare associated infection, including: Infection Control
Practitioners, Quality and Safety Managers, Day Procedure
Centre Managers.
http://www.achs.org.au/pdf/Prevention_and_Control_of_Healthc
are_Associated_Infection_12A.pdf
New in 2012:
Effective Clinical Handover
Presented by Karen Edwards, <strong>ACHS</strong> Surveyor.
Designed to give participants the skills to identify
the situations where clinical handover occurs and
understand the impact of handover on patient
safety. The workshop also covers the role of
leaders in improving handover and the relationship between
current evidence and good handover solutions, and the systems
needed to support clinical handover. The workshop is suitable
for Health Administrators, Directors of Allied Health, Directors of
Nursing, Nursing Administrators, Quality and Safety Managers,
Quality Managers, Clinical Managers, Clinical Unit / Department
Heads.
http://www.achs.org.au/pdf/Effective_Clinical_Handover_12A.pdf
Back by popular demand:
Medication Safety Mandated (Melbourne)
Several pharmacists present medication safety strategies,
including ‘Medication Safety is Everybody’s Business’. This
workshop is designed to EQuIP you with the tools you need to
improve medication safety in your organisation, and meet both
EQuIP5 and the NSQHS Standards. The program is suitable for
anyone who is responsible for medication safety and quality,
including: unit managers, senior nurses, nurse educators, quality
and safety managers, members of quality, medication safety and
drug committees, clinicians, pharmacists.
http://www.achs.org.au/pdf/Medication_safety_mandated_12A.pdf
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