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ACHS News - Australian Council on Healthcare Standards

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The <str<strong>on</strong>g>Australian</str<strong>on</strong>g> <str<strong>on</strong>g>Council</str<strong>on</strong>g><br />

<strong>on</strong> <strong>Healthcare</strong> <strong>Standards</strong><br />

C<strong>on</strong>tacts<br />

The <str<strong>on</strong>g>Australian</str<strong>on</strong>g> <str<strong>on</strong>g>Council</str<strong>on</strong>g> <strong>on</strong><br />

<strong>Healthcare</strong> <strong>Standards</strong><br />

5 Macarthur Street<br />

ULTIMO NSW 2007<br />

Australia<br />

Teleph<strong>on</strong>e 61 2 9281 9955<br />

Facsimile 61 2 9211 9633<br />

E-mail achs@achs.org.au<br />

Website http://www.achs.org.au<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> accreditati<strong>on</strong> is offered<br />

through its Evaluati<strong>on</strong> and<br />

Quality Improvement Program<br />

(EQuIP).<br />

safety, quality, performance<br />

In this issue…<br />

Awards h<strong>on</strong>our health care<br />

leaders<br />

EQuIP 4 Updates<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> annual report <strong>on</strong><br />

clinical indicator data<br />

Update: Nati<strong>on</strong>al Forum<br />

2008<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> <str<strong>on</strong>g>News</str<strong>on</strong>g><br />

The official newsletter of the <str<strong>on</strong>g>Australian</str<strong>on</strong>g> <str<strong>on</strong>g>Council</str<strong>on</strong>g> <strong>on</strong> <strong>Healthcare</strong> <strong>Standards</strong><br />

ACN 008 549 773 No 25. Summer 2007<br />

The Future is Taking Shape<br />

The year has ended with a number of<br />

important events taking place, not the<br />

least of which was the nati<strong>on</strong>al c<strong>on</strong>sultative<br />

workshop c<strong>on</strong>ducted by the <str<strong>on</strong>g>Australian</str<strong>on</strong>g><br />

Commissi<strong>on</strong> <strong>on</strong> Safety and Quality in<br />

Health Care (ACSQHC) held in Sydney <strong>on</strong><br />

30 November to discuss ‘the draft of the<br />

alternative model for safety and quality<br />

accreditati<strong>on</strong>’, but more <strong>on</strong> this shortly.<br />

November was a particularly important<br />

m<strong>on</strong>th for <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> with a meeting of the <str<strong>on</strong>g>Council</str<strong>on</strong>g>,<br />

the annual general meeting and annual dinner.<br />

Dr Michael Hodgs<strong>on</strong> AM was re-elected as<br />

President, Associate Professor Peter Woodruff<br />

was elected as Vice President and Mr John<br />

Smith was elected as Treasurer. Dr Noela<br />

Whitby AM did not seek reappointment as Vice<br />

President, a role which she performed with<br />

enthusiasm and great commitment for several<br />

years. She remains <strong>on</strong> the Board as a director.<br />

At the <str<strong>on</strong>g>Council</str<strong>on</strong>g> meeting two specific<br />

issues were the subject of discussi<strong>on</strong>. The first<br />

was the surveyor training and development<br />

program. The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> is in the process of<br />

seeking accreditati<strong>on</strong> for this program and<br />

councillors provided valuable input. The<br />

sec<strong>on</strong>d issue related to the relati<strong>on</strong>ship<br />

between indicators and accreditati<strong>on</strong>.<br />

While this may seem to be something of a<br />

perennial issue, its importance is increasing<br />

given the interest expressed by the incoming<br />

Federal government in performance<br />

measurement and some of the recent<br />

work being undertaken, under the<br />

sp<strong>on</strong>sorship of the ACSQHC.<br />

The annual dinner was a great success<br />

particularly the highly entertaining, but of<br />

course thoughtful and relevant after dinner<br />

speech by Professor Cliff Hughes with its<br />

central theme of the importance of working<br />

together. Professor Hughes is well known for<br />

his railway analogies, but <strong>on</strong> this occasi<strong>on</strong><br />

he took <strong>on</strong>e of his favourite topics to a new<br />

level of relevance and meaning.<br />

The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Medal was awarded to Professor<br />

William Rawlins<strong>on</strong> a distinguished virologist<br />

Wishing you a safe and<br />

happy holiday seas<strong>on</strong>…<br />

The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> offices will<br />

close from 1pm Friday<br />

21 December 2007<br />

and reopen Wednesday<br />

2 January 2008.<br />

Thank you for your<br />

c<strong>on</strong>tributi<strong>on</strong> and support throughout<br />

2007, we look forward to working with<br />

c<strong>on</strong>sumers, our members, surveyors,<br />

and other colleagues and stakeholders<br />

in 2008.<br />

from the Prince of Wales Hospital in Sydney.<br />

A feature <strong>on</strong> his very significant achievements<br />

appears elsewhere in this newsletter,<br />

al<strong>on</strong>g with details of winners of the quality<br />

improvement awards. The awards attracted<br />

a record 106 entries making it the largest<br />

nati<strong>on</strong>al award of its type.<br />

To mark 20 years of sp<strong>on</strong>sorship of<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g>, Baxter <strong>Healthcare</strong> provided a special<br />

award for service to quality in the <str<strong>on</strong>g>Australian</str<strong>on</strong>g><br />

health care system. The judging process<br />

resulted in this award being given to<br />

Ms. Christine Gee, Nati<strong>on</strong>al President of<br />

the <str<strong>on</strong>g>Australian</str<strong>on</strong>g> Private Hospitals Associati<strong>on</strong>.<br />

Dr. J<strong>on</strong> Mulligan, the previous President<br />

of <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> was recognised as a life member <strong>on</strong><br />

<str<strong>on</strong>g>Council</str<strong>on</strong>g>. This was a fitting tribute to J<strong>on</strong> who<br />

has made a major c<strong>on</strong>tributi<strong>on</strong> not <strong>on</strong>ly to<br />

our organisati<strong>on</strong>, but across many parts of<br />

the health industry.<br />

The evening included recogniti<strong>on</strong> of a<br />

number of <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> staff whose c<strong>on</strong>tributi<strong>on</strong>s<br />

help to make us what we are. Dr Marjorie<br />

Pawsey and Mr Brian Lewis have both recently<br />

retired from <str<strong>on</strong>g>ACHS</str<strong>on</strong>g>. They have been an<br />

important part of the public image and played<br />

significant roles in defining the organisati<strong>on</strong>.<br />

L<strong>on</strong>g serving staff members were also<br />

recognised. Mrs Margaret Jacks<strong>on</strong>, Ms Julie


Ings and Mrs Bernice Barbouttis have each given more than<br />

twenty years of invaluable service.<br />

The recent Commissi<strong>on</strong>’s nati<strong>on</strong>al workshop drew more<br />

than 150 participants. It discussed both the report to the<br />

Commissi<strong>on</strong> <strong>on</strong> the recent c<strong>on</strong>sultati<strong>on</strong> process and the<br />

document entitled “An Alternative Model for Safety and<br />

Quality Accreditati<strong>on</strong> – Draft”. The day took the form of three<br />

workshop sessi<strong>on</strong>s, the first two of which c<strong>on</strong>sidered:<br />

• Guiding principles for the alternative model<br />

• Accreditati<strong>on</strong> – minimising the risk of major systems failure<br />

The third sessi<strong>on</strong> was divided into four subject areas<br />

c<strong>on</strong>sidered by four clusters:<br />

• Achieving the outcomes – enforcement<br />

• Addressing the needs of c<strong>on</strong>sumers<br />

• Quality Improvement Framework<br />

• Expanded scope of accreditati<strong>on</strong>.<br />

Implicit in each of the topics was acceptance of the<br />

proposed alternative model and the discussi<strong>on</strong>s focused more<br />

<strong>on</strong> the implementati<strong>on</strong> and operati<strong>on</strong>al c<strong>on</strong>siderati<strong>on</strong>s. This<br />

approach appeared to have the tacit support of those present.<br />

My view is that as our program, EQuIP, has evolved it<br />

has a str<strong>on</strong>g alignment with the Commissi<strong>on</strong>’s proposed<br />

directi<strong>on</strong>s, although further adaptati<strong>on</strong> may well be required.<br />

The Commissi<strong>on</strong> is committed to proposing a regulatory<br />

model, but interestingly there is uncertainty as to the level at<br />

which legislated regulati<strong>on</strong> will be applied. Bey<strong>on</strong>d requiring<br />

participati<strong>on</strong>, self regulati<strong>on</strong> has substantial support within<br />

the industry. It is believed that accreditati<strong>on</strong> will become a<br />

mandatory requirement for health service providers.<br />

The next step is for the Commissi<strong>on</strong> to finalise its proposal<br />

for c<strong>on</strong>siderati<strong>on</strong> by <str<strong>on</strong>g>Australian</str<strong>on</strong>g> Health Ministers early next year.<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> ANNUAL GENERAL MEETING<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> has a new Vice President with the electi<strong>on</strong> of Professor<br />

Peter Woodruff at the recent annual general meeting. Professor<br />

Woodruff is the Director of Vascular Surgery at the Princess<br />

Alexandra Hospital in Queensland and represents the Royal<br />

Australasian College of Surge<strong>on</strong>s <strong>on</strong> the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> <str<strong>on</strong>g>Council</str<strong>on</strong>g>. Most<br />

recently he served as the Treasurer for the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Board.<br />

Mr John Smith, Chief Executive of West Wimmera Health<br />

Service, who represents the <str<strong>on</strong>g>Australian</str<strong>on</strong>g> <strong>Healthcare</strong> and Hospitals<br />

Associati<strong>on</strong> <strong>on</strong> <str<strong>on</strong>g>Council</str<strong>on</strong>g>, was elected as the new Treasurer.<br />

Dr Michael Hodgs<strong>on</strong> AM was re-elected as the President. Dr<br />

Hodgs<strong>on</strong> is a representative of the <str<strong>on</strong>g>Australian</str<strong>on</strong>g> Medical Associati<strong>on</strong><br />

<strong>on</strong> the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> <str<strong>on</strong>g>Council</str<strong>on</strong>g> and has been a Board Member since 1999.<br />

Dr Noela Whitby AM, Chair of <str<strong>on</strong>g>Australian</str<strong>on</strong>g> General Practice<br />

Accreditati<strong>on</strong> Limited (AGPAL), who represents the Royal<br />

<str<strong>on</strong>g>Australian</str<strong>on</strong>g> College of General Practiti<strong>on</strong>ers <strong>on</strong> the <str<strong>on</strong>g>Council</str<strong>on</strong>g>,<br />

stepped down from the role as Vice President and remains <strong>on</strong><br />

the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Board.<br />

The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Board and <str<strong>on</strong>g>Council</str<strong>on</strong>g> are made up of representatives<br />

of stakeholder groups from within the health industry, including:<br />

medical colleges and associati<strong>on</strong>s; allied health professi<strong>on</strong>al<br />

colleges; State and Territory health authorities and a peak<br />

c<strong>on</strong>sumer representati<strong>on</strong> body.<br />

The electi<strong>on</strong> of the new <str<strong>on</strong>g>Australian</str<strong>on</strong>g> Government comes at a<br />

time when many in the health industry and the wider community<br />

see the need for substantial changes and a redefining of the<br />

health systems priorities and directi<strong>on</strong>. Whilst health issues did not<br />

dominate the electi<strong>on</strong> campaign funding, workforce, changing<br />

patterns of disease, dental health, chr<strong>on</strong>ic illness, mental health,<br />

populati<strong>on</strong> health, performance measurement and public<br />

engagement all came into focus. Quality is a theme that will run<br />

through all of these issues. They will influence the future evoluti<strong>on</strong><br />

of standards and performance assessment activities and <str<strong>on</strong>g>ACHS</str<strong>on</strong>g><br />

welcomes the opportunity to work with the industry in these areas.<br />

Finally, planning is well advanced for the Nati<strong>on</strong>al Forum<br />

<strong>on</strong> Safety and Quality in Health Care to be held in Adelaide,<br />

28 – 31 October, 2008. We are delighted that Professor Martin<br />

Marshall, now with the Health Foundati<strong>on</strong> in England, will be<br />

<strong>on</strong>e of the internati<strong>on</strong>al speakers. He has been at the leading<br />

edge of research and policy formulati<strong>on</strong> in the important areas<br />

of public reporting of performance informati<strong>on</strong> and clinical<br />

leadership. His c<strong>on</strong>tributi<strong>on</strong> al<strong>on</strong>e will ensure the c<strong>on</strong>ference<br />

reaches the highest standard.<br />

I trust all of us have a w<strong>on</strong>derful Christmas and a very<br />

safe and happy holiday seas<strong>on</strong>. I look forward very much to<br />

c<strong>on</strong>tinuing to work with you in 2008. With best wishes <strong>on</strong><br />

behalf of the Board, <str<strong>on</strong>g>Council</str<strong>on</strong>g> and Staff.<br />

Brian Johnst<strong>on</strong><br />

Chief Executive<br />

EQuIP 4 Update<br />

The purpose of this update is to provide additi<strong>on</strong>al informati<strong>on</strong><br />

which has now formed part of the EQuIP 4 Guide. We recommend<br />

that members print off the Update (accessible <strong>on</strong> the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g><br />

website via the link below) and keep it with their EQuIP 4 Guide.<br />

Guidelines for the Management of Patients at Risk of<br />

Serious Self-harm and Suicide<br />

The intent of this EQuIP Update is to provide guidance for<br />

services <strong>on</strong> managing c<strong>on</strong>sumers / patients at risk of serious<br />

self-harm, including suicide and for surveyors in assessing how<br />

mental health services manage this task. The assessment and<br />

management of risk is a core expectati<strong>on</strong> of mental health<br />

services in order to ensure the safety of pers<strong>on</strong>s who may be at<br />

risk of serious self-harm, suicide or causing harm to others. At the<br />

same time, mental health services must provide a supportive and<br />

therapeutic envir<strong>on</strong>ment c<strong>on</strong>ducive to patient recovery.<br />

Within this update there are guidelines for mental health<br />

services <strong>on</strong> how to manage a pers<strong>on</strong> at risk of suicide in a<br />

health care organisati<strong>on</strong>.<br />

For the full update – follow the link provided:<br />

http://www.achs.org.au/EQuIP4Update/<br />

Members are reminded to login to the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> website as the<br />

Update is in the restricted access secti<strong>on</strong> of the website.<br />

2<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> NEWS Summer 2007


Annual Dinner 2007<br />

The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Annual Dinner was<br />

held <strong>on</strong> 22 November 2007 in<br />

Sydney for the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> <str<strong>on</strong>g>Council</str<strong>on</strong>g> and<br />

our stakeholders. Annually the<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> presents a series of awards<br />

and a guest speaker addresses<br />

the gathering. In 2007 we were<br />

fortunate to have Professor<br />

Clifford Hughes AO, Chief<br />

Executive Officer of the NSW<br />

Clinical Excellence Commissi<strong>on</strong><br />

address the audience and deliver<br />

an entertaining and insightful<br />

take <strong>on</strong> passi<strong>on</strong> and teamwork<br />

in healthcare.<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Annual Dinner 2007 Guest<br />

Speaker, Professor Clifford Hughes<br />

AO, Chief Executive Officer of the<br />

NSW Clinical Excellence Commissi<strong>on</strong><br />

Lifetime member of <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> <str<strong>on</strong>g>Council</str<strong>on</strong>g><br />

The dinner also provided the opportunity to recognise<br />

Dr J<strong>on</strong> Mulligan as a lifetime member of the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> <str<strong>on</strong>g>Council</str<strong>on</strong>g>.<br />

In May this year the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Board decided to award this<br />

recogniti<strong>on</strong>, which is rarely given and reflects the c<strong>on</strong>siderable<br />

appreciati<strong>on</strong> of Dr Mulligan’s c<strong>on</strong>tributi<strong>on</strong> to the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g>.<br />

The decisi<strong>on</strong> was made in recogniti<strong>on</strong> of Dr Mulligan’s l<strong>on</strong>g<br />

and meritorious service particularly as a member and ultimately<br />

President of the Board from 2002 – 2005.<br />

Previously a member of the <str<strong>on</strong>g>Council</str<strong>on</strong>g> (as the <str<strong>on</strong>g>Australian</str<strong>on</strong>g><br />

<strong>Healthcare</strong> Associati<strong>on</strong> nominee) Dr Mulligan joined the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g><br />

Board in 1995.<br />

During his time as President, the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> accreditati<strong>on</strong><br />

program significantly increased its focus <strong>on</strong> patient safety<br />

(including the introducti<strong>on</strong> of mandatory criteria), c<strong>on</strong>sumer<br />

involvement and the publicati<strong>on</strong> of informati<strong>on</strong>. He also<br />

oversaw the revisi<strong>on</strong> of the organisati<strong>on</strong>’s governance<br />

arrangements and guided the organisati<strong>on</strong>’s establishment of its<br />

internati<strong>on</strong>al business activities. Dr Mulligan led <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> through<br />

this period with a diplomatic and c<strong>on</strong>sidered approach and was<br />

a key factor in the effort to re-engage clinicians in accreditati<strong>on</strong>.<br />

Pictured from left to right: Mrs Margaret Jacks<strong>on</strong>, Project Assistant, Development,<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g>, Ms Julie Ings, <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Educati<strong>on</strong> Service and Mrs Bernice Barbouttis, <str<strong>on</strong>g>ACHS</str<strong>on</strong>g><br />

Business Services<br />

New Life Member of the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> <str<strong>on</strong>g>Council</str<strong>on</strong>g>: Dr J<strong>on</strong> Mulligan<br />

Employee and surveyor recogniti<strong>on</strong><br />

In additi<strong>on</strong> to thanking our retiring surveyors, the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g><br />

President took the opportunity at the 2007 Annual Dinner to<br />

thank several l<strong>on</strong>g serving employees of the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g>.<br />

Mrs Margaret Jacks<strong>on</strong>, who has worked with the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> for<br />

22 of the organisati<strong>on</strong>’s 33 years was acknowledged. The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g><br />

was <strong>on</strong>ly 11 years old when Margaret joined and in this time she<br />

has c<strong>on</strong>tributed in a range of business services and administrative<br />

roles. She is currently the Project Assistant in the Development<br />

unit. However telling you about these roles does not even scratch<br />

the surface of Margaret’s c<strong>on</strong>tributi<strong>on</strong> to the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g>.<br />

Dr Hodgs<strong>on</strong> commented <strong>on</strong> Margaret’s work as the epitome<br />

of quality and professi<strong>on</strong>alism. “Margaret’s knowledge of the<br />

organisati<strong>on</strong>, her attenti<strong>on</strong> to detail and her tireless pursuit of<br />

‘getting things right’ (when others just wanted to ‘get things<br />

d<strong>on</strong>e’) means she has helped to set and maintain a high<br />

standard of work in every team she has c<strong>on</strong>tributed to.”<br />

Ms Julie Ings who joined the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> <strong>on</strong> 14 September 1987<br />

and has worked with our Educati<strong>on</strong> Service throughout that<br />

time also received menti<strong>on</strong>.<br />

Julie joined as a part-time employee with the Educati<strong>on</strong><br />

Advisory Service – which was set up in July of 1987 with a<br />

generous grant from Baxter <strong>Healthcare</strong>. The service provided<br />

for workshops or c<strong>on</strong>sultancies; specifically designed for<br />

individual public and private sector members.<br />

At Julie’s recent 20 year celebrati<strong>on</strong> at the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> offices<br />

in Sydney, Margaret Jacks<strong>on</strong> made reference to Julie’s ability<br />

to get things d<strong>on</strong>e quickly, quietly, properly and with a<br />

minimum of fuss.<br />

The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> also acknowledged Mrs Bernice Barbouttis.<br />

Bernice joined the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> in a part-time role shortly after<br />

3<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> NEWS Summer 2007


Mr Brian Lewis with <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Customer Services Manager, Ms Brigitte Kaiser.<br />

Julie Ings <strong>on</strong> 16 December 1987. Bernice’s first role involved<br />

typing up survey reports with an electrical typewriter and<br />

Dr Hodgs<strong>on</strong> commented that “chances are if you’re an<br />

accredited <str<strong>on</strong>g>Australian</str<strong>on</strong>g> healthcare organisati<strong>on</strong> that Bernice has<br />

worked <strong>on</strong> your survey report.”<br />

The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Executive Manager, Customer Services, Ms Heather<br />

McD<strong>on</strong>ald also recognised the c<strong>on</strong>tributi<strong>on</strong> of Mr Brian Lewis to<br />

the organisati<strong>on</strong>.<br />

Brian was a surveyor with the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> for six years, was a<br />

<str<strong>on</strong>g>Council</str<strong>on</strong>g> member,Treasurer, member of the Survey Committee<br />

and in 1991 w<strong>on</strong> the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Gold Medal – <str<strong>on</strong>g>ACHS</str<strong>on</strong>g>’ highest h<strong>on</strong>our.<br />

Dr Marjorie Pawsey<br />

The Annual Dinner was also an opportunity to farewell Dr Marjorie<br />

Pawsey. The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> President acknowledged that the organisati<strong>on</strong><br />

would not be what it is today without Marjorie’s work.<br />

Dr Pawsey has acted as the organisati<strong>on</strong>’s Chief Executive,<br />

revoluti<strong>on</strong>ised our accreditati<strong>on</strong> standards by leading the<br />

development and introducti<strong>on</strong> of EQuIP and most recently<br />

steered the organisati<strong>on</strong>’s research functi<strong>on</strong>.<br />

While Marjorie will be taking time to spend with her<br />

grandchildren, we hope her input into the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> will c<strong>on</strong>tinue,<br />

given her skills and knowledge in relati<strong>on</strong> to quality and health<br />

accreditati<strong>on</strong> in Australia.<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> President, Dr Michael Hodgs<strong>on</strong> AM and Dr Marjorie Pawsey.<br />

MABEL Survey<br />

Medicine in Australia:<br />

Balancing Employment and Life<br />

The MABEL Survey will track a random stratified sample of<br />

around 15,000 doctors over an initial four year period. This<br />

will include GPs, private specialists, hospital doctors and<br />

doctors in specialist training. The first wave of the survey is<br />

planned for May 2008.<br />

This landmark study is of an enormous nati<strong>on</strong>al<br />

significance for the following reas<strong>on</strong>s:<br />

• The c<strong>on</strong>tinuing medical workforce shortages across<br />

Australia and increasing demands <strong>on</strong> the working<br />

and family lives of doctors are unsustainable<br />

• At the moment there is a lack of understanding of<br />

the decisi<strong>on</strong>s and trade-offs doctors make between<br />

their working and family lives throughout their career<br />

• MABEL is the first l<strong>on</strong>gitudinal survey of doctors in<br />

Australia and will enable researchers to examine the<br />

effect of changes in circumstances <strong>on</strong> the balance<br />

between the professi<strong>on</strong>al and pers<strong>on</strong>al lives of doctors<br />

• This study will provide important evidence relevant<br />

to the development of effective policies to support<br />

the medical workforce.<br />

For more informati<strong>on</strong> visit the MABEL website:<br />

www.mabel.org.au<br />

C<strong>on</strong>tacts: enquiries@mabel.org.au<br />

Professor Anth<strong>on</strong>y Scott – Melbourne Institute of<br />

Applied Ec<strong>on</strong>omic and Social Research, The University of<br />

Melbourne. Email: a.scott@unimelb.edu.au<br />

Dr Catherine Joyce – Department of General Practice,<br />

M<strong>on</strong>ash University. Email: Catherine.joyce@med.m<strong>on</strong>ash.edu<br />

Professor John Humphreys – School of Rural Health, M<strong>on</strong>ash<br />

University. Email: john.humphreys@med.m<strong>on</strong>ash.edu.au<br />

A/Professor Guy<strong>on</strong>ne Kalb – Melbourne Institute of<br />

Applied Ec<strong>on</strong>omic and Social Research, The University of<br />

Melbourne. Email: g.kalb@unimelb.edu.au<br />

Review of <strong>Standards</strong> for Mental Health Services<br />

As many of you may be aware, the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> is currently<br />

reviewing the Nati<strong>on</strong>al <strong>Standards</strong> for Mental<br />

Health Services (NSMHS), under c<strong>on</strong>tract with the<br />

Comm<strong>on</strong>wealth Department of Health & Ageing.<br />

The field review of the draft revised NSMHS is now<br />

closed. The feedback is being collated and will be<br />

c<strong>on</strong>sidered by the project Steering Group to inform any<br />

further changes to the revised NSMHS.<br />

For the latest update <strong>on</strong> the project,<br />

please visit the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> website:<br />

http://www.achs.org.au/StndsMentalHealth<br />

4<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> NEWS Summer 2007


<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Awards 2007<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Quality Improvement Awards 2007<br />

Supported by Baxter <strong>Healthcare</strong><br />

The 2007 Quality Improvement<br />

(QI) Award winners were<br />

recognised at this year’s <str<strong>on</strong>g>ACHS</str<strong>on</strong>g><br />

Annual Dinner <strong>on</strong> Thursday<br />

22 November 2007 in Sydney.<br />

The Awards program was<br />

launched in 1996 and has been<br />

supported by Baxter <strong>Healthcare</strong><br />

since 1998. The QI Awards are open<br />

to all members of <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> quality<br />

improvement programs and aim<br />

to recognise outstanding achievement in activities, programs,<br />

projects and strategies in health care organisati<strong>on</strong>s.<br />

Judging takes place annually during July and August. The<br />

panel c<strong>on</strong>sists of an <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> <str<strong>on</strong>g>Council</str<strong>on</strong>g>lor, an <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Surveyor and<br />

a representative of an EQuIP member organisati<strong>on</strong>. Judging of<br />

the QI Awards is always a difficult task given the c<strong>on</strong>sistently<br />

high standard of entries.<br />

All of the QI Awards participants not <strong>on</strong>ly help raise the standard<br />

of health care but through sharing their work they encourage<br />

quality improvement initiatives bey<strong>on</strong>d their own organisati<strong>on</strong>s.<br />

The valuable ideas from entries are available for review in<br />

the Quality Initiatives 2007 publicati<strong>on</strong>, available from the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g><br />

website, http://www.achs.org.au/QIAwards2007/ The publicati<strong>on</strong><br />

includes the complete winning and highly commended entries<br />

and a summary of all the other projects submitted.<br />

Notably in 2007 we received our first submissi<strong>on</strong> from an<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Internati<strong>on</strong>al member organisati<strong>on</strong>; the Kerala Institute of<br />

Medical Sciences in India.<br />

Jennie Jarvis, Executive Director of Nursing Services, Royal Children’s Hospital<br />

Melbourne and Catherine Crock, Physician, Royal Children’s Hospital Melbourne.<br />

Above: Pictured from left to right back row: Kenneth Gray, Partner, Baker & McKenzie;<br />

Alis<strong>on</strong> Hocking, Social Work, Peter Mac; Craig Bennett, CEO, Peter Mac; Jemimah<br />

Pentland, Corporate Relati<strong>on</strong>ship Manager, Peter Mac. Pictured from left to right fr<strong>on</strong>t<br />

row: Hamlata Bhana, Social Work, Peter Mac; Elizabeth Ballinger, Head – Social Work,<br />

Peter Mac; Vanya Kumar, Associate, Baker & McKenzie.<br />

Therese Kelly, Corporate Communicati<strong>on</strong>s Manager for Baxter<br />

<strong>Healthcare</strong> presented the awards to the following recipients:<br />

Clinical Excellence and Patient Safety Category:<br />

Royal Children’s Hospital – Melbourne for their submissi<strong>on</strong><br />

Day Procedures for Children Requiring Lumbar Puncture<br />

and B<strong>on</strong>e Marrow Aspirati<strong>on</strong><br />

The project improved the service in order to reduce the overall<br />

anxiety, distress and pain felt by patients and their family<br />

members due to lumbar punctures and b<strong>on</strong>e marrow procedures.<br />

In additi<strong>on</strong> to other initiatives music therapy is provided in<br />

the waiting room and special CDs have been produced for use<br />

in the procedure room to help reduce anxiety or boredom. The<br />

outcome is that children no l<strong>on</strong>ger require restraint for these<br />

procedures and are less fearful of coming to hospital.<br />

N<strong>on</strong>-Clinical Service Delivery Category:<br />

Peter MacCallum Cancer Centre, Melbourne for their submissi<strong>on</strong><br />

Cancer Patients’ Legal Assistant Program<br />

Pro b<strong>on</strong>o lawyers for the Peter MacCallum Cancer Foundati<strong>on</strong>,<br />

Baker & McKenzie, last year established a service for patients<br />

that require expert legal assistance falling outside the purview<br />

of Legal Aid, and who are not in a financial positi<strong>on</strong> to be<br />

able to employ professi<strong>on</strong>al services. They assist with matters<br />

including early access to superannuati<strong>on</strong>, Powers of Attorney,<br />

insurance claims and unfair dismissal cases.<br />

Health Care Performance Indicators Category:<br />

Hunter New England Health, Newcastle for their submissi<strong>on</strong>:<br />

Pre Hospital Acute Triage: Translating Evidence Into Practice<br />

by Improving Patient Access to Acute Stroke Care<br />

The project developed an effective tool that can be used to<br />

determine the appropriateness of which patients should be taken<br />

directly to a centre that is capable of giving acute therapies.<br />

The number of patients who received acute therapies was<br />

effectively tripled.<br />

5<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> NEWS Summer 2007


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Products and Services<br />

EQuIP 4 receives internati<strong>on</strong>al recogniti<strong>on</strong><br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> received accreditati<strong>on</strong> from the Internati<strong>on</strong>al Society for<br />

Quality in Health Care (ISQua) – the peak internati<strong>on</strong>al health<br />

accreditati<strong>on</strong> body – for the EQuIP 4 standards.<br />

The EQuIP 4 standards (which were developed via an<br />

extensive c<strong>on</strong>sultati<strong>on</strong> with c<strong>on</strong>sumer representatives,<br />

government bodies, peak industry associati<strong>on</strong>s and colleges)<br />

increase the emphasis <strong>on</strong> issues such as the safe management<br />

of blood, falls preventi<strong>on</strong>, c<strong>on</strong>tinuity of care between health<br />

care providers and infecti<strong>on</strong> c<strong>on</strong>trol and strengthen the focus<br />

<strong>on</strong> safe delivery of clinical care and c<strong>on</strong>sumer expectati<strong>on</strong>s.<br />

Encouragingly over 60% of <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> members elected to use<br />

these new standards prior to being required.<br />

There is also internati<strong>on</strong>al interest in these standards, with<br />

hospitals in India, the Asia Pacific and Middle East regi<strong>on</strong>s<br />

choosing to seek accreditati<strong>on</strong> under the EQuIP 4 standards.<br />

New Clinical Indicator Sets for 2008<br />

Three indicator sets have been reviewed in 2007. All indicator sets<br />

have been endorsed by the respective College / Society.<br />

Obstetrics Indicators Versi<strong>on</strong> 6<br />

Versi<strong>on</strong> 5 of the Obstetrics indicators had been collected since 2004<br />

and required review. The Royal <str<strong>on</strong>g>Australian</str<strong>on</strong>g> and New Zealand College<br />

of Obstetricians and Gynaecologists (RANZCOG) presented their<br />

suggesti<strong>on</strong>s and recommendati<strong>on</strong>s for a new indicator set to the<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g>. At the same time <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> became aware of another group that<br />

was working <strong>on</strong> the development of some nati<strong>on</strong>al obstetric indicators<br />

– the Core Maternity Indicator Project. The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> recognised that any<br />

revised <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> obstetric indicators should align as closely as possible<br />

with any proposed nati<strong>on</strong>al set. As a collector of indicators, the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g><br />

had been invited to participate in the discussi<strong>on</strong>s to develop the core<br />

maternity indicators by the Core Maternity Indicator project (CMIP).<br />

The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> acknowledged that the <str<strong>on</strong>g>Australian</str<strong>on</strong>g> Commissi<strong>on</strong> <strong>on</strong> Quality<br />

and Safety in Health Care was further progressing this initiative.<br />

A joint meeting of the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Obstetrics working party and<br />

the CMIP was c<strong>on</strong>vened to explore the areas of alignment across<br />

the two proposed sets. At the c<strong>on</strong>clusi<strong>on</strong> of the meeting there<br />

was a general c<strong>on</strong>sensus reached across a number of the indicators<br />

and the proposed new <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Obstetrics indicators reflect these<br />

areas of agreement.<br />

The revised set retains some of the existing indicators as well<br />

as including a number of new indicators such as: Postpartum<br />

Haemorrhage/Blood Transfusi<strong>on</strong>; Intrauterine Growth Retardati<strong>on</strong><br />

(IUGR); Peer review of Specified Adverse Events; Antibiotic<br />

Prophylaxis & Caesarean Secti<strong>on</strong> and Thromboprophylaxis &<br />

Caesarean Secti<strong>on</strong>.<br />

Rehabilitati<strong>on</strong> Medicine Indicators Versi<strong>on</strong> 4<br />

Versi<strong>on</strong> 3 of the Rehabilitati<strong>on</strong> indicators has been collected since<br />

2002 and required review.<br />

A number of changes to the Versi<strong>on</strong> 3 indicators were<br />

recommended by the indicator working party, including a change to<br />

WHO ‘Clean Care is Safer Care’ <str<strong>on</strong>g>News</str<strong>on</strong>g>Alert<br />

View the World Health Organizati<strong>on</strong>s’ First Global Patient Safety<br />

Challenge ‘Clean Care is Safer Care’ <str<strong>on</strong>g>News</str<strong>on</strong>g>Alert: http://www.who.<br />

int/gpsc/resources/newsalert/sept2007/en/index.html<br />

Coming so<strong>on</strong>…<br />

EAT 4 smart client functi<strong>on</strong>ality<br />

The purpose of the Electr<strong>on</strong>ic Assessment Tool 4 (EAT 4) smart<br />

client is to give users the opti<strong>on</strong> to work offline.<br />

The EAT 4 smart client is currently in the final stages of testing<br />

at the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> and is scheduled for pilot testing in the first quarter<br />

of 2008.<br />

If you would like to participate in the pilot tests, please email<br />

your request to it@achs.org.au by 31 December 2007 and we<br />

will be in touch.<br />

Thank you for your interest.<br />

the perspective of many of the indicators. Instead of counting when<br />

something has not happened, the Versi<strong>on</strong> 4 indicators require a count<br />

of when an event has happened. Two indicators have been deleted<br />

– Program Interrupti<strong>on</strong> and Inpatient Mortality. Two new outcome<br />

based indicators have been included – Functi<strong>on</strong>al Gain Achieved and<br />

Discharge Destinati<strong>on</strong>.<br />

Pathology Indicators Versi<strong>on</strong> 3<br />

Versi<strong>on</strong> 2 of the Pathology indicators have been collected since<br />

2003. These indicators focused <strong>on</strong> the interface between pathology<br />

laboratories and the health care instituti<strong>on</strong>, measuring the<br />

turnaround time for a range of comm<strong>on</strong>ly ordered pathology tests<br />

eg. potassium, haemoglobin as well as small and large biopsies of<br />

the GI tract.<br />

Feedback from RCPA members indicated that these indicators<br />

were not as clinically relevant as they could be. In the case of<br />

haemoglobin and potassium for example, the differences in indicator<br />

results may reflect differences in data definiti<strong>on</strong>s between instituti<strong>on</strong>s.<br />

This versi<strong>on</strong> (Versi<strong>on</strong> 3) attempts to address these issues by<br />

focusing <strong>on</strong> urgent tests ordered by emergency departments.<br />

Additi<strong>on</strong>ally, there is recogniti<strong>on</strong> of transport time to the<br />

laboratory and some indicators include a measure of Received to<br />

Validated times as well as Collected to Validated times. For chemical<br />

pathology, it is recognised that achieving the Versi<strong>on</strong> 2 targets has<br />

been challenging for some laboratories, so, at this point in time,<br />

the indicator c<strong>on</strong>tinues to focus <strong>on</strong> the Received to Validated times.<br />

However, it is anticipated that initiatives to improve service and<br />

achieve targets in haematology should flow through to chemical<br />

pathology in many laboratories.<br />

Versi<strong>on</strong> 3 also includes four new indicators: turnaround time<br />

of requests for Cerebrospinal fluid (CSF) samples and standard<br />

Coag tests from the Emergency Department. The existing<br />

turnaround time for small and large biopsies from the<br />

gastrointestinal tract has been revised to include requests for any<br />

biopsy with laboratories choosing biopsies appropriate to the<br />

range of activities normally provided.<br />

7 <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> NEWS Summer 2007


<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> <str<strong>on</strong>g>News</str<strong>on</strong>g> in brief… Nati<strong>on</strong>al Forum 2008:<br />

Australasian Clinical Indicator Report<br />

The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> annual report <strong>on</strong> clinical indicator data for Australasia<br />

(1998 – 2006) is now available. 681 health care organisati<strong>on</strong>s<br />

(HCOs) submitted data to the Clinical Indicator program over the<br />

nine year period with almost equal representati<strong>on</strong> from public and<br />

private sector organisati<strong>on</strong>s. The clinical indicator program covers a<br />

wide range of clinical areas from the reporting of aggregate rates of<br />

patient falls and pressure ulcers to specific measures such as the rate<br />

of complicati<strong>on</strong>s after radiology procedures.<br />

The purpose of the Report is for health care organisati<strong>on</strong>s<br />

to identify areas of difference to the nati<strong>on</strong>al results, investigate<br />

reas<strong>on</strong>s and make improvements if required.<br />

A particularly encouraging trend is the increase in the number of<br />

health care organisati<strong>on</strong>s participating in this voluntary program and<br />

the increasing number of indicators that each organisati<strong>on</strong> chooses<br />

to measure and submit.<br />

Another trend that emerges more clearly given the nine<br />

years of data is that most health care organisati<strong>on</strong>s have areas<br />

where they perform above the average as well as areas where<br />

improvement may be required.<br />

The <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Australasian Clinical Indicator Report for Australia<br />

and New Zealand 1998 – 2006 may be accessed via the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g><br />

website: www.achs.org.au under a link <strong>on</strong> the homepage.<br />

The printed Executive Summary of the Report (which includes<br />

a CD ROM of the full Report) has been mailed to <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> Members,<br />

Surveyors, <str<strong>on</strong>g>Council</str<strong>on</strong>g>lors and other stakeholders. If you would like to<br />

receive a hard copy please email: communicati<strong>on</strong>s@achs.org.au<br />

C<strong>on</strong>ferences and events<br />

Quality Carnivale<br />

Registrati<strong>on</strong> is now open for the QIP/AGPAL 4th Internati<strong>on</strong>al<br />

C<strong>on</strong>ference in Primary Health Care, 17–19 April 2008,<br />

Grand Hyatt Melbourne.<br />

Register <strong>on</strong>line via this link:<br />

http://registrati<strong>on</strong>.ozaccom.com.au/ei/2008/agp08/index.htm<br />

For more informati<strong>on</strong>, visit:<br />

http://www.qip.com.au/C<strong>on</strong>ferenceregister.asp<br />

6th Australasian C<strong>on</strong>ference <strong>on</strong> Safety and Quality<br />

in Health Care<br />

Bold Aims – Bold Outcomes<br />

1-3 September 2008.<br />

Christchurch C<strong>on</strong>venti<strong>on</strong> Centre, New Zealand.<br />

The Australasian Associati<strong>on</strong> for Quality in Health Care (AAQHC)<br />

has announced two keynote speakers for the C<strong>on</strong>ference <strong>on</strong><br />

Safety and Quality in Health Care:<br />

Charles Vincent<br />

Since 1985 he has carried out research <strong>on</strong> the causes of harm to<br />

patients, the c<strong>on</strong>sequences for patients and staff and methods<br />

of preventi<strong>on</strong>. He established the Clinical Risk Unit at University<br />

College in 1995 and now directs the Clinical Safety Research Unit<br />

Safety and Quality is<br />

Every<strong>on</strong>e’s Business<br />

Nati<strong>on</strong>al Forum <strong>on</strong> Safety<br />

and Quality in Health Care<br />

Adelaide C<strong>on</strong>venti<strong>on</strong> Centre, 29 – 31 October 2008.<br />

Internati<strong>on</strong>al keynote speaker announced:<br />

Professor Martin Marshall<br />

We are delighted to announce that Professor Martin Marshall,<br />

the Director of Clinical Quality for the UK’s Health Foundati<strong>on</strong><br />

will be <strong>on</strong>e of our internati<strong>on</strong>al keynote speakers. Martin’s<br />

expertise in clinical quality is extensive having acted as an<br />

expert advisor to (am<strong>on</strong>g others) the <strong>Healthcare</strong> Commissi<strong>on</strong>,<br />

the Modernisati<strong>on</strong> Agency, the Nati<strong>on</strong>al Patient Safety Agency,<br />

and the Nati<strong>on</strong>al Primary Care Collaborative.<br />

To register to receive updates <strong>on</strong> the Forum, please visit<br />

our website: www.achs.org.au<br />

Call for Abstracts<br />

The Call for Abstracts is open and abstracts are invited for all<br />

topics related to the following themes:<br />

• Workforce<br />

• Evidence into Practice<br />

• Knowledge and Informati<strong>on</strong> Management<br />

• Governance and Accountability.<br />

This Forum will be hosted by the <str<strong>on</strong>g>ACHS</str<strong>on</strong>g> in collaborati<strong>on</strong><br />

with the <str<strong>on</strong>g>Australian</str<strong>on</strong>g> Commissi<strong>on</strong> <strong>on</strong> Safety and Quality in<br />

Health Care and the Department of Health SA.<br />

To access the Call for Abstracts visit:<br />

http://www.sapmea.asn.au/forumsqhc2008/<br />

RACMA’s Annual Scientific Meeting<br />

In c<strong>on</strong>juncti<strong>on</strong> with the Forum, the Royal <str<strong>on</strong>g>Australian</str<strong>on</strong>g> College of<br />

Medical Administrators will host its Annual Scientific Meeting<br />

including its annual general meeting, fellowship graduati<strong>on</strong> and<br />

Langford Orati<strong>on</strong>.<br />

based in Department of Bio-Surgery and Surgical Technology,<br />

Imperial College L<strong>on</strong>d<strong>on</strong>.<br />

He is the author of Patient Safety (Elsevier, 2006), editor of<br />

Clinical Risk Management (BMJ Publicati<strong>on</strong>s, 2nd editi<strong>on</strong>, 2001), and<br />

author of many papers <strong>on</strong> risk, safety and medical error.<br />

Davis Balestracci<br />

Davis is a regular presenter at the prestigious Institute for <strong>Healthcare</strong><br />

Improvement United States and European annual forums.<br />

Davis has a B.S. degree in chemical engineering, an M.S. degree<br />

in statistics, yet describes himself as a “right-brained” statistician.<br />

He has c<strong>on</strong>sulted and given seminars in Canada, Palestine,<br />

Israel, Norway, Australia, New Zealand, Scotland, Wales, and,<br />

over 100 hospitals in England through the sp<strong>on</strong>sorship of the<br />

Nati<strong>on</strong>al Health Service’s Modernisati<strong>on</strong> Agency.<br />

For more informati<strong>on</strong> about the speakers and the 2008<br />

c<strong>on</strong>ference, email helen@c<strong>on</strong>ference.co.nz or visit www.aaqhc.org.au<br />

8<br />

<str<strong>on</strong>g>ACHS</str<strong>on</strong>g> NEWS Summer 2007

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