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The Australian Council on Healthcare Standards
AnnualReport 2015/2016
Errata
The Australian Council on Healthcare Standards 2015 – 2016
The following are errata are included for this year’s ACHS Annual Report:
Pg 22. The heading “Auditor’s Independence Declaration” in the box should be above the heading ‘Members’ Guarantee’ in the right hand column.
The heading “Auditor” in the same box should be deleted.
The Pitcher Partners letterhead, as below:
Level 22 MLC Centre Postal Address:
19 Martin Place GPO Box 1615
Sydney NSW 2000 Sydney NSW 2001
Australia Australia
Tel: +61 2 9221 2099 www.pitcher.com.au
Fax: +61 2 9223 1762 [email protected]
Pitcher Partners is an association of independent firms
Melbourne | Sydney | Perth | Adelaide | Brisbane| Newcastle
a) Should be included on page 23 – as part of the Auditor’s Independence Declaration to the Directors of the Australian Council on Healthcare Standards.
b) The letterhead should also be included on page 39 as part of the Independent Auditor’s Report.
September 2016
© The Australian Council on Healthcare Standards
Apart from any use as permitted under the Copyright Act 1968,no part may be reproduced by any process without prior writtenpermission from the Australian Council on Healthcare Standards.
The Australian Council on Healthcare Standards
Annual Report 2015 - 2016
ISBN: 978-1-921806-75-9 (Paperback)
ISBN: 978-1-921806-76-6 (E-book)
This Report is available in PDF format via the
ACHS website (under the Publications and
Resources menu option) from the homepage:
www.achs.org.au
To order a printed copy, please contact
Communications at:
The Australian Council on
Healthcare Standards
5 Macarthur Street
Ultimo NSW Australia 2007
T: 61 2 9281 9955
F: 61 2 9211 9633
www.achs.org.au
Common acronyms included in this Report
ACHS – The Australian Council on Healthcare Standards
ACHSI – ACHS International
ACSQHC – The Australian Commission on Safety and Quality in Health Care
AHHA – Australian Healthcare and Hospitals Association
ACIR – Australasian Clinical Indicator Report
AMA – Australian Medical Association
APHA – Australian Private Hospitals Association
ART – Assessment Recording Tool
EAT – Electronic Assessment Tool
EQuIP – Evaluation and Quality Improvement Program
EQuIPNational – The EQuIPNational Program
EQuIP5 – the 5th edition of the ACHS Evaluation and Quality Improvement Program
IAP – International Accreditation Programme
ISQua – The International Society for Quality in Health Care
NSQHSS – National Safety and Quality Health Service Standards
OWS – Organisation-Wide Survey
PIRT – Performance Indicator Reporting Tool
QI – Quality Improvement
SAC – State Advisory Committee
About ACHSVision, Mission and Values 1
Our IdentityA Corporate Overview 2
Our PerformancePresident’s and Chief Executive’s Report 4 Highlights of the year 6
Our OrganisationOrganisational Chart 8Our Executive Team 9
Recognising AchievementACHS Medal and ACHS Quality 10Improvement Awards 11
Division ReportsACHS International 12Customer Services and Development 14The Improvement Academy 15Corporate and Surveyor Workforce Unit 17
OverviewACHS Council Members 20
Director’s ReportDirector’s Report 21Auditor's independence declaration 23ACHS Board of Directors 24Financial Statements 26Notes to the Financial Statements 28Director’s Declaration 38Independent Auditor’s Report 39
ProfilePublications and Presentations 42
Glossary of Terms inside back cover
Contents
InspIrIng
excellence In healthcare
VisionOur vision statement is focused on our core business. We aspire to excellencein all aspects of healthcare and want to inspire others to strive for excellence.
ValuesValues are the essential foundation of our organisation. They describe what is
important to us and frame how we work.
Working Together
We work with our stakeholders to achieve goals
Accountability
We take responsibility for our performance
Commitment
We are committed to fostering an innovative and outcomes driven culture
Adaptability
Our flexibility enables us to adapt and embrace change
Responsiveness
We are quick to respond to the needs of our members and the ever-changing
health landscape
Excellence
We strive for excellence in everything we do
Mission To strengthen safe, quality healthcare bycontinuously advancing standards andeducation nationally and internationally.
ACHS ANNUAL REPORT 2015-2016 1
The Council
The Council
The Australian Council on Healthcare Standards(ACHS) has built on its many wins in recent yearsto ensure its continuity through the delivery ofservices, growing membership and a strongfinancial base.
The ACHS is an independent, not-for-profitorganisation dedicated to improving quality inhealth care as an approved provider ofaccreditation to a range of Australian andoverseas healthcare providers.
With a Council of 24 member organisations,drawn from peak bodies in the health industry,as well as representatives from governments,consumers and life members, ACHS is governedby a Board of 11 Directors.
ACHS is recognised by the International Societyfor Quality in Health Care (ISQua) for itsorganisational framework, its accreditationprograms and surveyor training.
As an organisation, ACHS has been a member ofISQua’s International Accreditation Programme(IAP) from 1999 when ISQua was launched, andis currently accredited until 2018.
ACHS Surveyors
Our surveyors continue to provide a critical
service in the surveying of our member’s
activities and facilities.
We rely on their assessment skills and evaluation
techniques and have invested strongly in the
ongoing education of surveyors throughout the
last financial year.
Critical to this is ensuring they are keeping up
with a range of changes in contemporary health
service delivery and that the training and support
are delivered to meet the needs of surveyors.
The majority of our surveyors continue to work
full-time in health as professional doctors,
nurses, consumers, medical administrators and
allied health professionals while contributing
to the ACHS mission on a volunteer basis.
Each year a number of our surveyors choose
to retire and we wish to acknowledge the length
and level of service provided by the following
surveyors (below). We thank them for their strong
contribution to the Australian healthcare industry,
and their loyalty and commitment to ACHS.
2 ACHS ANNUAL REPORT 2015-2016
A Corporate OverviewOUR IDENTITY
Professor David Barton
Mr Alan Lilly
Mr Bernard McNair
Ms Philippa Both
Ms Tina De Zen
Mr Peter Abraham
Dr Stephen Golding
Ms Clare Douglas
Mr John Wigan
Ms Sue Gilham
Name Type Speciality
VolunteerVolunteer
HonorariumVolunteer
Honorarium-
VolunteerVolunteer
Honorarium-
PsychiatristNurseNurse
-------
State Joined
Vic-
NSWSASA--
QLDVic-
2013200219952013200920072011200319951999
Total Surveys Yrs as a Surveyor
225454
11155
14135127
1.514212695
13217
Funding
ACHS maintains its status as an independent,
not-for-profit organisation, with the majority of
funding derived from membership fees.
Funding is also received from tenders and
projects undertaken on behalf of government
organisations, and other industry bodies as
well as from our strong educational offerings.
Retired ACHS SurveyorsJuly 2015 – June 2016
ACHS ANNUAL REPORT 2015-2016 3
Partnerships
ACHS works in partnership with a range of
industry organisations and has wide
representation on our Council which also
includes some Australian States and Territories.
All of our partnerships are critical to our success,
whether it be in the areas of program
development, member surveying, the enormous
ongoing contribution from surveyors or the input
from the industry into our Clinical Indicators.
Once again we have not only relied on, but
thrived on the many collaborative contributions
from member organisations, stakeholders, and
new partners in projects that have assisted us
improve our products and services and services
delivery.
Corporate and Strategic Plan
Following the Corporate and Strategic planning dayheld in February 2015, the Board and Executive staffhave adopted the framework the Plan provides. Itwill assist the organisation in determining futureplans as well as guiding key decisions.
ACHS is confident that the Plan provides a clearunderstanding of what our expectations are as a business going into the future.
Our Strategic Goals for the future are:
Strategic Goals
1. Expand our business reach
Build our business reach by strategically seeking out new opportunities that foster national and
international recognition
2. Grow our membership
Grow, maintain and sustain our national and international membership through the continued delivery
of outstanding service and products that directly meet our member’s needs
3. Build strategic alliances
Create strong partnerships and alliances that support collaboration and engagement and uphold,
develop and build on our vision
4. Inspire organisational performance
Inspire our organisation to always be its absolute best by putting our members at the centre, ensuring
our workplace celebrates and fosters the creative, innovative capacity of our workforce and members
and by providing strong leadership which creates our values-based organisational environment
5. Ensure sustainability
Deliver an efficient and financially sustainable business model underpinned by high standards of
accountability and quality assurance
6. Share our knowledge
Empower our members and stakeholders to deliver quality healthcare by harnessing our data and
actively seeking new opportunities to share information and knowledge that will support the delivery
of safe, quality healthcare
There were a number of keyachievements in 2015 - 2016across the business that we aredelighted to share with you.
Governance
Following the re-election of office-bearers at the
ACHS Annual General meeting on Thursday, 26
November 2015, the composition of the Board
in 2015 - 16 changed with the following
appointments:
z Mr John Smith PSM elected as President,
z Prof Len Notaras AM elected as Vice-
President, and
z Mr Stephen Walker was re-elected Treasurer.
The Board continued to oversee the
implementation of a range of new initiatives
conducted by the CEO and ACHS Executive.
These initiatives flowed on from the Corporate
Strategic Planning Day held in February 2015
and aim to consolidate ACHS’s position as the
leading healthcare accreditation provider in
Australia, with international members.
Key to ACHS’s ongoing development is the
building of a range of strategic alliances and
networks with key bodies, jurisdictions, private
health funders, public and private sector
stakeholders nationally and internationally.
Strong governance and leadership is necessary
for the ACHS to maintain its’ clear direction
as identified in its Corporate and Strategic
Plan. Through regular meetings, the Board
provides counsel and assists in strategic
direction decisions to assist ACHS maintain
its pre-eminent industry position. Areas of
focus include ongoing business development,
oversight of financials and the surveyor
workforce, membership retention as well
as ACHS staff.
In 2015 - 2016, ACHS succeeded in its goal
of maintaining its market dominance as the
leading provider of products and services for
accreditation.
Strategic Alliances
ACHS places a strong emphasis on being a
pivotal part of the healthcare accreditation
industry through its alliances.
z Launch of the new ACHS Improvement
Academy provides extensive educational
learnings to the industry with an immediate
high uptake of courses offered.
z High level delegation visits to jurisdictions,
key members, private and public
stakeholders, in Australia and overseas.
z Working with new partners with an interest
in extending healthcare accreditation into
other areas of Health.
z Strong feedback from members and the
industry that ACHS’s responsiveness to
feedback and willingness to listen and adapt
where there is a mutual benefit.
New Initiatives
Strategic projects undertaken included:
z Short Notice Surveys – a pilot project to
support an objective of shifting
organisational culture from an ‘event’ mindset,
to accreditation as an ongoing process or
constantly ready.
z A Single Approach to Achieving Dual
Accreditation. ACHS is working
collaboratively with the Australian Aged Care
Quality Agency (AACQA) to deliver a single
accreditation survey against two set of
standards concurrently.
z An ongoing review of our Constitution has
allowed us to consult with Board and Council
members for feedback on the future make-up
of the Council.
4 ACHS ANNUAL REPORT 2015-2016
President’s and Chief Executive’s ReportOUR PERFORMANCE
DUQuA
Following on from a large international study,
a new project focuses on Deepening our
Understanding of Quality In Australia (DUQuA),
modified for Australian circumstances. The
objective is to assess relationships between
quality management and patient outcomes in
Australian hospitals and the study is in 70
hospitals across six Australian states and
two territories.
Acknowledgements
There are many people, from various corners
of the health industry who have assisted in
making this last financial year such a
memorable one for ACHS in terms of new
advances, exciting projects and above all a
willingness to test established practices and
allow change to flourish.
With our members’ interests at the forefront of
everything we do, we are constantly looking at
new ways to ensure the accreditation experience
is both meaningful, and the positive changes it
brings are lasting.
As a not-for-profit organisation we are indebted
to both our members and surveyors for the
support they show us, and the feedback they
provide which assist us to improve.
To the members of the Board and Council,
as well as the organisations that nominate
representatives to Council, our State Advisory
Committee members who meet with us bi-
annually, we are grateful for your valuable
input and support.
Every year we thank our staff for their ongoing
commitment and this year is no exception. So
much has been collectively achieved over the
last 12 months that our sincere thanks are
placed on the record for their efforts and
success in growing the business.
Congratulations to all staff for a resoundingly
successful year of achievements.
We commend this report to you.
Mr John Smith PSM
President
Board of Directors
Dr Christine Dennis
Chief Executive Officer
ACHS ANNUAL REPORT 2015-2016 5
Key highlights in the past year were:
z To commemorate its 40 year anniversary, celebrated in 2014, ACHS publishes the 40 Year historical timeline created to mark the important occasion. The 20 page document “A timeline through the ages – 40 Years of ACHS History” covers the range of events, achievements, key personnel as well as products and programs developed over the last four decades. Published August 2015
z The ACHS International Medal 2015 is awarded to Dr Mohammed Sahadulla from Kerala, India in recognition of his ‘outstanding contribution at an international level to improving quality and safety in health services’.
z The Australasian Clinical Indicator Report
2007 – 2014 (16th edition) was launched in Melbourne at the ACHS / ACHSM Joint Congress on 28-30 October 2015. The report is Australia’s most statistically-detailed, national report on the performance of 807 healthcare organisations (HCOs) over an eight year period.
z Hunter New England Local Health District, Metro South Hospital and Health Service – Logan Hospital, and The Children’s Hospital at Westmead were announced as winners of the 18th Annual ACHS Quality Improvement Awards at the Joint Congress in Melbourne.
z The ACHS Board elects its new President, Mr John Smith PSM, and new Vice President, Prof Len Notaras AM. Mr Stephen Walker is also re-elected to his position of Treasurer at the Annual General Meeting, held in Sydney on 26 November.
z ACHS undertakes a review of its Constitution. A draft Constitution is submitted to the ACHS Council meeting in June 2016 for consultation, with ratification due at a later meeting.
z ACHS is to join forces again with the ACHSM to present a joint congress “The health
leadership challenge: making things happen”, to be held in Brisbane in October 2016. More than 430 delegates attended the 2015 Congress.
z The Performance and Outcomes Service releases five revised manuals for the Clinical Indicator Program: Mental Health, Pathology, Intensive Care Emergency Medicine and Hospital in the Home in the first half of 2016.
z Clinical Indicator sets are regularly updated to support clinicians in providing evidence-based
patient care, and flag areas in need of quality improvement initiatives.
z ACHS entered into a partnership with the Centre for Healthcare Resilience and Implementation Science (CHRIS), the Australian Institute of Health Innovation and Macquarie University, to undertake the DUQuA (Deepening our Understanding of Quality in Australia) research project, in order to assess relationships between quality management and patient outcomes in hospitals across Australia.
z In the first half of 2016, ACHS worked with Queensland Health to undertake the Patient Safety Audit. The audit was conducted against the safety and quality functions specified in the Hospital and Health Boards Act 2011 and the Hospital and Health Boards Regulation 2012.
z The ACHS works collaboratively with the Aged Care Quality Agency to deliver a single accreditation survey against two sets of standards concurrently.
z ACHS pilots Short Notice Surveys in two large regional health services in Queensland. The intent of this approach is to support an objective of shifting organisational culture from an ‘event’ mindset, to accreditation as an ongoing process or constantly ready.
z The new ACHS Improvement Academy is launched in Melbourne on 3 March 2016. The Academy offers practical training opportunities that align with the strategies and missions of organisations. Programs are tailored to the roles and needs of different staffing levels and will employ mixed modes of learning, including opportunities to participate in large scale collaborative improvement projects. Ms Bernie Harrison is appointed as the inaugural Director of the ACHS Improvement Academy.
z The initial response to both Improvement Academy lead programs (Quality Improvement Lead and Patient Safety Lead) was very strong, with interest from around Australia.
z ACHS has been awarded its third substantial contract by the Hong Kong Hospital Authority (HA) to assist implementing its hospital accreditation program.
z Implementation of the new EQuIP6 is scheduled from 1 July 2016. With the upcoming implementation of the new standards, the ACHS IT and Business Support Services teams upgrade the Electronic Assessment Tool (EAT) to version 6 (EAT6).
6 ACHS ANNUAL REPORT 2015-2016
HIGHTLIGHTS
1. Dr Christine Dennis ACHS CEO speaks at the 2015 ACHS – ACHS Joint Congress, in Melbourne.
2. Dr Dennis with fellow speakers at the congress – Neale Fong from WA, Eric De Roodenbeke, Director General, International Hospital Federation, Assoc Prof Munjed Al Muderis and Professor Chris Ham, CEO, The King’s Fund.
3. Certificate presentation at Hesse Rural Health Service.
4. Signing of Memorandum of understanding with the Korean Institute for Healthcare Accreditation (KOIHA)
5. Enoggera Health Service was presented with its Accreditation Certificate on 28 August, 2015.
6. Ms Bernadette Loughnane and Ms Rosemary Snodgrass
7. The launch of the ACHS Improvement Academy with Mr John Smith PSM, Dr Dennis, Mr John Wakefield, Ms Bernie Harrison and Mr Michael Roff.
1. 2.
3. 4.
5.
7.
6.
ACHS ANNUAL REPORT 2015-2016 7
8 ACHS ANNUAL REPORT 2015-2016
International BusinessExecutive Director
International Business
z Manager, InternationalBusiness Services
z Administrative Officer
Executive Officer Board ofDirectors / Communications
Assistant
Chief Executive
CommunicationsManager
Council
Executive Assistant
Accreditation AdministrationServices
z Managerz Senior Admin Assistantz Admin Assistants z Word Processing Officersz Clerical Assistantz Receptionistz Trainees
Education AdministrationServices
z Supervisorz Admin Assistants
Business Support Services
z Business Managerz Project Officers
Surveyor Workforcez ACHS & ACHSI Surveyorz Surveyor Resource Coordinatorz Surveyor Bookings Administratorz Surveyor Bookings Assistant
Financial Services/Human Resources
Managementz Managerz Assistant Accountantsz Accounts Officer
IT Servicesz IT Managerz Senior Analyst Programmerz Network Engineer z IT Support Analystz IT Support Officer
Corporate & SurveyorWorkforce
Executive Director
ACHS InternationalBoard of Directors
Customer Services& Development
Executive Director
Customer Servicesz Team Managerz Customer Services Managers
Research Support
Performance & OutcomesService
z Managerz Project Officerz Data Analyst
Standards & ProductDevelopment
z Managerz Project Officers
Organisational Chart
OUR ORGANISATION
ACHSBoard of Directors
Director Improvement Academy
Ms Linda O’ConnorBAppSc, Grad Dip (Med Ultrasound), MA (Org Com), AMS,CPHQ, GAICD
Executive Director – Customer Services and Development
Ms O’Connor is responsible for standards and productdevelopment, the ACHS Clinical Indicator program,customer services support and contract management.Ms O’Connor has worked in healthcare for 25 years, isa Board Certified Professional in Healthcare Quality,and works closely with the Australian Commission onSafety and Quality in Healthcare (ACSQHC).
Ms O’Connor has both national and internationalexperience. In the senior management team of HarvardMedical International, she worked between Boston andDubai to establish the Center for Healthcare Planningand Quality, Dubai Healthcare City.
Ms O’Connor has collaborated on projects with theJoint Commission, ISO and Accreditation Canada. She is a qualified ultrasonographer, and was a memberof the Commonwealth BreastScreen AustraliaAccreditation Review Committee. She holds a Master’sDegree in Organisational Communication, is a graduateof the Australian Institute of Company Directors (AICD),and is a surveyor for ISQua.
Dr Desmond YenB Com, MBA, DBA, FAICD
Executive Director – International Business
Dr Yen joined ACHS in July 1995. His current portfolioprimarily covers all aspects of international business.Prior to this role, he was responsible for CorporateServices. His multiple responsibilities have includedstrategy, policies and systems development, finance,risk management, IT and support services. He isexperienced in all aspects of healthcare accreditationrequiring member interaction.
Dr Yen’s broad depth of experience, mainly within largemulti-national organisations, covers a mix of local andinternational strategic management, finance, and ITroles. Dr Yen is a surveyor for ISQua and has surveyedfour international accreditation agencies.
Dr Yen holds graduate qualifications in commerce, both a Master’s Degree and a Doctorate in BusinessAdministration, and is a Fellow of the AICD.
ACHS ANNUAL REPORT 2015-2016 9
Dr Christine DennisBA Nursing, MHSM, DBA, Adjunct Associate Professor, FacultyHealth Sciences, Flinders University, SA, FCHSM, FAAQHC
Chief Executive Officer
Christine has worked in the health industry since 1976,having commenced in nursing and progressed toleadership positions in nursing and then broader healthservice management. Recent positions have includedCEO Southern Adelaide Local Health Network; ChiefOperating Officer, Top End Health Service; and, actingCE Northern Territory Health.
Christine’s career has included many and variedpositions both within Health Services and in HealthDepartments. Christine also worked as Manager of the State Coroner’s Office in SA and, has providededucation and training consultancies to the Ministry ofHealth, Singapore. Areas of expertise include strategicand operational planning, quality and safety systemsand, organisational change.
Her doctoral theses was titled ‘The Problematic Natureof Strategic Planning in Public Health Services; theperspectives of the health planner’.
Christine was appointed to the role of CEO ACHS inJuly 2014.
Dr Lena LowPhD, MBA, Grad Dip Mgmt, FAICD, FAAQHC, AFACHSM
Executive Director - Corporate and Surveyor Workforce
Dr Low has been with ACHS since 1995 with involvementin strategic development and operationalising healthcareaccreditation systems. She currently has responsibility for financial management, Information Technology,Human Resources, surveyor workforce logistics andperformance management with previous experiences as Chief Executive Officer and Company Secretary.
Dr Low has an MBA, Diploma Australian Institute ofCompany Directors and Doctor of Philosophy. Herdoctorate specialisation with the UNSW Faculty ofMedicine was in public health and community medicine.
Dr Low sits on the ISQua Accreditation Council, is anISQua surveyor and a member of the "ISQua Experts"panel. She is also a visiting Fellow at MacquarieUniversity and Board member of one of Sydney’sleading private golf clubs.
Dr Desmond YenMs Linda O’ConnorDr Lena LowDr Christine Dennis
Our Executive Team
OUR ORGANISATION
10 ACHS ANNUAL REPORT 2015-2016
to principles of clinical quality and move beyondsimple “box checking” to ensure better patientand provider safety.
Returning to Trivandrum in 2002, he establishedhigh quality care at a cost-effective price byopening KIMS Hospital, the flagship facility ofthe KIMS group of hospitals. KIMS Group nowconsists of six hospitals in India, three in theMiddle East, and five polyclinics throughout theGulf region. In 2006 KIMS Trivandrum wasaccredited by ACHSI as well as by the Indianaccreditation agency, National AccreditationBoard for Hospitals and Healthcare Providers,and holds the honour of being the first Indianhospital to receive both national andinternational accreditation.
Dr Sahadulla’s philosophy about quality is at the core of all KIMS decisions. He has been aquality pioneer throughout India with a focus ongood clinical practices to ensure patient safety.He recognises that the hospital is part of thecommunity and promotes this hospital as a good partner to the patients it serves. He hasalso prioritised access to care, championing the development of Indian emergency medicine, an under-developed specialty. He regards theEmergency Department as the hospital’s“welcome door” and ensures that clinical staffproperly triage and treat patients withininternational guidelines, initiating a US-styleresidency program with academic support from a Level 1 trauma centre. All KIMS ED residentsare required to work in the community andactively teach CPR and basic first aid to anyorganisation that asks.
To ensure patient safety, all KIMS employeesmust attend mandatory orientation activities and clinicians must present and prove theircredentials. Regular audits are performed onclinical outcomes and are published to staff.KIMS also publishes two internal academicjournals to encourage academic and patientsafety activities.
Dr Sahadulla has been a strong force for changein India, championing the concept of quality inevery aspect of hospital life, making KIMS a rolemodel. He encourages KIMS staff to exceed theminimum standards and treat patients as weourselves would wish to be treated.
ACHS Medal and ACHS Quality Improvements AwardRECOGNISING ACHIEVEMENT
ACHS Medal Winner 2015 Dr Sahadulla
ACHS International Medal 2015 Citation
The following citation was
given on 29 October, 2015.
ACHS International Medal Citation 2015 –
Winner – Dr Mohammed Sahadulla
Dr Mohammed I Sahadulla, Chairman and MD
of the Kerala Institute of Medical Sciences (KIMS
Group), has been a leader in establishing and
developing hospital quality standards in India.
Initially trained in Internal Medicine at Trivandrum
Government College, India, Dr Sahadulla
migrated to the UK during the 1970s to further
his clinical training. While there, Dr Sahadulla
also studied and obtained a MBM degree from
Hull University, pairing his clinical skills with the
principles of executive management.
From here he moved his family to Saudi Arabia,accepting a position with the Saudi ARAMCOhospitals (the world’s largest oil company) withits own hospital for employees and theirdependants. He was part of the clinicalmanagement team that prepared the hospitalfor accreditation from the US Joint Commission,one of the first hospitals accredited outside theUS. He served as a technical advisor to JCIand helped them understand how MiddleEast patients seek care and how accreditationguidelines should be developed to address theregion’s challenges. This exposed Dr Sahadulla
ACHS ANNUAL REPORT 2015-2016 11
ACHS Quality ImprovementAwards 2015
Hunter New England Local Health District, MetroSouth Hospital and Health Service – LoganHospital, and The Children’s Hospital atWestmead were announced as winners of the18th Annual ACHS Quality Improvement Awardsat the ACHS / ACHSM Joint Congress inMelbourne in October 2015.
The awards in three categories were presentedfor – Clinical Excellence and Patient Safety, Non-Clinical Service Delivery, and HealthcareMeasurement.
Almost 100 high quality submissions werereceived from Australian and International ACHS member and Clinical Indicator Programorganisations.
Hunter New England Local Health District wonthe Clinical Excellence and Patient Safety Awardfor their Preventing Catheter Associated UrinaryTract Infection (CAUTI) which accounts for 40%of all Healthcare-Associated Infections (HAIs).Metro South Hospital and Health Service – LoganHospital won the Non-Clinical Service DeliveryAward for their Preventing Infection throughCleaner Hospitals (PITCH): An Environmental
L to R: Dr Mark Burgess, ACHS, Christie Graham and AndreaKench, the Children’s Hospital at Westmead – HealthcareMeasurement Award, Mejoree Sehu, Metro South Hospitaland Health Service, Logan Hospital – Non-Clinical ServiceDelivery Award, Michelle Giles and Wendy Watts, HunterNew England Local Health District – Clinical Excellence and Patient Safety Award, Mr Brendan Cummins, DirectorHealthcare Solutions Baxter, Ms Linda O’Connor, ACHS.
Ms Kae MartinDr Laurence Lai (International)Christopher Brook PSMProfessor Robert ‘Bob’ GibberdProfessor Jeffrey BraithwaiteProfessor Bruce BarracloughDr Michael (Taffy) Jones AMAssociate Professor Christine Kilpatrick
Cleaning Bundle project to reduce HAIs and alsoreform and enhance hospital cleaning practice.This includes the introduction of ultraviolet gelauditing to assist in the visual review of cleaning.
The Healthcare Measurement Award was won by The Children’s Hospital at Westmead, forSustaining Improvements in Cystic Fibrosis (CF)Nutrition Outcomes for patients aged 2-18 years.
Competition within each of the three categorieshad increased in recent years, with each onehaving at least one ‘Highly Commended’ asrunner-up to the winners. The judges were onceagain impressed by both the scope and the veryhigh level of entries submitted.
A full list of Quality Initiatives entries received by ACHS was published in “Quality Initiatives –entries in the 18th Annual ACHS QualityImprovement Awards 201”’ which can bedownloaded from the ACHS website atwww.achs.org.au
Professor William RawlinsonProfessor Ross HollandDr Lisa HarveyMr Michael DooleyDr Ian O’RourkeDr John GreenwellMrs Phyllis NewnhamMr Brian Lewis
Mr Trevor PickeringMr Kevin DoddDr Lindsay ThompsonMr Brian CollopyMr Murray ClarkeDr Myles KehoeMs Doreen MooreDr Lionel Wilson
Previous ACHS Medal and ACHS International Medal recipients
MacauA gap analysis was conducted for the Centro SanJanuario General Hospital in January and this willbe their second EQuIP membership cycle.
The People’s Republic of ChinaThe University of Hong Kong – Shenzhen Hospitalunderwent their OWS in September 2015 and reachieved ACHSI accreditation, recognised by acertificate presentation in November.
SingaporeA total of 10 Fresenius Medical Care Clinicsare ACHSI accredited in Singapore with sevenundergoing their OWS for the EQuIP5 DayProcedures Centres program, receiving threeyear accreditation.
MalaysiaA total of five Fresenius Medical Care clinicsare ACHSI accredited in Malaysia with twoundergoing the EQuIP5 Day Procedure Centresprogram, receiving accreditation for three years.
TaiwanThe Sense & Beauty Dental Center and twoFresenius Medical Care Clinics in Taiwan havejoined the EQuIP membership program.
IndonesiaBIMC International Hospital, Bali underwent their Periodic Review in June 2016, receivingcontinuing accreditation.
Middle East Region
United Arab EmiratesEmirates Airlines Medical Services held an OWSin May 2016 and are in their third EQuIP cycle.
Kingdom of BahrainBahrain Defence Force Military Hospitalunderwent an OWS as part of their third EQuIPcycle, achieving accreditation for four years. Aspecialty topic workshop on Risk Managementwas held at the Bahrain Defence Force MilitaryHospital in May 2016.
Kingdom of Saudi ArabiaThe Abdul Latif Jameel Hospital held theirscheduled PR in December 2015 and wereaccredited.
State of QatarKIMS Qatar Medical Centre underwent their OWSin December 2015 and received full accreditation.The Al-Ahli Hospital held their OWS in April 2016and also received continuing accreditation.
ACHS International (ACHSI) extendsthe mission and vision of ACHSinternationally. Since 2007 it has aimedto create a strong presence in boththe Middle East and the Asia Pacificregions and it continues to grow.
Highlights of 2015 - 2016
z ACHSI approved by Dubai Healthcare City Authority to be an approved accreditor, amongst three organisations, for conducting accreditation of hospitals in Dubai Healthcare City (DHCC).
z Successful completion of the Accreditation Scheme Project of the Hospital Authority, Hong Kong, with all 15 hospitals achieving full accreditation status. ACHS awarded a third contract for the for this Project to accredita further 11 public hospitals.
z Commencement of activities for the Ministry of Health, Sri Lanka to establish a local accrediting body.
z Memorandum of Understanding (MoU) signed with the Korean Institute for Healthcare Accreditation (KOIHA) to collaborate with ACHS/I.
z ACHSI continued to host several international delegations from various countries such as United Arab Emirates, Korea, Japan, Vietnam and China.
A summary of activities and outcomes in 2015 –2016 are provided based on the two maingeographical areas of operation:
Asia Pacific Region
Hong KongACHSI was awarded the contract to provideaccreditation services to the Department ofHealth, School Dental Care Services’ nine dental centres.
A total of 20 on-site events comprising of acombination of Organisation-wide Surveys(OWS), Periodic Reviews (PR) and gap analyseswere held in the private and public sector duringthe 2015 - 2016 period.
The Dental Implant & Maxillofacial Centre(DIMFC) achieved ACHSI accreditation under theEQuIP5 for Day Procedure Centres standards.
12 ACHS ANNUAL REPORT 2015-2016
ACHS InternationalDIVISION REPORTS
Sultanate of OmanKIMS Oman Hospital also successfully achievedACHSI accreditation with a certificate presentationwas held in January 2016.
The Muscat Laser Eye Center also underwent a gapanalysis in May 2016 and is preparing for theirOWS, in early 2017.
ACHS ANNUAL REPORT 2015-2016 13
1. Survey team at work during the Periodic Review of thePamela Youde Nethersole Eastern Hospital, Hong Kong in June 2016.
2. Staff and survey team at the Periodic Review of the Matilda International Hospital, Hong Kong.
3. Left to right: KOIHA President Dr Suk, ACHS/I President Mr John Smith PSM and Dr Desmond Yen at the KOIHA premises in Seoul, South Korea.
4. Staff and survey team at the Organisation-wide Survey of the Dental Implant & Maxillofacial Centre (DIMFC), Hong Kong.
5. Periodic Review team of the Adventist Hospital – Tsuen Wan, Hong Kong.
6. Periodic Review team of the Adventist Hospital – Stubbs Road, Hong Kong.
1. 2.
3.
5.
4.
6.
Standards and ProductDevelopment
Standards and Product Development (SPD) isresponsible for the generation and maintenanceof ACHS quality improvement programs includingEQuIPNational, EQuIPNational Day ProcedureCentres, EQuIPNational Corporate HealthServices, EQuIP6, EQuIP6 Day Procedure Centresand EQuIP Corporate Services. This section alsodevelops associated resources and specialistpublications to support these programs.
In addition to the maintenance of existing
programs, this section develops new products
for ACHS including a proposed program to
recognise exemplary performance in healthcare
organisations. SPD also collaborates with
national and international organisations to
develop specialised healthcare programs
including EQuIP6 Hong Kong, EQuIP6 Oral
Health (international market) and EQuIP6 Dialysis
(international market). SPD works in consultation
with key internal and external stakeholders to
ensure program development reflects current
health priorities and contemporary best practice.
SPD coordinates the ACHS annual QualityImprovement (QI) awards, which acknowledgesand encourages outstanding quality improvementactivities, programs or strategies that have beenimplemented in healthcare organisations.
Key achievements 2015 – 2016
z Development of EQuIP6 Standards
ACHS completed the development of EQuIP6.
EQuIP is the core ACHS accreditation programs
and the basis of all such programs and products
offered to members. EQuIP6 will inform future
program updates. Member organisations locally
and internationally are thanked for their have
assistance, through their attendance on Working
Groups, at open consultations, onsite pilot
surveys and desktop audits.
Customer Services
During 2015 - 2016 the focus of the CustomerServices Managers (CSMs) was on businessretention.
Nearly 50% of accreditation program member-ships were due for renewal during the past yearand Customer Services is pleased to report thatwith support from Accreditation AdministrationServices the target set for membership renewalswas exceeded. During this same period ACHSalso exceeded its set target for obtaining newmemberships.
Throughout the year the CSMs also focussed on customer support and introduced newmethods, such as targeted newsletters and group presentations, for delivering support to our accreditation members.
Performance and OutcomesService
The Performance and Outcomes Service (POS)has been responsible for the ACHS ClinicalIndicator Program since 1989. More than 800healthcare organisations currently submit data fora range of Clinical Indicators every six months viathe web-based Performance Indicator ReportingTool (PIRT). In 2015 - 2016, POS providedhealthcare organisations with 314 ClinicalIndicators across 21 Clinical Indicator sets.
ACHS Clinical Indicators are developed by working parties comprised of practising cliniciansof relevant Australian and New Zealand medicaland nursing colleges, associations and societies,consumer representatives, statisticians and ACHSstaff. Clinical Indicator sets are regularly reviewedto ensure they are relevant for clinicians, that theycontinue to reflect today’s healthcare environment,that there is a consensus on collection andreporting requirements and that the set is regarded as useful for quality improvement.
Key achievements 2015 – 2016
z Publication of the Australasian Clinical
Indicator Report 2007 - 2014, 16th edition,
z Publication of five Clinical Indicator user manuals including Emergency Medicine (version6), Hospital in the Home (version 5), Intensive Care (version 5), Mental Health (version 7) and Pathology (version 4), Healthcare organisations from Sri Lanka and Sultanate of Oman commenced participation in the Clinical Indicator Program, joining other international members from Indonesia and Hong Kong.
Customer Services and DevelopmentDIVISION REPORTS
14 ACHS ANNUAL REPORT 2015-2016
DIVISION REPORTS
Adapted from the Health Foundation - Inspiring Improvement:Building Capability to improve safety. Event Report, August 2014)
Lead LevelThe Lead group are employed in roles within organisation to lead change and improvement. They need a highskill level and expertise in patient safety and quality improvement; in particular they are expert in improvementscience and collaborative improvement methods. They understand human factors and reliability theories andcan begin to work with front line teams to prospectively design and redesign care to prevent harm. They sit onconsumer councils within organisations to ensure changes meet the needs of patients and families. They aresenior within the organisation working closely with the executive and board to drive continuous improvement.
Practitioner LevelThis level is applicable to a wide range of staff with different roles. Most likely they will be middle managerswith direct responsibility for patient care. This level can also include finance and other administrative servicessuch as informatics. Their work should be informed by a clear understanding of the principles and practice ofcontinuous improvement in healthcare. They should actively encourage and support the professionaldevelopment of other members of their team. This level reflects a leadership role in quality improvement. This group should role model and champion change and innovation within their own local environment..
Foundation LevelAll staff working in health care settings who should have a raised awareness of principles that underpin qualityimprovement to drive patient safety and higher levels of service delivery. In addition the foundation levelshould include patient and carer. It is recommended that staff new to the organisation receive an introductionto quality improvement at induction programs.
ACHS ANNUAL REPORT 2015-2016 15
In October 2015 ACHS took theopportunity to redevelop itseducation offerings to both theAustralian and internationalmembers. Ms Bernie Harrison wasbrought into the organisation to develop training programs to meetinternational best practice in qualityand safety. The vehicle for doing thisis through the development of anImprovement Academy.
The vision of the Academy is to build the
capability of frontline clinical and executive
teams to best meet the challenges of health
care provision in the 21st Century and to
increase the alignment of continuous
improvement as contiguous with accreditation
and benchmarking through clinical indicators.
From October 2015 through to its launch in
March 2016, the Improvement Academy worked
on developing a suite of offerings using the
curriculum framework in the diagram below.
The Improvement Academy
Two programs were developed at the lead level;
The Patient Safety Lead (PSL) and the Quality
Improvement Lead (QIL) Training Programs. Both
these programs run for 12 months and are made
up of 4x2day face-to-face teaching modules. In
addition, participants undertake a work-based
patient safety or quality improvement project and
are supported through webinars, emails and
peer-to-peer support.
ACHS was able to identify an international and
local faculty who possessed both the theoretical
and practical real world experience in patient
safety and quality improvement, combined with
excellence in adult learning teaching methods.
For example: Dr Brent James - Intermountain
Health Care USA, Professor Lynne Maher - Ko
Awatea NZ, Professor Maxine Power - Salford
Royal Foundation Trust UK, Mr Peter Hibbert -
Macquarie University NSW, Dr Stephen Walker -
Cognitive Institute QLD, Dr Tim Smyth - Holman
Webb, NSW and Ms Bernie Harrison as Director
ACHS Improvement Academy.
On 3 March the Improvement Academy launched
these two programs in Melbourne at the Park
Royal Melbourne Airport. The launch was
opened by the President of ACHS, Mr John
Smith, PSM. Attendees were by invitation only
and included ACHS Board Members, Chief
Executives, ACHS Surveyors and other senior
leaders from member organisation. The keynote
speakers at the event were: Dr Brent James,
Chief Quality Officer and world renowned expert
16 ACHS ANNUAL REPORT 2015-2016
in clinical quality improvement from
Intermountain Health Care USA, Dr John
Wakefield, Deputy Director General Queensland
Health who is a recognised expert in patient
safety; and Ms Bernie Harrison Director ACHS
Improvement Academy who is a recognised
expert in patient safety and quality improvement.
Dr James was able to join the launch and
provide his presentation via a live video link.
The launch was a great success and was closed
by ACHS CEO Dr Christine Dennis.
Since the launch the ACHS Improvement
Academy has commenced Lead programs in
Sydney and in Melbourne. Both these sets of
programs will complete next year. The
attendance at these programs has vastly
exceeded our early expectations. We currently
have nearly 120 participants enrolled in these
programs. They are made up of medical and
nursing clinicians and patient safety and quality
managers and directors of clinical governance.
The session feedback has been extremely
positive and complimentary.
At the practitioner level we have offered one day
programs in; clinical incident management / root
cause analysis, clinical practice improvement,
executive masterclasses, business planning
and risk management and preparing for ACHS
Accreditation Surveys. To date 30 one day
workshops have been held across Australia,
with more than 500 participants.
The new Quality Safety Lead course started successfully inJune 2016 and was followed shortly by the first Patient Leadcourse, held at the UTS Sydney campus, also in June.
Corporate and Surveyor Workforce Unit
DIVISION REPORTS
ACHS ANNUAL REPORT 2015-2016 17
Corporate and Surveyor WorkforceUnit comprises five core sections:
1. Information Technology (IT)2. Finance and Human Resources
Administration3. Business Support Services (BSS)4. Accreditation Administration
Services (AAS)5. Surveyor Workforce (SW)
Key achievements 2015 – 2016
z Electronic Assessment Tool (EAT) 6 upgrade,
z Performance Indicator Reporting Tool (PIRT)
upgrade,
z Customer Relationship Management (CRM)
system upgrade,
z Server infrastructure upgrade,
z Redesign surveyor workforce allocation
and performance management system.
Information Technology (IT)
ACHS IT governance is concerned with the
strategic alignment between the goals and
objectives of the business and the utilisation
of its IT resources to effectively achieve the
desired results. ACHS IT is committed to
providing IT related business solutions and
systems integration in line with best practice
and consistent with the strategic direction of the
ACHS and ACHS International to ensure optimal
services to both internal and external customers.
Finance and Human ResourcesAdministration
The two main functions of this unit are the
management of finance and the management
of human resources.
z Finance plans, directs and coordinates the
formulation, preparation, execution, review
and analysis of the ACHS and ACHS
International’s operating budget and
monitors budget appropriations and actual
expenditures. The Finance unit works closely
with all department heads and gathers
information to create and maintain the annual
operating and capital budget. Financial
performance to budget is reported monthly to
the ACHS and ACHS International Board of
Directors to ensure that the organisations are
financially stable and to flag any potential
financial risks.
The review of corporate contracts such as
travel, accommodation and insurance are also
the responsibility of Finance together with
determination of pricing for ACHS products,
tenders and projects.
z Human Resources Management (HRM) has
generic functions which include:
z ensuring efficient human resource
information systems,
z administration of policies, programs and
practices,
z developing and running with a strategic
approach to human resources,
z monitoring compliance with legal
requirements as well as administering
award and corporate wellness
management, such as the development
and communication of policies and
procedures with regard to the
management of wellbeing;
z workplace health and safety including
the Employee Assistance Program and
health promotion programs such as free
influenza injections for staff as well as
ergonomics audits.
Business Support Services (BSS)
BSS is the repository of the ACHS and ACHS
International accreditation data, and it
collaborates with various departments and
university research partners on a variety of
projects. The BSS unit is responsible for data
extraction, data cleaning and reporting on the
data trends to stakeholders, jurisdictions,
members and surveyors.
BSS provides user support to all ACHS and
ACHS International members, surveyors and
staff in relation to the accreditation Assessment
18 ACHS ANNUAL REPORT 2015-2016
Recording Tool (ART), Electronic Assessment
Tool (EAT) and the in-house Customer
Relationship Management (CRM) system. These
services range from access; telephone and email
support; training and education; presentations;
help manuals; meetings and site visits.
BSS also administers, maintains and rehabilitates
the ACHS premises, including the office building
as well as the assets therein. The BSS strives to
ensure a safe working environment for the ACHS
staff, clients and visitors. Its responsibilities
include, amongst others, taking the necessary
steps to identify and mitigate the potential
hazards or risks in the working environment
from both health and hygiene aspects.
Surveyor and Survey Coordinator Development
Days are compulsory training days held annually
to ensure currency of knowledge of the surveyor
workforce. This training is required as part of
the reappointment process of the Surveyor
Workforce. These informative training days are
also structured to provide an opportunity for
skills development; additionally they provide
the opportunity for dialogue and peer support
between surveyors. The BSS team is responsible
for the management of these events.
State Advisory Committee (SAC) meetings are
held every six months in each state via face-to-
face meetings and/or teleconference. The role
of the SAC is to provide a forum for increasing
the engagement, as well as the dissemination
of information between the ACHS and its
stakeholders. The SAC meetings are vital for the
ACHS to enable it to be informed of and address
the issues that impact stakeholders in their local
environment. The BSS unit is responsible for all
aspects of organisation for these meetings as
well as the regulation of appointments and
re-appointments and measuring performance
of the committees against a set of agreed key
performance indicators.
The BSS also oversees Finance, IT and Surveyor
Workforce functions and related projects.
Accreditation AdministrationServices (AAS)
The core function of the AAS is to provide
administrative support to the Customer
Services Unit, accreditation administration
and education support services to member
organisations and surveyors to ensure the
success of the accreditation programs. This
includes participation in the review of business
processes at management and staff levels. The
AAS also has responsibility for management of
member records, their accreditation phases
and monitoring and reporting of membership
renewals and invoicing through the CRM.
Surveyor Workforce
The Surveyor Workforce Unit has responsibility
for selecting appropriate teams for on-site
surveys to ensure the credibility of the ACHS
accreditation programs and the satisfaction
of its members. These teams are now based
on skills and proficiency processes that lead
to more suitable surveyors being chosen
for surveys.
In addition, this unit is responsible for ensuring
surveyors are kept up to date with the latest
information via a dedicated surveyor newsletter
and regular updates to the surveyor section
of the ACHS website. Face-to-face education
is provided at an annual surveyor development
day in each state and additionally for
coordinators at a separate annual development
day. The development days are structured to
provide an opportunity for skills development
and for dialogue and peer support between
surveyors. Further education is provided via
eLearning, webinars and quarterly mandatory
competency quizzes.
The Surveyor Workforce Unit also provides
training for newly recruited surveyors as
required. The training program uses a mixture
of didactic and interactive learning and was
re-accredited this year. The interactive sessions
are structured to provide a simulated version
of the survey environment, and are presented
by experienced ACHS staff and survey
coordinators.
ACHS ANNUAL REPORT 2015-2016 19
The Surveyor Workforce Unit also has responsibility
for training and selecting appropriate surveyors
for projects. This year the team has worked with
various members of the surveyor workforce on
the following projects:
z Queensland Health Audit,
z Trauma Recovery Programme accreditation,
z Deepening our Understanding of Quality in
Australia (DUQuA) research together with
Macquarie University,
z Joint Accreditation Project with the Aged Care
Quality Agency;
z Short Notice Surveys.
Appropriate surveyors have also been selected
for consultancies for 23 organisations.
The unit monitors the performance of the
surveyor workforce on an ongoing basis to
ensure customer satisfaction and compliance
with requirements of the Australian Commission
on Safety and Quality in Health Care and
accreditation by the International Society for
Quality in Health Care (ISQua).
1. ACHS Staff and Surveyors at the SA Surveyor Development day, August 2015.
2. NSW Surveyor Inductee day, May 20163. ACHS Staff and Surveyors at the WA Surveyor Development day
September 2015.4. Keynote speaker Mr Peter Capp at the Vic Surveyor Development
day September 2015.
1. 2.
4.3.
ACHS Councillors 2016, as at 30 May 2016, was 29 Councillors, including three life members
Associate Professor Peter Bland
Royal Australian and New Zealand College of
Obstetricians and Gynaecologists (RANZCOG)
Ms Samantha Carney
Australian Day Hospital Association (ADHA)
Dr Margaret Cowling
MBBS, FFARACS, FANZCAAustralian and New Zealand College of Anaesthetists
(ANZCA)
Professor Geoff Dobb
BSc(Hons), MBBS, FRCP, FRCA, FANZCA, FCICM, FAMAAustralian Medical Association (AMA)
Ms Helen Dowling
BPharm, DipHospPharm (Admin), GradDipQlinHCare,CHP, FSHP, AICD Allied Health Professions Australia Ltd
Dr Iain Dunlop
MBBS(Hons), FRANZCO, FRACSAustralian Medical Association (AMA)
Associate Professor Brett Emmerson
MBBS, MHA, FRANZCP, FRACMAThe Royal Australasian College of Medical
Administrators (RACMA)
Dr Roger Jonathan Garsia
MBBS, PhD, FRACP, FRCPAThe Royal College of Pathologists of Australasia (RCPA)
Dr Michael Hodgson AM
FAMA, MBBS, FANZCA, FRCALife Member of ACHS Council
Dr David Hutton
MBBS, GradDipEconNSW Ministry of Health
Mr Mark Kearin
RN, ADCNS (Geront Nurs), BHSc (Mgt), MHSc (Mgt)Australian Nursing Federation (ANF)
Clinical Associate Professor Peter Kendall
MBBS, DA, FRACP, FCCPThe Royal Australasian College of Physicians (RACPS)
Mr Tony Lawson
BA, BSoc.Admin, FIPAA, FAIM, CPMgrConsumers’ Health Forum of Australia Ltd (CHF)
Adj Associate Professor Karen Linegar
RN, RM, MHA, BAppSc (Nursing), BBus, Dip.CommLaw, FRCNA, JPThe Australian College of Nursing (ACN)
Dr David Lord
MBBS, DPM, FRANZCPRoyal Australian and New Zealand College of
Psychiatrists (RANZCPS)
ACHS Council Members
OVERVIEW
Ms Angela Magarry
BHA, MPS, CGFNS, FCHSM Australasian College of Health Service Management
(ACHSM)
Dr Sally McCarthy
MBBS, MBA, FACEMAustralasian College for Emergency Medicine (ACEM)
Dr Roderick McRae
FAMA, MBBS (Hons), BMedSC (Hons), MBioeth, JD,PGDipPCCEAustralian Medical Association
Dr Jon Mulligan
MBBS, MHA, FRACP, FRACMA, GAICDLife Member of ACHS Council
Prof Leonard Notaras AM
AFCHSE, LLB, BA (Hons), DipComm, BMed, MHA, MAVice-President
Northern Territory Department of Health and Community
Services
Dr Eva Raik AM
MBBS, FRCPA, FRACPLife Member of ACHS Council
Mr Michael Roff
Grad Cert MgtAustralian Private Hospitals Association (APHA)
Dr Paul Scown
MMBS, BHA, FRACMA, AFACHSM, MAICDAustralian Healthcare & Hospitals Association (AHHA)
Mr John Smith PSM
MHA, GradDip HSM, AFACHSM, CHE, FAHSFMA,AFAHRI, AFAIM, FAICDPresident
Australian Healthcare & Hospitals Association (AHHA)
Ms Fiona Tito-Wheatland
BA (Hons) LLBHealth Care Consumers’ Inc.
Dr Phillip Truskett AM
MBBS, FACS, FRACS, FASCBI (Hons)The Royal Australasian College of Surgeons (RACS)
Ms Alison Verhoeven
BA, GradDipEd, MLitt, MBA, FAIM, GAICDThe Australian Healthcare & Hospitals Association (AHHA)
Mr Stephen Walker
AssDip.Eng, B.Bus, GradDipAcc, AFCHSE, MAICD Treasurer
Australian Private Hospitals Association (APHA)
Dr Noela Whitby AM
MBBS, GradDipHumNut, DPD, FRACGP, FAICDThe Royal Australian College of General Practitioners
(RACGP)
ACHS was still awaiting nominations from ACT Health, QldHealth and the Australasian Association for Quality in HealthCare at the time of publication.
20 ACHS ANNUAL REPORT 2015-2016
DIRECTORS’ REPORT
The Board of Directors (the Board) of The Australian Council on Healthcare Standards Limited (“ACHS”) in office at the date of this report present the results of The Australian Council on Healthcare Standards Limited and itscontrolled entities (collectively referred to as “the Group”) for the financial year ended 30 June 2016 and theIndependent Auditor’s Report thereon.
Directors and meeting attendanceAt the date of this report, the names of the members of the Board, the meetings of the Board and meetings of theBoard Finance Audit and Risk Committee (BFARC), and the number of meetings attended by each of the Boardmembers during the financial year are listed and summarised in the table below:
Mr Michael RoffAdj Assoc Prof Karen Linegar Mr John Smith PSM (Chair)Mr Stephen Walker (BFARC Chair)Ms Helen DowlingMs Jennifer BakerDr David LordProf Michael Cleary PSMProf Geoffrey DobbDr Noela Whitby AMMr Anthony LawsonProf Leonard Notaras AMA/Prof Brett Emmerson
Name Date appointed Date of Cessation
Board
Meetings
BFARC
MeetingsAttendance at ACHS Board MeetingsJuly 2015 – June 2016
2 Feb 200425 Nov 200424 Nov 200523 Nov 200627 Nov 200826 Nov 200926 Nov 200925 Nov 201025 Nov 201024 Nov 201124 Sep 201222 Nov 201225 Nov 2015
-----
25 Nov 2015-
30 Mar 2016
---
A B
9989839367885
9999949799995
A B
-2222-------
-2222-------
A I Number of meetings attended B I Number of meetings held during the time the director held office during the year
Directors have been in office since the start of thefinancial year to the date of this report unless otherwisestated. Details of directors’ qualifications, experienceand special responsibilities can be found on pages 24 to 25 of this report.
Company secretaryDr Christine Dennis has held the role of CompanySecretary since October 2014. Dr Christine Dennis is also the Chief Executive Officer of the ACHS.
Mission and strategyThe Group’s mission is to strengthen safe, qualityhealthcare by continuously advancing standards andeducation nationally and internationally.
The Group’s strategy for accomplishing its missioninclude:
z Expand our business reachz Grow our membershipz Build strategic alliancesz Inspire organisational performancez Ensure sustainability z Share our knowledge.
Principal activitiesThe principal activities of the Group during the financialyear remained unchanged and were dedicated toimproving the quality of healthcare in Australia throughcontinuous review of performance, assessment andaccreditation.
Review of operationsThe Group’s net surplus of $1,324,513 has beenachieved mainly due to savings in operational and on-sitesurvey costs. The Group has no loans or borrowings toany financial institution as at 30 June, 2016.
During the year a large number of accreditationmemberships were up for renewal with a high percentagerenewing their membership. On renewal, the majorityhave retained their existing accreditation program witha few changing to another ACHS accreditation program.
Performance measuresThe Group measures its performance through themonitoring of key performance indicators:
z To assess the cost effectiveness of the provision of product and services
z To ensure revenue derived is effectively directed back to servicing customers
z To assess member and stakeholder satisfaction with the programs and services received
z To assess the take up of programs and services z To assess the effectiveness of support and services
provided to customersz To assess and manage risks.
Risk Management The ACHS is committed to the effective management of risks. At the ACHS the ownership of the day-to-daymanagement of risks remains the responsibility of theChief Executive Officer with the support of ACHS staff.
ACHS ANNUAL REPORT 2015-2016 21
The Board Finance Audit and Risk Committee (BFARC)has the primary oversight of risk management practicesacross the ACHS.
Its responsibilities include assisting the Board throughperiodic review of the operation of the ACHS RiskFramework, through review of reports from the CEO.The BFARC meets at least twice a year to endorse allrisk monitoring, compliance, financial reporting,budgeting and forecasts for the Group. During the yearexisting controls are in place to ensure all identified risks are managed within an acceptable level consistentwith our risk appetite.
Members’ guaranteeACHS is incorporated as a company limited byguarantee. In accordance with the company’sconstitution each member of the company is liable tocontribute $50 if the company is wound up during thetime he/she is a member or within one year thereafter.As at 30 June, 2016 the total amount those members of the company were liable to contribute if thecompany is wound up is $1,500.
AUDITOR'S INDEPENDENCE DECLARATION
A copy of the auditor's independence declaration as required under section 307C of the Corporations Act 2001 is
set out on the following page.
Auditor
This report is made in accordance with a resolution of directors.
On behalf of the directors
Mr John Smith PSMPresident
Mr Stephen WalkerTreasurer
Sydney – 22 September 2016
22 ACHS ANNUAL REPORT 2015-2016
AUDITOR’S INDEPENDENCE DECLARATION TO THE DIRECTORS OF THE AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS
In accordance with the Section 307C of the Corporations Act 2001, as lead auditor of The Australian Council on
Healthcare Standards for the year ended 30 June 2016, I declare that, to the best of my knowledge and belief,
there have been:
z no contraventions of the auditor independence requirements as set out in the Corporations Act 2001 in
relation to the audit; and
z no contraventions of any applicable code of professional conduct in relation to the audit.
Pitcher Partners Sydney
Melissa AlexanderPartner
Dated in Sydney this 22nd day of September 2016
ACHS ANNUAL REPORT 2015-2016 23
Mr John Smith PSM (President)MHA, Grad Dip HSM, FAICD,FAHSFMA, AFACHSM, AFAHRI,AFAIM, CHE,z ACHS President from 2015z ACHS Vice President, 2011-2015z ACHS Treasurer, 2007-2011z ACHS Board member from 2005z ACHSI Treasurer, 2009-2012z ACHSI President from 2015z ACHSI Board member from 2008z ACHS Councillor (Australian Hospital
and Healthcare Association representative) from 2000
z National Councillor, AHHA from 2000z Director Victorian Healthcare
Association, 1997-2004z Board member, The Victorian
Hospitals Industrial Association Limited from 1994
z Vice Chairman, The Victorian Hospitals Industrial Association Limited
z Chief Executive Officer, West Wimmera Health Service
Professorr Len Notaras AM (Vice President)AFCHSE, LLB, BA (Hons), DipComm,BMed, MHA, MAz ACHS Vice-President from 2015z ACHS Board member from 2002z ACHSI Board member from 2009z ACHS Councillor (Northern Territory
Health representative) from 2002z Chief Executive Officer (CEO), NT
Department of Healthz Region #1 Top End Medical Disaster
Coordinatorz Executive Director National Critical
Care and Trauma Response Centre from 2009
z Medical Director of the NT Medical Administration Network from 2005
z Medical Superintendent Royal Darwin Hospital, 1994-2007
z NT Principal Medical Consultant, 1996-2002
z General Manager, Royal Darwin Hospital, 1995-2009
z Deputy CEO NT Health, 2000-2001z Senior Lecturer NT Clinical School,
1995-presentz Member NT Medical Board,
1996-2012z Chair NT Radiographers Board,
1997-2006z Chair NT Pharmacy Board,
1997-2006z Chair NT Radiographers Board,
1997-2006z Council Member National Council
for Safety and Quality in Healthcare,1999-2002
z Senior Superintendent NT Acute Care Network, 2003-2007
z Clinicians Involvement Working Group Chair, 2003-2004
z NT President ACHSE, 2003-2006z Chair NT Acute Care Quality
Committee, 2003-2008z Appointed Professor Fellow,
Flinders University SA, July 2015
Mr Stephen Walker (Treasurer)Ass DipEng, BA Bus, GradDipAcc,AFCHSE, MAICDz ACHS Treasurer from 2012z ACHS Board member from 2006z ACHSI Board member from 2011z ACHS Councillor (Australian Private
Hospital Association rerpresentative)from 2006
z Chief Executive Officer, St Andrew’s Hospital, Adelaide from 2001
z Member, SA Clinical Training Council
z Past Vice President, SA branch Australian College of Health Service Management (ACHSM)
z Past ACHS and Quality Health New Zealand Surveyor
Ms Jennifer Baker (ceased November 2015)
BHSc (Mgt), BBus (IR), MLegSt, MIR,FCHSM, CHEz ACHS Board member from 2009z ACHS Councillor (ACHSM
representative) from 2007z ACHSM Board member 2005-2012z Member, Australian Institute of
Radiographyz Fellow of the Australian College
of Health Services Managementz Fellowship Examiner ACHSM
Dr Michael Cleary PSM (ceased March 2016)
MBBS, MHA, FACEM, FRACMA, AFACHSMz ACHS Board member, from 2011z ACHS Councillor (QLD Health
representative) from 2011z Chief Operations Officer,
Department of Health and Deputy Director-General, Health Services and Clinical Innovation Division
z Member Medical Services Advisory Committee
z Chair and Deputy-Chair of the Australian Casemix Clinical Committee
z Treasurer and Councillorfor the Australasian College for Emergency Medicine
z Fellow of the Australasian College for Emergency Medicine
z Fellow of the Royal Australasian College of Medical Administrators
Professor Geoffrey DobbBSc (Hons), MBBS, FRCP, FRCA, FANZCA,FCICM, FAMAz ACHS Board Member from 2011z ACHS Councillor (Australian Medical
Association representative) from 2011z Chair, Advisory Council, Australian
Organ and Tissue Authorityz Board Deputy Chair, Child and
Adolescent Health Service, WA z Director, Australian Medical
Association Ltd
BOARD OF DIRECTORS
Adj Assoc ProfessorKaren Linegar
Mr John Smith PSM(President)
Mr Stephen Walker(Treasurer)
Ms Jennifer Baker Dr Michael Cleary PSM Ms Helen Dowling
Associate ProfessorBrett Emmerson
Mr Anthony (Tony) Lawson
Dr David Lord
Prof Len Notaras AM
Mr Michael Roff
Professor Geoffrey Dobb
Dr Noela Whitby AM
24 ACHS ANNUAL REPORT 2015-2016
z Head of Department, Intensive Care, Royal Perth Hospital
z Clinical Professor, School of Medicine and Pharmacology, University of WA
z Consultant in Intensive Care, Mount Hospital, Perth, WA.
z Consultant in Intensive Care, St John of God Hospital, Subiaco, WA
Ms Helen DowlingBPharm, DipHospPharm (Admin),GradDipQI in HCare, FSHP, AICDz ACHS Board member from 2008z ACHS Surveyor from 2009z ACHS Standards Committee
member from 2003z Chair, ACHS Standards Committee,
2007-2012z ACHS Councillor (Allied Health
Professional representative) from 2001
z Pharmacist Consultant Contractor, Australian Commission on Safety & Quality in Health Care from 2015
z Chief Executive Officer, The Society of Hospital Pharmacists of Australia from 2012-2015
z Director of Pharmacy, Hunter New England Local Health District, 2008-2012
z Director of Pharmacy, Greater Newcastle Sector, Hunter New England Health, 2001-2008
z Member ACSQHC Health Services Medication Expert Advisory Committee from 2012-2015
z Member ACSQHC Clinical Care Standards Advisory Committee from 2013
z Member NSW Health Caring Together Independent Panel, 2009-2011
z Member NSW Health Medication Safety Strategy Steering Committee, 2009-2012
z Member and President, Pharmacy Council of NSW, 2010-2015
z Vice President, Pharmacy Board of NSW, 2008-2010
z Federal President, The Society of Hospital Pharmacists of Australia (SHPA), 1999-2002
z SHPA GlaxoSmithKline Medal of Merit recipient 2005
Associate Professor Brett EmmersonMBBS, MHA, FRANZCP, FRACMAz ACHS Board Member from 2015 z ACHS Councillor, (RACMA
Representative) from 2009z Councillor, RANZCP 2000–2009z Chair, Central Queensland Mental
Health Clinical Network, 2007 - currentz Chair, Queensland Mental Health
Clinical Collaborative, 2005 - currentz Member, Queensland Health Medicine
Advisory Committee, 2000
z Executive Director, Metro North Mental Health from 1997 – current
z Stepping Stones Club House Board Member from 1995
z Member, ACHS Standards Committee from 1994 to current
z ACHS Surveyor from 1994 to currentz Director, Logan Mental Health Service,
1994-1997z Queensland Chief Psychiatrist,
1990-1994
Mr Anthony (Tony) LawsonBA, BSoc.Admin, FIPAA, FAIM, CPMgrz ACHS Board Member from 2012z ACHS Councillor (Consumers Health
Forum of Australia representative) from 2012
z ACHS Surveyor z Chair, CHF Ltdz Member, St Andrew’s Hospital
Consumer Reference Groupz Member, Australian Atlas of
Healthcare Variation Advisory Group - Australian Commission on Safety and Quality in Health Care
z Fellow, Institute of Public Administration Australia
z Fellow, Australian Institute of Management
z Managing Director, Tony Lawson Consulting
z Executive Director, Institute of Public Administration of Australia, SA Division (IPAA SA)
z Former CEO City of Mitchamz Former Commissioner for Consumer
Affairs SAz Former Chair, Health Consumers
Alliance of SA Incz Former member, Central Adelaide
Local Health Network Governing Council
Adjunct Associate Professor Karen LinegarRN, RM, MHA, BAppSc (Nursing), B Bus,Dip Comm Law, FACN, JPz ACHS President, 2011-2015z ACHS Vice President, 2008-2011z ACHS Board member from 2004z ACHSI Board member from 2008z ACHS Surveyor from 2005z ISQua Board Member, 2013-15z ACHS Councillor (Australian College of
Nursing / Australian Nursing Federation representative) from 2004
z Appointed ISQua expert 2013 z Acting Chief Executive Officer
Tasmanian Health Organisation - North West, 2010-2011
z Executive Director of Nursing, Midwifery and Care Redesign - Tasmanian Health Organisation - North West 2009–current
z Director of Nursing - North West Regional Hospital, Burnie, 1994-2009
z Chair ACHS Tasmanian Advisory Committee from 2005
z President, Royal College of Nursing, Australia, 2002-2004
z Board member, Royal College of Nursing, 2002-2007
z Chair, Nursing Board of Tasmania, 2000-2003
Dr David LordMBBS, DPM, FRANZCPz ACHS Board member from 2009z ACHSI Board member from 2011z ACHS Councillor (Royal Australian and
New Zealand College of Psychiatrists representative) from 2009
z ACHS Surveyor from 2007z Retired (2008) psychiatrist
Mr Michael RoffGrad Cert Mgt.z ACHS Board member from 2004z ACHS Councillor (Australian Private
Hospital Association representative) from 2004
z Chief Executive Officer, APHA from 2000z Member, National Health Performance
Committee, 2000-2008z Member, Private Health Industry Quality
& Safety Committee, 2000-2004z Director, Australian Centre for Health
Research, 2006-2010z Member, Private Hospital Sector
Committee (ACSQHC) from 2013z Member, Clinical Trials Advisory
Committee, 2014-2016z Member, National Health Performance
Authority Advisory Committee for Private Hospitals, 2014-2016
Dr Noela Whitby AMMBBS, Grad Dip HumNut, DPD, FRACGP,FAICDz ACHS Vice-President, 2005–2007z ACHS Board member, 2000–2009;
2012-presentz ACHS Councillor (RACGP representative),
2000–2009; 2012-presentz ACHSI Board member, 2006–2009z Deputy Chair RACGP Queensland
Faculty Board from 2013z Chair, National Expert Committee on
Standards of RACGP, 2002–2005z Member, National Expert Committee on
Standards of RACGP from 1994z Chair, AGPAL, 2003–2006z Director, AGPAL, 2000–2006z Director, Quality in Practice Pty Ltd,
2003–2006z Director, National Asthma Council
Australia, 2005-2014z Chair, National Asthma Council
Australia, 2008-2014z Member, Medical Services Advisory
Committee, Australian Government, from 2014
z General Practice Principal, Carindale Medical Clinic, Brisbane from 1979
z Associate Professor of General Practice,Bond University, 2006-2007
z Past ACHS Surveyorz Fellow of the AICD
Ms Helen Dowling
ACHS ANNUAL REPORT 2015-2016 25
ACHS Board Members I representing consumers, governments and the Australian healthcare industry
CONSOLIDATED STATEMENT OF PROFIT OR LOSS AND OTHER COMPREHENSIVE INCOME FOR THE YEAR ENDED 30 JUNE 2016
CONSOLIDATED STATEMENT OF FINANCIAL POSITION AS AT 30 JUNE 2016
26 ACHS ANNUAL REPORT 2015-2016
CONSOLIDATED STATEMENT OF CHANGES IN EQUITY FOR THE YEAR ENDED 30 JUNE 2016
CONSOLIDATED STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 30 JUNE 2016
ACHS ANNUAL REPORT 2015-2016 27
NOTES TO THE FINANCIAL STATEMENTS
28 ACHS ANNUAL REPORT 2015-2016
NOTES TO THE FINANCIAL STATEMENTS
ACHS ANNUAL REPORT 2015-2016 29
NOTES TO THE FINANCIAL STATEMENTS
30 ACHS ANNUAL REPORT 2015-2016
NOTES TO THE FINANCIAL STATEMENTS
ACHS ANNUAL REPORT 2015-2016 31
NOTES TO THE FINANCIAL STATEMENTS
32 ACHS ANNUAL REPORT 2015-2016
NOTES TO THE FINANCIAL STATEMENTS
ACHS ANNUAL REPORT 2015-2016 33
NOTES TO THE FINANCIAL STATEMENTS
34 ACHS ANNUAL REPORT 2015-2016
NOTES TO THE FINANCIAL STATEMENTS
ACHS ANNUAL REPORT 2015-2016 35
NOTES TO THE FINANCIAL STATEMENTS
36 ACHS ANNUAL REPORT 2015-2016
NOTES TO THE FINANCIAL STATEMENTS
ACHS ANNUAL REPORT 2015-2016 37
THE AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS
A.C.N. 008 549 773
DIRECTORS’ DECLARATION FOR THE YEAR ENDED 30 JUNE 2016
1. In the directors’ opinion:
a) the financial statements and notes set out on pages 9 to 19 are in accordance with the Corporations Act 2001,
including:
i. complying with Accounting Standards, and the Corporations Regulations 2001; and
ii. give a true and fair view of the consolidated entity’s financial position as at 30 June 2016 and
of its performance for the financial year ended on that date; and
b) there are reasonable grounds to believe that the company will be able to pay its debts as and when they
become due and payable.
This declaration is made in accordance with a resolution of the directors.
Mr John Smith PSMPresident
Mr Stephen WalkerTreasurer
Sydney – 22 September 2016
38 ACHS ANNUAL REPORT 2015-2016
INDEPENDENT AUDITOR’S REPORT
TO THE MEMBERS OF THE AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS
Report on the Financial Report
We have audited the accompanying financial report of The Australian Council on Healthcare Standards (‘the Group’) which
comprises the statement of financial position as at 30 June 2016, the statement of comprehensive income, statement of
changes in equity and statement of cash flows for the year then ended, notes comprising a summary of significant
accounting policies and other explanatory information, and the directors’ declaration of the consolidated entity comprising
The Australian Council on Healthcare Standards and the entities it controlled at the year’s end or from time to time during
the financial year.
Directors’ Responsibility for the Financial Report
The directors of the company are responsible for the preparation of the financial report that gives a true and fair view in
accordance with Australian Accounting Standards – Reduced Disclosure Requirements (including Australian Accounting
Interpretations) and the Corporations Act 2001 and for such internal control as the directors determine is necessary to
enable the preparation of the financial report that is free from material misstatement, whether due to fraud or error.
Auditor’s Responsibility
Our responsibility is to express an opinion on the financial report based on our audit. We conducted our audit in accordance
with Australian Auditing Standards. Those standards require that we comply with relevant ethical requirements relating to
audit engagements and plan and perform the audit to obtain reasonable assurance about whether the financial report is
free from material misstatement.
An audit involves performing procedures to obtain audit evidence about the amounts and disclosures in the financial report.
The procedures selected depend on the auditor’s judgement, including the assessment of the risks of material misstatement
of the financial report, whether due to fraud or error. In making those risk assessments, the auditor considers internal
control relevant to the entity’s preparation of the financial report that gives a true and fair view in order to design audit
procedures that are appropriate in the circumstances, but not for the purpose of expressing an opinion on the effectiveness
of the company’s internal control. An audit also includes evaluating the appropriateness of accounting policies used and
the reasonableness of accounting estimates made by the directors, as well as evaluating the overall presentation of the
financial report.
We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our audit opinion.
Independence
In conducting our audit, we have complied with the independence requirements of the Corporations Act 2001.
ACHS ANNUAL REPORT 2015-2016 39
Opinion
In our opinion, the financial report of The Australian Council on Healthcare Standards and its controlled entities is in
accordance with the Corporations Act 2001, including:
c) giving a true and fair view of the consolidated entity’s financial position as at 30 June 2016 and of its performance
for the year ended on that date; and
d) complying with Australian Accounting Standards – Reduced Disclosure Requirements (including Australian
Accounting Interpretations) and the Corporations Regulations 2001.
Pitcher Partners NSW
Chartered Accountants
Melissa AlexanderPartner
Dated in Sydney this 22nd day of September 2016
40 ACHS ANNUAL REPORT 2015-2016
ACHS ANNUAL REPORT 2015-2016 41
z ISQua Conference Doha
QUALITY IMPROVEMENT INITIATIVES
TACKLED BY HEALTHCARE ORGANISATIONS -
A 5 YEAR REVIEW OF ACHS ANNUAL QUALITY
IMPROVEMENT AWARDS.
M. W. Burgess, L. O'Connor, K. Linegar,
This abstract focussed on areas healthcare
organisations prioritise for quality improvement
by analysing ACHS Quality Improvement Awards,
both winning and highly commended
submissions, over 5 years.
Presentations and Submissions
PROFILE
Public recognition of achievement by a healthcare organisation, of requirements ofnational healthcare standards
A measure of the clinical management and outcome of care; a method of monitoringconsumer / patient care and services which attempts to ‘flag’ problem areas,evaluate trends and so direct attention to issues requiring further review
Contains the 10 NSQHS Standards and the 5 additional standards derived fromEQuIP5
A health professional trained by ACHS to assess the performance of healthcareorganisations against EQuIP standards and other quality improvement programs
Accreditation
Clinical Indicator
EQuIPNational
Surveyor
Definitions in this glossary are for use in the context of this Report
Glossary of terms
The Australian Council on Healthcare Standards (ACHS)
5 Macarthur Street Ultimo NSW 2007 Australia
T. 61 2 9281 9955 F. 61 2 9211 9633 E. [email protected]
www.achs.org.au