ACHSNEWS The Australian Council on Healthcare Standards

The official newsletter from ACHS to communicate to all member organisations and our stakeholders

ACHSNEWS

See Inside For: ACHS and ACHSI Medals ACHSI Update Education Dates

No. 51 Winter 2015

JOINT ACHSM/ACHS ASIA-PACIFIC ANNUAL CONGRESS

28—30 OCT 2015 SOFITEL MELBOURNE ON COLLINS

HEALTH LEADERSHIP: ODDS-ON FAVOURITE

Best In Show: and the challenge of Inter-Rater Reliability

For any survey or consultancy undertaken by the ACHS

that requires individuals to rate performance, it is

important to ensure a good level of inter-rater reliability.

The inter-rater reliability of surveyors – or the degree of

agreement among raters is one of the more frequently

raised issues from our member organisations and one

that ACHS has invested an impressive amount of time,

energy and resources over the last two years.

Inter-rater reliability is the most easily understood form of

reliability because everyone has experienced it (http://

explorable.com). For example watching any event using

judges such as Olympics ice skating or a dog show,

relies on human observers maintaining a degree of

consistency between observers. I remember the many

years my mother (pictured) tolerated the judging of her

prized corgis; the heated discussions that occurred when

she didn’t place yet alone win and, the excellent judging

when she won! Interestingly, the Dog Show Analogy has

been used to explore parallels between the treatment

and assessment of school students and canines at a dog

show (Hitt and Helms, 2009). This analogy-based activity

was believed to better present an approach to learning

that was compatible with the way people think, and help

people reflect on their behaviours, attitudes and

assessment biases in a parallel analogue. Simply and

succinctly the following occurs;

‘On the day of the Dog Show Analogy, we show students

[trainee teachers] a video clip of a Best in Show judging.

Before the judge makes his or her decision, we stop the

video and ask the students to choose a winner and

provide reasons for their choices.’

The students then share their views on the judge’s

decision and are asked to infer what type of criteria the

judge used to make his or her decision. Hitt and Helms

(2009) stated that with reflection, practice and

perseverance, it is possible to create more objective and

equitable learning environments.

From an ACHS perspective we are proud of the progress

we are making to continue to improve the validity of

assessments by keeping perceptions and biases in

check. We listen to the feedback we have received from

our State Advisory Committee (SAC) meetings, as well

as member feedback, and we know we have made an

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Dr Christine Dennis

improvement. We have contributed to research

(Greenfield et al 2008, Greenfield et al 2013) in an

attempt to better understand and achieve improved inter-

rater reliability and are mindful that the challenge in terms

of consistency in and across assessments, is a

demanding task (Greenfield et al, 2013). A challenge that

is described as being evident, as noted above, in many

areas of society.

We are also acutely aware that as we are working with

more than 342 peer surveyors in Australia (and 109

surveyors overseas) it is impossible to expect that every

single surveyor will interpret and assess information in an

exactly consistent manner that totally negates their own

personal background, clinical and work experiences.

They are, after all, health service professionals bringing

their skills and expertise to the task.

There is always an expectation from health care

organisations that we are providing the most appropriate

surveyor experience available for that survey, and it is

our goal to meet this expectation. We still have nearly

125 survey occasions to be held in the second half of

2015, and will continue to ensure our surveyors are

appropriate for each event, taking logistics, geography,

availability and a myriad of other external events into

consideration. I noted recently one of our SAC members

referred to it as ‘event management ’– and it is certainly

that – on a grand scale!

One of the biggest improvements in managing the output

of our surveyor workforce (to whom we are indebted for

their time and efforts) concerns the greater consistency of

Surveyor Co-ordinators in 2014. This ensures that there

is a greater continuity from the lead surveyor between

events, and we have received some very appreciative

member feedback on this. It has made a significant

difference to how the ‘corporate’ or historical knowledge

of an organisation can contextually be understood by the

survey team.

And finally in case you are wondering, the picture

features my mother being awarded the Queen’s Trophy –

excellent judging! Fair and objective and, using agreed

breed standards established by expert kennel clubs!

Unfortunately when mother and her champion dog were

presented to the Queen, the dog didn’t stop barking!

Naughty boy! You wouldn’t have won if I had been the

judge and that’s not how you behave in front of royalty!

A Hitt and E Helms (2009). Best in Show: Teaching Old Dogs

to Use New Rubrics. Sourced at: http://files.eric.ed.gov/fulltext/

EJ862760.pdf

D Greenfiled, M Pawsey, J Naylor and J Braithwaite (2008)

Are accreditation surveys reliable? International Journal of

Health Care Quality Assurance, Vol.22 No.2, pp 105-116.

D Greenfield, M Pawsey, J Naylor and J Braithwaite (2013).

Researching the reliability of accreditation survey teams:

lessons learnt when things went awry. Health Information

Management Journal, Vol 42 No.1

Brunswick Private Hospital, part of the

Healthe Care Group received its NSQHS

Standards accreditation certificate at a

special presentation held in early June.

Attended by ACHS Vice President, Mr John

Smith PSM, Brunswick Private staff

listened to how a consistent level of

improvement had been applied across the

organisation to the NSQHS Standards.

Healthe Care Group Chairman, Mr Geoff

Sam also attended the presentation.

Pictured from left to right, Brunswick

Private Hospital Quality Manager, Mr Wes

Carter, Mr Smith PSM and Mr Sam.

Brunswick Private Hospital

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Each year ACHS gives recognition to an individual for

their outstanding contribution to the Australian

healthcare scene with the awarding of the ACHS Medal.

Last year, for the first time, ACHS introduced the ACHS

International Medal for an individual working overseas

who has contributed to improving quality and safety in

health services, but at an international level in a country

where ACHS International continues the work of ACHS.

Following Dr Lawrence Li from Hong Kong being

awarded the medal, the ACHS Board has decided to

meet the expectation from overseas that we will

continue this valuable recognition again in 2015.

ACHS Chief Executive Officer Dr Christine Dennis said that ACHS realised that there was an expectation overseas that the ACHS International Medal would continue beyond 2014, and that it was important for ACHS to recognise those contributions that had helped to shape ACHS’ broader success internationally.

“Through our subsidiary ACHSI we have extended an extensive footprint throughout 18 countries where the ACHS model of accreditation – and our accreditation program - EQuIP5 – has been adopted and

recognised as a highly successful way of delivering healthcare accreditation,” she said.

“We are fortunate to be working with many talented and influential people in a range of health jurisdictions overseas who recognise the value of accreditation and continue to fly the ACHS flag. There have been some significant contributions made to improving the development of quality in health care overseas and we wish to honour this by awarding the ACHS International Medal to ensure suitable recognition.”

Nominees for the ACHSI Medal will need to demonstrate any or all of the following commitments to quality and safety in an international context:

Substantial achievement on research into quality and safety of health systems;

Distinguished leadership in quality practices sustained;

Outstanding achievement in maintaining a continuous quality improvement focus in healthcare delivery systems; or

Outstanding achievement in the promotion of quality in health care.

The closing date for nominations and completed forms is Friday 18 September, 2015. Details about eligibility and the nomination enrolment form are on the ACHS website at www.achs.org.au/about-us/honours-and-awards/achs-medal/. The ACHSI Medal will be presented on Thursday 29 October at the ACHS/ACHSM Joint Asia Pacific Congress to be held in Melbourne.

Nominations are also open for the ACHS Medal – and the nomination form can also be found at the link above. Check out the impressive list of previous recipients. The ACHS Medal winner will also be announced on 29 October.

Gold, Gold, Gold – ACHS medal and the ACHS International

Medal are both open for Entries

Dr Lawrence Lai, Adj Assoc Prof Karen Linegar, Ms Kae Martin

ACHSNEWS 4

Hong Kong

The major activities under the Accreditation Scheme Project during the March - July 2015 period included:

Surveyor Development Workshops: 20 and 26 May, 5, 8 & 9 June 2015

Hong Kong Surveyor Induction Workshop – 10 to 12 June 2015 (attended by 28 participants)

On-site surveys of two hospitals, Our Lady of Maryknoll Hospital (21 – 22 May 2015) and Pok Oi Hospital (1 – 3 June 2015).

In the private sector, the Canossa Hospital (Caritas) Hospital underwent a second cycle OWS on 15-17 June 2015. Two Fresenius Medical Care Centres in Hong Kong have undergone their Organisation-wide Survey (OWS) under the EQuIP5 for Day Procedure Centres and received successful accreditation status for three years. The centres are:

Fresenius Medical Care Hong Kong Limited - NephroCare Tuen Mun Dialysis Centre (NCTM)

Fresenius Medical Care Hong Kong Limited - NephroCare Wan Chai Dialysis Centre (NCWC).

An International Surveyor Induction Workshop was also held in Hong Kong on 27 – 29 May 2015. It was attended by 26 participants who represented an impressive skills-mix from an array of different countries that included Bahrain (1), Saudi Arabia (3), Qatar (2), Sri Lanka (5), Hong Kong (3), Singapore (3), Korea (2), Japan (5), and Malaysia (1).

ACHSI Update

Participants of the Hong Kong Surveyor Workshop with ACHS Executive and staff (10 to 12 June).

Singapore

Three Fresenius Medical Care Centres in Singapore also had their OWS in May 2015 under the EQuIP5 for Day Procedure Centres and were awarded three years accreditation status. They were some of the first clinics of the Fresenius group in Singapore to be accredited by ACHSI. The centres are:

Fresenius Medical Care Napier Dialysis Clinic

Fresenius Medical Care Singapore Pte Ltd - Asia Renal Care Mt Elizabeth Pte Ltd Dialysis Centre

Fresenius Medical Care Tanglin Dialysis Clinic.

Participants of the International Surveyor Induction

Workshop with ACHS Executive and staff.

China

The Hong Kong University of Shenzhen Hospital will undergo a three-day consultancy at the end June 2015 in preparation for an OWS in September 2015.

ACHS Hong Kong Surveyors and ACHS Executives at the Surveyor Development Day held on 20 May 2015.

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NEW IN 2015! Emergency and Disaster Management in Healthcare

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This workshop premiered in Brisbane on 18 June 2015. It was a very productive day and participants shared their

experiences and worked on strengthening governance frameworks and practical planning for Emergency and

Disaster Management in their organisations. The workshop is presented by Graeme Houghton, ACHS Educator and

Survey Coordinator.

ACHS Education Update

Webinars: ACHS webinars are designed to give wider access to ACHS education, presented by experienced

ACHS surveyors. Each session is scheduled for an hour, and all you need to join is a computer with

broadband access and a phone. Upcoming topics for 2015 include some for particular organisation types

such as Day Procedure Centres and Mental Health organisations:

ACHS Root Cause Analysis Training

ACHS has now provided 20 Root Cause Analysis (RCA) onsite Education Workshops for healthcare organisations in

2015. The program includes an introduction to Human Factors and Failure Mode Analysis and is a scenario-based

interactive workshop which has been very well-received.

In response to demand for education around patient safety using alternate methods for collecting data, analysing and

investigating adverse events, ACHS is working with Peter Hibbert to develop a new workshop which will use a

similar four hour, interactive, onsite model to introduce and workshop two of the methodologies to your staff.

For further workshop details, please email the ACHS Education Service at educate@achs.org.au

Feedback from attendees included:

‘Good group of people and class size was the right amount for everyone to have input’

Enjoyed: ‘Clearly defined learning objectives; explaining and understanding framework of writing disaster plan’

‘Group engagement and discussion; relevant information and links to risk’

‘Good overview and experienced presenter; nice mix of examples re: context for emergency planning’

Details of education events up to the end of 2015 are now available on the ACHS website at: http://www.achs.org.au/education-services/achs-calendar-workshops-and-webinars/

Date and time

Topic Link to webpage and more details

Tuesday 28 July 2015 @ 1400 (AEST)

NSQHS Standard 3: Hand Hygiene, Aseptic Technique and Invasive Devices

click here

Wednesday 5 August 2015 @ 1400 (AEST)

HOT TOPICS in Mental Health: NSQHS Standards 1, 2, 6 and 9

click here

Monday 17 August 2015 @ 1400 (AEST)

NSQHS Standard 5 – Patient Identification and Procedure Matching

click here

Thursday 20 August 2015 @ 1400 (AEST)

For Small Hospitals 1: Audit for NSQHS Standards 1-3 click here

Wednesday 2 September 2015 @ 1400 (AEST)

NSQHS Standard 8 – Preventing and Managing Pressure Injuries

click here

Tuesday 8 September 2015 @ 1400 (AEST)

Ask a Surveyor for Day Procedure Centres click here

ACHS Education: Phone: 02 9281 9955 email: educate@achs.org.au

Click here for more information and to register for Sydney 16 September 2015

ACHSNEWS 7

First half of 2015 - Clinical indicator data

submission reminder

This is a reminder that the deadline for submission of clinical

indicator data for the first half (January - June) 2015 is

Thursday 20 August 2015. Your assistance in submitting

data by the due date will enable us to return your reports

promptly. The data need to be submitted through the

Performance Indicator Reporting Tool (PIRT), click here.

Please note that data received after the due date cannot be

included in the ACHS National Aggregate Indicator

Database.

A new member of the

CSM team During the month of June

the CSM team welcomed a

new member.

Raman Dhaliwal (Customer

Services Manager for

Victoria public

organisations) gave birth to

a baby boy, Dilsher, on 16

June 2015. Whilst Raman is

enjoying motherhood (parental leave) Andrew

Harrison has been seconded to her position.

Andrew has been working at ACHS in the role

of Coordinator of Surveyor Resources for more

than 4 years and he is very familiar with the

ACHS accreditation processes. Andrew can be

contacted on 02 9218 9955 or

aharrison@achs.org.au.

Remember, if your CSM is not available at any

time, assistance can be provided by any

member of the CSM team.

New surveyor inductees

receive warm welcome

From left to right: Dr Peter O’Brien, Ms Deidre Giacomin,

Clin A/Prof Gary Lane, Ms Maureen Lewis, Assoc Prof

Robert Tam, Mr Shane Combs, Front: Mrs Jane Oldham,

Clin A/Prof Jonathan Gillis, Ms Louise O’Riordan, Dr

James Sweeney, Mrs Carol Moore, Dr Alison Dwyer, Ms

Irene Constantinidis. The group provides an impressive

skills-mix covering a range of critical areas in health and

contemporary health settings. Welcome and good luck in

your future work with ACHS.

ACHS recently hosted an enthusiastic group of 13 new

inductee surveyors in Sydney for an introduction to ACHS

and to surveying.

Take a trip through our

timeline history

To commemorate

its 40 year

anniversary –

celebrated last

year, ACHS has

printed the 40

Year historical

timeline it

developed 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. If you wish to secure a copy of

this limited-run publication, please contact Camille

Party, communications at cparty@achs.org.au to

secure a copy.

ACHSNEWS 8

CHS is pleased to announce several quality

improvements have been made to the

Assessment Recording Tool (ART). These

updates and improvements have been made as a result

of member organisation, stakeholder, and ACHS

Surveyor feedback.

Tailored Help Manuals

The ART team has created three assistance manuals

each tailored to three key groups. ACHS Surveyors,

ACHS coordinators, and ACHS member organisations.

These can be found on our website, on both the login

page of ART and in the ‘Help’ section once you have

logged in. The manual details how to use each section of

ART and includes Frequently Asked Questions (FAQ’s)

and contact details for the ACHS ART Help Team.

Copyright and Intellectual Property Update

ACHS has recently reviewed the copyrighting of its own

website information and has introduced a new procedure

to ensure that copyright conditions are understood by

users. Both ACHS members and authorised people are

able to access the information, but need to indicate that

they understand the terms and conditions of being able to

access such information when doing so. Under copyright

law, all materials on the ACHS website are owned or

licensed by ACHS and this limits what the user may do

with the materials, as some of the information is

confidential to ACHS. Agreeing to the ‘Conditions of

Usage’ is now necessary before proceeding to login to the

ART.

Managing ART Users

The “Manage users” section in ART has been upgraded

to an interactive format. This upgrade allows Organisation

Administrators to send user update requests, requests to

delete old/inactive users, and requests to add new users

directly through ART.

Feedback

Your feedback is important to us so in an effort to

streamline this process the current post survey PDF

feedback forms are being phased out with new concise

forms being incorporated into the ART and EAT5

systems. ACHS Coordinators are already using the newly

implemented forms. Phase 2, currently under

development, will cover the introduction of surveyor

forms. The final phase will be to implement organisation

feedback forms.

If you would like to assist us on our quality improvement journey by providing feedback on the Assessment Recording Tool (ART), please contact support staff at ART@achs.org.au.

A

CALL FOR EXPRESSIONS OF INTEREST:

Patient Safety: Data Collection and Investigation Techniques -

Onsite Education Workshops 2015

In response to demand for education around patient safety using alternate methods for collecting data, analysing

and investigating adverse events, ACHS has worked with Peter Hibbert to develop a new workshop which will use a

similar four hour, interactive, onsite model to introduce and workshop up to three methodologies for your staff.

Details are available at http://www.achs.org.au/education-services/patient-safety-onsite-workshops/

To register your interest in running a session at your organisation, please email educate@achs.org.au