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
ACHSNEWS 2
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.
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 [email protected]
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: [email protected]
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
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 [email protected] 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 [email protected].
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 [email protected]