ACHSNEWS The Australian Council on Healthcare Standards
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The official newsletter from ACHS to communicate to all member organisations and our stakeholders
No. 45 Spring 2013
ACHSNEWS
QI Awards info News from CIP Education Events
See Inside For:…..
ACHS undergoes survey for accreditation As I write this, ACHS is undergoing survey for its
own accreditation, and this is always a timely
reminder of the journey our members also travel.
This week we are being surveyed by the
International Society for Quality Health Care (ISQua)
who are visiting our offices in Ultimo for four days.
Over the last few months as we commenced our
preparations and reviewed what we have improved
and developed since we were last accredited, we’ve
experienced the same level of anticipation our
members go through.
As an approved accrediting agency to the National
Safety and Quality Health Service (NSQHS)
Standards, it is a condition that we must be
accredited ourselves and the preparation of our self-
assessment tool reflects the extensive self-
improvement journey we have been on for the last
four years.
A large amount of work has gone into preparing for
this survey, and it represents a great opportunity to
take stock of our achievements, opportunities for
improvement, as well as the
plans we have for our future.
Memberships
I am delighted to report that
the majority of our members
have elected to stay with
ACHS as their accreditation
provider.
The strong affirmation we have received from
members’ instils a great level of confidence in what
we undertake. We are proud to be the major
provider of accreditation services to the Australian
healthcare industry and our ‘Who we accredit’ story
on page 2 illustrates the extensive range of
organisations we are proud to have as our members.
As we approach our 40th anniversary in 2014, we
remain committed to bringing a new level of energy
and dynamism in delivering quality services to you.
I look forward to sharing more with you on how we
plan to celebrate our important milestone in the next
edition of ACHS News.
Adj. Assoc. Professor Karen J Linegar FACN JP, President
Left: Teamwork … Nikki Humphreys, Margaret Jackson and Jeff Yao go through some last minute details for the survey.
Australia’s StrongestStrongestStrongest Healthcare
Accreditation Organisation
ACHSNEWS 2
We accredit from coast to coast With more than 1,450 members dispersed throughout
the country, ACHS can lay claim to being Australia’s
largest healthcare accreditation provider.
Our members are made up of a
variety of health facilities,
organisations, private
businesses and associations
covering a range of services.
Geographically we accredit from
Christmas Island to Lord Howe
Island, from the Gulf of
Carpentaria down to Tasmania
and across the Nullarbor to
central Western Australia.
While hospitals make up a
strong component of our membership base, it also
includes: Forensic Medicine, prison hospitals, remote
community health centres in isolated areas, oral health
centres, private hospitals, private health organisations,
day procedure centres, radiation oncology units, IVF
centres and even a sleep clinic.
“We cover every possible aspect of health care
provided, and the diversity of our
member profile reflects how
robust our accreditation programs
are in assisting to deliver quality
healthcare accreditation,” said
Acting Chief Executive, Dr Lena
Low.
“Particularly in the last few years
we have evolved our programs to
meet our members’ needs, and at
the same time expanded
membership growth in diverse
areas,” she said.
“Our point of difference is that as a not-for-profit
organisation we use peer-review and value-add
programs based on a Continuous Quality Improvement
(CQI) approach.”
NSW
Junaa Buwal
Chris O'Brien Lifehouse at RPA
The George Street Specialist Centre Pty Ltd
Family Planning NSW
Genesis Care - Sydney
Genesis Care - Lake Macquarie
Sydney Sleep Clinic
QLD
Icon Cancer Care Townsville
VIC
Gippsland Medicare Local
Northern Melbourne Medicare Local Ltd
WA
Chemo @ Home
Goldfields-Midwest Medicare Local
Global Diagnostics (Australia) Pty
Genesis Care
ACT
Canberra Microsurgery
SA
Mission Australia, South Australian Drug and Alcohol Programs
TAS
M.H. Ghali
Pty Ltd
Raman Dhaliwhal is our newest Customer Services
Manager who will
look after all our
Victoria-based
members.
Raman is looking
forward to getting to know her members
and providing advice and assistance as
they work towards meeting their ac-
creditation requirements. “I am delight-
ed to join ACHS, and have an interest
in both quality and change manage-
ment,” she said. “I’m hoping to provide
valuable assistance wherever possible
and ensure that members feel support-
ed.”
Welcome to Raman
ACHS welcomes our newest Members
ACHSNEWS 3
Quality Improvement Awards 2013
A total of 102 entries were received for the 2013 ACHS
Quality Improvement Awards – one of the highest
number ever received.
The almost one-third increase over last year’s number
demonstrates the growing impact that encouraging
quality improvement initiatives is having in a range of
health settings around Australia.
“We are delighted at both the number of entries we
have received this year, as well as the quality behind
them,” said Ms Linda O’Connor, Executive Director
Development.
“A considerable amount of time and energy has gone
into presenting these entries and we have been
impressed by some of the innovation behind them that
marks 2013 as a special year in the QI awards history.
The highest increase was in the healthcare
measurement category, with an extra 19 entries,
where previously this category has been
under-represented.”
Overall there was a higher representation
from public facilities over private, with the
highest number of entries from Victoria,
followed closely by NSW. The three
categories are: Clinical Excellence and
Patient Safety Award, the Non-Clinical
Service Delivery Award, and the Healthcare
Measurement Award.
The QI Awards winners will be announced at the ACHS
Annual Dinner on 28 November at the Park Royal in
Sydney.
“In reviewing the themes chosen over the last 12 months,
it is clear that many organisations have spent time
working towards the NSQHS Standards and the theme
areas reflect this,” Ms O’Connor said.
Clinical Indicators Program (CIP)
Q. When did you last review the Clinical Indicators (CIs) that your healthcare
organisation collects?
Ensure clinicians know what is available
Recent changes mean that many clinicians may not be aware of relevant CIs.
Quality improvement works much better when ward and departmental clinicians get involved.
Indicators are pointers. They do not have the answers. Without a commitment to data consistency
and discussion of any changes observed, CI collection won’t improve anything.
CI data may be used as evidence for accreditation. However, it is your monitoring of, and response to,
the data that matters.
Know why you collect
Collection of ACHS CIs is voluntary. If a CI is no longer relevant to your organisation’s monitoring and
improvement program, do not persist.
Ensuring data are complete and accurate takes time, so you need to know why you collect for each CI.
Ensure that a staff member is responsible for monitoring and following up any changes within the data,
such as deteriorating trends and outliers.
NEW from the Performance and Outcomes Services (POS) team
CERTIFICATES are now available for all CIP Program members
1. Download an ACHS Certificate of Participation from the web-based Performance Indicator Reporting Tool
(PIRT).
2. The certificate can be laminated or framed to promote your involvement in the CIP.
3. Display in your office or beside your accreditation certificate.
ACHSNEWS 4
All details of the ACHS Education Workshop calendar for November 2013 to June 2014 are available on the ACHS website at: http://www.achs.org.au/education-support/education-workshop-calendar/
New workshops for 2014 include:
Corporate Systems and Safety: EQuIPNational Standard 15
Effective Risk Management to Support Quality Outcomes
Health Records in the Electronic Age
Achieving Accreditation with the ACHS National Safety and Quality Health Service (NSQHS) Standards
Program
Achieving Accreditation with the ACHS EQuIPNational Program
Back by popular demand: Workshops covering:
NSQHS Standard 1: Governance for Quality & Safety in Health Service Organisations
NSQHS Standard 2: Partnering with Consumers to Achieve Quality Outcomes in Healthcare
NSQHS Standard 4: Medication Safety Mandated
NSQHS Standard 5: Patient Identification and Procedure Matching (half day)
NSQHS Standard 6: Effective Clinical Handover
NSQHS Standard 8: Preventing and Managing Pressure Injuries (half day)
NSQHS Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care
NSQHS Standard 10: Preventing Falls and Harm From Falls (half day)
Establishing Audit for the NSQHS Standards (half day)
Community Health: Making Accreditation Work for You
Accreditation for Mental Health Services
Getting Started as a New Quality Manager
All workshops on the ACHS Education calendar are also available as customised ‘on-site’ workshops in your own organisation. ACHS also offers an on-site consultancy service. Contact us if you would like to find out more about these
options.
ACHS Education: Phone: +61 2 9281 9955 Email: [email protected]
Education Update
ACHSNEWS 6
Another Quality and Patient Safety Milestone for International Hospital Bahrain
The International Hospital Bahrain (IHB) celebrated an-other important milestone in its quality and patient safe-ty journey on September 29 when Dr Desmond Yen, Executive Director – International Business for ACHS presented the hospital’s first international healthcare accreditation certificate in recognition of achievement during their recent EQuIP5 Organization-wide Survey. He congratulated the team on their collective achieve-ment and acknowledged the importance of strong lead-ership and a culture of continuous quality improvement.
“Mr Zeerah and the IHB team deserve congratulations for achieving this wonderful result. The surveyors were impressed by many aspects of the Hospital and the effec-tive use of new technologies to enhance the delivery of clinical services,” he said.
The Hospital has enjoyed local recognition for a wide range of achievements over many years but this achieve-ment in particular demon-strates their intrinsic commit-ment to providing the best possible quality of services to the local community.
During the presentation, Mr Faysal Zeerah, IHB President and CEO acknowledged the partnership that had devel-oped between the Hospital and ACHS International, a partnership focused on the evaluation and improvement of outcomes for all patients accessing the Hospital’s services. He said the accreditation process and the preparation for organisation-wide survey had energised all health professions and support staff and unified them in a common goal.
Dr Orville Gundrun, Director of Quality and Patient Safety acknowledged the huge contribution from the entire hospital staff as they prepared for international accreditation. “I commend all staff for their dedication to quality and patient safety. Without their support, none of this would be possible.”
He also acknowledged the never ending nature of healthcare quality improvement: “We’re not done yet! This is just the beginning of our quality journey,” he said.
Mr Chris Lewis, the Hospital’s Chief Operations Officer said “From the initial exploratory meeting, through to the gap analysis, culminating in the actual accredita-tion survey, we found the whole ACHSI team abso-lutely professional in their approach and guidance ... to us the ACHSI teams are not 'surveyors', they have become firmly established as our partners in quality and patient safety.”
Mr David Miller, ACHS Consultant / surveyor said the IHB has demonstrated a huge appetite for improve-ment from the gap analysis through to the onsite sur-vey. I” had the pleasure of collaborating with them
during this time and wit-nessed their enormous capacity to get things done through staff en-gagement and motivation. It was quite extraordinary to witness and needs to be congratulated. Well done to all,” he said.
Mr Tim Gardner, the Hos-pital’s Administration Man-ager and seasoned ACHS Surveyor commented that the accreditation process provided an excellent way for the Hospital to develop teamwork and an organi-sation-wide culture of pa-tient safety and continu-ous quality improvement.
These points were echoed by Sr Vivian Macavinta,
Director of Nursing who said: “With ACHSI Accredita-tion our patients can be confident that there are appro-priate processes in place to ensure high standards of care based on an experienced and competent team, sound supervision and a care environment that en-sures safety, comfort and privacy.” The IHB is poised to build on their accreditation suc-cess to implement a new raft of ambitious patient ori-entated improvements. The energy generated by em-barking on EQuIP will stand them in good stead to achieve even more in the future and we wish them well in their aspirations and look forward to long-term collaboration with this valued member.
Spotlight on Bahrain
From left to right: Mr Tim Gardner – Administration Manager, Mr David Miller – ACHS Consultant/Surveyor, Mr Faysal Zeerah – IHB President and CEO, Dr Desmond Yen, Executive Director – Inter-national Business ACHS, Mr Chris Lewis, Chief Op-erations Officer, Dr Orville Gundren, Director –
Quality and Patient Safety.
ACHSNEWS 6
New National Accreditation Report National Accreditation Report National Accreditation Report to be Released
The National Report On Health Services
Accreditation Performance 2011 – 2012 will be
released at the ACHS Annual Dinner on 28th
November.
The focus of this biennial report
is upon the survey outcomes of
ACHS members during the
preceding two years,
highlighting in particular those
organisations that received
Outstanding Achievement (OA)
ratings during survey. In
addition, the report describes
the ACHS membership,
surveyor workforce and
accreditation programs, and the
company’s involvement in
accreditation research.
The National Accreditation
Report 2011 – 2012
demonstrates that positive accreditation trends
noted in the previous edition of the report
continued and strengthened following the
implementation of EQuIP5, as measured by
increased frequency of EA and OA ratings in
association with decreased AC60 survey and
High Priority Recommendation (HPR) outcomes.
Areas of outstanding performance under EQuIP5
include continuous quality improvement, the
governance of research, care evaluation and
waste and environmental management.
A second performance trend that continued during
the 2011 – 2012 reporting period is that the areas
requiring improved performance by
members are predominantly non-
clinical. Under EQuIP5, AC60 and
HPR survey outcomes were most
frequently associated with
emergency and disaster
management, workplace health and
safety, risk management and
credentialling.
The EQuIP5 program included a new
criterion addressing nutritional care. In
the National Accreditation Report 2011
– 2012, performance of members in this
vital area of health care is the focus of
the essay Spotlight on Nutrition.
Briefly, 84% of members surveyed
against the nutritional care criterion received a rating
of MA or better, with three organisations achieving
an OA rating.
Copies of The National Accreditation Report 2011 –
2012 will be distributed to members and other
stakeholders during December, and an electronic
version of the report will be available on the ACHS
website.
New EQuIPNational Corporate Health Services due for release in early 2014
On I January 2014, ACHS will implement EQuIPNational Corpo-
rate Health Services, an accreditation program tailored to the
needs of local health networks, area health services and the cor-
porate offices of private healthcare providers.
Developed in consultation with the Australian Commission on Safety and Quality in Health Care, this pro-
gram is aligned with EQuIPNational and contains 15 Standards based upon the 10 National Safety and
Quality Health Service (NSQHS) Standards and the five EQuIP-content Standards of EQuIPNational, utilis-
ing only those actions relevant to a corporate office. EQuIPNational Corporate Health services focuses upon
the oversight and governance responsibilities of the corporate office and facilitates alignment of quality sys-
tems between the corporate office and its healthcare organisations.
Further information on the EQuIPNational Corporate Health Services accreditation program will be provided
on the ACHS website.