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: Educate@achs.org.au

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.