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The Quarterly is the Journal of The Royal AustralasianCollege of Medical Administrators

It is published quarterly and distributed throughout Australia andNew Zealand to approximately 900 College Fellows, Members andCandidates.

Publisher

The Royal Australasian College of Medical AdministratorsA.C.N. 004 688 21535 Drummond Street, Carlton, Victoria 3053Telephone: (03) 9663 5347Facsimile: (03) 9663 4117Email: info@racma.edu.au

Honorary Editor Dr Andrew RobertsonC/- The Royal Australasian College of Medical Administrators

Honorary Deputy Editor:

Dr Wayne McDonaldC/- The Royal Australasian College of Medical Administrators

The Quarterly contents may be reproduced without permission from theEditor providing the ‘RACMA Quarterly’ and issue date are clearly shownand where relevant, authors or other publishers are cited.

Opinions expressed by editorials and articles in The Quarterly are thoseof individual authors and do not necessarily represent official views orpolicies of The Royal Australasian College of Medical Administrators.

Reader Classification: Fellows, Members and Candidates of The RoyalAustralasian College of Medical Administrators. These include medicallyqualified senior executives of health care organisations.

Please contact the publisher for advertising bookings and deadlines.

The Quarterly is prepared by staff of the RACMA Secretariat.

Design and Production:

Thinking PrintingUnit 4, 160 New Street, Ringwood, Victoria 3134Telephone: (03) 9879 8722

The Royal Australasian College of Medical Administrators

The College was founded in 1967 as the Australian College of MedicalAdministrators and attained its Royal Prefix in 1978. In August, 1998when links with New Zealand were formally established, the Collegechanged its name to The Royal Australasian College of MedicalAdministrators. The College when first established had the aim ofpromoting and advancing the study of health services administration by medical practitioners.

Profound changes in health administration have occurred since thattime, but the need for competent well-trained health sector managershas not diminished.

The College works to achieve its aims through a rigorous university-based training course, supervised posts in medical administration andpostgraduate education programmes for Fellows, Members andCandidates.

The College headquarters are situated at 35 Drummond Street, Carlton,Victoria 3053 and there are active Committees in each State andTerritory of Australia and New Zealand.

2006/2007 Office Bearers

President, Dr Gavin FrostVice President, Dr David RankinImmediate Past President, Dr Philip MontgomeryHonorary Secretary, Dr Roger BoydHonorary Treasurer, Dr Peter BradfordCensor-in-Chief, Dr Lee GrunerNational Director, Continuing Education/Recertification, Dr Kim HillChief Executive, Dr Karen Owen

ISSN 1325-7579

ROYM 13986

Website: http://www.racma.edu.au

Email: info@racma.edu.au

CONTENTS

Editorial Dr Andy Robertson 2

Sub Editorial Dr Wayne McDonald 3

Letter to the Editor 4

President’s Report Dr Gavin Frost 6

A Summary Introduction to EQuIP 4th Edition Brian Johnston 7

Palliative Care in Far North QueenslandAssoc. Prof. Kathleen Atkinson 9

Achieving Performance TargetsThe BQB ApproachDr Amanda Ling and Brian Davies 16

Focus on qualityRisk Management – Building SharedResponsibility Dr Lee Gruner 18

Accreditation: Are there Lessons from thePast? Dr Bill Appleton 21

The Theory of ConstraintsDr Miriam Martin 24

Candidates Corner Dr Meredith Arcus 27

Book Review: Disputes and Dilemmas in Health Law Dr Mukti Biyani 28

Changes in the National Secretariat 29

Conferences 2007 30

40th Council and College Office Bearers 2006 31

List of Fellows 33

List of Candidates 35

List of Members 35

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EDITORIAL

One of my recurrent themes in these Editorials hasbeen disaster preparedness, a theme that wastested again in June 2006 with Australia's responseto the Yogyakarta earthquake, which left nearly6000 dead and over 30000 injured. As proposedpreviously, in March 2005, medical administratorsmay have an important role as team leaders of suchteams, where well-developed health managementskills can be put to good use in interesting andchallenging circumstances. I know in WA Healththat we are looking for at least 2 additional teamleaders to train up to manage such teams. I amgrateful to Wayne and Karen stepping in whilst Iwas in Java to get the June 2006 issue out.

I have recently been fortunate to attend HealthProtection 2006, the annual conference of theUnited Kingdom's Health Protection Agency, inCoventry. While much of the focus was on a rangeof public health issues, from healthcare acquiredinfections to measles to the Buncefield fire, therewere several presentations on risk communicationand getting difficult messages across to the public.We often concentrate on the facts and the target ofthe message to the detriment of getting aneffective message across to the public. Thecommunicator and their relationship with theaudience and the relevance of the message to thepublic, need to be carefully considered. Use thewrong messenger and, at best, the message will beignored. I am sure we can all cite good examples ofwhere that has happened. When we are trying to get critical public health messages across, this may be very counter-productive. Effective riskcommunication is an important skill for healthmanagers to develop.

We have another excellent issue of The Quarterlyand I appreciate the regular offerings from anumber of contributors. All contributions are mostwelcome and I would encourage all Fellows,Members and particularly Candidates tocontribute.

This is the end of yet another busy year duringwhich there have been significant changes in ourCollege. I wish you all well and a safe holidayperiod. We will be in touch again in 2007.

Dr Andy RobertsonEditor

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SUB EDITORIAL

I would like to offer my seasons greetings to theloyal readers of this illustrious publication and wishyou all the best for 2007. The festive season reallygets underway now with office parties, drinks andgenerally it happens to you that there is a feeling of“….well another year is over”, so I will save myselffor the “big one” next year.

I am moving around with my work and my locumEDMS at Mount Isa Health Service finishes inDecember. I am very lucky to be taking up a locumEDMS position on the Queensland coast in thedelightful but hot, steamy and wet Cairns whichwill prove a bit different to a semi-arid Mount Isawith all its rugged scenic splendour.

I have really enjoyed learning about theQueensland Health system and appreciating thedifficulties in maintaining a well functioning andsustainable medical workforce in such an isolatedplace as Mount Isa (Pop 23,000) 1,800 kms fromBrisbane.

The RACMA communication survey results havebeen collated by Colin Dunn with some help from“Monkey”. I understand there was a moderateresponse but enough to get some definite ideasabout the type of material people want to read andalso a map for change in how the material ispresented. There is a way forward on how we tacklethe issue of peer review for publishable articles fromFellows and Members/Candidates of the College.The next step is to determine the “how” for thatway forward and to get College support for thatchange. The Chief Executive no doubt will take thison and I will be very interested to be involved.

I attended the 2006 Biennial Health Conference,Exploring and Debating Acute Care Provision, in

November in Sydney. It was a good valueconference and very well put together by DOHAwith an excellent selection of high profile speakersfrom the private health insurance industry, theprivate sector and the acute public sector as well assome State and DOHA bureaucrats for goodmeasure. It was disappointing not to see manyother medical managers there but perhaps they aresaving themselves for the Casemix conferencewhich is also sponsored by DOHA and alternateswith this one. Dr Russell Stitz, President and Chairof Council and Executive, RACS was adamant thatthe chronic under-resourcing in Australian publichospitals had resulted in many instances ofcompromised care for patients and he emphasisedthe need for clinicians to be involved in findingsolutions for more effective and efficient care. Healso stressed that health administration should belean and orientated towards health outcomesrather than being totally focussed on the bottomline. This may be a challenge that RACMA can takeup by giving a presentation at the next BiennialConference. It would be good for one of our seniorFellows or the Chief Executive to temper thisapproach and to explain the role of a medicaladministrator in tackling those particular issues.

In this edition of The Quarterly we have even moreinformative articles for you. Kathleen Atkinson hasprovided an overview of the challenges sheencountered when establishing a palliative careservice in a rural and remote region of Australia.The article written by Amanda Ling and BrianDavies shows how Best Quartile Benchmarking(BQB) can drive change in the tertiary hospitalsector in WA by involving clinical divisions in theanalysis of the raw data.

Fortunately, we do have regular contributors to TheQuarterly. Lee Gruner discusses risk managementand the concept of shared responsibility, MiriamMartin has written about the Theory of Constraintand dealing with that overloaded feeling whentrying to recruit a suitable locum. I always enjoyreading Meredith Arcus’s Candidates Corner as it isreflecting on life in Alice Springs in the NorthernTerritory; another very isolated spot on the map. Iwould like to thank the Chief Executive, KarenOwen for the extra work she puts into The Quarterlymaking it more interesting, full of good bookreviews, journal updates and other regular features.

Dr Wayne McDonaldDeputy Editor

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LETTER TO THEEDITOR

Dear Dr Robertson

I read with interest, but concern, the article entitledThe role of podiatric surgery in Western Australia byDr Biyani in the July Edition of The Quarterly.

The role of medical management is highlighted byDr Biyani as challenging in reviewing andrestructuring existing health services to improveaccess whilst operating within tight budgetaryconstraints. Perhaps more challenging is the abilityto advocate for adequate resources particularly forpriority areas and ensure that standards aremaintained, monitored and any variability that isbeyond normal practice is identified and corrected.I believe the enquiries generated within the UnitedKingdom, King Edward Memorial Hospital andBundaberg Hospital have demonstrated thatadvocacy for standards is critical. Without thisbudget compliance, not access, does not have ameaning.

The other key for medical management is to beable to recognise appropriate standards and therequirements to achieve them. I totally agree thatthe delivery of services needs to be reviewed withmore effective models always being activelydesired. Health care is a 'team game'. Within theclinical team tasks can and should be effectivelydelegated. The development of the PhysicianAssistant model in the United States is a primeexample where clinicians can focus on thediagnostic and therapeutic aspects of care whilstthe essential administrative activities areundertaken by another member of the team, underthe leadership of the clinician. This is an approachconsistent with the view articulated by theCommittee of Presidents of Medical Colleges, aswell as individual Colleges, and described in theMedical Journal of Australia (Collins, Hillis, Stitz). Thiswas also the view explained clearly to theProductivity Commission in undertaking the report‘Australia's Health Workforce’. It was theseresponses, amongst others, that caused theProductivity Commission to remove commentsabout Podiatric Surgery from its draft report.

The role of paediatric surgery requires carefulanalysis. Unfortunately Dr Biyani in the article does

not appear to differentiate these issues clearly.Podiatry in Australia is based on Chiropody whichhas a very important role in the care of feet.Traditionally this has been focussed on the forefootand particularly nail care. They play a veryimportant role in the team approach to foot careparticularly with the diabetic and vascularcompromised populations. Podiatry in the UnitedKingdom has a similar profile and role. Podiatry inthe United States of America is different with thepaediatric surgeon also having a degree in PodiatricMedicine which may be considered comparable toa medical degree, before they undertake a surgicaltraining program. The American training is mostsubstantial.

So the first question that the medical managerneeds to raise is “Does a medical degree matter?”.Having been educated in the era when basicsciences, pathology, pharmacology, infectiousdiseases were stressed in medical courses, I need todeclare both personal interest and I assume aconflict of interest. However, a medical degree doesmatter. Secondly, “Does a Surgical Fellowshipmatter?” Every professional group states they arewell trained. However the rigour applied to thetraining program in Australia and New Zealand fororthopaedic surgery and also plastic andreconstructive surgery is high. Fellows of the RoyalAustralasian College of Surgeons (FRACS) wouldhave performed close to 2000 operations beforethey become independent specialists. All specialistsurgical training posts are accredited andsupervised. This is not the case for the AustralasianCollege of Podiatric Surgeons and its academicallyfocused program. Again I need to declare a conflictof interest as I am the Chief Executive Officer of theRoyal Australasian College of Surgeons (RACS).However the answer is that a surgical Fellowshipaccredited by the Australian Medical Council doesmatter. The foot is not a simple anatomicalstructure and the ankle joint substantially complexwith all the challenge of weight bearing. The third question is one that was answered for me in a morbidity and mortality meeting twenty yearsago “is there such a thing as minor surgery?” The answer is never if you are the patient.Unfortunately, however, there are occasionallyminor surgeons. So the question should and doescome back to the issue of quality and standards. Inthe case of podiatrists they should be calledpaediatric proceduralists.

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Is the College structure (recognised by theAustralian Medical Council) the only way to obtainsurgical training? Absolutely not, and no Collegeacts in a monopolistic manner with regards tostandards or training. The common theme is alwaysthe availability of proper training roles that areclinically relevant and adequately supervised. TheCollege (RACS) is working closely with otherproviders of surgical training to improve the qualityand breadth of the training experience. However, Ido need to highlight that a medical degree and aformal Surgical Fellowship have their own validityand importance.

The medical manager plays a substantially differentrole today compared to a decade ago. Clinicalgovernance is real. Politicians, policy makers andfunders have ensured that medical practitioners areable to provide high quality services to theAustralian public. Medical managers must identifythe treatment standards for the patients that arecared for by their Organisation. Is it at the level

required with peer review, audit and rapididentification of clinical risk issues? These areimportant issues. As the health sector worksthrough issues of task delegation, systems redesign,change management, healthy doses of turfprotection and conservatism it is too simplistic totalk only of budgets and access. Do standardscount? Absolutely!

Yours sincerely

Dr David Hillis Chief Executive Officer Royal Australasian College of Surgeons

MBBS (Hons), MHA, FRACGP, FRACMA, FCHSE,FAIM, FAICD

'Collins, J.P., Hillis, D.J., Stitz, R.W. Task Transfer: Theview of the Royal Australasian College of Surgeons. MedJ Aust 2006; 185 (1): 25-26.

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PRESIDENT’S REPORT

Dear Candidates, Members and Fellows,

I am honoured and delighted to take this, my firstopportunity to talk with you.

My first wish is to thank Phil Montgomery and theCouncil for the honour they have done me byelecting me to this position. The College is in fineshape, and the past presidents and staff can takecredit for that.

But now we have several important jobs to do.

Members, in particular, tell us they want moreopportunities to interact with the College, forformal and informal continuing professionaldevelopment; we need to find those ways.Candidates need to have greater input into Collegeaffairs-we have recently welcomed our firstcandidate to national Council, and look forward toeven more knowledge tapped to benefit theCollege as a whole.

Our Censor-in-chief is working hard with ourEducation Co-ordinator and secretariat staff tocontinuously develop our training program and Iknow what a challenge this task is. The Hon.Treasurer is engaged in the balancing task withwhich most of us are only too familiar-the eternalincome/expenditure battle. We continue to try todevelop alternate income streams to keep our subsat a manageable level, and continue to offer moreand better educational and support services to themembership.

We have a new Strategic Plan 2006 -2009 that ischallenging but achievable. I hope that you have allhad a chance to read this document which is on ourweb site. It describes an exciting future for ourcollege and I hope that you will all support us toachieve this. It is your college after all.

Thank you for the helpful suggestions you havemade in our recent on-line survey. As I believe ourmain task is to develop and maintain a communityof medical managers committed to teaching andlearning, we need to ensure that measures of ourcommitment (such as preceptorship, mentoring,CPD etc) are evident to all. Our new ChiefExecutive and I will work with Council to meet youraspirations of the College.

Being in good standing with this (or any other)learned college is a matter of great pride to me andto you. We need to continue the task begun bythose who preceded us and progress theseimportant matters for the future of a better healthsystem in Australia, New Zealand and wherever elseyou may be reading this.

Please join us in this exciting endeavour.

Dr Gavin FrostPresident

RACMA

Website:http://www.racma.edu.au

E-mail: info@racma.edu.auMP

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A SUMMARYINTRODUCTION TOEQuIP 4TH EDITION

After a lengthy and highly consultativedevelopment phase, August 2006 saw the releaseof EQuIP 4th edition; the accreditation standardsfrom the Australian Council on HealthcareStandards (ACHS).

Since the current 3rd edition standards of theEvaluation and Quality Improvement Program(EQuIP), were finalised in April 2002, there havebeen significant changes impacting on the nationalpatient safety agenda. In total 35 criteria from the43 in the 3rd edition have been retained as criteriain EQuIP 4. In addition key issues identified by theprevious Australian Council on Safety and Quality inHealth Care have been given greater emphasis toaddress these changes.

EQuIP 4 is an evolution from the 3rd edition as itretains all the key content, however some 3rdedition criteria have been reconfigured. Forexample some multiple criteria have beencondensed into one, some single criterion havebeen separated into more than one and othercriteria have been included in EQuIP 4 as elements.

There are 14 mandatory criteria for EQuIP 4, whichwere determined through a lengthy consultation,involving an electronic survey to which almost 900responses were received.

CONSULTATION AND REVIEW

Commencing in November 2004, the review ofEQuIP 3rd edition and development of EQuIP 4began with an examination of the relevantliterature and a comparison of the EQuIP standardsand criteria with those of the UK, Canada, the USA,New Zealand, Ireland, France and Japan. The ACHSestablished over ten different working groups aswell as reference panels, expert advisory groupsand focus groups throughout Australia for specifictopics in addition to other consultative forums andpilot studies. The final version of EQuIP 4 wassubsequently adopted by the ACHS Board in May2006.

One of the outstanding features of this reviewprocess, apart from it being the most extensive everundertaken by the ACHS, has been the high level ofinput received from across the industry. Thecomments and advice provided have had asignificant effect on the final version and the way inwhich the program is to be published andoperated.

Through EQuIP 4 the focus of the program hasbeen strengthened in relation to clinical care andconsumer participation. As part of the effort toincrease the clinical focus of EQuIP thearrangement of the EQuIP 3rd edition standards insix topic areas, known as functions, has beenrestructured into three topic areas: clinical, supportand corporate, for EQuIP 4.

EVOLVING STANDARDS

The Australian Commission on Safety and Quality inHealth Care is undertaking a review ofaccreditation, which was recommended by thePatterson Review of the future governancearrangements into safety and quality. This reportwas handed down last year. The review is stronglysupported by the ACHS as it offers a majoropportunity to develop stronger symmetriesbetween the various and increasing number of setsof standards that impact on the health system. It isexpected to not only impact on all sets of standardsbut influence what we do and how we do it in thefuture. Updates of EQuIP 4 will be made asnecessary, to reflect the outcomes of this nationalreview of accreditation.

TIMING FOR IMPLEMENTATION

Organisations scheduled to undergo a self-assessment or an onsite survey from 1 January 2007to 30 June 2007 will have the option to utilise eitherEQuIP 3rd edition or EQuIP 4. From 1 July 2007, allACHS member health care organisations need toself-assess and be surveyed against EQuIP 4.

This introductory period is aimed at addressingconcerns that the four-year cycle of EQuIPmembership requires the same organisations to bethe first assessed by the new standards each timethey are updated.

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THE DIFFERENCES BETWEEN EQuIP3RD EDITION AND EQuIP 4?

While there is a new function structure, whichmakes the standards appear quite different at firstglance, the focus of the update has really been tostrengthen the existing standards rather thancreating a new framework.

The vast majority of issues addressed in EQuIP 4were also included in EQuIP 3rd edition. Most ‘new’criteria were in the 3rd edition as elements.

In addition to the 35 criteria from EQuIP 3rd editionretained as ‘criteria’ in EQuIP 4, key patient safetyissues which were included as elements andguidelines in the 3rd edition now appear as‘criteria’. The purpose is to strengthen the focus onthese issues. For example: medicationmanagement, correct site surgery, fallsmanagement, and management of blood andblood components, which were addressed underthe Continuum of Care function in the 3rd edition,are now specified as criteria in EQuIP 4.Credentialling, which was previously addressed inthe elements of the Human Resources criteria, isnow a specific criterion.

RIGHT PROCEDURE - RIGHT PATIENT -RIGHT TIME

‘Appropriateness’, one of the nine dimensions ofquality, was introduced into this edition after a gapwas identified and it is intended to ensureorganisations have systems in place to determineand evaluate the ‘appropriateness’ of careprovided. In other words do organisations have aprocess for assessing if an intervention is necessary – isit the right procedure on the right patient at the righttime and in the right setting?

As a ‘developmental’ criterion for a four-yearperiod, organisations will work towards achievingthe standard, however rating of this criterion willnot be considered when determining anorganisation’s accreditation status. The purpose ofthis approach is to create awareness, encourageimprovement and research and commencecollaborative national action.

ACHIEVABLE STANDARDS?

The standards need to provide a realistic frameworkfor improving the safety and quality of care.Consultation with industry helps ensure they areachievable. It is also important to note that the vastmajority of safety and quality issues highlighted inEQuIP 4 were already included in the 3rd edition.

ACHS accreditation standards have been reviewed13 times before the introduction of EQuIP in 1996and, including this latest review, four times since.

As always, the ACHS will be providing supportinginformation as well as the assistance of ourCustomer Services Managers who work to helpprepare organisations for accreditationassessments. In addition the final standards areavailable around ten months prior to when it will beessential for organisations to be surveyed againstthem.

The ACHS is confident that EQuIP 4 is a clear stepforward in improving the safety and quality ofhealth care in Australia. The standards address thesafety and quality issues identified as nationalpriorities.

For the first time the standards (Part 2 of theEQuIP 4 Guide) are accessible via the ACHSwebsite, www.achs.org.au - under What’s New?

Mr. Brian Johnston ACHS Chief Executive

For your EQuIP 4 questions, please email: equip4@achs.org.au

Alternatively you may contact the AustralianCouncil on Healthcare Standards on: +61 2 9281 9955.

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PALLIATIVE CARE INFAR NORTHQUEENSLAND

Assoc. Prof. Kathleen Atkinson

A/Medical Superintendent Innisfail Health ServiceDistrict

QUEENSLAND HEALTH SERVICE DISTRICTSNORTHERN ZONE

ABSTRACT

The provision of end of life care to rural and remoteAustralians presents many challenges for clients,carers and health professionals. Whilst there is apaucity of Australian literature examining rural andremote palliative care, there are indicators thatgeographic isolation, accessibility and affordability

of health services influence when and how ruralindividuals cope with poor health, chronic disease,malignancy and terminal illness1 .

The following literature review and discussionillustrate the experience of providing end-of-lifecare in far North Queensland. Service deliveryissues are examined, as are the challenges ofmanaging pain and symptom control forindividuals living far from major population centres.

The importance of providing culturally sensitiveservices to Indigenous clients with limited English isdiscussed in detail. Communication, theimportance of addressing grief, loss, funerals andbereavement are vital in reducing pathologicalgrieving in Indigenous communities. Indigenousliaison officers can provide support to clients andcontextual cultural links to communities.

Managing client and family expectations aroundend-stage renal disease is an area that needs furtherexamination as the overall population of clients ondialysis in Northern Australia increases.

This report proposes a direction for health policymakers and planners with the further developmentand funding of integrated, community-basedpalliative care services. Local health careprofessionals can be encouraged to develop theirskills in this area and supported with education,advice backup and support wherever necessary.

Some of the directions presented includestrengthening the links between acute, mainstreamhealth services and the community sector andaffirming community palliative services with afunding level commensurate to their activity.

INTRODUCTION ANDBACKGROUND

The treatment of life limiting illness and provision ofend of life care to rural and remote Australianspresents many challenges for clients, carers andhealth professionals.

Isolated, marginalized, itinerant and IndigenousAustralians have reduced access to health servicesincluding specialist palliative care and oncology2.

Geographic isolation, reduced life expectancy,cultural traditions and expectations- includingplace of terminal illness and circumstancessurrounding death, determine quality of life, griefand bereavement3.

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Rural Health and Palliative CareThe body of Australian ‘rural health’ literature doesnot specifically examine rural and remote palliativecare. There are indicators, however, that issues suchas geographic isolation, accessibility andaffordability of health services influence when andhow rural individuals cope with poor health,chronic disease, malignancy and terminal illness.The Australian Institute of Health and Welfare,19984 and 20035 and Humphreys, 19996 state that“the identified rural health disadvantage is notsolely a result of poorer Indigenous health but,instead, reflects the unique issues that relate toliving conditions, social isolation and distance fromhealth services”.

Recent articles on health service provision, mortalityand morbidity data give some indicators of healthstatus. The all cause mortality rate declineexperienced in New South Wales between 1970and 1994 was significantly reduced in small ruralcommunities7. Explanatory factors included poorersocioeconomic status in rural areas and lack ofaccess to health services. General Practitionersprovide most end-of-life care in remote areas8. withonly 12% of medical specialists working rurally,many of whom are visiting, not resident. Most ruralspecialists work as general physicians or surgeons,occasionally with a sub-specialty interest.1

Indigenous Palliative CareThere is a growing body of literature examiningrural and remote Indigenous palliative care issues inAustralia. The ‘living model’ of Indigneous palliativecare service delivery9. places the patient andextended family at the centre of care. Issues ofcultural safety, community participation, personaladvocacy, empowerment and choice supportpatient and family care.

Communication issues outlined by McGrath et al-ensuring the “right story” is told to the “rightperson”10 highlight the struggle associated witheffective communication when working in a crosscultural setting at the interface of Indigenous andWestern health care.

Whilst only 2% of Australia’s population isIndigenous, in the Northern Territory and Far NorthQueensland percentages are significantly higher. (NT24.9%, Cairns Health Service District 9.5%, CapeYork 51.1%, Torres Strait 74%11). There aredifferences in the cultural practices between manyTorres Strait Islander people and the many differentgroups of Aboriginal people12. Language issues arealso significant. 16% Torres Strait Islanders speak anAustralian Indigenous language and there are over40 language groups in the Northern Territoryalone13/14.

Maddocks and Rayner15 examined issues inpalliative care in Indigenous communities in SouthAustralia in 2003. Reaching similar conclusions toMcGrath et al, they found that Indigenous peopleuse health care services reluctantly, preventativeservices, rarely (leading to late presentations ofcommon malignancies16 particularly carcinoma ofthe cervix17. The stated reasons being lack of accessto acceptable services for reasons of geography andcultural appropriateness.

Premature mortality in Indigenous Australians,particularly in young adults at 5-8 times and anoverall reduced life expectancy of 19 yearscompared to non-Indigenous leads to an almostcontinuous, community-wide grieving. Highsuicide rates and high prevalence of mental illness(Queensland Health, 200118 and National RuralHealth Alliance, 2003 1 place this population atextremely high risk of abnormal or pathologicalgrieving with cumulative grief experiences.

Both McGrath P, and McGrath C, identify theimportance of place of death (preferably their ‘owncountry’), post-death practices involvingcommunity elders, and funerals as a critical part ofthe mourning and healing process. In an effort toaddress the cultural and psychosocial issues whichplace Indigenous communities at such high risk ofabnormal grieving, the National Palliative CareProgram and Mangabareena Aboriginal Corp haveproduced a resource kit to facilitate culturallyappropriate palliative care provision to IndigenousAustralians19.

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include hospitals at Mareeba, Atherton, Chillagoe,Croydon, Georgetown, Herberton, Babinda andInnisfail.

These facilities are staffed by skilled remote areanurses, indigenous health workers, generalistmedical practitioners with some limited residentand regular visiting surgeons and generalphysicians from Cairns.

Indigenous community controlled health servicesare located in Cairns, Mareeba, Ravenshoe andInnisfail with regular attendance by localIndigenous people at Queensland Health facilities –acute, primary, community and mental health.

Limited specialist medical oncology, haematology,palliative care, interventional radiology, respiratorymedicine, cardiology, neurology andgastroenterology services are available at CairnsBase Hospital. The renal dialysis unit is the secondbusiest in the state. There is no resident publicsector urology, radiation oncology, neurosurgery orinterventional cardiology.

SERVICE DELIVERY ISSUES

The Cairns, Cape York and Torres Strait IslandHealth Service Districts provides services to apopulation of approximately 200,000 peoplesituated across a geographic area the size ofVictoria. The population density maps indicate thedegree of remoteness of most of the health servicedistrict.

The non-Indigenous population of the regionreflects that of Australia overall with almost 13%aged over 65 years. The Cairns HSD also cares forthe seasonal influx of international tourists and‘grey nomads’, some of whom require medicalservices whilst visiting the area.

Small rural hospitals (1-3 doctors maximum) arelocated at Thursday Is., Bamaga, Cooktown,Mossman and Weipa. Remote Primary Health carecentres (1 remote area nurse with visiting medicalclinics from Royal Flying Doctor Services (RFDS), atAurukun, Coen, and on most of the inhabitedTorres Strait Islands. Tablelands Health services

Far North Population Data: Australian Bureau of Statistics Census 2001Far North (SD 350) 269223.9 sq. Kms

PERSONS MALES FEMALES PERSONS %

Aged 15 years and over(a) 96,306 95,808 192,114 78.48

Aged 65 years and over(a) 12,975 13,226 26,201 10.70

Aboriginal 7,866 7,901 15,767

Torres Strait Islander 4,742 4,773 9,515

Both Aboriginal and Torres Strait Islander(b) 1,760 1,867 3,627

Total Indigenous persons 14,368 14,541 28,909 11.81

Born in Australia 89,544 86,955 176,499

Born overseas(c) 17,686 18,086 35,772

Speaks English only 95,165 92,722 187,887

Speaks other language(d) 12,227 12,944 25,171

Indigenous persons aged 18 years and over 7,863 8,392 16,255 6.64

Australian citizen 101,947 99,492 201,439

Australian citizen aged 18 years and over 74,235 73,253 147,488

Enumerated in private dwelling(a) 112,543 111,899 224,442

Enumerated elsewhere(a)(e) 10,695 9,649 20,344

Overseas visitors 7,963 9,172 17,135 7.00

Total persons(a) 123,238 121,548 244,786 100.00

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The palliative care unit is located at GordonvaleHospital, 25km south of Cairns. Palliative careservices are also provided at Cairns Base Hospitaland Cairns Private Hospital. The medical oncologyunit at Cairns Base has expanded from 170 to 600patients since the arrival of a single resident medicaloncologist in 2004.

Health services have varying degrees of accessibilityby road, air and sea. Wet season flooding,landslides and cyclones prevent access to manyparts of the Cape between November and April.Aeromedical evacuation is available in emergenciesusing the Careflight helicopter and Royal FlyingDoctor Service. Some islands in the Torres Strait areaccessible only by light aircraft and boat.

CAIRNS HEALTH SERVICE DISTRICT

DISCUSSIONProviding adequate services to the bush meansovercoming geographic isolation and lack ofaccess to generalist and specialist facilities.Screening services are often absent or underutilizedleading to late diagnosis of preventablemalignancy. Across northern Australia these issuesare often compounded by language and culturalbarriers 5 6 7 8

One of the major issues explored by McGrath in2004 and 2005 focuses on relocation anddislocation of Indigenous people when they areforced to leave their communities for treatment.Clients and families are confronted by abewildering array of technology, difficulties inunderstanding explanations about complexmedical treatments and procedures, problems inachieving ‘informed consent’ for treatment andinadvertent cultural insensitivity by healthprofessionals.

Barriers to education lead to communicationdifficulties exacerbated by language and culturalissues. (McGrath P et al, 2005) discusses this indetail in the Living Model of Indigenous PalliativeCare. Indigenous (and non-Indigenous) individualswith end-stage renal disease are living longer withdialysis. Pre-dialysis counseling is often undertakenwithout an interpreter and many patients really donot understand the palliative nature of dialysis.This, in turn, creates compliance issues and hugeproblems around the end stage. Ashby et al 23.have explored these issues in a predominantly non-Indigenous Victorian dialysis unit.

Cairns Base Hospital has the second busiest unit inQueensland, receiving referrals from the TorresStrait, Cape York Peninsula and coastalcommunities. Queensland Health’s Informationcentre (Qhealth, 2005 19) showed renal dialysisadmissions topping the list of inpatient DRG’s2003/4(see Table).

Two-thirds of Cairns’ dialysis patients areIndigenous. Demographic issues, language, racialand cultural differences between the Cape YorkAboriginal people, the Torres Strait Islander andindividuals from PNG provide service deliverychallenges for the social work department with onlya very limited number of Indigenous LiaisonOfficers. It is particularly important to ensurecultural sensitivity around gender issues (eg. Femalegenital malignancies would require a female ILO).Health worker burnout is a constant threat.

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DISTRICT PUBLIC HOSPITAL EPISODES OF CARE FOR TOP 10 DRGS (V4.2) 2003/2004 :TOTALINPATIENTS (PUBLIC AND PRIVATE) 19

DRG NO DRG NAME No. OF EPISODES

L61Z Admit for Renal Dialysis 9,454

R63Z Chemotherapy 1,472

O65B Other Antenatal Admission W Moderate or No Complicating Diagnosis 1,113

O60D Vaginal Delivery W/O Complicating Diagnosis 1,086

O64Z False Labour 689

G44C Other Colonoscopy, Sameday 663

O65A Other Antenatal Admission W Severe Complicating Diagnosis 489

G45B Other Gastroscopy for Non-Major Digestive Disease, Sameday 477

J64B Cellulitis (Age>59 W/O Catastrophic or Severe CC) or Age<60 457

C08Z Major Lens Procedures 418

(Queensland Health: Health Information Centre Review Date: November 2005)

psychiatric history or multiple psychosocial stressorswithin the family or community.

It is recognized that Indigenous communities carrya large burden of unresolved grief due to multiplelosses. The high mortality rate in youngpeople(Indigenous people living on average 20years less than non-Indigenous Australians), highsuicide rate and high prevalence of mental illnessplace this population at extremely high risk ofabnormal or pathological grieving with cumulativegrief experiences. 3, 10 The importance of place ofdeath (preferably their ‘own country’),post-deathpractices involving community elders, and funeralsare identified as a critical part of the mourning andhealing process.

Death, dying and funerals take on special culturalsignificance for Indigneous peoples. It is ofteninappropriate to use the name of the deceasedperson and funerals become community-wideoutpourings of grief. There are particular issuesassociated with attribution of cause and blamewhich may limit the willingness of health workers tobe involved with dying indigenous clients.

The distances in remote north Queenslandpreclude anything other than telephonebereavement follow-up. This is less than ideal whenpeople are in transit, itinerant, have limited accessto transport and only mobile telephonecommunication. Mobile networks rarely operateoutside large population centres and the cost ofCDMA and satellite telecommunication is beyondthe budget of many palliative care clients.

LOGISTICS OF SERVICE PROVISION,PATIENT TRANSPORT AND COSTSpecialised interventional procedures (radiology,radiation oncology and interventional urology)often require a trip to Brisbane or Townsville.Resource allocation becomes a real issue with evenurgent radiation oncology up to a 6-8 week wait.Providing symptomatic relief for frail, elderly orpalliative clients may mean choosing betweensuboptimal symptom control or painful, timeconsuming travel for clients and their families.Emergency transport services are also a limitedresource. Access is determined by centralizedclinical coordinators who have an acute care focus.Circumstances do arise where palliative clients get‘offloaded’ in transit for ‘more acute’ emergencies.

It is impossible to meet patient expectations underthese circumstances.

The costs of returning to a remote islandcommunity is often prohibitive for families. ILO’sand social workers spend hours organizing ‘Angelflights’ to move people around at times of crisis.Transportation of deceased persons is also costlyand almost never seen as a priority by medicalevacuation services.

GRIEF, LOSS AND BEREAVEMENTPalliative care team policy aims to identify those athigh risk of pathological or abnormal grieving.Indicators for this would include repeated losseswithin a short time period, very sudden, violent orunexpected death (such as a suicide), previous

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RURAL AND REMOTE PALLIATIVE CARE –CHALLENGES AND SOLUTIONSMany of the patients treated in rural and remotesettings with advanced malignancy are unable toaccess treatment modalities regarded as standardwithin metropolitan settings. Late presentations forpotentially preventable cancers are more prevalent,particularly in indigenous, indigent or very remoteclients.

Palliative treatment in the form of chemotherapy orradiation oncology is only available in larger centres(Cairns, Townsville, Brisbane) necessitating longdistance travel or even relocation by whole familiesduring the course of a protracted illness. Healthpolicy and planning needs to take into account thedifficulties in providing services closer to homeversus the impact of travel and relocation.

Ageing infrastructure and reduced numbers of allhealth care providers make the challenges ofdelivering palliative care services to rural andremote dwellers, quite formidable.

Generalists providing these services located closeto, or flying distance from, scattered populationsare responsible for the vast majority of end of lifecare in the bush. Larger centralized health servicesneed to support these providers with timely backup and advice. Relocation of dying patients topalliative treatment centres removes them fromtheir community at the very time that they wouldmost benefit from having supports close to home.Every effort needs to be made to provide serviceslocally if possible.

Strengthening the links between acute, mainstreamhealth services and the community sector wouldenable the ‘fast-tracking’ of community clientswithin the system into radiation and medicaloncology services located in Townsville, Cairns andBrisbane. Integration of service delivery betweenthe Indigenous community controlled healthsector, mainstream medical care and communitybased palliative care would improve end of life carefor Indigenous clients. Affirming communitypalliative services with a funding levelcommensurate to their activity would assist inmeeting community expectations in this area.

With further development and funding ofintegrated, community-based palliative careservices, local health care professionals can beencouraged to enhance their skills in this area. Aservice delivery model of this type facilitates theprovision of continuing education, advice, backupand clinical support.

Examples of service delivery integration are alreadyoccurring in North Queensland with RFDS doctorsseeking attachments to the palliative care unit inCairns. Education and inservice delivery at thenursing, medical and health worker level is now aregular event at the Wuchoppern CommunityControlled Indigenous health service.

2006 should see the further development of aregional service to the Cape York Peninsula and TorresStrait. Finally, data collection and evaluation of servicedelivery models will be integral from the outset.

CONCLUSIONHigh quality end of life care can be achieved in ruraland remote settings. Required, is a commitmentfrom health policy makers and planners,mainstream health services and the local andvolunteer sectors in each small community.

Palliative services need to be recognized as of equalpriority to acute services and adequately funded.

General physicians and general practitioners needto be encouraged to develop their skills in this areaand supported with education and advicewhenever necessary.

Indigenous health services should be recognized asvital cultural bridges and affirmed in assisting withaspects of end of life decision making for theirclients and families.

Managing client and family expectations aroundend-stage renal disease is an area that needs furtherexamination as the overall population of clients ondialysis in Northern Australia increases.

This report proposes a direction for health policymakers and planners with the further developmentand funding of integrated, community-basedpalliative care services. Local health careprofessionals can be encouraged to develop theirskills in this area and supported with education,advice and backup wherever necessary.

Some of the directions presented includestrengthening the links between acute, mainstreamhealth services and the community sector andaffirming community palliative services with afunding level commensurate to their activity.

Associate Professor Kathleen Atkinson is A/MedicalSuperintendent Innisfail Health Services District.Dr Atkinson has applied to become a candidate of TheRoyal Australasian College of Medical Administrators

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BIBLIOGRAPHY

1. National Rural Health Alliance : HealthyHorizons: A framework for Improving thehealth of rural, regional and remoteAustralians. Part I & Part II – Rural, Regionaland Remote Australians. National RuralHealth Alliance Publication, NRHA ACT 1999pp11-13

2. Australian Bureau Of Statistics 3124.0Demography Working Paper 2001/2 -Aboriginal and Torres Strait IslanderMortality: Evaluation of ExperimentalIndigenous Life Tables Australian GovernmentPublications 2002

3. McGrath P, Watson J, Derschow et al:Indigenous palliative care service delivery - aliving model: companion book. Darwin:UniPrint, Charles Darwin University 2004.Available at: <www.mcgrath-research.net.au>

4. Australian Institute of Health and Welfare(AIHW) Health in Rural and Remote AustraliaAIHW Cat. No. PHE 6. Canberra: AIHW, 1998

5. Australian Institute of Health and Welfare(AIHW) Rural, Regional and Remote Health: Astudy on Mortality in Australia AIHW Cat. No.PHE 45. Canberra: AIHW, (Rural Health seriesNo 2.), 2003

6. Humphreys J. Rural health status: what dostatistics show that we don't already know?.Australian Journal of Rural Health. 7(1):60-3,1999 Feb.

7. Hayes LJ. Quine S. Taylor R New South Walestrends in mortality differentials between smallrural and urban communities over a 25-yearperiod, 1970-1994. Australian Journal of RuralHealth. 13(2):71-6, 2005 Apr

8. Johnston G. Wilkinson D. Increasinglyinequitable distribution of generalpractitioners in Australia, 1986-96. Australian& New Zealand Journal of Public Health.25(1):66-70, 2001.

9. McGrath CL: Issues influencing the provisionof Palliative Care services to remoteAboriginal Communities in the NorthernTerritory Aust J. Rural Health (2000) 8, 47-51

10. McGrath P, Ogilvie K, Rayner R, Holewa H,Patton, MAS: The “right story” to the “rightperson”: communication issues in end of lifecare for Indigenous people. Aust Health Rev2005: 29(3): 306-316

11. Queensland Health Torres Strait andNorthern Peninsula Area Health ServiceDistrict Orientation Manual athttp://qheps.health.qld.gov.au/torres/html/induction.htm

12. Queensland Health: Aboriginal & Torres StraitIslander Issues in Cairns Base Hospital ResidentMedical Officers Information Manual Section 3 –General Information. 3-1-3-5. QueenslandHealth Publications. Reviewed 2000

13. Carrol P: Aboriginal Health: Social andCultural Transitions in ConferenceProceedings, Northern Territory University,Darwin September 1995. Centre for SocialResearch and the Faculty of Aboriginal andTorres Strait Islander Studies. NTU Press 1995

14. Australian Bureau Of Statistics 2001, Censusof Population and Housing. AustralianGovernment Publications 2002

15. Maddocks I, Rayner RG: Issues in palliativecare for Indigenous communities. Med J Aust2003; 179: S17-S19

16. Tong S. Hughes K. Oldenburg B. Del Mar C.Kennedy B. Socio-demographic correlates ofscreening intention for colorectal cancer.Australian & New Zealand Journal of PublicHealth. 24(6):610-4, 2000 Dec.

17. Condon J.R., BT Cunningham J., Armstrong B.(2004). “Long-term trends in cancer mortalityfor Indigenous Australians in the NorthernTerritory.” M J Aust 180(10):504-507

18. Queensland Health Cairns Health ServiceDistrict Population and Socio DemographicData at:http://qheps.health.qld.gov.au/profiles/cairns.htm#data

19. Commonwealth Dept. Health and Ageing:National Palliative Care Program: Providingculturally appropriate palliative care toIndigenous Australians (MangabareenaAboriginal Corp. for Commonwealth Dept.Health and Ageing, Commonwealth ofAustralia 2004 Ch 3 pp23-48

16

ACHIEVINGPERFORMANCETARGETS

THE BQB APPROACH

Dr Amanda Ling and Brian Davies

BACKGROUND

North Metropolitan Area Health Service (NMAHS) isone of the two major metropolitan health networksin Perth, and includes Sir Charles Gairdner Hospital,Osborne Park Hospital, Swan Kalamunda HealthService and Graylands Hospital. Sir Charles GairdnerHospital, one of the major teaching tertiary hospitalsin Perth, and the two major hospitals from the SouthMetropolitan Area Health Service, Royal PerthHospital and Fremantle Hospital, participated in aproject to improve hospital performance.

In the autumn of 2005, comparisons of hospitalperformance against Health Roundtable datashowed a significant gap, and as a result NMAHSinitiated the Best Quartile Benchmarking (BQB)project, an initiative for improving, the length of stayof acute inpatient episodes, the percentage ofelective surgical procedures treated as same-dayepisodes, and the percentage of multi-day electivesurgery inpatients admitted on their day of surgery.The BQB set performance targets at best quartilebenchmarks when compared to peer group hospitalsnationally, with targets at clinical department level,and composite targets set at clinical division, hospitaland health service levels.

The NMAHS Executive monitored progress througha monthly balanced report card process, monthlygeneration of league tables, and also offered areward for consistent achievement of targets over aminimum of a three consecutive month periodaggregated to the clinical division level. The raw datawas made available to the clinical divisions allowingdetailed analysis and verification of the results.

The results in the July to December 2005 HealthRoundtable report showed significant improvement,and the January to June 2006 showed further gains.

Revised BQB targets for 2006 – 2007 will furtherrefine the targets and add the increasing challenge ofachieving best quartiles. The initial project did notinclude the secondary hospitals, however, peergroup benchmarks will be available from 2006-2007.

METHODOLOGY

Best Quartile Benchmarks were constructed fromnationwide data obtained through membership witha peer organisation, the Health Roundtable (HRT),and were based on the Diagnosis-Related Groups(DRG) classification system, version 4.2. Thisfacilitated the tailoring of performance targets to

match the casemix of each department, division, andwhen necessary, individual clinicians.

The DRG classification system groups inpatientepisodes into over 600 groups DRGs, is usednationally for coding, and in some States, thefunding of hospital based episodes of care, andforms the basis of much of the Health Roundtabledata. However, the use of DRGs assumes hospitals inthe reference group and the evaluation group havereasonably similar clinical case profiles. While DRGclassification schemes and cost weights facilitatecomparisons among similar hospitals, they do notprovide a robust comparison of hospitals with majorclinical differences, such as the comparison of adedicated maternity hospital to a general hospitals,or tertiary hospitals to secondary hospitals.

Hospitals in the HRT peer group were ranked foreach inpatient DRG, and the best quartileperformance was identified and defined as thebenchmark for each DRG. This was in contrast toearlier benchmarks, which measured quartiles acrossall episodes of care. Departmental, divisional andhospital targets were then derived according to thecontribution of each inpatient DRG to theirrespective workloads.

The construction of the Sameday Episode Rates andthe Day of Surgery Admission Rates were developedusing a similar methodology. Hospitals in the HRTpeer group were ranked for each of these rates, andthe best quartile performance was identified anddefined as the benchmark. Departmental, divisionaland hospital targets were then derived.

The development of the BQBs required thereplication of the HRT methodologies to facilitate thecomparison of BQB results, with results in otherstandard HRT reports. One example of theseadaptations was the exclusion of sameday dialysisepisodes from most of the comparisons. A furtheradjustment was due to the difference between thestandard measure of length of stay, which are date-based, and the HRT measure of length of stay, whichis time-based. The existence of multiple variations ofsimilar performance indicators was a source ofconfusion at all levels.

The Reference Data Set was Version 3 of the HRT2003/2004, as this data set had been analysedextensively by members in WA and elsewhere. Thisversion of the AR-DRGs was in current use by theDepartment of Health, Royal Street, and had beenused for HRT analyses and reports up to 2003/04.Derived data items in this database were based onAR-DRG v4.2 (Victorian adaptation), and NationalCost Weights were available for this version.

Implementation of the benchmarked data occurredthrough the monthly balanced report card andleague table process, with detailed review of theresults by Area and hospital executives, divisionaldirectors and divisional business managers. Monthly

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meetings occurred with each of the divisions todiscuss these performance measures and ongoingoperational plans. Areas of concern were reviewedad hoc for further analysis and the development ofspecific action plans. The league tables weredisseminated at the Hospital Executive meeting fordiscussion and review.

The divisional business managers had access to theraw patient level data allowing detailed analysis andverification of this data, and details of themethodology for the generation of the benchmarkswas available on the shared drive. This access to thedata provided a transparent report generationprocess that alleviated the concerns of the divisionsregarding accuracy of the reports. The divisionbusiness managers compiled the monthly reports.

RESULTS

Results for the July to December 2005 half year wereencouraging when compared to the previousfinancial year. The HRT reports showed that for the37,951 inpatient episodes with an average caseweight of 1.23, benchmarked in the six monthperiod, the Relative Stay Index decreased from 112%to 94%, the Sameday rate reduced from 49% to48% and the Day of Surgery Admission Rate wentfrom 82% to 84%.

The average length of stay for multi-day acuteepisodes, based on standard NHDD definition,reduced by 16%, from 6.5 days in 2004-2005 to 5.4days in 2005-2006.

Table 1. Results for the BQB Project based on HealthRoundtable Data October 20051 and March 20062

The use of best quartile benchmarks, derived at theDRG level for peer group hospitals, resulted in workpractice changes at the patient and ward level, andextended the focus into community based care. Adetailed understanding of the DRGs that fell outsidethe target range supported clinical departments todevelop specific plans to address these lengths ofstay variances. The ability to closely monitor theperformance targets on a regular basis ensured thatsteady progress was achieved.

FURTHER DEVELOPMENT:

Best Quartile Benchmarking targets for 2005-2006were determined using HRT peer group data for2003-2004, and revised targets for 2006-2007 havebeen based on similar data for July-December 2005.Average Length of Stay Targets for some clinicalspecialties require investigation and refinement.Examples of skewed targets include MedicalOncology, which are too high, and EmergencyMedicine, which are too low. As the overallperformance of the peer group improves each year,the 2006-2007 targets are more challenging thanthe current set. The revised average length of staytarget is approximately half a day shorter.

The initial project only included the tertiary hospitals,and for 2006-2007 targets have also been developedfor the non-teaching hospitals in NMAHS, and forthe two teaching hospitals in SMAHS.

Amanda LingMBBS, FRACGP, MBA

A/Area Executive Director Sir Charles Gairdner Group

Amanda has worked in public and private hospitalmanagement, mainly in the areas of clinical andmedical management. She also has a special interest inperformance management and evaluation, and hasspent time working in Casemix analysis anddevelopment.

Brian Davies B.Sc.,

Manager, Management Information ServicesNorth Metropolitan Area Health Service

WA Department of Health

A mathematical statistician by training, Brian hasmainly worked in the public sector health services andhospital management areas, with some excursions intomining, groundwater, and international fisheriesmanagement.

1 Health Roundtable, Clinical Service GroupData for Total All Cases, version 1, October2005

2 Health Roundtable, Clinical Service GroupData for Total All Cases, version 1, March2006

Full Year Half Year2004-2005 July-Dec 2005

WA SCGH WA SCGH

Total Separations 192,199 71,132 97,301 37,951

Relative Stay Index 105% 112% 95% 94%

Same Day AdmissionRate 47% 49% 48% 48%

Day of SurgeryAdmission Rate 78% 82% 83% 84%

DISCUSSION

The development of the Best Quartile Benchmarkingproject provided a framework for measuring andmanaging the performance of acute inpatienthospital care. Access to reliable benchmarking datafrom peer group hospitals and access to the detailedinpatient data was critical to the adoption andintegration of the project into the managementculture. Compilation of the balanced report cards bythe division business managers alleviated concernsregarding the transparency and accuracy of the dataand provided the necessary skill set to performdetailed analysis of key areas of concern.

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FOCUS ON QUALITY

RISK MANAGEMENT –BUILDING SHAREDRESPONSIBILITY

Dr Lee GrunerDirector, Quality Directions Australia

For some time I have been concerned by themomentum engendered by the risk managementmovement. It has seemed to me that we haveplaced ourselves on an every speeding roller coasterand put ourselves in its power with our brainstotally disengaged.

We have adopted the jargon:

➣ Risk ratings➣ Root cause analysis➣ Airline industry➣ Blame free culture

These terms that were barely in existence inAustralia 5 years ago are now blithely bandiedabout and regarded as gospel.

However, after 5 years we need to ask ourselves:

➣ Are we better off?➣ Are our patients better off?➣ Are our health services better off?➣ Have we demonstrated better outcomes?

The answers to these questions are far from clear.

It is true that there have been positives:

➣ We have a better knowledge base aboutrisks and this has improved how we thinkabout risk management to a degree

➣ We have increased the reporting ofincidents although how useful this has beenis debateable

➣ We are more aware of risk and so have putin place some better systems

➣ We have learnt a new tool- the redoubtableRoot Cause Analysis (RCA)

On the other hand the questions that I have askedmyself and others are:

➣ Are we using our knowledge baseeffectively?

➣ Are we using our new tool appropriately?➣ Is the reporting of increased numbers of

incidents beneficial?➣ Has awareness made an impact on

outcomes?

It is clear to me that we need to get back to firstprinciples and ask ourselves, why we are focusingon risk management and what we are trying toachieve.

Firstly let us consider the airline industrycomparisons that we hear about ad infinitum. Howfar can we stretch this analogy? How close is healthcare to flying a plane? In an aeroplane we have twopilots and hundreds of people in a confined spacethat they can’t escape from easily all dependent onthese two pilots and very complex equipment thattells them what is happening every step of the way.In health care, we are far more dependent onindividuals who need to demonstrate clinicalacumen and need to work together as amultidisciplinary team with complementary skills.We are far less dependent on equipment in mostsituations and if something goes wrong we do nothave hundreds of people at our mercy.

Certainly the airline industry is a useful learningmechanism about the importance of systemsthinking, but is that all there is?

What about RCA? What is RCA but a structuredproblem solving tool adapted for a specificpurpose. However, over time its use has becomeinappropriate in many situations and considerabletime is given to the use of the tools with thelearnings often not clear. Because it is used for aspecific purpose i.e. examining bad apples, thesystems results are extrapolated from one eventand often using a team that does not understandthe specific circumstances. This is incontradistinction to the structured problem solvingapproach that aims to look at present processeswith a team that understands the process and thus

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move the quality curve to the right. This is based onin depth knowledge of the present system and thusis not merely an extrapolation. RCArecommendations are often non specific and/ ornot adopted and/ or fallacious if the process hasbeen inappropriate. In addition RCA is just a tool.You can’t build a robust structure with just one tool.Ask any builder!

I was asked in questions time, how it possible is itthat RCA has nevertheless become so popular thateveryone is demanding training. My answer to thisis twofold. Firstly it has been taken up bygovernments as the investigation panacea and thisis very powerful. Secondly it demonstratesmarketing theory very clearly. New products aretaken up by people as follows:

➣ innovators, ➣ early adopters, ➣ early majority, ➣ late majority ➣ laggards

We are now in the stage of the late majority, wherepeople who have not had training feel left out ofthe process and feel an enormous urge to get onthe roller coaster to be like everyone else. By thistime of course the innovators have been intosomething new for a long time and the earlyadopters are busily adopting this!

So what about incident reporting. This hasspawned a whole new industry! There has beennew software and new technology, hosts of peopleemployed and even organisations formed to meetthe demand. I am still to see what this hugeinvestment in time and energy has delivered. I amnot even sure that what it is supposed to deliver istotally clear.

The issue is that we do need to think much morecarefully about how we spend our ever limitedresources and what outcomes we expect toachieve. Where is the real cost benefit? We need tostart looking beneath the jargon and question moreopenly. I have heard from learned colleges thatdoctors have not been engaged in the riskmanagement movement and I have observed thismyself. How is it that key professionals have notbeen engaged and what is being done about this?

Are we really looking for a blame free culture? Ihave found that many health care professionals andparticularly doctors find this terminology

inappropriate. They ask what should happen ifsomeone does do the wrong thing? Should therenever be any blame? In fact we have seen plenty ofblame apportioned in some of the prominentadverse events, despite the jargon. The question isthen where can we look to enhance our learningabout the sort of culture we need to engage allhealth professionals and increase quality and safetyin health care?

I believe that there is a lot to learn from modernculture and the epitome of this is the reality TVshow. One of the most popular in this genre isSupernanny, an English nanny who tries to sort outdysfunctional families. This provides us with one ofthe most important principles that one can apply torisk management in health care- THESUPERNANNY PRINCIPLE OF CONSEQUENCES.

This principle demonstrates what happens wherethere is no culture of shared responsibility:

➣ The parents have abrogated theirresponsibility to discipline their children toensure they become good citizens

➣ The children have not learnt to beresponsible for the consequences of theiractions

What Supernanny does is introduce consequences.If the children’s behaviour is “unasseptable” theyneed to spend time on the naughty step/ corner/spot to reflect on what they have done. TheSupernanny Principle Of Consequences relies on:

• Engaging children by getting down to theirlevel and speaking their language

• Explaining the impact of their behaviour onothers

• Clearly relating the consequences of theirbehaviour to outcomes

• Educating parents on how to carry outthese steps consistently, so that childrenmake the right behavioural choices

• Parents putting the time energy and effortinto this

In this way:

• Responsibility is instilled in children by theuse of consequences

• Responsibility is instilled in parents by theuse of education on how to introduceconsequences

How can we relate this to risk management inhealth care?

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In health care, we need to develop a culture ofshared responsibility if we are really to make inroadsin improvement of quality and safety:

• Leadership needs to be educated to ensurethat it will listen to staff, assess the evidenceand take action where evidencedemonstrates clear risk to the organisation

• Staff need to understand the consequencesto themselves, patients and the organisationif they do not speak up about areas ofsignificant risk or if they make the wrongchoices

Based on the Supernanny principle ofconsequences:

• Staff need to be engaged using the righttechniques and language

• They need to understand how theirbehaviour can impact on patients and staff

• There need to be appropriate consequencesclearly related to outcomes

• Management needs to be educated inconsistently carrying out these steps so thatstaff make the right behavioural choices

• Management putting time, energy andresources into this

It is not only modern culture that has lessons toteach us. Sixty years ago, that great quality pioneer,William Edwards Deming was teaching theJapanese to become self sufficient by espousing his14 principles. Principle number 8 still has a lot toteach us: DRIVE OUT FEAR

This has always been my favourite Demingprinciple. Organisations that successfully do thisdevelop a culture where all staff contribute overand above the call of duty.

What are we fearful off?

➣ Retribution➣ Not being listened to➣ No action being taken➣ Questioning the status quo

Driving out fear acknowledges that not everythingrelates to systems. People are an important part ofthe equation and they may make the wrongchoices for many reasons so things go wrong:

➣ Accepting the status quo➣ Not asking if they don’t know➣ Trying to do it all themselves➣ Impatience or lack of time ➣ Lacking competence

This is why we need not to talk about a blame freeculture, but a culture of shared responsibility thatinvolves staff and management:

• A culture of responsibility means that ifpeople make the wrong choice and thus dothe wrong thing, they know that there willbe consequences

• A culture of responsibility means thatleadership must establish consequences forbehaviour and support staff to developappropriate behaviours

• A culture of responsibility means thatmanagement must visibly lead the effort

• A culture of responsibility means that allstaff should question and evaluate acceptednorms

We need to accept that in health care as in life, therewill always be consequences. Consequences mustbe appropriate to the actions taken and are notnecessarily punitive, but may involve education,changes in procedure, and more resources forexample. However if we change the terminology weare likely to develop enhanced risk managementsystems and engage staff more effectively.

This paper was supposed to be controversial andengender some discussion. I was approached bymany people at the conference who had beenthinking the same and congratulated me forspeaking out. I am encouraged that they will returnto their organisations and institute changes in whatthey are doing.

In promoting quality and safety we should alwaysbe thinking whether we are doing the right thingand then if we are doing it the right way. Oncewhat we are doing and the way we are doing itbecomes the only way, we have a major problem.

We need to stop simply doing and start seriousreflection and evaluation in relation to our riskmanagement experiences and procedures:

• Are we doing the right thing?• Are we doing it in the right way?• Are we continually thinking about the

underlying principles?• Are we continuing to enhance and apply

our learning from the world around us?• What outcomes do we still need to achieve?• What progress have we really made

towards a culture of shared responsibility?

THIS PAPER WAS PRESENTED TO THE AAQHCCONFERENCE IN AUGUST 2006

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ACCREDITATION: ARE THERE LESSONSFROM THE PAST?

INTRODUCTION

To assist with the preparation for Australian MedicalCouncil (AMC) college accreditation in 2008, priorAMC accreditation reports of other specialtycolleges were reviewed to identify any commonareas of concern.

The review covered the accreditation of theColleges of General Practitioners, Physicians,Psychiatrists, Obstetricians and Gynaecologists, andAnaesthetists. These reviews were undertakenbetween 2002 and 2005. The first accreditationreport related to the College of Anaesthetists, andno formal recommendations were made in themain body of the report. However, for eachsubsequent college review, there have been suchrecommendations, and the number of these foreach college has varied from 34 to 72.

To the maximum extent possible, individualrecommendations were assigned to the standard orstandards to which they were most closely related.In some cases, this was not easy as somerecommendations were only loosely linked toparticular AMC standards.

In this context, the philosophy of the AMCaccreditation would appear to be based stronglyaround an interactive process of broad review. Forexample, for each of the defined standards, therewas not necessarily evidence that complianceagainst some defined objective standard had beenrigorously or comprehensively evaluated. Rather,the standards appeared to define parametersoutlining particular areas of interest in the review.They seem to define a curriculum for theassessment, rather than represent specific criteriafor evaluation.

WHAT WERE THE RESULTS?

A total of just under 200 recommendations werereviewed, and these covered 22 of the 26 discreteareas in which AMC has defined standards. 90% ofthese recommendations relate to the trainingprogram. Of the last 10%, about half relate tocontinuing professional development and under-performing fellows, and the other half relate to theCollege ensuring there is appropriate liaison withrelevant related agencies and the community inestablishing the education goals for training.

A breakdown of the recommendations relating tothe training program is set out in Table 1. Two ofthe three standards relating to training positionswere far and away the most prominent area inwhich past recommendations have been made.Given this prominence, it will be important for theCollege to look closely at this aspect of its trainingprograms in the preparation for accreditation.

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FURTHER ANALYSIS OF THEHOSPITAL/TRAININGPOSITIONRECOMMENDATIONS

There are three AMC standards for this area, andthese are set out in table 2.

TABLE 2: ACCREDITATION OFHOSPITALS/TRAINING POSITIONS

• The training organisation specifies the clinicalexperience, infrastructure and educationalsupport required of the accredited hospitaland/or training position, and implementsclear processes to determine whether theserequirements are met.

• The training organisations accreditationrequirements cover: clinical experience,structured educational programs,infrastructure supports such as library,journals and other learning facilities,continuing medical education sessionsaccessible to the trainee, dedicated to timefor teaching and training and opportunitiesfor informal teaching and training in thework environment.

• The accreditation standards of the trainingorganisation are publicly available.

There were no recommendations regarding thepublic availability of training position accreditation,and there was considerable overlap with regard tothe two other standards. In other words, manyrecommendations embraced aspects of both ofthese. On further review, it was possible to identify five main themes underlying therecommendations, and these are discussed below:

• The Nature of the Training Program. 13recommendations concerned how the trainingprogram was constructed. The majority relatedto structural aspects of the particular trainingprograms, and are probably not of greatrelevance in our context. There were tworecommendations of possible interest.Consideration of encouraging more trainingposts in the private sector, and a suggestionthat ongoing dialogue with health serviceproviders in relation to workplace training mayenable better understanding of workplacepriorities, while still ensuring the educationalneeds of the college are appropriately met.

• Availability of Training Positions. A fewrecommendations appear to have arisen fromconcerns of trainees that they faced variousbarriers in terms of accessing training positionsrelevant for there needs. The workforce studiesalready undertaken in medical administrationhave considered various aspects of the supplyand demand for training positions.

• Work issues. Nine recommendations concernedwork issues, such as long hours of work,arduous on-call responsibilities, or geographicalrelocation. It was believed these issuesinterfered with study commitments, andcreated difficulties in terms of work and familybalance, particularly for women. A recurrenttheme was difficulties in accessing part timetraining positions, or these not being availableat all. It would be important for the College tounderstand whether our candidates believethere are significant concerns in this area.

• Training Requirements and the Standards andAssessment of Training. There were 18recommendations related to this area, which isprobably the most substantive area of concern.However, it is a complex issue as ouraccreditation of designated work experience ismanaged differently from other colleges, and atleast some of the recommendations may notreally be relevant. However, the college needsto be mindful of the high focus of pastrecommendations relating to this area in thelead up to accreditation, and for us to be quitearticulate in specifying what our particularrequirements for administrative training are,and how these are defined and assessed.

• Education Support. This was concerned with theavailability and access to formal educationsupport, such as library facilities and othereducational resource material. Again, ourcontext may well be different. However, somefurther review of whether there is sufficienteducational resource material available to ourcandidates and whether these resources areuniversally accessible may well be worthwhile.

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For RACMA there is nothing overwhelming ordaunting in any of the recommendations. Mostappear to have arisen from concerns, or comments,expressed by members of the relevant collegecommunity during the accreditation visits, and theygenerally encourage the college to continue withits endeavours into this particular area. The greatestfocus appears to have been on various aspects of

the training positions. While many of the concernsthat were raised may not actually be of particularrelevance to our training program, the RACMA isencouraged to give this area some priority in thelead up to accreditation.

Dr Bill AppletonAccreditation Co-ordinator

A BRIEF OVERVIEW OF ALL RECOMMENDATIONS

Table 3 outlines each of the broad areas covered by the AMC accreditation, with the total number ofrecommendations from the four survey reviews, and a brief commentary on each area, except for trainingposition accreditation, which has already been discussed in more depth.

TABLE 3: SYNOPSIS OF ALL AMC RECOMMENDATIONS

Topic Number of Brief CommentsRecommendations

Standards Relating toCollege Overall

12 There is a significant expectation that Colleges will consultwidely with all relevant stakeholders, including other serviceproviders and the community at large, in terms of setting anddefining goals and objectives of their education programs.

Content ofEducation &Training

22 The recommendations seek more formality and rigour indefining both the curriculum, and ensuring it is consistent withgoals and objectives of training.

Assessment &Examination

37 There are a large number of recommendations regardingassessment, embracing the accuracy and competency ofassessment, providing feedback to trainees in regard toassessment outcomes, and working towards betterunderstanding issues contributing to difficulties faced by trainees

Hospital/TrainingPositionAccreditation

74 These recommendations are discussed in the section above.

Supervisors,Assessors, Trainers& Mentors

40 Recommendations embrace a strong push for more formaltraining and evaluation of supervisors and others responsiblefor training, with clear cut and effective two-way feedback onperformance.

Trainee Selectionand Recognition of OverseasTrained Specialists

25 There are recommendations in these areas for all four Colleges.

Outputs &Outcomes ofTraining

10 There are few recommendations in this area, and theserecommendations do not appear particularly onerous.

ContinuingProfessionalDevelopment

13 There is nothing unexpected or surprising in any of theserecommendations, which emphasise continuing developmentof these programs towards universal involvement, and greatermonitoring to ensure activities actually meet relevant needs.

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made over the whole system but only a resultantsmall overall improvement. This is because the ratelimiting step only has small modifications andimprovements.

Manufacturing and business systems that haveapplied the Goldratt TOC approach haveexperienced 10-20% improvements in overallthroughput and productivity. This has resulted inmassive improvements in profit and customersatisfaction.

The TOC approach penetrated the Health Sector inthe NHS in the late 1990s. You can read about whathappened to Oxford-Radcliffe Hospital onhttp://www.goldratt.co.uk/succ/oxfordstory.pdf .This was a typical small NHS hospital with typicalissues around access block and trolley waits in theEmergency Department. The hospital hasapproximately 30,000 patients per year throughthe Emergency Department and trolley waitsexceeding 12 hours on a regular basis (does thissound familiar?). The problems experienced wererelated to delays in moving patients from one kindof care to the next. As the Emergency Departmentis the only area in the hospital with “spare capacity”the patients end up there blocking the system evenif the block actually relates to discharging patientsout into the community.

The TOC approach at the Oxford-Radcliffe Hospitalwas to identify the main cause of access block in theEmergency Department and then work on thoseconstraints one at a time. The resultantimprovement in throughput was a startling 30-50% and the results were sustainable over a longperiod. They then went on and worked onconstraints right through the hospital to thedischarge process and into the community. Onehospital even eliminated its two year neurosurgerywaiting list in 12 months using TOC. This approachhas been repeated in many hospitals in the NHSwith equivalent or even better results.

The TOC Approach:1. IDENTIFY the system constraint2. EXPLOIT (maximise the use of) the constraint3. SUBORDINATE everything to the constraint4. ELEVATE (remove load from the constraint)5. GO BACK (don’t let inertia become the

system’s constraint)

The TOC approach is not just about improvingthroughput. It is also a management tool that helps

THE THEORY OFCONSTRAINTS

GET MORE LOAVES AND SLICE BREAD FASTER,

Sick of access block and waiting lists? Read on…..

DR MIRIAM MARTIN

MBChB, DCH, DipObst, DipCEM, TOC Practitioner

miriam@ausstat.com.au

Miriam is a long term locum and now works inrecruitment and has an interest in systems andprocesses.

“The more complicated the problem, the simpler thesolution must be”

Dr Eli Goldratt

The Theory of Constraints (TOC) is a managementtool devised in the 1980s. Eli Goldratt, a physicistby trade, got involved somewhere, somehow, inproduction and management. The TOC approachis a management approach to identify the ratelimiting step. Solving the issues around the ratelimiting step is the key to improving the overallsystem. The great thing about this approach hasbeen good buy in from staff, quick implementationof good changes and a consultative approach thatachieves more results than screeds of paper.

Current thinking is that to improve an overallsystem all you need to do is make local efficiencygains. However, this does not deal with issues of“links within the chain”. A huge effort could be

25

you to identify all the problems within a system,develop a really good picture around the currentreality and devise a solution that is robust andsustainable. Identifying the “core conflict” within asystem is extremely important. Believe it or not,usually there are a whole lot of symptoms within asystem resulting from the core conflict. As doctorswe all know this intuitively, remember they alwaystold you that for any set of symptoms there isusually only one pathology? Just think aboutthyroid disease –a raft of symptoms that appeartotally unrelated but with one core problem (figure1). A hospital may have a core conflict aroundtreating acute patients versus chronic patients.(figure 2). In my discussions with many medicalmanagers in Australia it is becoming apparent thatcore conflicts can include things like “Politicalinterference”, “under-funding” or “poorleadership”.

FIGURE 1. SYMPTOMS OF HYPERTHYROIDISM

FIGURE 2. THE CORE CONFLICT WITHIN A HOSPITAL

To verbalise this conflict you say: In order to “havean effective hospital” we must “run a good healthservice in the short term” and in order to “run agood health service in the short term” we must“spend resources on short term solutions”. Then forthe other side of the conflict: In order to “have aneffective hospital” we must “run a sustainableservice in the long term” and in order to “run asustainable service in the long term” we must“spend money and resources on long termsolutions”. As a result “spend resources on shortterm solutions” and “spend money and resourceson long term solutions” are in conflict.

To develop a meaningful and sustainable solutionyou must break the core conflict. As part of theprocess you investigate any negative effects thatyou might have and then devise a strategic plan forimplementing the solutions. So the age oldproblem of: “what to change”, “what to changeto”, and “how to change” are addressed with thisapproach.

As managers, we are involved in selling ideas to ourstaff, clients and boards all the time. The TOCapproach is excellent at developing an “unrefusableoffer”. The unrefusable offer is a sales propositionthat is so good that the buyer cannot refuse. This isbecause you have listened well and devised asolution that fits exactly what they are wanting.

We all have people coming to us with “half bakedideas”. This is the enthusiastic person who isconvinced that their solution will solve all thehospitals problems (if only…). The TOC thinkingprocesses tools are useful in being able to quicklyevaluate these kinds of ideas in a non-confrontational way that communicates to theperson that you have been listening.

Communication of change is also very important.The TOC approach has a large emphasis on thepresentation of improvements within the system;this vastly improves buy-in and thus the success ofthe project.

THE QUARTERLY ISGOING ELECTRONIC

The Quarterly is now available in an electronicform that enables you to just select those

articles that interest you most. Follow the linkunder Member Services on the RACMA

website at

www.racma.edu.au

In the future as we move to a data baseweb site you will be able to complete

searches for articles on topics of interest.

26

To learn about TOC you can read any of EliGoldratt’s books. These are very readable andwritten like novels in a narrative style. Purchasethese via www.amazon.com as they are not readilyavailable in Australia or New Zealand. Start with“The Goal” and then go on to “Its Not Luck” or“Critical Chain”. In 2006 a book was publishedspecifically about Healthcare and TOC called “WeAll Fall Down”. You can also now do a Masters inHealth Care Management at the University ofNottingham (UK) in TOC. Alternatively you canattend an introduction or course on TOC bycontacting me on miriam@ausstat.com.au. Formore information just drop me a line.

Dr Miriam MartinTOC Practitioner

References and more reading:

Oxford-Radcliffe Storyhttp://www.goldratt.co.uk/succ/oxfordstory.pdf

Eliyahu M. Goldragtt and Jeff Cox, Third RevisedEdition 2004. “The Goal, A Process of OngoingImprovement”. North River Press. –go to

www.amazon.com

MSc –Theory of Constraints (Health CareManagement)http://www.ntu.ac.uk/postgrad/coursefinder/course/Theory-Of-Constraints-Health-Care-Management/1C297A59-833E-45B2-BAB9-55493FF9727B

Wright, J, King, R; 2006. We All Fall Down,Goldratt’s Theory of Constraints for HealthcareSystems. 2006. www.amazon.com

A guide to implementing the Theory ofConstraints (TOC). Kelvyn Youngman,http://www.dbrmfg.co.nz/ This website has alarge section on Healthcare and TOC.

Breen, AM; Burton-Houle, T; Aron, DC. 2002.Applying the Theory of Constraints in Health Care:Part 1: The Philosophy

http://www.goldratt.com/for-cause/applyingtocinhcpt1fco.htm AGI GoldrattInstitute Website, but previously published inSpring 2002 (Volume 10, Number 3) of QualityManagement in Health Care, Aspen Publishers,Inc. This includes links to other good TOCHealthcare information.

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CANDIDATES CORNER

Superb, amazing, absolutely spectacular. Myexpedition to St Petersburg was a great success andI would recommend the destination to any of youwho enjoy the arts. Since I was a teenager I hadwanted to visit the city and a “Medico legalconference” finally gave me the opportunity.

Three hundred years ago Peter the Great decidedto build a European styled city named after St Peter.It was Catherine the Great who brought Russia tothe world stage of art and created the Hermitagewhich houses one of the world’s largest artcollections. I counted 14 Gauguin’s including thefirst he painted in Tahiti. There were over 5 roomsof Picassos and the list goes on and on. The WinterPalace, Catherine’s residence is next to theHermitage. We also visited the Summer Palaceoutside the city.

More sobering is the recent history of this greatcity. Only 60 years ago during WWII the Nazis laysiege to Leningrad for 900 days. They neverentered the city but a third of the 3 millioninhabitants died. Stalin was not kind to those whoremained. Many of the palaces and buildings havebeen restored to their former glory. The stunningAmber room at the Summer Palace is an example ofthis. The magnificence of the city and thedesperation of the recent past create the mysterythat is the Russian people.

A highlight for me was attending the MariinskiyTheatre (can we put in IMG290 photo heresomehow) built in 1860 to see the Kirov ballet.Both Pavlova and Nureyev began their careers inthis theatre. (Did you know Pavlova died when shedeveloped pneumonia while touring in Australia?) Ialso attended the opera Eugene Onegin based on a

novel by Pushkin. A performance of Shostakovichsymphony 8 and 12 completed my cultural feast.He wrote the 7th Symphony during the 900 daysiege and the 8th soon after. These performanceswere held during the White Nights Festival of thenorthern summer.

Finally, I attended a performance of Giselle in theHermitage theatre. This was Catherine’s privatetheatre and it is quite understated and beautiful. Icould just imagine Catherine sitting in her throne inthe centre of the theatre enjoying performances ofthe artists she had brought from across Europe.

My suitcase was lost for 3days, so I learnt the truevalue of a clean pair ofsocks. I stayed in a greathotel and ate atwonderful restaurants.Nothing was going tostop me from enjoyingthis amazing city. Irecommend it to you all.

The cultural life in AliceSprings continued whileI was away. I missed thebeanie festival andcamel cup! Nextweekend is the famousHenley on Todd regattaduring the DesertFestival. Of course I willbe marching in the

Town Band in the parade. A highlight of the Festivalis the Desert Mob Exhibition were recent worksfrom Aboriginal art centres in Central Australiawhich are shown at the Araluen Gallery.

In my first “Candidates Corner” I stated that amonth was a long time in medical administration.

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BOOK REVIEW:DISPUTES ANDDILEMMAS INHEALTH LAW

By: Dr Mukti Biyani,Medical Administration Registrar, DOH, W.A.

Freckelton I and Petersen K, The Federation Press,2006, 691 Pages, medium size soft cover, RRP A$125.00, ISBN 1862875537. Distributed by TheFederation Press, Telephone: + 61 2 9552 2200 orwebsite: http://www.federationpress.com.au.

Hot on the heels of its predecessor “Controversiesin Health Law”, “Disputes and Dilemmas in HealthLaw” (by the same editors) delves much deeperinto the ever changing landscape of Health Lawand draws upon the opinions and expertknowledge of more than 36 well known anddedicated lawyers, health professionals and policymakers. Undeniably designed to be more of acomprehensive guide than a pocket sizedreference, Freckelton and Peterson have done aremarkable job in beefing up the current editionwith over 30 stimulating chapters compared to just18 chapters for its predecessor.

With Health Law gaining more prominence thanever before in health care delivery as a result ofadvancement in technology, scientific knowledgebase, increase in community expectations,changing legislations and human rights, this well-referenced book does well by providing well-supported and logical discussions on the matter.Although eminently readable, the target audienceremains people experienced in Health Law.Therefore, it is hardly surprising that with mylimited exposure to Health Law in medical schooland early years of residency (not uncommon formost medical students), the material was a bitinundating. However, it has served to be a usefulresource and provided a good overview of differentkinds of controversial and challenging issues thathealth professions are likely to face during theirworking life today and into the future.

The Chapters are broken up into parts coveringLitigation and Liability; Reproductive Technologies;The Sequelae of the End of Life; Public Health;Ethical Frameworks and Dilemmas; Regulations;Human Rights and Therapeutic Jurisprudence;Research and Vulnerability and Information; Privacyand Confidentiality. While the book primarily dealswith dilemmas and disputes in Health Law in theAustralian context, it also has enough common lawmaterial from international jurisdictions to keepnon-Australian readers interested.

Over all, this book is a handy reference for Healthprofessionals, lawyers and policy makers keen ongaining an understanding of the core controversialconcepts in Health Law. Given that generally everychapter can be read in isolation, it gives the readerthe flexibility to focus on his / her interests withoutneeding to read the whole book.

Well, it’s happened again and I am now theDirector of Medical and Clinical Services at AliceSprings Hospital. The Northern Territory is land ofopportunity and challenges!

Another rare species in the NT are Preceptors forRACMA candidates. When I was involved in GPpolitics the rural GPs would constantly say that thetraining was city based and irrelevant to them. Inthe centre of Australia I am developing a better

understanding of their concerns. We need “MedicalAdministrators without borders”! I am sure apreceptor will appear in the desert. I am off to apatient flow workshop in Melbourne today. See younext edition and take self care.

Dr Meredith ArcusSnr District Medical Officer

Central Australia Remote Healthmeredith.arcus@nt.gov.au

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CHANGES IN THENATIONALSECRETARIAT

2006 has seen big changes in the profile of staff inthe National Secretariat. I would like to introducetwo new members of staff to you.

NEW ASSISTANT DIRECTOR –CURRICULUM ANDMARKETING

Colin Dunn has recently been appointed to thisnew position in the College. He came to RACMAfrom RMIT University in Melbourne where he wasSenior Lecturer in Small Business andEntrepreneurship and Program Coordinator of theUniversity’s Bachelor of Business (Entrepreneurship)program. He co-wrote the curriculum for thisinnovative undergraduate degree program, the firstin the world to have a focus on building a businesswhilst studying business at the University level.

Colin has over 30 years experience in curriculumdevelopment and teaching and in managingnational and international projects mainly focusingon innovation, entrepreneurship and enterprise.From 2005 to June 2006, Colin was President of theInternational Council for Small Business (ICSB). Thisinternational academic organization has over 2200members and in June this year celebrated it’s 51stanniversary in Melbourne at the annual ICSBconference. Colin convened and managed theconference which had over 450 attendees most ofwhom submitted academic papers through a peerreview process.

Prior to becoming President of the ICSB, as ICSBPresident Elect, he led the team that built the newCouncil website. Colin was president of theAustralasian affiliate of the ICSB, the SmallEnterprise of Australia and New Zealand (SEAANZ),from 2002 to 2005 and co- managed the SEAANZSecretariat from 1998 to 2006 largely beingresponsible for its financial affairs. SEAANZ has over300 members in Australia and New Zealand.

Colin’s focus will be to support the CEP programand the development of new training activities,including:

• more opportunities for relevant and innovativeprofessional development;

• an improved website; and • greater level of support for it’s annual

conference,

Colin’s appointment is welcome. Colin can becontacted at the National Secretariat at any time.

NEW BUSINESS SUPPORTOFFICER

Ms Kathy Griffiths has recently been appointed tothe College in this role.

The role is to take daily responsibility to liaise withcandidates, fellows and members, organizeworkshops, meetings and respond to the numerousenquiries that come to the Secretariat on a dailybasis.

Kathy will be the first person to answer thetelephone when you ring the National Secretariat.She has taken over from Ben Trewarn in this. Shehas already begun to organize the office andestablish connections and new administrativesystems. Please contact Kathy as a starting point ifthere is anything you need.

Kathy received an introduction to RACMA whenshe attended to help with the Hobart examinationsearlier this year. Candidates may recall her beingthere and helping the new Chief Executive with theorganization and co-ordination of arrangements forexaminations, Council meetings and the LangfordOration.

Kathy comes to RACMA with considerableexperience as an administrative officer in thetertiary education sector. She has also beeninvolved with the International Council for SmallBusiness where she helped to organize the 2006World Conference. This included organizing thedesign and publication of posters, brochures andother promotional materials, networking withmanagement staff at the conference andestablishing a data base of more than 500interested people and organizations across theworld. This experience and other responsibilitieswith the Small Enterprise Association of Australiaand New Zealand, make her an ideal appointmentto support RACMA activities.

We welcome Kathy to The Royal AustralasianCollege of Medical Administrators.

assisting the College’s web developer to convertthe web site to a content management system backend.

The new Secretariat team has had much to learnand your forbearance is appreciated. The transitionhas been challenging in the absence of ‘old hands’in the office and I can assure you all that we arecontinuing every effort to meet each person’sneeds.

Dr Karen OwenChief Executive

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BEN TREWARN

Ben Trewarn has been with this College for nearlyeighteen months in a number of administrativesupport roles. Ben has a strong interest in mattersIT and has been studying a business course througha Melbourne TAFE program with a view to movinginto an information technology/web developmentrole.

Ben’s role has returned to part-time work and iscurrently updating the files for the web site and

CONFERENCES 2007

6 – 9 February“Medicine meets Virtual Reality 15”The Hyatt Regency Long Beach Hotel, Long Beach, California, USA, www.inderscience.com/mapper.php?id=17

22 -23 MarchClinical Decisions, Ethical Challenges, Cairns, Queensland, www.changechampions.com.au

17 – 18 AugustThe Eighth International Mental HealthConference Mental Health Prevention – FromPolicy into Practice, Holiday Inn Gold Coast,www.qcimh.com.au

28 – 30 AugustThird International Conference on Information Technology in Health Care: Socio-technical Approaches, www.hic.org.au

29 – 31 AugustAnnual conference of The Royal AustralasianCollege of Medical Administrators, Holiday InnSurfers Paradise, Queensland Telephone: 07 3858 5500;Email:racma07@eventplanners.com.au;www.racma.org.au

AMERICAN COLLEGE OF HEALTHCAREEXECUTIVES 200750TH Annual Congress on Healthcare Leadership –“Innovation”, March 19 -22, 2007, New Orleans,Louisiana, USA. Go to the Congress area ofwww.ache.org

The American College of Healthcare Executives isan international professional society of healthcareexecutives who lead hospitals, healthcare systemsand other healthcare organizations. Thisconference may have interest for some.

BAMM SUMMER SCHOOL AND AGM 2007June 27th - 29th 2007“Beyond the Box” - Creativity and Innovation inDelivering Healthcare,

The BAMM Summer School is being planned andmay be have interest.

Do you have something to say?Contributions, letters and articles for The Quarterly are

welcomed and should be addressed to:

The Editor, C/- National Secretariat

35 Drummond Street, Carlton, Victoria 3053.

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40TH COUNCIL ANDCOLLEGE OFFICEBEARERS 2006

EXECUTIVE OF COUNCIL

The Executive of Council consists of 7 Fellows of theCollege. They are - the President, Vice-President,Honorary Secretary, Honorary Treasurer, NationalDirector of Continuing Education/ Re certification,Censor-in-Chief and the Immediate Past-President.Current Executive Members are:

A/Prof G. W. Frost - PresidentMB BS, MPH (Syd) FRACMA, FAFPHM FHKCCM (Hon)

Dr Gavin Frost has recently been appointed asDomain Head Population and Public Health at theSydney School of Medicine Notre Dame University.A Censor of the College, Dr Frost was appointed tothe position of Censor-in-Chief of RACMA in 1999and was reappointed to this position for a furtherthree year term in August, 2002. Dr Frost becameVice President in 2004. Dr Frost has an activeinterest in health care systems, their measurementand improvement.

Dr D. Rankin - Vice President MBCHB MPH MHA DO FRACMA

Dr David Rankin is the Senior Advisor on healthissues to the New Zealand Ministry of SocialDevelopment. Prior to this appointment he wasGeneral Manager at the Accident CompensationCorporation, with oversight for the health servicesportfolio. David has served for eight years as acensor for the college and has championed theestablishment of the New Zealand branch ofRACMA. He is Chairperson of the New ZealandHealth Information Standards Organisation and hasa special interest in provider behaviour change.

Dr R. Boyd - Honorary SecretaryMB BS (Syd), MBA (Geneva),MHP (NSW), FRACMA, AFCHSE

Dr Roger Boyd joined the Council in 2001 and wasappointed Honorary Secretary in 2002. Dr Boyd isthe principal of Boyd Health Management,providing consulting services in healthmanagement, policy and planning. He is currentlyChair of the National Prescribing Service and is theimmediate past Chairman of the New South WalesState Committee.

Dr P. Bradford - Honorary TreasurerMB BS (NSW), MPH (NSW), FCHSE, FRACMA

Dr Peter Bradford joined the Council in 1996 andwas appointed Honorary Treasurer in 2001. DrBradford is a member of the Victorian StateCommittee. He is Executive Director MedicalServices at Peninsula Health.

Dr K. N. Hill - National DirectorContinuing Education/RecertificationMB BS (Syd), MHP (NSW), FRACMA

D. Kim Hill joined the Council in 1991 and wasHonorary Secretary from 1994 to 2002. In 2002

Dr Hill was appointed National Director ContinuingEducation/Recertification. Dr Hill is Director ofClinical Governance at the Hunter New EnglandArea Health Service NSW.

Dr L. Gruner - Censor-in-ChiefMB BS, B Sc, BHA, MBA, FRACMA, GAICD

Dr Lee Gruner is the Director of Quality DirectionsAustralia Pty Ltd. Dr Gruner joined Council in 2003.In 2005 she was appointed as Censor in Chief.

Dr P. Montgomery - Immediate PastPresidentMB BS, FRACMA

Dr Philip Montgomery joined the Council in 1996.In 1997 he was appointed National DirectorContinuing Education/Recertificationand carriedout this role until his appointment in 2002 as VicePresident. Dr Montgomery was President between2004 - 2006. Dr Montgomery has served asHonorary Treasurer of the Western Australian StateCommittee and as CEP Coordinator and continuesto serve as a member of the Western AustralianState Committee. Dr Montgomery is the ExecutiveDirector of Royal Perth Hospital.

OTHER COUNCIL MEMBERS

The Council Members comprises Fellows of theCollege who are elected on a bi-annual basis.Current Council Members are detailed below.

Dr R. AshbyMB BS (Qld), BHA (NSW), FRACGP, FRACMA, FACEM, FIFEM

Dr Ashby was appointed to Council in 2005, havingbeen a Fellow since 1986. He is currently theExecutive Director of Medical Services at thePrincess Alexandra Hospital in Brisbane and is amember of the Qld State Committee.

32

Dr J. W. Menzies MB BS (Hons), MHP, FRACMA, AFCHSE, CHA

Dr John Menzies is the senior consultant medicaladviser in JTA International Health Consulting. DrMenzies was appointed to Council as one of theQueensland State representatives in 1999 and wasHonorary Treasurer in 2000/01. He is the Chair ofthe Queensland State Committee.

Dr H. M. J. McArdleB Med Sci, MB BS, MPH, FAFOM, FRACMA

Dr Helen McArdle is the Director of MedicalServices and Occupational Physician at the RoyalHobart Hospital.

Dr McArdle is also the CEP Coordinator forTasmania and was appointed the Tasmanianrepresentative on Council in 2005.

Dr B. KotzeMB BS FRANZCP, FRACMA

Dr Beth Kotze is the Area Director of Mental HealthServices for the South Eastern Sydney and IllawarraArea Health Service in NSW. She is the recipient ofthe Bernard Nicholson Prize in 2000 and the NewFellows Achievement Award in 2005. She is aCensor of the College. She is currently Chair of theNSW State Committee RACMA. Beth was firstappointed to Council in 2006.

Dr R. LawrenceMB BS, FRACMA

Dr Robyn Lawrence was appointed to Council in2006. Dr Lawrence is also a Censor of the College anda member of the WA State Committee as the CEPCoordinator. Dr Lawrence is currently the A/ExecutiveDirector of the Child and Adolescent Health Service.

Dr A. NelMB BCh, MBA, FRACMA

Dr Andre Nel is Chief Medical Officer of Nelson-Marlborough District Health Board. Dr Nel wasappointed to Council in 2004 as one of the NewZealand representatives.

Dr M. S. PlatellMB BS, FRACMA, FAFPHM

Dr Mark Platell is the Acting Area Chief ExecutiveNorth Metropolitan Health Service, Perth, WesternAustralia, including Sir Charles Gardiner Hospital.Dr Platell is a Censor of the College and since 1998has also served as the Censor for Case Studies. DrPlatell joined Council 1999.

Associate Professor W. P. Ramsey AM CSCMB BS, BMed Sc, MHA, FRACMA

Dr Wayne Ramsey became the ACT representativeon Council in 2002. Dr Ramsey is currently Chair ofthe ACT committee.

Dr V. SathianathanMB BS, FRACMA

Dr Vino Sathianathan is the Deputy MedicalSuperintendent at Royal Darwin Hospital andbecame the Northern Territory representative onCouncil in 2002. Dr Sathianathan also serves asChair of the Northern Territory Committee and isthe CEP Coordinator.

Dr B. StreetMB BS, DGM, FRACMA

Dr Bernie Street is Clinical Director of GeriatricMedicine at the Bendigo Health Care Group. He iscurrently Honorary Secretary of the Victorian StateCommittee. Dr Street joined Council in 2004.

Dr S. Svilans PhD, MB BS(FUSA), MHA(UNSW), AFACHSE, FRACMA, CHE, ASIM

Dr Svilans is A/Medical Director, Central NorthernAdelaide Health Services, Royal Adelaide Hospital.She is Chair of the Board of Studies, for the SouthAustralian Committee and joined the Council first in2005.

Dr B. SwansonMB BS, B Sc (Maths), B Ec (Hons), MHA, FRACMA

Dr Bruce Swanson is Medical Adviser, ResearchPolicy and Ethics in the South AustralianDepartment of Human Services. He is also amember of the South Australian State Committeeand is the local CEP co-ordinator and joinedCouncil in 2002.

CANDIDATEREPRESENTATIVE

Dr H. LanderBachelor of Medicine (Newcastle)

Dr Lander is currently a Director of Medical Serviceswith Eastern Health in Melbourne. He wasappointed as the inaugural Candidaterepresentative on Council in 2006. He is also anactive member of the Victorian State Committee.

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AUSTRALIAN CAPITALTERRITORYAustin (AM), Tony KBaker, Jennifer LCheah, David FDe Souza (AM), DavidDonovan (ED), John WDumbrell, David MElvin, Norman AEvans (OBE), Cyril PHallett, PhilipLambert, Rodney PLangsford (OBE), William AMason, E RobynO’Leary, Elizabeth MOrchard, Barbara WProudfood, AlexanderRamsey (AM, CSC), Wayne PRefshauge (AC), Sir William DSherbon, Anthony KWells (AM), Ronald HWhite, Gordon EWilkins (MBE), Peter S

NEW SOUTH WALESAlexander, Jennifer AAppleton, JoanneBaker, AndrewBashir (AC), Marie Bearham (Jnr), George P Benjamin, Susanne JBennett, Andrew GBennie, Alexander SBest, John BBlizard, Claire MBlok, Charles RBoger, John RBolton, Patrick GBoyd, Roger GBrennan, Leonard BBull, Robert RBurnand, Josephine TBurrows, Donald LCable (RFD), Ronald HCampbell, John DCarless, Alan JCatchlove, Barry RChan, Steevie SChild (AM), Donald SCleary (OAM), Maurice PCollie, Jean PCollins, John MConley, Jeanette CConstance, Theodore JCurrow, Elwin GCurteis, Owen GCurtis, Paul WDe Carvalho, Vasco EDesgrand, Vincent GDewdney, John CDonnelly, Roy DDoolan, DavidDouglas, PaulDuggan (AM), John MEllis, Vivienne MFinlayson, Peter JForster, Lesley SFrost, Gavin WGalton-Fenzi, Brian LGardiner, Brett P

Gibbs, Cedric CGilhotra, Jagmohan SGobius, Risto JGodding, RobynGraves, Debra JGreenwell, John BGrimes, DonaldGrunseit, Barbara AGuanlao, Luisito PHaski, Robert RHely, Joanna KHill, Kim NHills, Michael WHo, Leong KHolland, Howard JHooper, Roger CHorvath (AO), Diana GHoyle, Philip MHughes, Geoff CJones, Roslyn EJump, Marie AKasap DraginjaKillen, Alice RKotze, Beth LLatta, AlisonLaughlin, Allan DLee, Lynette AMackertich, Martin PMallarky, Stephen GMcDonald, Wayne LMcEwin (AM), Roderick GMiskell, SharonMok, Anne MLMorey, Patricia SMurthy, RaghuMurugesan, Ganapathi ANiall, Paul DO’Brien, Lisa JO’Connor, NicholasPalmer (AM), David HPalmer, George RPantle, Annette CParrish, Mark MPeters (OAM), HarryPilowsky, Eva JPisk, Dennis WPorter, Robert KPrice, Edward DReeve (CBE, AC), Thomas SRepin, George DRewell, Ian LRoss, Bronwen ARuscoe, Warwick JRushbrook, Elizabeth CSaave (OBE), Jan JSanderson, Russell BSanger, Margaret MSara, Antony FScarf, Christopher GSesnan, KevinShea, Peter BShepherd, Webster GSmith, Denis ASpencer, Ronald BStewart, Gregory JSwierkowski, PiotrTindal, Mabel LTse, VickiTridgell, Paul KVago, Leslie

Vanderfield (OBE, AO), RogerWard, Nicola MWasti, Syed FWaterhouse, Tamsin RWebb, Freda HWestwood, GeoffreyWestphalen, John BWills, James TWoolard, Thomas JWooster, Arthur GYoong, Helen PYu (AM), John S

NORTHERN TERRITORYJoyce, Brian BKatekar, Leonie VMathews, Colin LSathianathan, Vinothini IWalker, Alan CWilson (AM), Pauline I

QUEENSLANDAlcock, AnnabelleAshby, Richard HBaker, Christine ABell, Brian LBrennan, Colin KBrierley, Stephen ABromwich, Christine ECampbell (AM), Bryan CCatchpole, Michael JChick, Pamela HCooper, Barbara MCostello, Gerard JDaly, Michael PDevanesen (AM), Dayalan MDoherty (AO), Ralph LDonald, Kenneth Jdu Preez-Wilkinson,GabrielleEdwards, Sir Llewellyn REmmerson, William BEvans, David KFalconer, Anthony DFitzgerald, Gerard JFitzhardinge, RuthFothergill, John LFranklin, C IanGinsberg, Samuel AGolledge (AM), John GGraves, Judith AGriffin, James VHenderson, AlanHerriott, Bruce AHodge, Jonathan VHolloway, Alison MHouston, James HHudson, Julie DJaumees, KayJeffery, Robert JJellett, Leon BJensen, Graeme RJohnson, Andrew JKeating, Darren WKennedy, Christopher JKing, Jennifer MKitchener, Scott JKuehnast, Barbara ALe Ray, Lance ELivingstone (AO), Peter GMargetts, Craig CMartin, Donald JMattiussi, Mark P

McFarlane, Jean FMcGregor-Lowndes, Victor AMenzies, John WMiller, Peter MckMorton, Peter GMowatt, Keith SO’Donnell, John JO’Dwyer, Susan MO’Sullivan, Donna MPakchung, David NPearn (AM), John HPegg (AM), Stuart PPorter, RobertPowell, Owen WReilly, Robert QRussell, Douglas AScanlan, Brian JShapiro, Ralph AShaw, Alexis EShearer, Alexander BSparrow, John LStable, Robert LStuart, Duncan JTaylor, James RThomas, David AUlrich, Peter EWaller (RFD, AM), John PWaters, Mark FWeinstein, Stephen RWilkinson, David PWuth, Gregory KYoung, Jeannette R

SOUTH AUSTRALIAAllan, Barbara MBarrington, Dianne LBarron, Vincent JBeal, Robert WButtfield, Ian HCockington, Richard ACzechowicz, Andrew SDowie, Donald AFarmer, Christopher JFrewin (AO), Derek BFuller, Clarence OGermann, Peter SHackett, Earle WHart, GavinHoff (RFD), Lothar CJelly (RFD), Michael TKearney (AM), Brendon JLian-Lloyd, Nes BMcCoy, William TMylius, Raymond EReynolds, David JRozenbilds, Elizabeth SScragg (OBE), Roy FSvilans, Susan ESwanson, Bruce AVan Deth, Arthur GWagner, Christopher AWebb, Richenda M

TASMANIAAyre, Stephen JMacCarrick, Geraldine RMcArdle, Helen MMcCann, Paul ERenshaw, Peter JRoss, Alasdair DSparrow (AM), John M

LIST OF FELLOWS – 2006

34

VICTORIAAhern, Susannah FAppleton, William TBaker, Muriel TBarker, Coralee ABartlett, Jennifer RBatten, Tracey LBearham, George P (Snr)Bennett, Noel MckBessell, Christine KBlake, Douglas HBradford, Peter SBrand (AM), Ian ABreheny, James EBrennan, Peter JBrook, Christopher WCampbell, David HCarnie, John ACarson, IanChampness Leonard TChristie, John CCole, Brian ECollopy (AM), Brian TDavis, Alan SDevanesen, ShereneDuncan, David RDwyer, Alison JFearon (AM), David NFlower, Clifford J MckFlynn, Eleanor MFunder, John WGallichio, John LGraham, Ian SGray (AO), Nigel JGriffin, James JGrogan, Robert SGruner, LeeGurner, Colin MHall, Robert GHamley, LeeHanning, Brian WHillis, David JHunt, Brett TJones, Michael RKrupinski, JerzyLeslie, Peter LLubliner, MarkMaclean, Alison MMajoor, Jennifer WMalon, Robert GMcCleave, Peter JMcCloskey, Bertram PMcNab, KirstyMead (PSM), Catherine LMorris (AO), Jack PNaidoo, Humsha KOliver, Brian HOsborne, Clifford BO’Rourke, Francis JPerrignon, Andrew CPeyton, Thomas MPisasale, Nella MPower, John MRace, DavidRatnayeke, Valentine JSachdev, Simrat PSandford, Alan SSchofield (OBE), Graeme CScown, Paul WSdrinis, SusanShepherd (AM) Stuart JStoelwinder, Johannes U

Stoller, AlanStreet, Bernard JSumithran, LakshmiSummers, Robert OSunderland, Ian STrevaks (AM), GadTrye, Peter JTurner, Mary JWake, Arlene HWalsh, Laurence NWarburton, David JWarton, Robert BWatson, Andrew LWatson, Sara EWellington, Clive VWellington, Heather LWooldridge, MichaelYeatman, John S

WESTERN AUSTRALIABayliss, Colin TBeresford, WilliamCurruthers, Kenneth JCoid, Donald RDe Campo, John FDunjey, Malcolm VDurkin, Helen CEllis, Archie SFlett, Penelope RForgione, Salvatore NFry, David FGill, Jagjeet SKelly, Shane PKing (AM), Alan JLawrence, Robyn ALee, (Norman) Kwang BLipton, George LLoh, PKMasters, Geoffrey HMahmood, FarhatMander, Anthony JMcNulty, James CMontgomery, Philip DMulligan, Jonathan BMurphy, Kevin JNickel, Norma ROldham, David RPlatell, Mark SQuadros, Caetano FRoberts, William DRobertson (CSC), Andrew GRussell-Weisz, David JSalmon, Mark ASmith, Darcy PStewart, Lindsay A

NEW ZEALANDAllen, Patricia IArya, Dinesh KBolevich, Zoran Boyd. George RBrenner, Bernard NChamberlain, Nicholas JFeek, ColinGillies, Peter SGollop, Bruce RGootjes, Peter RHolmes, John DHood, Dell AHope Virginia TKelly, FrancescaLevy, Lester

Leung, Ting-hungMorris, Kevin ANel, AndrePatel, Arvind CPike, Pieter WRankin, David BRichards, RuthRobinson, Peter HWhite, Janis MYoung, Wilson W

OVERSEASCheng, Beatrice – Hong KongCheng, Man-Yung – Hong KongChoi, Teresa Man-Yan – Hong KongChow, York Yat-ngok – Hong KongChiu, Lily – Hong KongChoy, Khai Meng – Hong KongChristie, John C – Papua New GuineaDavidson, Lindsay A – United KingdomDuncan, David R – Saudi ArabiaFong, Ben Y – Hong KongFung, Hong – Hong KongHedley, Anthony J – Hong Kong Ho, William S – Hong KongJacobalis, Samsi – IndonesiaJones, Fredrick G – United States of AmericaKukreja, Anil K – MalaysiaLai, King-kwong – Hong KongLai, Lawrence Fook-ming – Hong KongLam, David – Hong KongLam Tat Tin, David – Hong KongLee, Shiu H – Hong KongLeung, Pak-yin – Hong KongLo, Chi Yuen – Hong Kong Lo, Su Vui - Hong KongMa, Hok Cheung – Hong KongMak, Sin-ping – Hong KongMarikar, Kadar M.A. – MalaysiaParker, Ronald W – EnglandRajput Abdul M – PakistanRees, Neville C – United Arab EmiratesSannasey, Gummadi – MalaysiaSathiaseelan, Nagamoney K – MalaysiaShaw, Rosalie J – SingaporeSills, Thomas D – United States of AmericaSingh, Kartar – MalaysiaSmart, Timothy F – FijiSo, Kathleen – Hong KongSpence, Derek W – EnglandStokoe, Philip – IndonesiaTinsley, Helen – Hong KongTung, Sau Ying – Hong KongYeoh, EK – Hong KongWalsh, Michael K – QatarWong, Vivian Chi–woon – Hong Kong

35

AUSTRALIAN CAPITALTERRITORYBuckingham, John MDickson, Graham JGatenby, Paul AGriffin, Robert CHallam, LaviniaKiller (AO), Graeme TLooi, Jeffery C.LMays, Lawrence JRoss, James A

NEW SOUTH WALESAlexander, Ion SArthurson, Robert MBaylis, Martin, SBrown, Katherine MBrydon, Michael PBull, Colin AByth, Philip LChallis, Daniel EChung, StephenClark, Leon WDayan, Linda SDennington, Peta MEinfeld, Stewart LEllis, Peter SEvans, Lynleigh Gatt, Stephen PGoh, Shyan LiiGrace, JulienneGupta, Bipin KHanson, Ralph MHenry, Richard LHo, Maria TKossoff, LanaKremer (OAM), Edward PLee Cheok SLi, Stephen CLiddell, Stephanie JLiew, Siew FLowe, Kevin GMackie, James DMalik, Mushtaq AMatheson, John MMcGrath, KatherineMcInnes, Jennifer EMcLean, Anthony SMilross, ChristopherMolloy (RFD, ED), William BMortimer, JonPritchard, Geoffrey RRajkumar, SadanandReppas, Napoleon PRoberts, John CRobinson, Denise MRumma, Pauline YShell, Allan MSmith, Michael CSpeechley, Ronald AStone, Bevan HThye, Hsu-Ming

Vinen, John DVirgona, Angelo JWalker, AndrewWay, Raymond TWells, John VWhite, Leslie

NORTHERN TERRITORYDelima, Jennifer FLum, Gary D

QUEENSLANDAbdi, Ehtesham AAllison, Roger WBrecciaroli, Fabio RBuckland, Stephen MChoo, Kelvin, Li-MingCleary, Michael TColby, Anthony CCostello, Stephen MDascalu, JackDavies, Keith LEmonson, David LGabbett, Michael TGroessler, Adrian JHanson, Dale WJoshi, VineyKiller, Douglas VKirubakaran, Meshach GLanglois, Suzanne LLewin, Morris WLewis-Driver, David JLikely, Michael JLindeman, Jason CMahlo, Karen LMahoney, Mary DMansoor, ManadethMcCrossin, Robert BMenon, MaheshMoss, Gerald AMottarelly, Ian WMoyle, Robert JNydam, KeesO’Connor, LeuchairsO’Connor, Clive BO’Shea, Barbara FQuigley, David TReddan, Jill GRowan, Christian ARudd, Shaun TSchedlich, Russell BSeet, Geoffrey PSpencer, John CStaines, Donald RStone, Michael JThomas, DaleUnwin, Alston MVecchio, Phillip CVenkatesh, MurthyWilson, John GWithers, Stephen JXabregas, Antonio A

LIST OF CANDIDATES – 2006 LIST OF MEMBERS – 2006

AUSTRALIAN CAPITALTERRITORYBlakely, Roslyn JSeah, Michael T

NEW SOUTH WALESAsh, NicoleBeswick, Theresa ABurnett, LeslieChoudhary, SachinCurtis, Nicole MDuncan, Darrell JEaling, Catherine AFarrow, Glendon BFletcher, Nicholas JGallagher, Siun MKarnaghan, Joanne EKing, Michael RLakos, Marc PMackinnon, Angus MMcGirr, Joseph GMacpherson, LindaMoore, Carmel, MOlsen, John RPaul, Gershu CParsons, Helen ERamesh, NadarajahRobbins, AphraSaker, Stuart BSeidl, Isaac ASharkey, Sarah ETiernan, Paul JWilliamson, Geoffrey DYeats, HeidiZwatrzka, Nelly

NORTHERN TERRITORYArcus, Meredrith

QUEENSLANDAtkinson, KathleenAlcorn, DavidBrandt, MatthewChern, Inglis WDelaney, Darren JDines, Amanda JDuke, Benjamin JamesFarmer, JillianGopalan, Vinod ALe Bacq, FrankLee Archer, MatthewMah, Sher-PhernMilns, Nick RMistry, YogeshMontague, Andrew JMoss, GeraldNaidoo, MelissaParmar, NilishPolong, Jose ABPrado, Luis M

Trujillo, MonicaWakefield, JohnWard, David I

SOUTH AUSTRALIABrayley, John QLynch, Stuart, DTideman, SallyWong, Anthony K

TASMANIANil.

VICTORIABydder, Sean ACendana-Paiva, Maria ECudmore, Gerard PDamodaran, Saji SDavies, Glenn AGarwood, Mark, I. McK.Golding, Stephen JHowlett, Glenn RKatsoris, JoanneKaya, Yelda Kelly, Catherine BLander, HarveyLongmore, Peter GLoh, Erwin, Chun KMadas, EshwarMohr, Malcolm LOakley Browne, Mark AReilly, Claire AileenSaxena, AtimaStafrace, Simon PTaylor, Michael D

WESTERN AUSTRALIAAdesanya, AdesinaBijani, MuktiBentley, Peter JFrazer, Amanda RLRobins, Anthony MSwan, Christopher CWong, Kingsley S

NEW ZEALANDChew, Gerald SHulme, Richard I CJessamine, Stewart SKerruish, TimothyPelkowitz Allan RWong, Deanne L

OVERSEASJeremijenko, Andrew M -IndonesiaMurray, A. Campbell –United States of America

SOUTH AUSTRALIAAtkinson, Robert NBaggoley, Christopher JByrne, Peter DDel Fante, PeterEdwards, Robert MHale, Claire MLee, Wah HLethlean, Margaret GMcGee, Roderick IMisan, David ROlver, Ian NPenhall, Robert KPhillips, Patrick JRainsford, Paul MRoex, Alphonse JShroff, Behzad DSingla, Amita ASoo, Kenneth L FSzekely, Suzanne, M

TASMANIAFlett, Peter JHickman, John AHo, VincentLamplugh, RossMuller, Hans K

VICTORIAAllen, David GAmbikapathy, ArunasalamArgumugam, Arumugam ABalasubramanian, VaidyaBaker, Muriel TBarton, David ABell, RichardBohra, SureshBolsin, Stephen NBoyce, Neil WBrooks, Anne Marie VBryan, SheilaBurrows (AO), Graham DCallaly, ThomasCastle, Robert NChao, Michael WChau, RogerChinnasamy, DhamodharanChopra, Prem KClark, Catherine FConyers, Robert ACordner, Stephen MDamodaran, Saji SDewan, Patrick ADohrmann, Peter JDrummond, Roslyn MFawcett, Rodney IFielding, John M

Fisher, SimonFitzgerald, Mark CFraser, Simon HGoh, Chin C KGoh, EugeneHaddad, MauriceHandley, Paul AHaughton Marianne WIbrahim, Joseph EJanson, Adam RJefford, Michael HJensen, Frederick OJudson, Rodney TKambourakis, Anthony GKennelly, Eric JLowthian, Peter JLynch, Rodney MMudaliar, Selva NPerera, Mahendra HPetersen, Rodney WPhelps, Grant Prince, Henry MRambaldo, SalvatoreRodrigo, Rohith Rosenfeld, JeffreyRozen, LeonSchifter, Denis AShearer, William ASmith, Jacqueline BSnell, Anthony PSpencer, John CSteele, Brendan JStocky, Andrew JTan, Gim AVan Der Veer, MeindertVaughan, Stephen LVijayakumar, KandasamyWassertheil, JeffWaters, Mary JWaxman, Bruce PWeeks, Anthony MWhite, Craig AWilliams, Daryl LWilliams, Richard AWolff, Alan MWong, Michael TWoodhouse, Paul D

WESTERN AUSTRALIABarratt, Peter SDavidson, Rowen MDavies, Diane MDonnelly, AnneGraydon, Robert HJoseph, David JKeller, Anthony J King, BenedictLangford, Stephen AMark, Paul DMcGrath, Gregory BMcLaughlin, Virginia AO’Connor, Alan ERaza, FarhanaRhodes, Helen CStokes (RFD), Bryant AVaughan, Richard J

NEW ZEALANDBrown, Ian MChoi, Philip MCurrie, Hillary Keam, Susan JRasiah, Rebecca DRosman, JohanSage, David JShirley, Alan J

OVERSEASBaqir, Yasir A – OmanForeman, Mark J - ChinaGiele, Henk P – United KingdomHawkins, Robert C – MalaysiaKisely, Stephen R - Canada Kishore, Karmal - Lam, Tai-Pong – Hong KongMcEachen, Stuart C – South AfricaMenon, Suresh K - IndiaThomas, Adrian P – United States of AmericaWaring, Paul M – United States of AmericaWin, Kyaw - BurmaYon, Rohaizat B – MalaysiaZeng, Guang J - China

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