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The Australian Council on Healthcare

Standards National Report on Health

Services Accreditation Performance

2009 – 2010

© The Australian Council on Healthcare Standards

This work is copyright. Apart from any use as permitted

under the Copyright Act 1968, no part may be

reproduced by any process without written permission

from The Australian Council on Health Standards (ACHS).

Requests and inquiries concerning reproduction and

rights should be addressed to the Chief Executive, The

Australian Council on Healthcare Standards (ACHS),

5 Macarthur Street, ULTIMO NSW 2007.

Recommended citation

Australian Council on Healthcare Standards. The ACHS

National Report on Health Services Accreditation

Performance 2009 – 2010. Sydney NSW; ACHS; 2011.

Published by The Australian Council

on Healthcare Standards

5 Macarthur Street

ULTIMO NSW 2007

Fourth edition December 2011

Third edition November 2009

Second edition June 2007

First edition June 2005

(ISBN No. 13) 978-1-921806-20-9 (Paperback)

(ISBN No. 10) 1-921806-20-6

(ISBN No. 13) 978-1-921806-21-6 (Web)

(ISBN No.) 101-921806-21-4

Copies available from the ACHS Publications Service

Telephone: 02 9281 9955

Facsimile: 02 9211 9633

Email: [email protected]

Website: www.achs.org.au

Key Findings 2

Section 1: Accreditation Performance 4

Introduction

Overview of ACHS accreditation programs

Executive Summary 6

ACHS accredited organisations

Accreditation survey results

Advanced Completion in 60 days surveys (AC60s)

High Priority Recommendations (HPRs)

Extensive and Outstanding Achievement

Recommendations and Areas for Improvement

Spotlight on Infection Control

Spotlight on Credentialling

Spotlight on Organisational Systems

Section 2: Member Satisfaction 32

Standards and criteria

Support

Surveys

Survey coordinator

Surveyors

Survey report

Self assessment

Section 3: Research 37

Accreditation and organisational performance research

Appendix A: Background on ACHS and EQuIP 40

Appendix B: OA summaries by criterion 48

C O N T E N T S

Foreword 1

A C K N O W L E D G E M E N T S

The Australian Council on Healthcare Standards

(ACHS) would like to thank the healthcare

organisations participating in the ACHS Evaluation

and Quality Improvement Program for their data

(de-identified), which form the content of this report.

This report draws partially on data previously

published in The ACHS National Report on Health

Services Accreditation Performance 2007 – 2008.

Contributors

ACHS Executive

Mr Brian Johnston, Chief Executive

Ms Laurie Leigh, Executive Director – Customer Services

Ms Lena Low, Executive Director – Corporate Services

Ms Linda O’Connor, Executive Director – Development

Mr Desmond Yen, Executive Director – International Business

Content and Editing

Ms Elizabeth Kingsley, Project Officer – Standards and

Program Development

Ms Linda O’Connor, Executive Director – Development

Ms Deborah Jones, Senior Project Officer – Standards and

Program Development

Ms Lesley Bateman, Executive Assistant – Development

Ms Anne McIntosh, Project Officer – Development

Ms Margaret Jackson, Project Officer – Business Support

Services

Data Analysis

Ms Lena Low, Executive Director – Corporate Services

Mr Jeffrey Yao, Business Manager – Business Support Services

Ms Myla Ponce, Project Officer – Business Support Services

Ms Nikki Humphreys, Project Officer – Business Support

Services

ACHS Board Editorial Group

Dr David Lord

Mr Stephen Murby

Research Support

Mr Mark Avery, School of Public Health, Griffith University

F O R E W O R D

On behalf of the ACHS Board, it gives me great pleasure to present the fourth ACHS National Report

on Health Services Accreditation Performance 2009 – 2010.

The Report both assesses and reviews the impact of accreditation in hospitals and health services

Australia-wide. An overview of national accreditation performance is provided. While this Report

focuses upon accreditation performance during the years 2009 – 2010, it also examines emerging

trends over the four years of EQuIP 4, with data from over 900 surveys forming the basis of this

analysis.

Membership statistics, members’ satisfaction and a summary of our involvement with research into

accreditation that is at the leading edge internationally are incorporated.

The definition and clarity of information that the Evaluation and Quality Improvement Program (EQuIP)

collects allows ACHS to build an expansive picture of healthcare performance achievements based

on organisations’ self assessments and the results of on-site surveys against the standards. The data

collected begin with the introduction of EQuIP 4 in January 2007; EQuIP5 replaced the earlier edition in

July 2011. Its introduction was deferred to align with the introduction of the National Safety and Quality

Health Service Standards by the Australian Commission on Safety and Quality in Health Care.

The analysis of trends over four years underscores the performance of EQuIP 4 itself. The areas or

criteria which have been consistent in improving performance are identified, as are the ratings that

qualify the degree of change instigated.

While not the sole measure of a health service’s performance, accreditation carries important

responsibilities in terms of risk evaluation and overall safety levels, as well as commitment to quality

in all its activities. This Report provides a strong influence for the review of policies and practices,

areas where further investment in terms of skills development, workforce planning and physical

resources could be made. It has relevance at societal, political, policy and operational levels.

I have great pleasure in commending the report to you.

Associate Professor Peter Woodruff

President

November 2011

ACHS National Report on Health Services Accreditation Performance 2009 - 2010

1

2 ACHS National Report on Health Services Accreditation Performance 2009 - 2010

The ACHS National Report on Health Services Accreditation Performance 2009 - 2010 describes the performance

of healthcare organisations participating in the Australian Council on Healthcare Standards’ accreditation program,

EQuIP 4. This report focuses upon the performance of member organisations during surveys conducted between

1 January 2009 – 31 December 2010. These Key Findings provide an overview of survey trends observed across

2007 – 2010, the four years of the EQuIP 4 accreditation cycle, in addition to highlighting areas of high performance

and areas that continue to present a challenge.

K E Y F I N D I N G S

Survey Trends

Advanced Completion in 60 Days Surveys

13% (67/509) of organisations were required to undertake an Advanced Completion in 60 days survey

(AC60) for at least one criterion during 2009-2010, compared to 16.5% (77/468) of organisations

in 2007-2008.

The rate of AC60 reviews decreased by 21%, indicating a positive trend.

High Priority Recommendations

10% (52/509) of organisations were issued a High Priority Recommendation (HPR) for at least one

criterion during 2009-2010, compared to 13% (60/468) of organisations in 2007-2008.

The rate of HPRs decreased by 23%, indicating a positive trend.

Extensive Achievement Ratings

Extensive Achievement (EA) ratings represented 14% (2425/17046) of total ratings awarded during

2009-2010, compared to 11% (1435/12752) of ratings awarded in 2007-2008.

The award of EA ratings increased by 27%, indicating a positive trend.

Outstanding Achievement Ratings

Outstanding Achievement (OA) ratings represented 0.5% (90/17046) of total ratings awarded during

2009-2010, compared to 0.4% (53/12752) of ratings awarded in 2007-2008.

The award of OA ratings increased by 25%, indicating a positive trend.

(Note: This improvement is based upon a small proportion of overall ratings)

Comment: These improvements have occurred in the context of a consistent surveyor workforce and survey

methodology. Initiatives to support consistent evaluation of organisational performance include education at

survey coordinator development days focusing on requirements for EA and OA ratings.

Contributing factors to the positive trends noted for AC60, HPR, EA and OA results may include improved

organisational performance, increased familiarity with the EQuIP 4 standards supported by ACHS resource

tools, implementation of surveyor suggestions for improvement and focused educational activities.

Survey Outcomes

Accreditation Awards

86% (435/509) of organisations achieved full or continuing accreditation at survey during 2009-2010.

A further 11% (55/509) of organisations achieved full or continuing accreditation following an AC60 review.

1% (7/509) of organisations achieved one-year conditional accreditation at survey during 2009-2010.

2% (12/509) of organisations achieved one-year conditional accreditation following an AC60 review.

Comment: The 19 organisations that achieved conditional accreditation received ACHS customer service

support to assist the organisation improve and were re-assessed after 12 months.

Areas Requiring Further Improvement

126 Advanced Completion in 60 days surveys (AC60s) and 88 High Priority Recommendations (HPRs) were

received from 509 surveys in 2009-2010. Areas most received:

1. Emergency and disaster management system to support safe practice and a safe environment*

(n=28 AC60) (n=25 HPR) Category: non-clinical

2. Integration of organisation-wide risk management policy and system to ensure corporate and clinical

risks are identified, minimised and managed* (n=22 AC60) (n=16 HPR) Category: non-clinical

3. Processes for credentialling and defining the scope of clinical practice to support safe, quality health care*


4. Infection control systems to support safe practice and ensure a safe environment for consumers / patients

and healthcare workers* (n=10 AC60) (n=8 HPR) Category: clinical

5. Continuous quality improvement system to demonstrate commitment to improving outcomes of care and

service delivery* (n= 9 AC60) (n=5 HPR) Category: non-clinical

6. Documented corporate and clinical policies to assist organisations to provide quality care*


7. Safety management systems to ensure safety and wellbeing for consumers / patients, staff, visitors

and contractors* (n=6 AC60) (n=4 HPR) Category: non-clinical

Comment: All seven areas requiring improvement were mandatory criteria. For these criteria it is considered

that without Moderate Achievement (evaluation), the quality of care and/or safety of people within the

organisation could be at risk.

Six of the seven areas requiring further improvement are classified as non-clinical criteria. These findings

demonstrate the importance of monitoring the performance of non-clinical systems as part of a comprehensive

organisation-wide assessment.

* denotes mandatory criterion


3

Areas of High Performance

90 Outstanding Achievement (OA) ratings were awarded from 509 surveys in 2009-2010. Areas most awarded:

1. Learning and development systems to ensure the skill and competence of staff and volunteers

(n=8) Category: non-clinical

2. Medication management to ensure safe and effective practice (n=7) Category: clinical

3. Research program to develop knowledge, protect staff and consumers / patients, with a process to

manage organisational risk (n=7) Category: non-clinical

4. Care evaluation by health care providers, with the consumer / patient and carer* (n=6) Category: clinical

5. Systems to ensure the care of dying and deceased consumers / patients is managed with dignity and

comfort (n=6) Category: clinical

Comment: High performance was demonstrated across both clinical and non-clinical areas. The majority of

OAs were awarded in non-mandatory criteria.

* denotes mandatory criterion

Introduction

The Australian Council on Healthcare Standards

(ACHS) is an independent, not-for-profit

organisation that has been an important part

of the Australian healthcare industry since 1974.

The ACHS provides healthcare organisations

with the opportunity to achieve their best

possible levels of performance through an

accreditation program that provides a structure

within which organisations can assess, monitor

and improve their services.

Healthcare accreditation involves performance

assessment against an industry-agreed set of

standards that measure both the clinical and

non-clinical aspects of health service delivery;

it “promotes safe patient care and continuous

quality improvement of health service

organisations through a process of regular

assessment and review.”1 The basis of the

ACHS’s accreditation service is its Evaluation

and Quality Improvement Program (EQuIP),

which is designed to achieve both safety and

quality improvement. While some sections of

the program are mandatory, and performance

must be assessed to a specified level for

accreditation to be awarded, EQuIP provides

a framework within which improvement

opportunities may be identified and prioritised

in all areas of health service delivery.

Many organisations have been successfully

accredited with the ACHS over a period of

years. Initially, ACHS members were hospitals;

today, the membership of the ACHS reflects

the changing structure and diversity of the

healthcare system. One of the major aims of

the ACHS is to adapt to a changing healthcare

environment, to continue to offer the most

relevant products to its member organisations.

In 2011, this involves responding to healthcare

reform and the introduction of the Australian

Commission on Safety and Quality in Health

Care’s National Safety and Quality Health

Service Standards.

In January 2007, the ACHS introduced the 4th

edition of its EQuIP accreditation program.

This program contains 13 standards across

3 functions (Clinical, Support, Corporate) that

address 45 specific areas (criteria), which are

A C C R E D I TAT I O N P E R F O R M A N C E


assessed by ACHS surveyors during the

accreditation process. The EQuIP standards

are developed by the ACHS under the

governance of the ACHS Board. The standards

are reviewed every four years to ensure they

remain current and reflect the most important

quality and safety issues. The review of EQuIP

4, which involved extensive consultation with

members, surveyors and other stakeholders,

began in September 2008, with EQuIP5

implemented from 1 July 2011.

The ACHS National Report on Health Services

Accreditation Performance 2009 – 2010 (the

National Accreditation Report) brings together

all of the results of accreditation surveys from

EQuIP 4 member organisations and looks at

their combined performance. Viewing the

ACHS data in this way provides an overview

of Australian healthcare organisations, together

with their collective strengths and opportunities

for improvement.

This is the fourth biennial National Accreditation

Report. Unlike the previous editions, which

examined a two-year reporting period, while

still focusing upon accreditation performance

during 2009 – 2010 this edition of the National

Accreditation Report also examines trends in

the performance of ACHS members across a

four-year timeframe, the ‘lifespan’ of EQuIP 4.

During this time, a majority of ACHS members

will have experienced the full EQuIP

accreditation cycle, comprising two Self-

Assessments and two onsite surveys: an

Organisation-Wide Survey (OWS) and a

Periodic Review (PR).

The accreditation assessment data reported

here include surveys conducted from 1 January

2007 – 31 December 2010 (n=977), with a cut-

off of 31 March 2011 for the finalisation of

survey data.

The previous National Accreditation Report,

covering accreditation performance during the

period 1 January 2007 – 31 December 2008

only, may be found at the ACHS website:

http://www.achs.org.au/pdf/NationalAccreditation

Report_0708_WebVersion.pdf

1 Australian Commission on Safety and Quality in Health Care (ACSQHC). Accreditation. Sydney NSW; ACSQHC. Accessed

from: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-07 on 8 November 2011.

S e c t i o n 1

Overview of ACHS accreditation programs

ACHS offers a variety of programs to meet the specific

needs of its member organisations.

EQuIP5

The Evaluation and Quality Improvement Program,

developed and conducted by the ACHS, which through a

four-year cycle of self assessment and surveying provides

a framework for managing healthcare organisations to

ensure safe, quality care and services and to achieve

quality improvement. Implemented 1 July 2011.

EQuIP5 Day Procedure Centres

Replacing EQuIP for Day Hospitals. For stand-alone day

procedure centres, day hospitals, day surgeries and any

facilities that do not provide overnight accommodation.

Implemented 1 July 2011.

ACHS Requirements for Private Healthcare

Organisations Not Required to be Licensed

Amended to align with EQuIP5 Day Procedure Centres.

This is an additional accreditation module for healthcare

organisations not required to be licensed by State / Territory

health authorities because of the nature of the medical

services provided or the level of anaesthesia used.

EQuIP5 Corporate Health Services

For corporate offices of healthcare organisations, which

support the provision of health care and services through

centralised governance and leadership. Implemented

1 July 2011.

EQuIP Corporate Member Services

For corporate offices that provide services to members

or customers such as colleges, associations or health

insurance agencies.

ACHS Quality for Divisions Network

For the National Divisions of General Practice.

EQuIP Certification

ACHS offers a certification program for newly established

organisations, or those organisations undertaking formal

quality improvement for the first time, as a first step to

joining a full accreditation program.

EQuIP In-Depth Reviews

Evaluation of clinical services against external (non-ACHS)

standards.

In development:

EQuIPNational

Comprehensive organisation-wide assessment program

to assess healthcare systems and to support and

complement the National Safety and Quality Health

Service Standards.

Remote Health Accreditation Standards (in partnership

with the Royal Australian College of General Practitioners,

Australian General Practice Accreditation Limited and the

Northern Territory Department of Health).

National Critical Care and Trauma Response Centre

Standards (in partnership with the National Critical Care

and Trauma Response Centre).

ACHS International

ACHS continues to expand its international presence,

building partnerships in a number of regions including

Hong Kong, Macau, South Korea, Saudi Arabia, Bahrain,

United Arab Emirates, India and Sri Lanka. In addition to

accrediting healthcare facilities, ACHS also assists with

the development of locally administered accreditation

programs, and provides services such as consultation,

education, and clinical indicator programs. ACHS has

also hosted numerous delegations from countries seeking

insight into the Australian model of healthcare

accreditation.

EQuIP is also used in New Zealand through a license

agreement now with the DAA Group.


5

Extensive Achievement (EA) ratings awarded at a rate

of 18% for mandatory criteria and 11% for non-

mandatory criteria

for the non-mandatory criteria, Little Achievement

(LA) ratings awarded at a rate of 0.05%, and Some

Achievement (SA) ratings at a rate of 3%.

High-performance areas

Areas in which ACHS members performed well, based

upon OA ratings awarded, include:

staff learning and development

medication management

research

care evaluation

end-of-life care.

Required improvements

Areas most commonly identified as requiring

improvement, based upon Advanced Completion in

60 days survey (AC60) outcomes and High Priority

Recommendations (HPRs), were related to:

emergency and disaster management

risk management

infection control

credentialling

quality improvement.


During 2009 – 2010, 509 organisations participated in

an EQuIP 4 Organisation-Wide Survey or Periodic

review, with an accreditation outcome finalised by

31 March 2011.

Of these, 86% gained full accreditation or had

ongoing full accreditation confirmed at survey.

A further 11% of organisations gained or maintained

full accreditation after addressing issues of concern

within 60 days of the Organisation-Wide Survey or

Periodic Review at an Advanced Completion in 60

days survey (AC60).

Conditional (one-year) accreditation, with or without

an AC60 survey outcome, was granted to 3% of

organisations because of inadequate systems to

manage a variety of risks.

No organisation was non-accredited.

E X E C U T I V E S U M M A R Y

This National Accreditation Report on the performance

of healthcare organisations participating in the Australian

Council on Healthcare Standards’ (ACHS’) Evaluation

and Quality Improvement Program (EQuIP) reports on

509 organisations that underwent onsite surveys during

2009 and 2010, for which an accreditation outcome was

finalised by 31 March 2011. An additional 24 reports for

surveys in 2010 (15 Organisation-Wide Surveys and 9

Periodic Reviews) were not complete by 31 March 2011,

and were unable to be included in this report.

The main outcomes from the 2009 – 2010 data are

summarised below.

In addition, this report examines accreditation

performance across the years 2007 – 2010, the

‘lifespan’ of EQuIP 4. Reviewing data collated during the

four years of this accreditation program allowed a clearer

picture of organisational performance, including both

the challenges and the areas of required improvement,

to emerge. The previous edition of the National

Accreditation Report, covering accreditation performance

during the period 1 January 2007 – 31 December 2008

only, may be found at the ACHS website:

http://www.achs.org.au/pdf/NationalAccreditationReport

_0708_WebVersion.pdf

The findings in this report will assist organisations

participating in EQuIP to consider their performance

within a national context and provide information to

support learning around improvement in health facilities.

This information also provides an opportunity for health

policy makers and other stakeholders to identify key

issues, which may assist them to support healthcare

providers in the delivery of safe, high quality health care.


Over the period January 2009 – December 2010,

performance in EQuIP resulted in:

full accreditation for 97% of organisations

conditional accreditation (one year) for 3% of

organisations

no organisation non-accredited, compared with two

organisations during 2007 – 2008

Outstanding Achievement (OA) ratings awarded on

90 occasions to 49 different organisations


Areas in which healthcare organisations perform well

Outstanding Achievement (OA) ratings represented

0.5% of all ratings.

Organisations were more likely to receive an OA rating

in a non-mandatory criterion than a mandatory criterion.

Outstanding Achievement practices included:

• care evaluation that was accurate, consistent and

collaborative, and supported by benchmarking and

research;

• end-of-life care that was focused upon consumer /

patient preferences, embraced spiritual and cultural

needs, maintained dignity and comfort, and

supported families;

• medication management programs that sought and

found methods to reduce medication errors,

increased pharmacy involvement, maintained

consistent, frequent medication reconciliations and

offered well-designed consumer / patient education;

• staff learning and development systems highlighted

by imaginative education programs in a variety of

formats, extensive use of e-Learning and other

technology, the development of supporting toolkits,

and continuing education programs offered for

numerous staff groups and disciplines;

• research programs that were well-governed and

collaborative, aimed at the improvement of systems

and practices, supported by appropriate resources

and education, and in which results translated into

altered practices and improved outcomes.

Extensive Achievement (EA) ratings represented 14%

of all ratings.

Organisations were more likely to receive an EA rating in

a mandatory criterion than a non-mandatory criterion.

Extensive Achievement practices included:

• comprehensive infection control management

supported by education, collection and use of

indicator data and benchmarking;

• safety management systems that were organisation-

wide, promoted and maintained by staff

representatives and ‘champions’, and subject to

consistent evaluation and improvement;

• quality improvement programs actively supported by

management, with clinician involvement, and in

which initiatives were assessed and improvements

implemented and disseminated;

• incident and complaint management systems that

were highlighted by rigorous investigation and

follow-up, open communication, dissemination of

outcomes and changes to practices.

Required improvements

In the key safety and quality areas (mandatory criteria):

infection control programs that include comprehensive

systems for sterilisation practices, hand hygiene, food

safety and surveillance;

quality improvement programs championed by

governing bodies and managers, with appropriate

resourcing, support for staff, and ‘follow-through’ on

quality initiatives;

risk management systems that are integrated with the

quality improvement program, in which identified risks

are eliminated or mitigated, risk registers are well-

maintained and frequently updated, and systems are

regularly evaluated and improved;

credentialling and scope-of-practice policy and

procedures that cover all aspects of credentialling and

recredentialling, delineation of scope of practice, and

the introduction of new interventions or treatments,

which encompasses all clinicians including allied

health professionals, and in which recredentialling is

linked to performance appraisal;

emergency and disaster management systems

governed by a current, tested and regularly evaluated

plan, under which all fire safety requirements, including

responses to recommendations, are met, and all staff

undergo education and practical training to ensure

necessary competence on all shifts and across all areas.

In non-mandatory areas:

medication management systems that are evaluated

and improved with greater emphasis on error

reduction, storage, reconciliation and pharmacy

involvement;

blood and blood component management that is

evaluated and improved with respect to consent,

compliance, storage and transport practices, and

education and training;

falls management that is evaluated and improved to

ensure that management is multidisciplinary, that there

is site-to-site and area-to-area consistency, that

available equipment is appropriate, and that falls are

prevented as well as managed once they have

occurred;

buildings, plant and equipment management that

encompasses testing of body and cardiac protected

areas and biomedical equipment, ensures that

buildings are up to code, and includes regular,

monitored maintenance and preventative maintenance

programs;


7

security management that reflects organisational

need with respect to aggressive behaviour, out-of-hours

visitors, high-risk areas such as pharmacies, ATMs and

car parks, and provides all necessary support for staff

working off-site, in remote locations, travelling long

distances or conducting home visits.

Advanced Completion in 60 days surveys (AC60s)

The option for an ‘Advanced Completion in 60 days’ survey

(AC60) was introduced with EQuIP 4 to ensure that risks

identified during survey are eliminated or mitigated in the

quickest possible time. During 2009 – 2010:

13% of organisations surveyed (n=67) received an AC60

outcome due to identified risks

of these, 82% (n=55) gained or maintained full

accreditation after identified issues were addressed; 18%

(n=12) were granted conditional (one-year) accreditation;

no organisation was non-accredited

more AC60 outcomes were issued during Organisation-

Wide Survey (14%) than during Periodic Review (12%)

a large organisation was more likely to receive an AC60

outcome than a small one; however, there was a marked

improvement by ≥500 bed organisations during this

survey period (AC60 outcome for 5% surveys compared

to 38% during 2007 – 2008)

issues most frequently resulting in an AC60 outcome

related to:

• emergency and disaster management (staff training,

fire safety, response to recommendations)

• risk management (evaluation of systems, current risk

register, mitigation of identified risks)

• infection control (sterilisation practices, hand hygiene,

food safety)

• credentialling (incomplete systems, not linked to

performance appraisal)

• quality improvement (incomplete systems, lack of

action plan, response to recommendations).

Spotlight on – Infection Control

An overall improvement by EQuIP members in the

management of infection control was observed during

2009 – 2010, compared to 2007 – 2008

There was a reduction in both AC60 survey outcomes

(10 from 509 surveys, compared to 17 from 454

surveys) and HPRs (8, compared to 13) during this

two-year period

Organisations were awarded 177 EA ratings from 509

surveys, the highest number for any mandatory

criterion, as well as one of the most marked increases

between 2007 – 2008 and 2009 – 2010

OA ratings increased from one to four

Surveyor recommendations, including HPRs, most

frequently highlighted issues around sterilisation

practices, hand hygiene and food safety

High-performing organisations were commended for

their comprehensive and effective Infection Control

Plan, governing body support for staff education

and training, including extra competencies,

multidisciplinary involvement in management, rigorous

auditing and surveillance, high food safety and kitchen

standards, and staff immunisation and bodily fluid

exposure management.

Spotlight on – Credentialling

Performance in the area of credentialling improved

during 2009 – 2010, compared to 2007 – 2008

Little change was observed with respect to AC60

outcomes (11 from 509 surveys, reduced from 14 from

454 surveys) and HPRs (6, reduced from 7)

There was a marked improvement in performance at

the EA level, with 62 EA ratings from 509 surveys

awarded compared to 35 from 454 surveys during the

previous survey period

No organisation achieved an OA rating for this

criterion under EQuIP 4

Surveyor recommendations, including HPRs,

addressed flaws in the fundamental management of

credentialling, particularly the introduction of new

interventions and treatments, correct composition

and functioning of committees, the need to link

recredentialling to performance appraisal and a lack

of evaluation

High-performing organisations had robust systems

supported by comprehensive documentation,

responded well to challenges associated with

particular staff groups, such as General Practitioners,

extended credentialling to all staff groups, and met

Key Performance Indicators for the completion of

credentialling processes.



Spotlight on – Organisational Systems

Analysis of survey outcomes indicates that many

organisations found challenging the governance and

management of the setting in which their care and

services were provided, as well as the frameworks within

which a safe environment was created and maintained

and risks were eliminated or mitigated

Across the four years of EQuIP 4, a number of criteria

from the Support and Corporate Functions were

consistently amongst those most frequently associated

with surveyor recommendations, including High Priority

Recommendations, and AC60 survey outcomes

Non-clinical operational aspects remain areas of required

improvement for many organisations, particularly

emergency and disaster management, safety systems,

the management of buildings, plant and equipment, risk

management, quality improvement, policies and

procedures and credentialling.

Member satisfaction with ACHS services

ACHS requests, collates and analyses feedback data from

its members, in order to assess its own performance and

identify its own areas for improvement. Members are

surveyed regarding the EQuIP standards and criteria, the

support received from ACHS, their surveys, their survey

coordinators and surveyors, the survey report and the

self-assessment process.

In most cases, members declared themselves to be

‘satisfied’ or ‘highly satisfied’ at a level of 90% or greater.

The highest levels of satisfaction were recorded for aspects

of the survey process, including the conduct of the survey

coordinator and surveyors and the content and clarity of the

survey report. The standards and criteria themselves also

scored highly.

The main area in which member feedback indicated that

improvement was required was the Electronic Assessment

Tool (EAT), although increased satisfaction was recorded

across the years 2007 – 2010, with scores lifting from a

low of 76% in 2007 to a high of 86% in 2010. The other

aspect that may require improvement is the self-assessment

process, for which satisfaction levels varied between

82% - 92% across 2007 – 2010.

Research

For the first time, the National Accreditation Report

provides a summary of ACHS’ activities and

collaborations in the area of healthcare accreditation

research. Key citations are included.


9



1.1 Consumers / patients are provided with highquality care throughout the care delivery process.

1.1.1 The assessment system ensures current andongoing needs of the consumer / patient are identified.

1.1.2 Care is planned and delivered in partnershipwith the consumer / patient and when relevant, thecarer, to achieve the best possible outcomes.

1.1.3 Consumers / patients are informed of theconsent process, understand and provide consentfor their health care.

1.1.4 Care is evaluated by health care providers andwhen appropriate with the consumer / patient andcarer.

1.1.5 Processes for discharge / transfer address theneeds of the consumer / patient for ongoing care.

1.1.6 Systems for ongoing care of the consumer /patient are coordinated and effective.

1.1.7 Systems exist to ensure that the care of dyingand deceased consumers / patients is managed withdignity and comfort.

1.1.8 The health record ensures comprehensive andaccurate information is recorded and used in caredelivery.

1.2 Consumers / patients / communities have accessto health services and care appropriate to their needs.

1.2.1 The community has information on, and accessto, health services and care appropriate to its needs.

1.2.2 Access and admission to the system of care isprioritised according to clinical need.

1.3 Appropriate care and services are provided toconsumers / patients.

1.3.1 Health care and services are appropriate anddelivered in the most appropriate setting.

1.4 The organisation provides care and services that achieve expected outcomes.

1.4.1 Care and services are planned, developed anddelivered based on the best available evidence and inthe most effective way.

1.5 The organisation provides safe care and services.

1.5.1 Medications are managed to ensure safe andeffective practice.

1.5.2 The infection control system supports safepractice and ensures a safe environment forconsumers / patients and health care workers.

1.5.3 The incidence and impact of pressure ulcers areminimised through a pressure ulcer prevention andmanagement strategy.

1.5.4 The incidence of falls and fall injuries isminimised through a falls management program.

1.5.5 The system for prescription, sample collection,storage and transportation and administration of bloodand blood components ensures safe and appropriatepractice.

1.5.6 The organisation ensures that the correct patientreceives the correct procedure on the correct site.

1.6 The governing body is committed to consumerparticipation.

1.6.1 Input is sought from consumers, carers and thecommunity in planning, delivery and evaluation of thehealth service.

1.6.2 Consumers / patients are informed of their rightsand responsibilities.

1.6.3 The organisation makes provision for consumers /patients from culturally and linguistically diverse back-grounds and consumers / patients with special needs.

2.1 The governing body leads the organisation in itscommitment to improving performance and ensuresthe effective management of corporate and clinicalrisks.

2.1.1 The organisation’s continuous qualityimprovement system demonstrates its commitment toimproving the outcomes of care and service delivery.

2.1.2 The integrated organisation-wide riskmanagement policy and system ensure that corporateand clinical risks are identified, minimised andmanaged.

2.1.3 Health care incidents, complaints and feedbackare managed to ensure improvements to the systemsof care.

2.2 Human resources management supports qualityhealth care, a competent workforce and a satisfyingworking environment for staff.

2.2.1 Human resources planning supports theorganisation’s current and future ability to addressneeds.

2.2.2 The recruitment, selection and appointmentsystem ensures that the skill mix and competence ofstaff, and mix of volunteers, meets the needs of theorganisation.

2.2.3 The continuing employment and performancedevelopment system ensures the competence ofstaff and volunteers.

2.2.4 The learning and development system ensuresthe skill and competence of staff and volunteers.

2.2.5 Employee support systems and workplacerelations assist the organisation to achieve its goals.

2.3 Information management systems enable theorganisation’s goals to be met.

2.3.1 Records management systems support thecollection of information and meet the organisation’sneeds.

2.3.2 Information and data management and collectionsystems are used to assist in meeting the strategic andoperational needs of the organisation.

2.3.3 Data and information are used effectively tosupport and improve care and services.

2.3.4 The organisation has an integrated approachto the planning, use and management of informationand communication technology (I&CT).

2.4: The organisation promotes the health of thepopulation.

2.4.1 Better health and wellbeing for consumers /patients, staff and the broader community arepromoted by the organisation.

2.5 The organisation encourages and adequatelygoverns the conduct of health and medical researchto improve the safety and quality of health care.

2.5.1 The organisation’s research program promotesthe development of knowledge and its application in thehealth care setting, protects consumers / patients andmanages organisational risks associated with research.

3.1 The governing body leads the organisation’sstrategic direction to ensure the provision of quality, safe services.

3.1.1 The organisation provides quality, safe care throughstrategic and operational planning and development.

3.1.2 Governance is assisted by formal structuresand delegation practices within the organisation.

3.1.3 Processes for credentialling and defining thescope of clinical practice support safe, quality healthcare.

3.1.4 External service providers are managed tomaximise quality care and service delivery.

3.1.5 Documented corporate and clinical policiesassist the organisation to provide quality care.

3.2 The organisation maintains a safe environment foremployees, consumers / patients and visitors.

3.2.1 Safety management systems ensure safety andwellbeing for consumers / patients, staff, visitors andcontractors.

3.2.2 Buildings, signage, plant, equipment, supplies,utilities and consumables are managed safely andused efficiently and effectively.

3.2.3 Waste and environmental management systemssupport safe practice and a safe environment.

3.2.4 Emergency and disaster management supportssafe practice and a safe environment.

3.2.5 Security management supports safe practiceand a safe environment.

1. CLINICAL 2. SUPPORT 3. CORPORATE

Figure 1: EQuIP 4 functions, standards and criteria

Mandatory Criteria

Developmentalstandard / criterion

Figure 3: EQuIP 4 OWS and PR surveys by bed

number (2007 – 2010, accreditation achieved by

31 March 2011, n=977)

The survey data analysed for this report are from 977

EQuIP 4 surveys conducted and completed between

1 January 2007 and 31 December 2010, where

accreditation outcomes were finalised on or before

31 March 2011. Of these, 520 surveys (53%) were

Organisation-Wide Surveys and 457 (47%) were Periodic

Reviews, as determined by each member organisation’s

stage in the four-year EQuIP cycle. Of the organisations

accredited under EQuIP 4 during the years 2007 – 2010,

529 (54%) were in the private sector, and 448 (46%) were

in the public sector.

0 - 49(43%)

0

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

50 - 99(20%)

100 -199(18%)

Beds

200 - 499(13%)

> 500(7%)

420

192 175

125

Figure 2: EQuIP 4 OWS and PR surveys by State / Territory

(2007 – 2010, accreditation achieved by 31 March 2011, n=977)

Vic(32%)

0

10%

20%

30%

NSW(29%)

Qld(16%)

SA(10%)

WA(9%)

Tas(2%)

NT(1%)

ACT(1%)

308285

156

101 85

17 13 12

Figure 4: EQuIP 4 OWS and PR survey outcomes by organisation type

(2007 – 2010, accreditation achieved by 31 March 2011, n=977)

Ho

sp

itals

Health S

erv

ices

Multip

le S

ites

Day P

roced

ure

C

entr

e

Co

mm

unity H

ealth

Multip

urp

ose

Serv

ice

#O

ther

Sp

ecia

lity

Serv

ice

Co

rrectio

nal H

ealth

Serv

ice

Menta

l H

ealth

Ora

l H

ealth

*Oth

ers

Palli

ative C

are

0

100

200

300

400

500

60052%

19%15%

6% 2% 2% 1% 1% 1% 1% 1%

(#”Other speciality service” includes counselling services, drug and alcohol services, and various non-government organisations)

(*”Others” includes day hospitals, population health organisations and ambulance services)


11

65


During an Organisation-Wide Survey (OWS), an

organisation is assessed on its performance in all 45 EQuIP

4 criteria; while during Periodic Review (PR), performance

in the 14 EQuIP 4 mandatory criteria is assessed.

Following a successful OWS, an organisation is awarded

accreditation for four years, with its ongoing performance

reviewed after two years during PR, when accreditation

can be continued, withdrawn or changed to a one-year

conditional accreditation, depending on the survey

team’s findings.

Accreditation survey results

The ACHS EQuIP accreditation program is designed to

guide healthcare organisations to identify and prioritise

their opportunities for improvement. Accreditation is

also a form of external recognition for high-performing

healthcare organisations and the many people who work

within them, and provides an opportunity for organisations

and their staff to demonstrate what they do well. On

survey under EQuIP 4, organisations are assessed

against 45 different criteria that consider aspects of

both their clinical and non-clinical functions. There are

14 mandatory criteria under EQuIP 4. To be accredited,

organisations are required to achieve a Moderate

Achievement (MA) rating in all mandatory criteria; an

MA rating reflects the establishment of policies and

procedures to manage, monitor and evaluate key tasks.

Performance against the mandatory criteria is assessed

at both Organisation-Wide Survey and Periodic Review,

while non-mandatory criteria are assessed at

Organisation-Wide Survey only.

Accreditation outcomes (2007 – 2010)

Of the organisations undergoing Organisation-Wide

Survey (OWS) or Periodic Review (PR) during the years

2007 – 2010, 83% (814/977) achieved full or continuing

accreditation at survey. A further 12% (114/977) of

organisations achieved full or continuing accreditation

after first addressing issues raised via an Advanced

Completion in 60 days (AC60) survey. A further 2%

(19/977) of organisations received one-year conditional

accreditation upon initial survey, while 3% (28/977)

received conditional accreditation after AC60 survey

outcomes were addressed. Two organisations (0.2%)

were not accredited. Both of these outcomes occurred

during the 2007 – 2008 survey period, and included one

organisation whose status was not finalised until after

the cut-off date for inclusion in the previous National

Accreditation Report.

Performance against individual criteria

The data in Figures 6, 7 and 8 represent the overall

outcomes for the complete four-year EQuIP 4 cycle,

with a majority of organisations undergoing both

Organisation-Wide Survey and Periodic Review

and being assessed for all 45 criteria, including the

developmental criterion 1.3.1.

Full / continuing(95%)

0

100

200

300

400

500

600

700

800

900

1000

One-year conditional(5%)

Non-accredited(0.2%)

Accreditation on initial survey Accreditation after AC60

814

114

28

19

0

2

Figure 5: Outcomes of EQuIP 4 surveys,

2007 – 2010 (n=977)

Rating

OA

EA

MA

SA

LA

N/A

Totals

Mandatory criteria

(977 surveys)

Non-mandatory criteria

(520 surveys)

All criteria

(977 surveys)

Figure 6: Distribution of ratings across all criteria (EQuIP 4 surveys, 1 January 2007 – 31 December 2010, n=977)

49

2239

11380

1

1

8

13678

94

1621

13082

688

5

630

16120

143

3860

24462

689

6

638

29798

(0.5%)

(13%)

(82%)

(2%)

(0.02%)

(2%)



1.1.1

1.1.2

1.1.3

1.1.4

1.1.5

1.1.8

1.5.2

2.1.1

2.1.2

2.1.3

3.1.3

3.1.5

3.2.1

3.2.4

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.2%

0.0%

0.1%

0.1%

0.1%

0.1%

0.1%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.0%

0.0%

0.0%

0.0%

0%

83%

84%

89%

75%

84%

89%

69%

75%

82%

82%

90%

90%

81%

92%

17%

16%

11%

24%

16%

11%

31%

24%

17%

17%

10%

10%

18%

8%

1%

0%

0%

1%

0%

0%

1%

1%

1%

0%

0%

0%

0%

0%

Assessment system

Planned and delivered in partnership with consumer / patient

Consent

Care evaluation

Discharge and transfer of care

Health record

Infection control

Continuous quality improvement

Risk management; corporate and clinical

Incidents and complaints management

Credentialling and scope of clinical practice

Corporate and clinical policies

Workplace health and safety (including dangerous goods,hazardous substances and radiation, manual handling)

Emergency and disaster management

Criterion

No.N/A LA SA MA EA OARelated to

Figure 7: Ratings for EQuIP 4 mandatory criteria surveyed at OWS andPR from 1 January 2007 – 31 December 2010 (n=977, organisationsaccredited as of 31 March 2011; percentages rounded).


13

1.1.6

1.1.7

1.2.1

1.2.2

1.3.1#

1.4.1

1.5.1

1.5.3

1.5.4

1.5.5

1.5.6

1.6.1

1.6.2

1.6.3

2.2.1

2.2.2

2.2.3

2.2.4

2.2.5

2.3.1

2.3.2

2.3.3

2.3.4

2.4.1

2.5.1

3.1.1

3.1.2

3.1.4

3.2.2

3.2.3

3.2.5

6%

18%

0%

1%

3%

0%

1%

17%

3%

30%

6%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

1%

34%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

1%

0%

0%

0%

0%

0%

0%

3%

3%

1%

0%

4%

3%

3%

6%

6%

11%

7%

8%

3%

4%

4%

3%

9%

5%

4%

3%

3%

3%

3%

6%

11%

2%

3%

6%

3%

3%

4%

85%

65%

91%

89%

85%

83%

83%

64%

77%

53%

80%

75%

89%

90%

83%

92%

87%

74%

91%

84%

86%

85%

84%

79%

42%

83%

86%

89%

91%

82%

92%

7%

12%

8%

10%

7%

14%

12%

13%

14%

7%

7%

17%

7%

5%

13%

6%

4%

19%

5%

13%

11%

11%

12%

14%

10%

14%

11%

5%

6%

14%

5%

0%

2%

0%

0%

1%

1%

1%

0%

0%

0%

0%

1%

0%

1%

0%

0%

0%

2%

0%

0%

0%

0%

1%

2%

3%

1%

0%

0%

0%

1%

0%

Ongoing care

Decision making at end of life

Information about services

Access is appropriate and prioritised according to clinical need

Right care and services are provided in the right setting

Care and services are best evidence based and processes are effective

Medication safety

Pressure ulcer prevention and management

Falls prevention and management

Blood management

Correct patient, procedure, site

Involvement of consumers

Rights and responsibilities

Cultural and special needs

Human resources planning

Recruitment, selection and appointment

Continuing employment / professional development

Learning and development system

Support and workplace relations

Records management

Information and data management systems

Data and information used effectively

Information and communications technology

Health promotion, health protection and surveillance

Encouraging and governing research

Strategic and operational planning

Governance structures, delegations and financial management

Non-clinical external service providers

Buildings, signage, plant, equipment, supplies, utilities & consumables

Waste and environment

Security management

Criterion

No.N/A LA SA MA EA OARelated to

Figure 8: Ratings for EQuIP 4 non-mandatory criteria surveyed at

OWS from 1 January 2007 – 31 December 2010 (n=520, organisations

accredited as of 31 March 2011; percentages rounded).

In the mandatory criteria, there was a trend towards

improved performance over the four years, with an

increased percentage of EA and OA ratings in the 2009 –

2010 period for most criteria, compared to the 2007 –

2008 period reported in the previous edition of the

National Accreditation Report. Across both two-year

periods, the highest percentages of EA ratings were

associated with the criteria governing infection control

(1.5.2), the continuous quality improvement system (2.1.1),

and the care evaluation process (1.1.4). Similarly, the care

evaluation and quality improvement criteria attracted OA

ratings in both periods; while during 2009 – 2010, OA

ratings were also awarded to organisations with respect

to the criteria governing assessment processes (1.1.1),

infection control and risk management (2.1.2).

In the non-mandatory criteria, there was increased

achievement at the EA level during the 2009 – 2010

period; however, at the same time OA ratings were

awarded against fewer criteria. The criteria attracting the

highest percentages of EA ratings were similar across the

two time periods, with organisations performing strongly

in the areas of learning and development (2.2.4), consumer

participation (1.6.1), strategic and operational planning

(3.1.2), effectiveness of care (1.4.1) and falls prevention

and management (1.5.4). During 2009 – 2010, health

promotion (2.4.1) and waste management (3.2.3) were

both associated with a marked improvement in

performance at the EA level. Across the four years of

EQuIP 4, research governance (2.5.1) and health

promotion (2.4.1) most frequently attracted OA ratings;


(* Developmental criterion)


while during 2009 – 2010, a higher proportion of

organisations also performed at the OA level in end-of-life

care (1.1.7) and learning and development (2.2.4).

The LA and SA ratings awarded with respect to the

non-mandatory criteria can indicate areas of performance

which organisations find challenging. During 2009 – 2010,

7.5% of organisations surveyed received an SA rating

against the blood management criterion (1.5.5), indicating

that organisations are not always satisfactorily evaluating

and as necessary improving this critical clinical area.

Nevertheless, it should be noted that there was a

decrease in SA outcomes against this criterion between

2007 – 2008 and 2009 – 2010, and that while MA

performance remained steady, there was an increase in

the percentage of EA ratings awarded across the same

time periods (0.5% to 11%), indicating an overall

improvement in performance in this area.

Advanced Completion in 60 dayssurveys (AC60s)

At Organisation-Wide Survey or Periodic Review, if the

survey team assigns an LA or SA rating in a mandatory

criterion, or makes a High Priority Recommendation

for any criterion, or if high risk is identified in a non-

mandatory area, full (following OWS) or continuing

(following PR) accreditation cannot be awarded. In any

of these situations, the organisation may be offered an

Advanced Completion in 60 days survey (AC60) to

improve performance.

In this event, the survey outcome is not finalised until

after a review of the action taken by the organisation

to address the AC60, which is carried out by the ACHS

surveyors within 60 days of the initial survey. If the

organisation is considered to have addressed the

identified issue(s), accreditation can be awarded or

continued either for the full term or for a one-year

conditional period, depending upon the outcome of

the review. If the surveyors consider that the AC60 issue

has not been addressed within the assigned timeframe,

accreditation is not achieved by the organisation.

An AC60 result has the dual outcome of drawing

attention to a shortcoming in an organisation’s operation,

while simultaneously providing the organisation with an

opportunity to work in partnership with the ACHS and

its surveyors to improve the systems or processes in

question. The ACHS regards the AC60 review as a

successful system that maintains performance standards

and supports organisations to achieve the required

accreditation standards in a timely manner, resulting in

a positive outcome for organisations and consumers.

During the years 2007 – 2010, there were 156 instances of

organisations being required to undertake an AC60 review

for at least one criterion, with 144 of these completed by

31 March 2011. Following review, 114 of the organisations

(79%) achieved full or continuing accreditation; 28 (19%)

received one-year conditional accreditation; and 2 (1%)

were non-accredited (see Figure 5).

An AC60 was more often the outcome of an Organisation-

Wide Survey (94/520 surveys, 18%) than a Periodic

Review (50/457 surveys, 11%), and occurred at higher

frequency in the public sector (105/448, 23%) than the

private sector (39/529, 7%). Larger organisations were

more likely to receive an AC60, with the 200-499 bed

number organisations receiving 22% of the AC60

outcomes overall. However, the data also indicate a

marked improvement in the performance of the largest

organisations (i.e. with 500 beds or more) across the

four-year survey period, with the percentage of AC60

outcomes dropping from 38% (9/24) during 2007 – 2008

to 5% (2/41) during 2009 – 2010.

Across the States / Territories, Tasmania had the highest

percentage of AC60 surveys (5/17, 29%), and Victoria

(26/308, 8%) and the ACT (1/12, 8%) the lowest. Victoria,

although having more completed surveys than any other

State or Territory (308/977, 32%), had an AC60 incidence

of approximately half that of the remaining States /

Territories.


15

2007 (16%)

2008 (17%)

2009 (13%)

2010(13%)

0

50

100

150

200

250

300

No. non-AC60 surveys No. AC60 surveys

163

30 228

47

240

36

202

31

Figure 9: AC60 surveys by year

(EQuIP 4 surveys, 2007 - 2010, n=977)

Public (23%)

Private (7%)

0

100

200

300

400

500

600

No. non-AC60 surveys No. AC60 surveys

343

105490

39

Figure 10: AC60 survey outcomes by health sector

(EQuIP 4 surveys, 2007 – 2010, n=977)


Figure 11: AC60 survey outcomes by organisation size

(EQuIP 4 surveys, 2007 – 2010, n=977)

0 - 49(10%)

0

50

100

150

200

250

300

350

400

450

50 - 99(15%)

100 -199(19%)

Beds

200 - 499(22%)

> 500(17%)

376

163

14298

54

44

2933

2711

No. non-AC60 surveys No. AC60 surveys Percentage of AC60 surveys

Figure 12: AC60 survey outcomes by State / Territory

(EQuIP 4 surveys, 2007 – 2010, n=977)

Tas(5/17)

0

10%

5%

15%

25%

20%

30%

Qld(30/156)

WA(15/85)

NSW(50/285)

NT(2/13)

SA(15/101)

ACT(1/12)

Vic(26/308)

29%

19% 18% 18%

15% 15%

8% 8%

During 2008, the process for issuing AC60 outcomes

was changed. Whereas previously the number of AC60

results that could be issued per organisation per survey

was unlimited, at this time policy was introduced to limit

the number of criteria to four, other than in exceptional

circumstances and at the discretion of the ACHS and its

surveyors, so that organisations are not set an unrealistic

number of issues requiring comprehensive remedial

action within 60 days.

Throughout the 2007 – 2010 survey period, a total of

303 individual AC60 outcomes were issued across 144

organisations. The majority of organisations receiving

an AC60 outcome did so in only a single criterion

(66/144, 46%).



17

Figure 13: Number of criteria assessed at AC60

per organisation receiving any AC60 outcome

(EQuIP 4 surveys, 2007 – 2010, n=144)

1(66/144)

0

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2(37/144)

3(17/144)

4(19/144)

> 5(5/144)

46%

26%

12% 13%

3%

No. criteria assessed at AC60 per organisation

Of the 45 EQuIP 4 criteria against which organisational

performance was assessed during 2007 - 2010, 34 were

associated with at least one AC60 survey outcome (see

Figure 14), including all 14 mandatory criteria. The ten

criteria most frequently associated with an AC60 outcome

are indicated by shading in Figure 14.

The AC60 results were not confined to a single area of

organisational operation, but distributed across the three

EQuIP functions (Clinical, Support, Corporate), with 76%

(16/21) of the Clinical criteria, 79% (11/14) of the Support

criteria and 70% (7/10) of the Corporate criteria

associated with an AC60 result. Five out of the ten criteria

most often allocated an AC60 outcome were positioned

within the Corporate function; three were Clinical criteria;

and two were Support criteria. Of these ten criteria, nine

are mandatory, indicating that organisations may find

challenging even those areas of operation most

fundamental to the safe delivery of care and services.

Three clinical criteria, all of them mandatory, were

amongst those most frequently associated with an AC60

outcome: infection control (1.5.2), the health record

(1.1.8) and care evaluation (1.1.4); while the remaining

seven criteria were those governing organisations’ safety

management and quality improvement processes, with

emergency and disaster management (3.2.4), risk

management (2.1.2), continuous quality improvement

(2.1.1), safety management (3.2.1) and the management

of buildings and equipment (3.2.2) amongst those with

the highest incidence of AC60 outcomes. These data

underscore the requirement for healthcare organisations

to operate holistically, with high quality clinical care

delivered within a framework of systems and processes

that create and maintain a safe and continuously

improving environment.

The data also indicate that the procedures for managing

the day-to-day functioning of healthcare organisations

may represent a further challenge, with a significant

number of AC60 outcomes associated with the criteria

governing credentialling (3.1.3) and corporate and clinical

policies (3.1.5). These figures highlight the need for

ongoing monitoring, evaluation and improvement of the

systems, policies and procedures that comprise the

framework within which care and services are delivered

(see: Spotlight on Organisational Systems).


3.2.4

2.1.2

1.5.2

3.1.3

1.1.8

2.1.1

3.1.5

3.2.2

1.1.4

3.2.1

1.1.3

1.1.2

2.1.3

3.2.5

1.5.1

1.1.5

1.5.5

1.5.4

1.5.6

2.2.2

2.2.3

1.1.1

1.1.6

1.4.1

1.5.3

1.6.2

1.6.3

2.2.1

2.2.4

2.3.1

2.3.3

2.4.1

2.5.1

3.1.4

Corporate

Support

Clinical

Corporate

Clinical

Support

Corporate

Corporate

Clinical

Corporate

Clinical

Clinical

Support

Corporate

Clinical

Clinical

Clinical

Clinical

Clinical

Support

Support

Clinical

Clinical

Clinical

Clinical

Clinical

Clinical

Support

Support

Support

Support

Support

Support

Corporate

66

37

27

25

19

17

14

13

13

13

10

8

6

5

3

3

3

2

2

2

2

1

1

1

1

1

1

1

1

1

1

1

1

1

56

24

21

13

5

9

6

12

10

8

4

4

1

5

3

2

2

1

0

0

0

0

0

0

1

0

0

0

1

0

1

1

0

0



Infection control


Health record



Buildings, signage, plant, equipment, supplies, utilities and consumables

Care evaluation

Workplace health and safety (including dangerous goods,hazardous substances and radiation, manual handling).

Consent



Security management

Medication safety


Blood management

Falls prevention and management

Correct patient, procedure, site

Recruitment, selection and appointment

Continuing employment / professional development

Assessment system

Ongoing care and management

Care and services are best evidence based and processes are effective

Pressure ulcer prevention and management

Rights and responsibilities

Cultural and special needs

Human Resources planning

Learning and development system

Records management

Data and information used effectively

Health promotion, health protection and surveillance

Encouraging and governing research

Non-clinical external service providers

Criterion

No.Function No. AC60

outcomes

No. HPRs*Related to

Figure 14: Number of AC60 survey results per criterion, 2007 – 2010(EQuIP 4 surveys, n=977; italicised text indicates a mandatory criterion; shadedtext indicates the ten criteria most frequently associated with an AC60 outcome)

(*HPRs = High Priority Recommendations)


High Priority Recommendations (HPRs)

In the five-tier EQuIP accreditation system, a Little

Achievement (LA) rating indicates that organisations

are aware of the requirements (jurisdictional, legislative

and otherwise) for a particular area of operation,

while a Some Achievement (SA) rating indicates that

appropriate systems and processes have been

implemented. To achieve a Moderate Achievement (MA)

rating, organisations must be able to demonstrate that

they evaluate the effectiveness of their systems and

processes and that, based upon this evaluation, they

make improvements as required. An organisation must

receive an MA rating in all mandatory criteria to achieve

accreditation.

During survey, surveyors will make recommendations

for improvements to organisational systems and

processes (see: Recommendations and Areas for

Improvement). Recommendations will frequently address

how organisations might improve their practice around

implementation of systems and processes, alignment of

policies and procedures with jurisdictional requirements,

evaluation and benchmarking. However, when a survey

team observes a system or practice which, upon the

basis of a structured risk assessment, could compromise

consumer / patient care or jeopardise the safety of

consumers / patients or staff, a High Priority

Recommendation (HPR) will be issued. The issuing of

an HPR usually, although not always, results in an AC60

outcome for the relevant criterion. The organisation is

expected to address all HPRs in the shortest possible

time, and failure to do so will adversely affect its

accreditation status.

Across 2007 – 2010, 190 HPRs were issued by survey

teams (see Figure 15). These were associated with 22

of the 45 EQuIP 4 criteria, of which 13 were mandatory

and nine non-mandatory; the six criteria most frequently

associated with an HPR are indicated by shading in

Figure 15.

Of these six, five were mandatory and one non-

mandatory; two of the six were clinical and four

non-clinical. The management of infection control (1.5.2)

remains a major area of concern, with HPRs resulting

from a variety of specific issues, in particular sterilisation

practices, hand hygiene and food safety (see: Spotlight

on Infection Control). Detected shortcomings in the

systems and processes of infection control included lack,

or inadequacy, of staff education and training, failure to

conduct appropriate auditing, and failure to evaluate the

infection control plan, its implementation and its

effectiveness. In the area of care evaluation (1.1.4),

surveyors highlighted the necessity of appropriate care

evaluation frameworks, regular, multidisciplinary case

review, clinical pathways based upon best evidence,

and systems for the capture and use of relevant data.

The majority of HPRs were associated with the operational

framework and management of organisations as a whole

(see: Spotlight on Organisational Systems), with survey

teams expressing concern in the areas of emergency and

disaster management (3.2.4), risk management (2.1.2),

credentialling (3.1.3), and management of buildings and

equipment (3.2.2). It is of note that some areas of concern

overlapped criteria, emphasising the need for functional

integration of organisational systems.

The criterion attracting the highest number of HPRs was

emergency and disaster management (3.2.4). While many

of these were related to the requirements for fire safety,

the most frequent area of concern was staff training. Of

the wide range of issues encompassed by the criterion

governing the management of buildings and equipment

(3.2.2), the most frequent concern involved shortcomings

in cardiac and body protection testing.

The HPRs associated with risk management (2.1.2)

highlighted a number of basic operational flaws, including

the absence of a current risk register, inadequate

identification of risks, failure to mitigate identified risks,

lack of an action plan or the failure to act upon it, and a

failure to evaluate the risk management system and to

make necessary improvements. Other concerns were

gaps between policy and procedures, and the absence

of true multidisciplinary consultation in risk management

processes, including a lack of clinician involvement.

Credentialling (3.1.3) was a new criterion in EQuIP 4,

and while this area continues to attract a significant

number of HPRs, across the four-year survey period it

can be seen that a process of improvement has taken

place (see: Spotlight on Credentialling). Whereas initially

a number of organisations were without any formal

system for credentialling and/or defining scope of

practice, over time the issued HPRs have become more

frequently associated with inadequate evaluation of

aspects of the credentialling system, documentation

of processes, and committee formation and operation.

However, fundamental deficiencies in credentialling

systems are still evident in some organisations, and the

management of the introduction of new interventions

remains an area of concern.


19


Mandatory criteria

For EA and OA performance during the years 2007 –

2008, please see the previous edition of the National

Accreditation Report, available at the ACHS website:

http://www.achs.org.au/pdf/NationalAccreditationReport

_0708_WebVersion.pdf

For the 2009 – 2010 period, encompassing 509

surveys (Organisation-Wide Survey and Periodic Review),

performance with respect to the mandatory criteria

was rated at the level of Outstanding Achievement on 30

occasions, representing 0.4% of the total survey outcomes.

An Extensive Achievement award was associated with a

mandatory criterion on 1312 occasions, or 18% of the time.

There was an increase in the number of EA ratings

awarded by survey teams for the mandatory criteria

between the 2007 – 2008 (14%, 927 from 454 surveys)

and 2009 – 2010 (18%, 1310 from 509 surveys)

survey periods, indicating that an increasing number

of organisations had moved beyond the evaluation

of their systems and processes to the use of internal

and/or external benchmarking techniques, including

clinical indicators, and research to improve their

operation. While an increase in EA ratings occurred for

each individual mandatory criterion, the improvement in

certain areas was more evident.

A marked increase in the number of EA ratings awarded

was recorded for the management of infection control

(1.5.2). This was an encouraging result in light of the

AC60 and HPR data, which indicate that this is an area

of operation that some organisations continue to find

challenging. Similarly, there was improved performance

in the vital systemic areas of safety management (3.2.1),

quality improvement (2.1.1) and credentialling (3.1.3).

The mandatory criterion most consistently associated

with a high level of achievement by organisations was

care evaluation (1.1.4), for which high numbers of both

EA and OA ratings were awarded by surveyors. While this

outcome was generally maintained across the four years

of EQuIP 4, the care evaluation criterion was associated

with a greater number of EA ratings during the 2009 –

2010 survey period.

Extensive and Outstanding Achievement

Organisations that are considered to have reached a

significantly high level of performance in an area of

operation may be awarded an EA (Extensive Achievement)

or an OA (Outstanding Achievement) rating at survey.

To be assessed at an EA level, there must be evidence

across the organisation of advanced implementation

systems and outcomes related to that criterion. An EA

rating requires that the organisation is participating in

external benchmarking or research in the area, or other

equivalent methods to validate their level of performance.

For all criteria surveyed across the four-year EQuIP 4

cycle (i.e. both mandatory and non-mandatory), a rating

of Extensive Achievement represented 13% (3860/29798)

of the total individual ratings (see Figure 6), with

mandatory criteria assessed at the EA level on 2237

occasions from 977 surveys, and non-mandatory criteria

on 1621 occasions from 520 surveys. At the same time,

an Outstanding Achievement award represented 0.5%

of total individual ratings (143/29798), with mandatory

criteria assessed at the OA level on 49 occasions from

977 surveys, and non-mandatory criteria on 94 occasions

from 520 surveys.

Criterion number

3.2.4

2.1.2

1.5.2

3.1.3

1.1.4

3.2.1

2.1.1

3.1.5

1.1.8

1.1.3

1.1.2

1.1.5

2.1.3

No. HPRs*

56

24

21

13

10

8

9

6

5

4

4

2

1

163

Criterion number

3.2.2

3.2.5

1.5.1

1.5.5

1.5.3

1.5.4

2.2.4

2.3.3

2.4.1

No. HPRs

12

5

3

2

1

1

1

1

1

27

Mandatory criteria Non-mandatory criteria

Figure 15: Number of High Priority Recommendations percriterion, 2007 – 2010 (EQuIP 4 surveys, n=977; italicisedtext indicates a mandatory criterion; shading indicates thesix criteria most frequently associated with an HPR)


(*HPRs = High Priority Recommendations)

1.1.1

1.1.2

1.1.3

1.1.4

1.1.5

1.1.8

1.5.2

2.1.1

2.1.2

2.1.3

3.1.3

3.1.5

3.2.1

3.2.4


21

Non-mandatory criteria

Performance in the EQuIP 4 non-mandatory criteria was

assessed during 320 Organisation-Wide Surveys during

the 2009 – 2010 period. A rating of Outstanding

Achievement was awarded on 60 occasions, representing

0.6% of the total survey outcomes, the same as for the

2007 – 2008 period. An Extensive Achievement rating

was awarded on 1113 occasions from the 320 surveys,

representing 11% of total outcomes, an improvement

from 8% (508 from 200 surveys) during the 2007 – 2008

period. However, unlike the mandatory criteria, there were

individual non-mandatory criteria for which performance

remained steady or a lower number of EA ratings were

awarded, notably the management of security (3.2.5)

and external service providers (3.1.4).

A greater number of EA ratings were awarded for several

non-mandatory criteria in both clinical and non-clinical

areas of operation. The most marked improvement was

in the area of blood management (1.5.5), which also

attracted two OA ratings, none having been awarded for

the 2007 – 2008 period. A similar pattern was observed

for the management of pressure ulcers (1.5.3), for which

two organisations also received OA ratings. Also of note

is that seven organisations received an OA rating for their

management of medications (1.5.1), whereas no

organisation did so during 2007 – 2008.

The distribution of the non-clinical areas of improvement

indicated a willingness on the part of organisations to

strive for excellence across the full framework of their

operation. The highest number of EA ratings was awarded

for waste and environmental management systems (3.2.3),

an outcome in accordance with a greater government

and societal emphasis upon responsible environmental

conduct. Many organisations received recognition for the

learning and development system (2.2.4) by which they

ensured the skill and competence of staff and volunteers;

while a culture that encouraged research (2.5.1), while also

providing strong governance and control of associated

risk, was another area of excellence. These two citeria

were further associated with eight and seven OA ratings,

respectively.

Organisations were also acknowledged for improved

performance in the areas of human resources planning

(2.2.1) and consumer participation (1.6.1).

96

91

57

139

83

56

177

138

97

100

62

59

109

48

1312

3

2

0

6

0

1

4

4

4

2

0

1

1

2

30

Assessment system


Consent

Care evaluation


Health record

Infection control






Workplace health and safety (including dangerous goods, hazardous substances

and radiation, manual handling)


Criterion

No.EA OARelated to

Figure 16: Mandatory criteria assessed at EA and OA levels

during 2009 – 2010 (EQuIP 4 surveys, n=509)

Outstanding Achievement

An OA is the highest assessment rating that an ACHS

survey team can allocate to an individual criterion. To

achieve an OA rating, the requirements of the elements

of LA, SA, MA and EA need to be met (see Figure 25),

in conjunction with a demonstration of leadership. An

organisation that receives an OA rating for a particular

criterion is considered to be a leading organisation in the

relevant field. This does not necessarily mean that the

organisation is the best in Australia. It may mean that the

organisation can demonstrate that it is the best or is

outstanding amongst peers.

During 2009 – 2010, ACHS survey teams awarded 90 OA

ratings, which were associated with 31 of the 45 EQuIP 4

criteria, including the developmental criterion 1.3.1. The

ratings were distributed to 49 organisations across the

States and Territories, in both the public and private

sectors, and to a variety of healthcare facilities including

hospitals, day procedure centres, community health

services and other speciality services.

Extracts from the relevant surveyor reports have been

included in this report to provide insight into the varied

means by which organisations demonstrated leadership

in different areas of operation (see: Appendix B: OA

summaries by criterion).


1.1.6

1.1.7

1.2.1

1.2.2

1.3.1#

1.4.1

1.5.1

1.5.3

1.5.4

1.5.5

1.5.6

1.6.1

1.6.2

1.6.3

2.2.1

2.2.2

2.2.3

2.2.4

2.2.5

2.3.1

2.3.2

2.3.3

2.3.4

2.4.1

2.5.1

3.1.1

3.1.2

3.1.4

3.2.2

3.2.3

3.2.5

24

44

25

30

25

49

43

50

50

34

27

61

22

19

50

22

18

70

17

48

39

36

43

51

34

44

34

11

20

55

18

1113

0

6

1

2

2

3

7

2

1

2

0

2

0

3

1

0

0

8

1

0

0

0

3

A˝ˆ˙ˇ C ˝ H - ACHS · Ms Myla Ponce, Project Officer – Business Support Services Ms Nikki...

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