St John of God Murdoch Hospital celebrated its 18th birthday with a

certificate presentation recognising the hospital’s recent accreditation by

ACHS. On hand to present the certificate was CEO Brian Johnston

(centre).

From left to right: St John of God Health Care Group CEO Dr Michael

Stanford, Murdoch Quality and Risk Management Vanessa Unwin, and

on the right hand side, Murdoch CEO Peter Mott with Murdoch Quality

Manager Rita McIlduff.

ACHSNEWS The Australian Council on Healthcare Standards

The official newsletter from ACHS to communicate to all member organisations and our stakeholders No. 40 Autumn 2012

Brian Johnston Chief Executive

ADDRESSING YOUR

ACCREDITATION

ASSESSMENT NEEDS Welcome to Autumn, which so far isn’t feeling any different

from our Summer. For those of us in the Eastern states a

little less rain would be most welcome! We sincerely hope

no-one has suffered a catastrophic loss and those affected

are re-establishing themselves.

At ACHS we have been busy ensuring that all current and

potential member organisations have a full range of

options for accreditation available. Our product range has

been revised and our procedures streamlined. We are

ready to meet your accreditation service requirements.

The range of products now extends to:

EQuIP5

National Standards only

EQuIPNational which includes the National

Standards as well as the extension components

contained in EQuIP and not covered by the National

Standards; and

EQuIP5 Day Procedure Centres

EQuIP5 Corporate Health Services.

EQuIPNational has been designed to take the external,

independent assessment of your organisation’s

performance well beyond compliance.

We can advise you as to the product that best suits your

needs and there will be more exciting developments

released in the months ahead.

ACHS is also able to respond on your behalf to any

reporting requirements if your organisation will be

assessed against the National Standards. The exact

nature of those requirements is still being finalised, but our

electronic systems are structured to respond to any third-

party requirements. One requirement for being authorised

to undertake assessments against the National Standards

is to provide data to the Australian Commission on Safety

and Quality in Health Care.

Those requirements may extend in the future to all

jurisdictions, the newly established National Health

Performance Authority and the Australian Institute for

Health and Welfare.

We appreciate that there is a degree of frustration being expressed by

some that not all details of the requirements for those undergoing

surveys to the National Standards are known. The Commission’s staff

members are working to resolve those outstanding matters, and they are

consulting with the authorised accreditation agencies as part of this

process.

Meanwhile, Laurie Leigh and our Customer Service Managers have

been busy conducting a highly successful round of well-attended

education sessions focusing on EQuIPNational. These sessions have

included discussions on the National Standards. We have answered

those questions that we could and undertaken to provide information

once received from the Commission.

The good news is that from the initial sample of assessments against the

National Standards, more than 90% of the measures have been

achieved, so the stretch to fully comply is well within the reach of most, if

not all. Due to the very small sample size this is not statistically

significant, however more comprehensive information about performance

results will progressively be made available by us over the coming

months. ACHS will continue to offer these gap analyses free to all

members for the remainder of this year.

We look forward to continuing to work with you.

CALL FOR ABSTRACTS CLOSE C.O.B. 30 APRIL 2012

ACHS continues to demonstrate its commitment to accreditation at an

international level – with its own EQuIP5 Day Procedure Centres Standards now formally accredited by the

International Society for Quality in Health Care (ISQua). The endorsement in February 2012 by ISQua recognises

the strengths of the standards program as an important tool all Australian day procedure centres can utilise to

ensure their delivery of care is at the highest possible level. “The Day Procedures Centres Standards have been

developed to meet the needs of this important healthcare sector, and we are justifiably proud of this recognition from

ISQua,” said Linda O’Connor, Executive Director of Development. The accreditation of EQuIP Day Procedure

Centres is valid from February 2012 until January 2016.

ISQua Accreditation for EQuIP5 Day

Procedure Centres Standards

National Conference Date Announced

The ACHS, along with its collaborators – the Australian Healthcare and Hospitals Association (AHHA) and the Women’s Hospital and Children’s Hospitals Australasia – have announced the date for their national conference this year. The conference will be held on Monday 24 September, concluding on Wednesday 26 September. The Quantum Leap: Measurement: redefining health’s boundaries? will be this year’s theme. Put the dates in your diary now. Register your interest at: admin@thequantumleap.com.au.

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Farewell to a Loyal ACHS Supporter A former ACHS Medal winner, and a long-time supporter of the ACHS, Dr John

Greenwell, passed away on 6 January.

Dr Greenwell made an important contribution to ACHS in its formative foundation years, and

will be remembered by many who worked in the public hospital sector in NSW for both his

wisdom and the friendship he extended to many. His interest in and involvement in health

industry matters was regarded as impressive by many, and his calm demeanour reassuring.

Appointed as the Medical Superintendent of the Royal Hospital for Women in 1951, he had a

long association with the hospital, subsequently becoming its General Medical

Superintendent in 1963.

Among his many career highlights, a notable one was establishing the Royal’s Birth Centre in 1983 as the premier alternative

birthing unit in NSW. Altogether, his contributions to health care spanned 41 years.

He was a Councillor to the ACHS representing the Australian College of Obstetricians and Gynaecologists for many years, at

one time the longest serving director of the Council, as well as serving the Standards Committee for many years. From

September 1990 until November 1991 he served as ACHS Vice President. Dr Greenwell is survived by his children Lisa

Greenwell and Robert Greenwell and grandchildren Jonathon, Jocelyn and Charles.

Dr John Greenwell

There is continued interest in the introduction of the upcoming NSQHS standards

ACHS recently invited members to comment on the newly drafted EQuIPNational Standards, as well as conducting free workshop sessions for members around Australia throughout February 2012.

Here we explain what the new EQuIPNational Standards mean to our members.

Why were the National Safety and Quality Health Service (NSQHS)

Standards Developed?

The Australian Commission on Safety and Quality

in Health Care (the Commission) commenced on

1 January 2006. The Commission was established

by the Australian, State and Territory Governments

to develop a national strategic framework and

associated work program to guide its efforts in

improving safety and quality across the healthcare

system in Australia.

In September 2011, Australian Health Ministers

endorsed a set of National Safety and Quality

Health Service (NSQHS) Standards. The NSQHS

Standards were developed by the Commission to

“provide a nationally consistent and uniform set of

measures of safety and quality for application

across a variety of health services”. In addition,

Health Ministers and regulators will receive

information on the results of accreditation of health

services to enable them to determine whether there

are systems in place to assure minimum standards

of safety and quality.

Following the planned full implementation in

January 2013, accreditation data from assessment

against the NSQHS Standards in all Australian

hospitals and day procedure services will be

provided to regulators and to the Commission for

reporting and review. Currently, the feedback and

results from accreditation are generally shared

between the health service and the accrediting

agency only.

Why has ACHS developed

EQuIPNational?

The content of the ten NSQHS Standards mirror

some of the components of ACHS’ established

EQuIP5 product. However, to allow members to

retain the organisation-wide evaluation and quality

improvement program that is EQuIP, without

duplication of assessment to the NSQHS

Standards, ACHS offers EQuIPNational to all its

members.

EQuIPNational will be presented in the same

format as the NSQHS Standards, to provide a

seamless product for organisations that want to

retain an organisation-wide perspective on their

health service. The program consists of the ten

NSQHS Standards, then provides a further five

Standards that focus on the performance of non-

clinical systems. They are designed for healthcare

organisations which would like to retain the robust,

comprehensive organisational approach that ACHS

products have historically had, and to complement

the ‘patient safety’ approach of the NSQHS

Standards. To assist in the seamless integration of

the NSQHS Standards and EQuIP, the rating scale

of EQuIPNational will also be aligned to the

NSQHS Standards.

ACHS currently offers member organisations a gap

analysis against the NSQHS Standards during their

EQuIP5 survey.

After the implementation of the NSQHS Standards

in January 2013, organisations can choose to be

assessed against either the NSQHS Standards

only, or to continue to benefit from the overall focus

on improvement across the organisation that

EQuIPNational will deliver.

Copies of the NSQHS Standards are available on the Commission’s website: www.safetyandquality.gov.au

A draft copy of EQuIPNational is available to view on the ACHS website: www.achs.org.au

For further information on EQuIPNational or the NSQHS Standards, please contact your dedicated CSM at ACHS on (02) 9281 9955

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Research into Accreditation Programs Strengthening organisational performance through accreditation research:

THE ACCREDIT PROJECT

ACHS continues to play a key research and

educational role in the field of accreditation.

Notably, the ACHS is a collaborator in the

Accreditation Collaborative for the Conduct of

Research, Evaluation and Designated

Investigations through Teamwork (ACCREDIT)

project. The ACCREDIT project partners include

Australian General Practice Accreditation

Limited, the Aged Care and Standards

Accreditation Agency, the Australian

Commission on Safety and Quality in Health

Care, and the New South Wales Clinical

Excellence Commission and Professors

Braithwaite and Westbrook and colleagues at

the University of New South Wales (UNSW).

Together, we are partners in an Australian

Research Council Linkage Grant. The

collaboration, across 2011 to 2015, is

implementing a multi-method, triangulated series

of studies to evaluate current accreditation

processes – see Figure 1.

WHY RESEARCH INTO

ACCREDITATION?

There is evidence that accreditation programs

can promote change and the standardisation of

services and organisational processes, including

how decisions about care are made. However,

the research literature is either inconsistent or

does not support the contentions. Hence this project plans to produce results which will link with other similar studies

underway in Europe.

The ACCREDIT project builds upon research previously conducted by ACHS and Professors Braithwaite and Westbrook

and colleagues, who previously carried out four studies into accreditation between 2005 and 2008.

As the ACCREDIT project is implemented and results are produced, findings will be made available via the ACHS and

UNSW websites, and at national seminars and conferences. Questions and inquiries about the project can be directed to

ACHS executives or UNSW staff - Dr David Greenfield, who leads the research team (d.greenfield@unsw.edu.au), Dr Max

Moldovan (m.moldovan@unsw.edu.au) or Dr Reece Hinchcliff (r.hinchcliff@unsw.edu.au).

Advertisement

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Figure 1: Research strategy and studies

National Report on Accreditation Released

ACHS has released the 4th

biennial ACHS National Report

on Health Services

Accreditation Performance, for

the years 2009 – 2010.

The Report contains

aggregate information from

509 accreditation surveys of

Australian healthcare

organisations between 2009 –

2010, assessing their

combined performance and

emerging trends.

The healthcare organisations

participating in this survey are members of the ACHS

Evaluation and Quality Improvement Program (EQuIP) and

include hospitals, day hospitals, clinics, community and mental

health services.

ACHS President, Adjunct Associate Professor Karen Linegar,

said “The overall data suggest an ongoing consistent level of

improvement by organisations building on previous years’

efforts, across the spectrum of health care. There are some

positive trends throughout the Report and these developments

may have been supported by increased familiarity with the

EQuIP 4 Standards.”

Highlights include survey trends indicating four areas of marked

improvement in performance compared to the previous survey

period, namely:

- the rate of Advanced Completion in 60 day surveys

(AC60s) decreasing by 21%,

- the rate of High Priority Recommendations (HPRs)

decreasing by 23%,

- a 27% increase in the awarding of Extensive Achievement

(EA) ratings, and

- a 25% increase in the awarding of Outstanding

Achievement (OA) ratings.

Key areas identified as needing further improvement included:

- Emergency and disaster management systems,

- Organisation-wide risk management policies and systems,

- Processes for credentialling clinicians, and

- Infection control systems.

It is of note that six of the seven areas requiring further

improvement are classified as non-clinical.

The purpose of the Report is to establish broad national

comparisons for accreditation performance, to assist healthcare

organisations evaluate their own performance against the

aggregate.

“The Report includes information on the majority of healthcare

organisations in Australia and has three themed commentaries

(on infection control, credentialling and organisational systems)

as well as a report on accreditation performance research and

detailed summaries by criterion of organisations which attained

Outstanding Achievement (OA) ratings,” Adjunct Associate

Professor Linegar said.

For copies of the Report, access the website or contact Ian

McManus at imcmanus@achs.org.au for a print copy.

CLINICAL INDICATOR PROGRAM Update March 2012 Second Half 2011 Data Collection

Data for the first half of the 2011 collection was submitted on 20 February 2012. Comparative reports will be available

for all participating organisations in early April 2012. These can be sent directly to your email inbox by logging into

PIRT and selecting ‘Reports, General and Peer Comparison Reports’.

Working Party Activity

The Paediatric working party met at ACHS’s office on 16 February 2012. The working party consisted of 23 members

who represented the majority of States and Territories in Australia, including both regional and metropolitan areas.

Members reviewed the existing clinical indicators from the Paediatric, ICU and Surgical sets, and discussed a number

of potential new paediatric clinical indicators. The new Paediatric clinical indicator set is expected to be released in

2013.

A new set of clinical indicators for Domiciliary / Community nursing is to be added to the existing 22 indicator sets, with

a newly formed working party meeting in May 2012. The Infection Control clinical indicators are due to be reviewed and

the working party is scheduled to meet in June 2012.

Education

The Measurement in Health Care: How to Maximise the Benefits of Clinical Indicators workshops continue to be well

attended. Remaining scheduled workshops for 2012 include Melbourne (Thursday 3 May) and Sydney (Thursday 10

May). Customised workshops for individual healthcare organisations / districts / clusters / networks are also available.

Australasian Clinical Indicator Report 2004 - 2011

This annual publication is currently being compiled, and will be officially launched at the ACHS Conference The

Quantum Leap in September 2012. This 13th

edition will provide valuable analysis on the 350 indicators available

across 22 clinical streams.

5 Closing Date 20 July 2012

Changes in EAT5 for

Self-Assessment (SASS) FOR ORGANISATION MEMBERS

Organisations can now upload a copy of their risk register before survey submission. Please note the following in relation to this new feature:

The file must be in a PDF file format

The file size must be no larger than 20mb

You will not be able to submit your SASS if you have not attached your Risk Register Attaching your risk register is very simple. Please follow the instructions outlined below:

1. In your “In Progress” SASS Review phase, click on the menu item “Upload / View Risk Register”

2. Click “Browse” to go to the file path of a PDF document

3. When you have located and opened the file, click “Save” in EAT

4. A link should then be available to access the file with the option to delete so that a different file can be uploaded if so desired. Check that the file can be accessed from the link.

FOR SELF-ASSESSMENT READERS

Organisations will now upload a copy of their risk register as part of the submission for SASS Review phases. To view the Risk Register that the organisation has uploaded, please follow the instructions outlined below:

1. Click on the left hand navigation menu item “Upload / View Risk Register”

2. Click on the file link provided.

A new feature called “SASS Summary” has been added to EAT5 SASS Review phases. In this

section SASS Readers should enter general comments regarding the organisation’s Member Details

section, which covers the organisation’s background information. This new section replaces the

need to enter feedback for SASS Review Phases into the Function Summary as previously advised.

If you have any questions regarding these new features or any other EAT related enquiries, please

do not hesitate to contact EAT support staff eat@achs.org.au or via AHCS Reception on

02 9281 9955.

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ISQua Geneva Conference

The annual ISQua Conference will be held in

Geneva in October 2012. More than 50 speakers

from 20 countries have already been confirmed,

and hundreds of papers have been submitted as

abstracts. The ACHS will wait to hear whether

their abstracts have been successful. Information

about attending the conference can be found at www.isqua.org

ACHS Surveyor Ms Manbo Man, who is the Director of Nursing Services at Hong Kong Sanatorium and

Hospital, was awarded the Medal of Honour by the Hong Kong SAR Government for her valuable

contribution to the regulatory work of Chinese medicine practitioners. The presentation ceremony was held

on 29 October 2011 at Government House in Hong Kong.

Manbo has been a member of the Chinese Medicine Practitioners Board and the Chinese Medicine Council

for six years and was the Chairman of the committee on assessment for the Chinese Medicine Degree

Course for Hong Kong and Mainland China.

Ms Manbo Man

Kowloon East Cluster Team

visit ACHS ACHS welcomed a new delegation to its offices in a Leap Year.

On Wednesday 29 February 2012, a delegation from the Kowloon East Cluster, Hong Kong,

learnt firsthand about ACHS services and the Council’s knowledge of the Australian

healthcare industry as it met with staff in Ultimo.

Photo: K F Chung presents Brian Johnston from ACHS with a souvenir of thanks.

New in 2012: Getting Started as a New Quality Manager

Presented by Cathy Balding, ACHS Surveyor. This program is

designed for newly appointed Quality Coordinators and

Managers and those considering moving into a quality

management role. This workshop will assist participants in

defining the key components of their role and understanding where

the role fits within their organisation and the broader quality

context. It will also help them to prepare for the challenges of the

role and to identify key quality and change tools.

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

anager.pdf

NEW INITIATIVE in 2012 ACHS now provides one discounted registration (cost = $120) to a

healthcare consumer on a ‘first come-first serve’ basis, in each full

day ACHS calendar workshop which runs from 1 January 2012

onwards. Click here for details:

Eligibility for Healthcare Consumer Space CLICK HERE to

access.

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

Space.pdf

ONLINE LEARNING Will soon be available to members to support the upcoming

introduction of the National Safety and Quality Health Service

Standards (NSQHSS). The eLearning will outline options for ACHS

members in organisations in which the standards will be

mandatory, and how this will fit with the EQuIP program. eLearning

is easy to access and user friendly. Once available, members will

be able to access from the link on the homepage of the ACHS

website.

eLearning for ACHS Members CLICK HERE to

access.

If you do not have a password, it is easy to go online and apply

via the ACHS website at: http://www.achs.org.au/memberregform

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ACHS Education Update Continued from Page 8

All the workshops are available as customised on-site workshops in your own organisation.

ACHS also offers an on-site consultancy service.

Please do not hesitate to contact us if you would like to find out more about these options.

ACHS Education Phone: +61 2 9281 9955 Email: Educate@achs.org.au

March 2012

UPDATE EQuIP5 and the National Safety and Quality Health Service Standards Several short sessions have been held in February and March

2012 outlining the plans for the upcoming introduction of the

National Safety and Quality Health Service (NSQHS) Standards.

These sessions have outlined options for ACHS members in

organisations in which the Standards will be mandatory, and how

this will fit with the EQuIP program. The sessions have been well

attended and well received. To support the introduction of the

NSQHS Standards, several workshops are now running which

are designed to assist members in covering both the EQuIP5

and the NSQHS Standards. These include:

New in 2012: Introduction to EQuIP and the National Safety and

Quality Health Service Standards

Presented by several experienced ACHS surveyors, this

workshop is designed to give participants understanding of the

EQuIP5 process, cycle, structure and ratings, including the 15

mandatory criteria. The workshop will cover how EQuIP

interfaces with the National Safety and Quality Health Service

Standards. It also allows participants to understand what is

needed in the summary of supportive evidence. The program is

suitable for all staff and volunteers in healthcare organisations,

Quality and Governance team members, health workers,

educators, project workers, consumer representatives, quality

coordinators and Board members.

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

ety_and_Quality_Health_Service_Standards_12A.pdf

New in 2012: Prevention and Control of Healthcare Associated

Infection

Presented by David Gunderson, ACHS Surveyor.

This workshop is designed to give participants an

understanding of the intent and elements of the

new National Safety and Quality Health Service

Standard 3: Preventing and Controlling Healthcare Associated

Infections, together with the intent and additional elements of

EQuIP5 Criteria 1.5.2 / 1.3.2. This workshop is suitable for

anyone who is responsible for the prevention and control of

healthcare associated infection, including: Infection Control

Practitioners, Quality and Safety Managers, Day Procedure

Centre Managers.

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

are_Associated_Infection_12A.pdf

New in 2012: Effective Clinical Handover

Presented by Karen Edwards, ACHS Surveyor.

Designed to give participants the skills to identify

the situations where clinical handover occurs and

understand the impact of handover on patient

safety. The workshop also covers the role of

leaders in improving handover and the relationship between

current evidence and good handover solutions, and the systems

needed to support clinical handover. The workshop is suitable

for Health Administrators, Directors of Allied Health, Directors of

Nursing, Nursing Administrators, Quality and Safety Managers,

Quality Managers, Clinical Managers, Clinical Unit / Department

Heads.

http://www.achs.org.au/pdf/Effective_Clinical_Handover_12A.pdf

Back by popular demand: Medication Safety Mandated (Melbourne)

Several pharmacists present medication safety strategies,

including ‘Medication Safety is Everybody’s Business’. This

workshop is designed to EQuIP you with the tools you need to

improve medication safety in your organisation, and meet both

EQuIP5 and the NSQHS Standards. The program is suitable for

anyone who is responsible for medication safety and quality,

including: unit managers, senior nurses, nurse educators, quality

and safety managers, members of quality, medication safety and

drug committees, clinicians, pharmacists.

http://www.achs.org.au/pdf/Medication_safety_mandated_12A.pdf

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ACHS Education Update The ACHS Education Workshop calendar for January to June 2012 is available on the ACHS website at: http://www.achs.org.au/EduCalendarmonth/