The Australian Council on Healthcare Standards

ACHSNEWS The official newsletter from ACHS to communicate to all member organisations and our stakeholders No. 47 Winter 2014

New Chief Executive for ACHS The Australian Council on Healthcare Standards (ACHS) announced today the appointment of its new Chief Executive, Dr Christine Dennis. “I am delighted to announce that Dr Dr Christine Dennis Christine Dennis has been appointed by the Board of ACHS and will commence on 21 July, 2014,” ACHS President Adjunct Associate Professor Karen Linegar said. “Christine has an extensive background in safety and quality and worked as a senior executive in numerous roles, most recently Acting CEO Northern Territory Health. Christine brings strong strategic leadership skills, knowledge and experience to the position coupled with a high level of engagement across the health sector. Christine will complement the executive staff at ACHS and continue to position ACHS at the forefront of the safety and quality agenda.” A/Prof Linegar said. A/Prof Linegar also expressed “The Board would like to acknowledge the work of Dr Lena Low as Interim CE over the past year for her passion and commitment and know she will continue to provide leadership as she resumes her previous role of ACHS Executive Director Corporate Services & Surveyor Workforce.”

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“Over a challenging transition period Lena and the team positioned the not-for-profit ACHS to successfully adapt to a competitive environment with the introduction of a regulated healthcare accreditation industry with a strong focus on retention of existing members, improved growth, listening to the needs of members and promoting the many benefits of ACHS membership to ensure ACHS retains its premier position as the industry leader as it celebrates its 40th year in 2014.” At her first interview on her role as ACHS CE Christine stated “I am honoured and excited to take the helm of this important and respected organisation. Having worked in the health care industry for 35 years, I have gained extensive experience in senior leadership roles and, in leading safety and quality system development. “My goal is to bolster ACHS’s long-time mission to be the leading provider of products and services for accreditation – importantly accreditation that supports and drives performance excellence in safety and quality programs for a broad range of health service providers and for our consumers. “As CE, I will place a high priority on continuing to increase ACHS’s visibility, participation and leadership in national and international efforts to provide safe and effective care of the highest quality.” Dr Dennis said.

 QI Awards Winners

 ACHS Group Medal 2014


Happy 40th birthday to ACHS! The Board of ACHS recently took the opportunity to share a morning tea with staff to celebrate our 40th birthday together.

with the EQuIPNational and EQuIP programs we have developed, we provide accreditation services our members want and need.

Together with the Board, all staff were delighted to have the opportunity to also congratulate those staff who have worked for the organisation for a number of years, with 12 staff having worked at ACHS for more than a decade, with some even closing in on their third decade of service!

I am particularly proud of the Clinical Indicator Program (CIP) which since its inception in 1989 to facilitate consistent measurement of clinical care for our members, is, we believe, the world’s only dedicated clinical indicator data collection program. The Board thanks the many colleges, societies, associations and clinicians who contribute to keeping the indicator sets relevant and current.

Celebrations, birthday cake and pride in a workplace that employs more than 50 staff was a reminder of the many achievements ACHS has attained over the last four The benefits of the CIP can be immeasurable to our decades and how it has carved out an important niche in the members and it is a service we offer for free – just another example of how as a not-for-profit organisation we are for Australian healthcare industry. the industry – and seek to make returns to the industry that Key to all of our many accomplishments is the range of supports us. Happy Birthday to ACHS – and thank you – programs we have developed and provide to members as a our members, staff, surveyors and stakeholders for your leading healthcare accreditation provider. With our 16 support over the last 40 years – we couldn’t have done it programs we currently offer accreditation to the National without you. Safety and Quality Health Service (NSQHS) Standards, and Adj. Assoc. Professor Karen J Linegar FACN JP, President


ACHS Group Medal 2014 In celebration of its 40th year, ACHS is offering an ACHS Group Medal to be awarded in recognition of the importance of group work in healthcare. The ACHS Group Medal will be awarded to an inspiring group of individuals who have worked together to produce better quality healthcare in Australia. An important aspect in awarding the ACHS Group Medal is that the group’s contribution to improvement should be in a manner consistent with our mission and values.* (see far right) ACHS President Adjunct Associate Professor Karen Linegar said that ACHS is delighted to extend the award to capture the many group projects and undertakings that are performed both locally and internationally which previously have not been targeted to enter. “The Board were keen to include the many group efforts which take place in health care and recognise the strong contribution groups make,” she said.

contemporary excellence in quality and performance that is achieved through group efforts.” “Our surveyors tell us they are acutely aware of the number of high quality and safety projects they come across while on survey and that many would be suitable for higher recognition.” Adjunct Associate Professor Linegar said. The closing date for nominations and completed forms is Thursday 31 July, 2014. Visit our website at to find out more about eligibility and to fill out a nominations enrolment form. The ACHS Group Medal will be presented on Tuesday 9 September at The Quantum Leap conference in Sydney.

ACHS Mission: To be the leading provider of products and services for accreditation that support performance, excellence in safety and quality programs for a broad range of health service providers and consumers. ACHS Values: Accountability, Consumer focus, Excellence, Integrity and Teamwork.

“The ACHS Group Medal 2014 will acknowledge the

Surveyors - we want to hear your story

Every ACHS surveyor has a story to tell, and we would like to hear your story of your experience surveying for ACHS. As we celebrate ACHS' 40th anniversary in 2014, it is an important reminder to prepare for the future - and to celebrate the past with the stories from the people who made ACHS what it is today - our surveyors. We are aiming to create a 'bank' of surveyor stories that tell the ACHS story from the surveyor perspective, located under the surveyor section on the website. This new page is mostly for surveyors (and ACHS staff) and is an opportunity to share your stories and reminisce on some of the more interesting surveys you've been on.

In submitting any stories it is worthwhile remembering that if you are going to use another surveyor's name you may wish to check with them first that they are happy about this. Similarly, you will need to also think about the use of an organisation's name, and whether, if they had a choice, they would like to see it used in the context given. There is no set word limit, but we would suggest 500 800 words may be a suitable length of words to tell your story. Alternatively, as they say, a picture paints a 1,000 words, so photos are welcome too. If you have a story to tell, please contact ACHS Communications Manager Ian McManus at [email protected] or 02 8218 2743.


It’s all about innovation ACHS’s annual Quality Improvement Awards are set to show off members’ achievements and innovations for 2014 It’s on again – ACHS members are invited to celebrate with their peers and bring their achievements and innovations to the fore by entering into the annual ACHS Quality Improvement (QI) awards for 2014. The QI Awards make an important contribution to the Australian healthcare industry, promoting the development of excellence in achieving quality improvement. ACHS Executive Director Customer Services and Development, Ms Linda O’Connor said that in 2013, there were 104 QI Award entries from most Australian jurisdictions and international members including New Zealand, Hong Kong and Sri Lanka. “Last year saw a massive increase of 35% in the number of entries from 2012 and this year is set to be even bigger,” she said. This year entries are open to all Australian and International ACHS members – including all EQuIP programs, ACHS National Safety and Quality Health Service (NSQHS) Standards, and the Clinical Indicator Program. ACHS members are invited to submit entries in the three categories – Clinical Excellence, NonClinical Service Delivery and Healthcare Measurement. In 2013, the Clinical Excellence category was very popular with members making up 54% of all QI award entries.

Why do ACHS members enter into the QI awards?  The awards acknowledge and encourage outstanding quality improvement within the health service  It’s an opportunity to be recognised by peers for the good work of their health organisation  A culture of quality improvement is promoted, through the recognition from other departments of your health service. Applications for the 2014 ACHS QI Awards are now open. The Application Guidelines, Application Form and Report Templates are available on the ACHS website. For more information CLICK HERE or visit the ACHS website at and scroll down to ACHS QI Awards 2014 under the “News” tab. The deadline for electronic submissions by email is Friday 8 August, 2014 @ 5.30pm AEST (+10:00 GMT). Award winners will be announced at the ACHS Annual Dinner on Thursday 27 November, 2014. If you have any questions regarding the 2014 ACHS QI Awards please email [email protected] or phone ACHS on +61 (02) 9281 9955.

Updates: Met with Merit Ratings ACHS members who are currently accredited to either EQuIPNational or the National Safety and Quality Health Service (NSQHS) Standards recently received an Update on a change to the existing rating process. As from 1 July, 2014 organisations will no longer be able to self-rate at the ‘Met with Merit’ (MM) level. The MM rating button will no longer be available at the organisation level in the Assessment Recording Tool (ART). However, organisations can still enter evidence in the self-assessment to assist the survey team to determine whether an MM rating is appropriate.

ACHS Interim Chief Executive Dr Lena Low said this change in process will not impact on the survey team awarding MM ratings where appropriate. “Met with Merit ratings will continue to be awarded when evidence demonstrating that the organisation is at the MM level is provided to the survey team,” Dr Low said. This alteration to process should be noted in the relevant pages of the Standards books for both programs, and in any other documentation prepared by organisations to assist in their Pre-Survey Assessment preparation. Further inquires may be directed to your Customer Services Manager on +61 9281 9955. ACHSNEWS 4

Tell us what you think! Attend a State Advisory Committees to have your voice heard State Advisory Committee (SAC) meetings are a valuable forum for members to engage with ACHS on local, political and a range of stakeholder issues. First established in 2001, the SACs were introduced to ensure a stronger engagement between ACHS members and stakeholders in each State with ACHS and to ensure it occurred on a regular basis. Over the years they have proved to be an influential channel of communication and are a vital aspect to how ACHS aims to conduct business throughout each

state. We need to hear what our members think at the local level. We encourage all CEOs or Senior staff with good knowledge of ACHS to lead and participate by attending their local SAC meetings. If you are interested in ensuring ACHS delivers tangible results to the way it interacts and informs its members, please contact Nikki Humphreys, Project OfficerBusiness Support Services via [email protected] or 02 8218 2745 by 30 June. The SAC meetings are held in each state twice a year.

Remote surveying in the Torres Straits Peninsula of Cape York.

Torres Strait and Northern Peninsula Area Health Service District is a remote health service encompassing Torres Strait Islands, Thursday Island and Bamega, a town situated on the Northern Peninsula of Cape York. Culturally Torres Strait—Northern Peninsula Hospital and Health Service HHS serves Torres Strait Islanders and Aboriginal people who make up a large part of the population. Thursday Island has the largest population in Torres Strait followed by Bamega on the Northern

It was an adventure for the survey team to get to Thursday Island, several flights, a bus and a ferry eventually saw us arrive. The Health Service District is well organised and supported by highly skilled clinical professionals who manage a large number of emergencies from the 21 Island clinics and on Thursday Island and Bamega. Helicopters and fixed wing aircraft are used for medical evacuations. We were struck by the beauty of Torres Strait. It’s turquoise waters, hiding dangers of course – stingers, sharks, box jelly fish and crocs! So alas, no swimming!

ACHS Surveyors get to meet Torres Strait health workers.

Vale Judith Cornell Former ACHS Board member and long-time ACHS supporter, Ms Judith Cornell, AM passed away in April, aged 73.

ACHS employee, Judith was known for her strong advocacy of nursing and her calm and reassuring manner.

As an ACHS Councillor and Board member Judith served the Council as a representative of the College of Nursing. Described as “a great lady and a tireless worker for nurses” by one longstanding

Tributes to Judith have been made by the NSW Operating Theatre Association as well as the Victorian Perioperative Nurses Group. The ACHS remembers Judith fondly and sends their condolences to her family. ACHSNEWS 5

ACHS Education Update Education events for May to December 2014 are now available on the ACHS website at: New in 2014: Webinars: ACHS Education is pleased to announce the expansion of the 2014 webinar series. These webinars are designed to give wider access to ACHS education, presented by experienced ACHS surveyors. Each session is scheduled for an hour, and all you need to join is a computer with broadband access and a phone. Hot webinar topics for 2014 include: Mental Health: NSQHS Standard 9 Clinical Deterioration Wednesday 2 July 2014 @ 1400 (AEST) For further details and registration options click here. NSQHS Standard 8 Preventing and Managing Pressure Injuries Friday 11 July 2014 @ 1400 (AEST) For further details and registration options click here. NSQHS Standard 5 Patient ID and Procedure Matching Thursday 17 July 2014 @ 1400 (AEST) For further details and registration options click here. Details of these and many more webinar topics are available at: New workshop topics in 2014 include: NSQHS Standards: Audit, Evidence and Survey Preparation Corporate Systems and Safety: EQuIPNational Standard 15 Effective Risk Management to Support Quality Outcomes Achieving Accreditation with the ACHS National Safety and Quality Health Service (NSQHS) Standards Program Achieving Accreditation with the ACHS EQuIPNational Program ACHS eLearning is also available for ACHS members at:

All ACHS workshops and webinars are also available as customised ‘on-site’ events 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: 02 9281 9955 email: [email protected] ACHSNEWS 6

Goulburn Valley Health goes for the Quadrella Goulburn Valley Health (GVH) in Sheparton, Victoria certainly likes a challenge when it comes to accreditation.

them as a result of combining the group effort to achieve goals in a set time period.

GVH is the first ACHS member to undertake four surveys simultaneously: the National Safety and Quality Health Service (NSQHS), Standards, the National Standards for Mental Health Services (NSMHS), the Community Care Common Standards (HACC) as well as the Victorian Department of Human Services Standards.

“While there may have been a bit of work to bring it all into a common cycle, it shouldn’t be a problem to replicate this in the future.” Dale said. “I was only appointed to the role seven months prior to survey so it was important to have a clear, solid plan of how to approach this. While

When GVH Chief Executive Mr Dale Fraser was asked why his organisation underwent four accreditations simultaneously, the answer was simple “Why not?”

Director of Quality & Risk, Ms Annette Penney, the National Safety and Quality Health Service (NSQHS) Standards were “easy to follow”. “Of particular help was a consultancy review we did with ACHS lead surveyor Ms Kaye Hogan AM in 2013, which was immensely useful,” Annette said. “This gave us enormous confidence in what we were undertaking, as Kaye was very strong in giving us both positive and negative feedback, to guide us during the survey preparation phase and the survey week. More than 150 staff across all hospital and community sites provided strong support for the four day survey week, as well as support received from the Board and the local community.

“The decision represented the organisation’s culture and values Annette Penney, Director Quality & Risk, Dale Dale concludes “We took a of quality and safety systems that Fraser, CEO, Elizabeth Smith, Clinical Coordinator commonsense approach to the should be standard to every Infection Control, Leasa Rabl, Transfusion Nurse & entire task and decided not to ‘boil Project Lead NSQHS Standard 7. practice. We don’t fear the the ocean’ – we had a good, accreditation cycle, it is a comprehensive plan, and one of there were some doubts you just validation of our good work,” he said. our internal goals was to have our have to work through the business of preparation completed by December “We see our role of providing quality getting the day-to-day stuff done.” he 2013 – allowing three months to fineand safety as our number one issue said. tune and fill in the gaps.” in providing health services, we don’t “I was not sure how the organisation just see it as an additional chore.” When asked how they all feel, would respond and I was blown away Annette said “We are in post One of the benefits of conducting all with the commitment of staff to accreditation bliss – and our Chief surveys at once was the synergies achieve a common goal.” Medical Officer described us as created; communications plans, Hospital activity levels actually rose exhausted but exhilarated! We are documentation, and resource during the survey period, and all very happy,” she said. allocation etc. All had logical steps to according to Dale and his colleague

ACHS Member Forum NSW: “Lessons Learned” Friday 22 August 2014 The NSW session will be held in the morning on Friday 22 August 2014 at Liverpool, NSW. ACHS has invited speakers from organisations which have undergone an EQuIPNational accreditation survey since the major changes in January 2013. The forum will allow members to learn and share in lessons learned through the process. The session is suitable for anyone who is working in an ACHS EQuIPNational member organisation and preparing for survey in the next 12-18 months. This session is FREE OF CHARGE for ACHS members, you must register to attend. The maximum group size is 100 people. For more details and to register, go to:


Pride in ACHSI Accreditation Certificate Presentations The accreditation certificate presentation of the organisation was held on 8 May, 2014 and was attended by the Minister of Health, Dr Subramaniam Sathasivam along with a number of local dignitaries. ACHSI was represented by ACHS and ACHSI Board Member Dr David Lord, and Dr Desmond Yen, Executive Director – International Business. Dr Lord said that the experience of attending the certificate presentation ceremony was “quite moving, and it was obvious to see the great pride they had in their achievement”.

ACHS President Adj. Assoc. Prof Karen Linegar presents the accreditation certificate to Dr Walton Li, Medical Superintendent at the Hong Kong Sanatorium and Hospital.

In March 2014, the ACHS and ACHSI President Adj. Assoc. Prof Karen Linegar visited Hong Kong to officiate at the accreditation certificate presentations of the Prince of Wales Hospital (4 March 2014), North District Hospital (4 March 2014), Kowloon Hospital (5 March 2014) and Hong Kong Sanatorium and Hospital (6 March 2014). It was a joyous occasion and a time to celebrate for each organisation. Whilst it was the first time for the Prince of Wales Hospital, North District Hospital and Kowloon Hospital to receive ACHS accreditation, it was the second ACHS accreditation award for the Hong Kong Sanatorium and Hospital, having completed their first Evaluation and Quality Improvement Program (EQuIP) membership cycle in December 2013.

The Al-Ahli Hospital in Doha, Qatar, also made history as it became the first ACHSI accredited organisation in the State of Qatar. In April 2014, accreditation certificate presentations were held for the Md Bin Khalifa Bin Sulman Al Khalifa Cardiac Centre in Manama, Kingdom of Bahrain and the Abdul Jameel Latif Hospital in Jeddah, Kingdom of Saudi Arabia. Both events were attended by Dr Yen on behalf of ACHSI. The Treasurer of the Board of ACHSI, Mr John Smith PSM officiated at the accreditation certificate presentations for the 2,000 bed United Christian Hospital, as well as Pok Oi Hospital in the New Territory and Evangel Hospital in Hong Kong which has 62 beds. Mr Smith said “You couldn’t imagine the appreciation demonstrated across the three hospitals and the importance of their achievement, ranging from the United Christian Hospital a major (continued on page 9)

Four organisations, namely Evangel Hospital and United Christian Hospital in Hong Kong, Sunway Medical Centre Sdn Bhd in Malaysia and Al-Ahli Hospital in Qatar held their first Organisation-Wide Survey (OWS) in the first quarter of 2014. All four organisations successfully achieved full accreditation status for a period of four years and it was a proud moment for both management and staff. The Sunway Medical Centre Sdn Bhd located in Kuala Lumpur, Malaysia, became the first ACHSI accredited hospital in the South East Asia region.

R to L: Dr Joseph Lui, Cluster CE of Kowloon East Cluster and CEO of United Christian Hospital, Mr John Smith PSM Vice President ACHS Board and Treasurer ACHSI Board, Mr John Li, Chairman, Hospital Governing Committee.


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healthcare organisation, to the Evangel Hospital, whilst small in bed number lacked nothing in appreciation and gratitude. The presentation ceremony obviously meant a great deal to them, and I was honoured to attend on behalf of ACHSI.”

“It is easy to underestimate the importance the introduction of accreditation has had in this country in recent years, and ACHSI has had a large role to play in this, and we trust, will continue to be an important accreditation provider and further develop its strong contribution to this cause in the future,” Mr Smith said.

“I could appreciate from a very positive view what accreditation has achieved in this country and the fact that it has come such a long way since I first started attending certificate presentations. It is obvious to see how committed they are and realise the importance of undertaking an accreditation program, both in their public and private sectors.” Mr Smith said that he was also fortunate to be involved in attending the OWS of the St Paul’s Hospital in Hong Kong. “The ACHSI survey team displayed efficiency in reviewing the recommendations they had given, and were doing this prior to the pre-summation meeting to ensure the health service would be happy.”

L to R: Dr Desmond Yen (ACHSI Executive Director— International Business), Madam Najia Jameel (Chairperson of the Board/Owner), Mr Alaa Hamza (Vice Chairman of the Board/Owner), Mr Ehab Al-Samannody (Owner), Dr Youssef Abdelrahman (Chief Executive Officer).

Performance and Outcomes Services The Performance and Outcomes Service is pleased to release two revised manuals for the Clinical Indicator Program. Infection Control and Gynaecology have been completely updated to reflect the continuing improvements within their respective clinical specialties. All Clinical Indicators are developed by specialists in their field. Gynaecology will focus on

Infection Control will focus on

1. Blood transfusion

1. Infection surveillance

2. Injury to a major viscus

2. Occupational exposures to blood and/or body fluids

3. Laparoscopic management of an ectopic pregnancy 4. Thromboprophylaxis for major gynaecological surgery 5. Mesh repair 6. Menorrhagia

3. Haemodialysis—associated bloodstream infection surveillance 4. Vancomycin Resistant Enterococci (VRE) 5. Staff immunisation

The President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists stated "The College welcomes the new ACHS Clinical Indicators for Gynaecology. Clinical indicators need to adapt to changing patterns of practice and the new descriptors combine utility of collection with developing benchmarks of contemporary gynaecological practice."

6. Surgical antibiotic prophylaxis (SAP) The Australasian College for Infection Prevention and Control who assisted in its development and endorsed the manual congratulated the Working Party stating "Well done, a good reflection of current surveillance activities that are needed. No duplication, nice and 'clean', welcome reduced numbers of CIs.”

These Clinical Indicators are for collection starting 1st July 2014. Manuals can be downloaded from the ACHS website, ACHSNEWS 9