2015/2016 - achs · profile publications and presentations 42 glossary of terms inside back cover...

The Australian Council on Healthcare Standards

AnnualReport 2015/2016

Errata

The Australian Council on Healthcare Standards 2015 – 2016

The following are errata are included for this year’s ACHS Annual Report:

Pg 22. The heading “Auditor’s Independence Declaration” in the box should be above the heading ‘Members’ Guarantee’ in the right hand column.

The heading “Auditor” in the same box should be deleted.

The Pitcher Partners letterhead, as below:

Level 22 MLC Centre Postal Address:

19 Martin Place GPO Box 1615

Sydney NSW 2000 Sydney NSW 2001

Australia Australia

Tel: +61 2 9221 2099 www.pitcher.com.au

Fax: +61 2 9223 1762 [email protected]

Pitcher Partners is an association of independent firms

Melbourne | Sydney | Perth | Adelaide | Brisbane| Newcastle

a) Should be included on page 23 – as part of the Auditor’s Independence Declaration to the Directors of the Australian Council on Healthcare Standards.

b) The letterhead should also be included on page 39 as part of the Independent Auditor’s Report.

September 2016

© The Australian Council on Healthcare Standards

Apart from any use as permitted under the Copyright Act 1968,no part may be reproduced by any process without prior writtenpermission from the Australian Council on Healthcare Standards.

The Australian Council on Healthcare Standards

Annual Report 2015 - 2016

ISBN: 978-1-921806-75-9 (Paperback)

ISBN: 978-1-921806-76-6 (E-book)

This Report is available in PDF format via the

ACHS website (under the Publications and

Resources menu option) from the homepage:

www.achs.org.au

To order a printed copy, please contact

Communications at:

The Australian Council on

Healthcare Standards

5 Macarthur Street

Ultimo NSW Australia 2007

T: 61 2 9281 9955

F: 61 2 9211 9633

E: [email protected]

www.achs.org.au

Common acronyms included in this Report

ACHS – The Australian Council on Healthcare Standards

ACHSI – ACHS International

ACSQHC – The Australian Commission on Safety and Quality in Health Care

AHHA – Australian Healthcare and Hospitals Association

ACIR – Australasian Clinical Indicator Report

AMA – Australian Medical Association

APHA – Australian Private Hospitals Association

ART – Assessment Recording Tool

EAT – Electronic Assessment Tool

EQuIP – Evaluation and Quality Improvement Program

EQuIPNational – The EQuIPNational Program

EQuIP5 – the 5th edition of the ACHS Evaluation and Quality Improvement Program

IAP – International Accreditation Programme

ISQua – The International Society for Quality in Health Care

NSQHSS – National Safety and Quality Health Service Standards

OWS – Organisation-Wide Survey

PIRT – Performance Indicator Reporting Tool

QI – Quality Improvement

SAC – State Advisory Committee

About ACHSVision, Mission and Values 1

Our IdentityA Corporate Overview 2

Our PerformancePresident’s and Chief Executive’s Report 4 Highlights of the year 6

Our OrganisationOrganisational Chart 8Our Executive Team 9

Recognising AchievementACHS Medal and ACHS Quality 10Improvement Awards 11

Division ReportsACHS International 12Customer Services and Development 14The Improvement Academy 15Corporate and Surveyor Workforce Unit 17

OverviewACHS Council Members 20

Director’s ReportDirector’s Report 21Auditor's independence declaration 23ACHS Board of Directors 24Financial Statements 26Notes to the Financial Statements 28Director’s Declaration 38Independent Auditor’s Report 39

ProfilePublications and Presentations 42

Glossary of Terms inside back cover

Contents

InspIrIng

excellence In healthcare

VisionOur vision statement is focused on our core business. We aspire to excellencein all aspects of healthcare and want to inspire others to strive for excellence.

ValuesValues are the essential foundation of our organisation. They describe what is

important to us and frame how we work.

Working Together

We work with our stakeholders to achieve goals

Accountability

We take responsibility for our performance

Commitment

We are committed to fostering an innovative and outcomes driven culture

Adaptability

Our flexibility enables us to adapt and embrace change

Responsiveness

We are quick to respond to the needs of our members and the ever-changing

health landscape

Excellence

We strive for excellence in everything we do

Mission To strengthen safe, quality healthcare bycontinuously advancing standards andeducation nationally and internationally.

ACHS ANNUAL REPORT 2015-2016 1

The Council

The Council

The Australian Council on Healthcare Standards(ACHS) has built on its many wins in recent yearsto ensure its continuity through the delivery ofservices, growing membership and a strongfinancial base.

The ACHS is an independent, not-for-profitorganisation dedicated to improving quality inhealth care as an approved provider ofaccreditation to a range of Australian andoverseas healthcare providers.

With a Council of 24 member organisations,drawn from peak bodies in the health industry,as well as representatives from governments,consumers and life members, ACHS is governedby a Board of 11 Directors.

ACHS is recognised by the International Societyfor Quality in Health Care (ISQua) for itsorganisational framework, its accreditationprograms and surveyor training.

As an organisation, ACHS has been a member ofISQua’s International Accreditation Programme(IAP) from 1999 when ISQua was launched, andis currently accredited until 2018.

ACHS Surveyors

Our surveyors continue to provide a critical

service in the surveying of our member’s

activities and facilities.

We rely on their assessment skills and evaluation

techniques and have invested strongly in the

ongoing education of surveyors throughout the

last financial year.

Critical to this is ensuring they are keeping up

with a range of changes in contemporary health

service delivery and that the training and support

are delivered to meet the needs of surveyors.

The majority of our surveyors continue to work

full-time in health as professional doctors,

nurses, consumers, medical administrators and

allied health professionals while contributing

to the ACHS mission on a volunteer basis.

Each year a number of our surveyors choose

to retire and we wish to acknowledge the length

and level of service provided by the following

surveyors (below). We thank them for their strong

contribution to the Australian healthcare industry,

and their loyalty and commitment to ACHS.

2 ACHS ANNUAL REPORT 2015-2016

A Corporate OverviewOUR IDENTITY

Professor David Barton

Mr Alan Lilly

Mr Bernard McNair

Ms Philippa Both

Ms Tina De Zen

Mr Peter Abraham

Dr Stephen Golding

Ms Clare Douglas

Mr John Wigan

Ms Sue Gilham

Name Type Speciality

VolunteerVolunteer

HonorariumVolunteer

Honorarium-

VolunteerVolunteer

Honorarium-

PsychiatristNurseNurse

-------

State Joined

Vic-

NSWSASA--

QLDVic-

2013200219952013200920072011200319951999

Total Surveys Yrs as a Surveyor

225454

11155

14135127

1.514212695

13217

Funding

ACHS maintains its status as an independent,

not-for-profit organisation, with the majority of

funding derived from membership fees.

Funding is also received from tenders and

projects undertaken on behalf of government

organisations, and other industry bodies as

well as from our strong educational offerings.

Retired ACHS SurveyorsJuly 2015 – June 2016


Partnerships

ACHS works in partnership with a range of

industry organisations and has wide

representation on our Council which also

includes some Australian States and Territories.

All of our partnerships are critical to our success,

whether it be in the areas of program

development, member surveying, the enormous

ongoing contribution from surveyors or the input

from the industry into our Clinical Indicators.

Once again we have not only relied on, but

thrived on the many collaborative contributions

from member organisations, stakeholders, and

new partners in projects that have assisted us

improve our products and services and services

delivery.

Corporate and Strategic Plan

Following the Corporate and Strategic planning dayheld in February 2015, the Board and Executive staffhave adopted the framework the Plan provides. Itwill assist the organisation in determining futureplans as well as guiding key decisions.

ACHS is confident that the Plan provides a clearunderstanding of what our expectations are as a business going into the future.

Our Strategic Goals for the future are:

Strategic Goals

1. Expand our business reach

Build our business reach by strategically seeking out new opportunities that foster national and

international recognition

2. Grow our membership

Grow, maintain and sustain our national and international membership through the continued delivery

of outstanding service and products that directly meet our member’s needs

3. Build strategic alliances

Create strong partnerships and alliances that support collaboration and engagement and uphold,

develop and build on our vision

4. Inspire organisational performance

Inspire our organisation to always be its absolute best by putting our members at the centre, ensuring

our workplace celebrates and fosters the creative, innovative capacity of our workforce and members

and by providing strong leadership which creates our values-based organisational environment

5. Ensure sustainability

Deliver an efficient and financially sustainable business model underpinned by high standards of

accountability and quality assurance

6. Share our knowledge

Empower our members and stakeholders to deliver quality healthcare by harnessing our data and

actively seeking new opportunities to share information and knowledge that will support the delivery

of safe, quality healthcare

There were a number of keyachievements in 2015 - 2016across the business that we aredelighted to share with you.

Governance

Following the re-election of office-bearers at the

ACHS Annual General meeting on Thursday, 26

November 2015, the composition of the Board

in 2015 - 16 changed with the following

appointments:

z Mr John Smith PSM elected as President,

z Prof Len Notaras AM elected as Vice-

President, and

z Mr Stephen Walker was re-elected Treasurer.

The Board continued to oversee the

implementation of a range of new initiatives

conducted by the CEO and ACHS Executive.

These initiatives flowed on from the Corporate

Strategic Planning Day held in February 2015

and aim to consolidate ACHS’s position as the

leading healthcare accreditation provider in

Australia, with international members.

Key to ACHS’s ongoing development is the

building of a range of strategic alliances and

networks with key bodies, jurisdictions, private

health funders, public and private sector

stakeholders nationally and internationally.

Strong governance and leadership is necessary

for the ACHS to maintain its’ clear direction

as identified in its Corporate and Strategic

Plan. Through regular meetings, the Board

provides counsel and assists in strategic

direction decisions to assist ACHS maintain

its pre-eminent industry position. Areas of

focus include ongoing business development,

oversight of financials and the surveyor

workforce, membership retention as well

as ACHS staff.

In 2015 - 2016, ACHS succeeded in its goal

of maintaining its market dominance as the

leading provider of products and services for

accreditation.

Strategic Alliances

ACHS places a strong emphasis on being a

pivotal part of the healthcare accreditation

industry through its alliances.

z Launch of the new ACHS Improvement

Academy provides extensive educational

learnings to the industry with an immediate

high uptake of courses offered.

z High level delegation visits to jurisdictions,

key members, private and public

stakeholders, in Australia and overseas.

z Working with new partners with an interest

in extending healthcare accreditation into

other areas of Health.

z Strong feedback from members and the

industry that ACHS’s responsiveness to

feedback and willingness to listen and adapt

where there is a mutual benefit.

New Initiatives

Strategic projects undertaken included:

z Short Notice Surveys – a pilot project to

support an objective of shifting

organisational culture from an ‘event’ mindset,

to accreditation as an ongoing process or

constantly ready.

z A Single Approach to Achieving Dual

Accreditation. ACHS is working

collaboratively with the Australian Aged Care

Quality Agency (AACQA) to deliver a single

accreditation survey against two set of

standards concurrently.

z An ongoing review of our Constitution has

allowed us to consult with Board and Council

members for feedback on the future make-up

of the Council.


President’s and Chief Executive’s ReportOUR PERFORMANCE

DUQuA

Following on from a large international study,

a new project focuses on Deepening our

Understanding of Quality In Australia (DUQuA),

modified for Australian circumstances. The

objective is to assess relationships between

quality management and patient outcomes in

Australian hospitals and the study is in 70

hospitals across six Australian states and

two territories.

Acknowledgements

There are many people, from various corners

of the health industry who have assisted in

making this last financial year such a

memorable one for ACHS in terms of new

advances, exciting projects and above all a

willingness to test established practices and

allow change to flourish.

With our members’ interests at the forefront of

everything we do, we are constantly looking at

new ways to ensure the accreditation experience

is both meaningful, and the positive changes it

brings are lasting.

As a not-for-profit organisation we are indebted

to both our members and surveyors for the

support they show us, and the feedback they

provide which assist us to improve.

To the members of the Board and Council,

as well as the organisations that nominate

representatives to Council, our State Advisory

Committee members who meet with us bi-

annually, we are grateful for your valuable

input and support.

Every year we thank our staff for their ongoing

commitment and this year is no exception. So

much has been collectively achieved over the

last 12 months that our sincere thanks are

placed on the record for their efforts and

success in growing the business.

Congratulations to all staff for a resoundingly

successful year of achievements.

We commend this report to you.

Mr John Smith PSM

President

Board of Directors

Dr Christine Dennis

Chief Executive Officer


Key highlights in the past year were:

z To commemorate its 40 year anniversary, celebrated in 2014, ACHS publishes the 40 Year historical timeline created to mark the important occasion. The 20 page document “A timeline through the ages – 40 Years of ACHS History” covers the range of events, achievements, key personnel as well as products and programs developed over the last four decades. Published August 2015

z The ACHS International Medal 2015 is awarded to Dr Mohammed Sahadulla from Kerala, India in recognition of his ‘outstanding contribution at an international level to improving quality and safety in health services’.

z The Australasian Clinical Indicator Report

2007 – 2014 (16th edition) was launched in Melbourne at the ACHS / ACHSM Joint Congress on 28-30 October 2015. The report is Australia’s most statistically-detailed, national report on the performance of 807 healthcare organisations (HCOs) over an eight year period.

z Hunter New England Local Health District, Metro South Hospital and Health Service – Logan Hospital, and The Children’s Hospital at Westmead were announced as winners of the 18th Annual ACHS Quality Improvement Awards at the Joint Congress in Melbourne.

z The ACHS Board elects its new President, Mr John Smith PSM, and new Vice President, Prof Len Notaras AM. Mr Stephen Walker is also re-elected to his position of Treasurer at the Annual General Meeting, held in Sydney on 26 November.

z ACHS undertakes a review of its Constitution. A draft Constitution is submitted to the ACHS Council meeting in June 2016 for consultation, with ratification due at a later meeting.

z ACHS is to join forces again with the ACHSM to present a joint congress “The health

leadership challenge: making things happen”, to be held in Brisbane in October 2016. More than 430 delegates attended the 2015 Congress.

z The Performance and Outcomes Service releases five revised manuals for the Clinical Indicator Program: Mental Health, Pathology, Intensive Care Emergency Medicine and Hospital in the Home in the first half of 2016.

z Clinical Indicator sets are regularly updated to support clinicians in providing evidence-based

patient care, and flag areas in need of quality improvement initiatives.

z ACHS entered into a partnership with the Centre for Healthcare Resilience and Implementation Science (CHRIS), the Australian Institute of Health Innovation and Macquarie University, to undertake the DUQuA (Deepening our Understanding of Quality in Australia) research project, in order to assess relationships between quality management and patient outcomes in hospitals across Australia.

z In the first half of 2016, ACHS worked with Queensland Health to undertake the Patient Safety Audit. The audit was conducted against the safety and quality functions specified in the Hospital and Health Boards Act 2011 and the Hospital and Health Boards Regulation 2012.

z The ACHS works collaboratively with the Aged Care Quality Agency to deliver a single accreditation survey against two sets of standards concurrently.

z ACHS pilots Short Notice Surveys in two large regional health services in Queensland. The intent of this approach is to support an objective of shifting organisational culture from an ‘event’ mindset, to accreditation as an ongoing process or constantly ready.

z The new ACHS Improvement Academy is launched in Melbourne on 3 March 2016. The Academy offers practical training opportunities that align with the strategies and missions of organisations. Programs are tailored to the roles and needs of different staffing levels and will employ mixed modes of learning, including opportunities to participate in large scale collaborative improvement projects. Ms Bernie Harrison is appointed as the inaugural Director of the ACHS Improvement Academy.

z The initial response to both Improvement Academy lead programs (Quality Improvement Lead and Patient Safety Lead) was very strong, with interest from around Australia.

z ACHS has been awarded its third substantial contract by the Hong Kong Hospital Authority (HA) to assist implementing its hospital accreditation program.

z Implementation of the new EQuIP6 is scheduled from 1 July 2016. With the upcoming implementation of the new standards, the ACHS IT and Business Support Services teams upgrade the Electronic Assessment Tool (EAT) to version 6 (EAT6).


HIGHTLIGHTS

1. Dr Christine Dennis ACHS CEO speaks at the 2015 ACHS – ACHS Joint Congress, in Melbourne.

2. Dr Dennis with fellow speakers at the congress – Neale Fong from WA, Eric De Roodenbeke, Director General, International Hospital Federation, Assoc Prof Munjed Al Muderis and Professor Chris Ham, CEO, The King’s Fund.

3. Certificate presentation at Hesse Rural Health Service.

4. Signing of Memorandum of understanding with the Korean Institute for Healthcare Accreditation (KOIHA)

5. Enoggera Health Service was presented with its Accreditation Certificate on 28 August, 2015.

6. Ms Bernadette Loughnane and Ms Rosemary Snodgrass

7. The launch of the ACHS Improvement Academy with Mr John Smith PSM, Dr Dennis, Mr John Wakefield, Ms Bernie Harrison and Mr Michael Roff.

1. 2.

3. 4.

5.

7.

6.



International BusinessExecutive Director

International Business

z Manager, InternationalBusiness Services

z Administrative Officer

Executive Officer Board ofDirectors / Communications

Assistant

Chief Executive

CommunicationsManager

Council

Executive Assistant

Accreditation AdministrationServices

z Managerz Senior Admin Assistantz Admin Assistants z Word Processing Officersz Clerical Assistantz Receptionistz Trainees

Education AdministrationServices

z Supervisorz Admin Assistants

Business Support Services

z Business Managerz Project Officers

Surveyor Workforcez ACHS & ACHSI Surveyorz Surveyor Resource Coordinatorz Surveyor Bookings Administratorz Surveyor Bookings Assistant

Financial Services/Human Resources

Managementz Managerz Assistant Accountantsz Accounts Officer

IT Servicesz IT Managerz Senior Analyst Programmerz Network Engineer z IT Support Analystz IT Support Officer

Corporate & SurveyorWorkforce

Executive Director

ACHS InternationalBoard of Directors

Customer Services& Development

Executive Director

Customer Servicesz Team Managerz Customer Services Managers

Research Support

Performance & OutcomesService

z Managerz Project Officerz Data Analyst

Standards & ProductDevelopment

z Managerz Project Officers

Organisational Chart

OUR ORGANISATION

ACHSBoard of Directors

Director Improvement Academy

Ms Linda O’ConnorBAppSc, Grad Dip (Med Ultrasound), MA (Org Com), AMS,CPHQ, GAICD

Executive Director – Customer Services and Development

Ms O’Connor is responsible for standards and productdevelopment, the ACHS Clinical Indicator program,customer services support and contract management.Ms O’Connor has worked in healthcare for 25 years, isa Board Certified Professional in Healthcare Quality,and works closely with the Australian Commission onSafety and Quality in Healthcare (ACSQHC).

Ms O’Connor has both national and internationalexperience. In the senior management team of HarvardMedical International, she worked between Boston andDubai to establish the Center for Healthcare Planningand Quality, Dubai Healthcare City.

Ms O’Connor has collaborated on projects with theJoint Commission, ISO and Accreditation Canada. She is a qualified ultrasonographer, and was a memberof the Commonwealth BreastScreen AustraliaAccreditation Review Committee. She holds a Master’sDegree in Organisational Communication, is a graduateof the Australian Institute of Company Directors (AICD),and is a surveyor for ISQua.

Dr Desmond YenB Com, MBA, DBA, FAICD

Executive Director – International Business

Dr Yen joined ACHS in July 1995. His current portfolioprimarily covers all aspects of international business.Prior to this role, he was responsible for CorporateServices. His multiple responsibilities have includedstrategy, policies and systems development, finance,risk management, IT and support services. He isexperienced in all aspects of healthcare accreditationrequiring member interaction.

Dr Yen’s broad depth of experience, mainly within largemulti-national organisations, covers a mix of local andinternational strategic management, finance, and ITroles. Dr Yen is a surveyor for ISQua and has surveyedfour international accreditation agencies.

Dr Yen holds graduate qualifications in commerce, both a Master’s Degree and a Doctorate in BusinessAdministration, and is a Fellow of the AICD.


Dr Christine DennisBA Nursing, MHSM, DBA, Adjunct Associate Professor, FacultyHealth Sciences, Flinders University, SA, FCHSM, FAAQHC

Chief Executive Officer

Christine has worked in the health industry since 1976,having commenced in nursing and progressed toleadership positions in nursing and then broader healthservice management. Recent positions have includedCEO Southern Adelaide Local Health Network; ChiefOperating Officer, Top End Health Service; and, actingCE Northern Territory Health.

Christine’s career has included many and variedpositions both within Health Services and in HealthDepartments. Christine also worked as Manager of the State Coroner’s Office in SA and, has providededucation and training consultancies to the Ministry ofHealth, Singapore. Areas of expertise include strategicand operational planning, quality and safety systemsand, organisational change.

Her doctoral theses was titled ‘The Problematic Natureof Strategic Planning in Public Health Services; theperspectives of the health planner’.

Christine was appointed to the role of CEO ACHS inJuly 2014.

Dr Lena LowPhD, MBA, Grad Dip Mgmt, FAICD, FAAQHC, AFACHSM

Executive Director - Corporate and Surveyor Workforce

Dr Low has been with ACHS since 1995 with involvementin strategic development and operationalising healthcareaccreditation systems. She currently has responsibility for financial management, Information Technology,Human Resources, surveyor workforce logistics andperformance management with previous experiences as Chief Executive Officer and Company Secretary.

Dr Low has an MBA, Diploma Australian Institute ofCompany Directors and Doctor of Philosophy. Herdoctorate specialisation with the UNSW Faculty ofMedicine was in public health and community medicine.

Dr Low sits on the ISQua Accreditation Council, is anISQua surveyor and a member of the "ISQua Experts"panel. She is also a visiting Fellow at MacquarieUniversity and Board member of one of Sydney’sleading private golf clubs.

Dr Desmond YenMs Linda O’ConnorDr Lena LowDr Christine Dennis

Our Executive Team

OUR ORGANISATION


to principles of clinical quality and move beyondsimple “box checking” to ensure better patientand provider safety.

Returning to Trivandrum in 2002, he establishedhigh quality care at a cost-effective price byopening KIMS Hospital, the flagship facility ofthe KIMS group of hospitals. KIMS Group nowconsists of six hospitals in India, three in theMiddle East, and five polyclinics throughout theGulf region. In 2006 KIMS Trivandrum wasaccredited by ACHSI as well as by the Indianaccreditation agency, National AccreditationBoard for Hospitals and Healthcare Providers,and holds the honour of being the first Indianhospital to receive both national andinternational accreditation.

Dr Sahadulla’s philosophy about quality is at the core of all KIMS decisions. He has been aquality pioneer throughout India with a focus ongood clinical practices to ensure patient safety.He recognises that the hospital is part of thecommunity and promotes this hospital as a good partner to the patients it serves. He hasalso prioritised access to care, championing the development of Indian emergency medicine, an under-developed specialty. He regards theEmergency Department as the hospital’s“welcome door” and ensures that clinical staffproperly triage and treat patients withininternational guidelines, initiating a US-styleresidency program with academic support from a Level 1 trauma centre. All KIMS ED residentsare required to work in the community andactively teach CPR and basic first aid to anyorganisation that asks.

To ensure patient safety, all KIMS employeesmust attend mandatory orientation activities and clinicians must present and prove theircredentials. Regular audits are performed onclinical outcomes and are published to staff.KIMS also publishes two internal academicjournals to encourage academic and patientsafety activities.

Dr Sahadulla has been a strong force for changein India, championing the concept of quality inevery aspect of hospital life, making KIMS a rolemodel. He encourages KIMS staff to exceed theminimum standards and treat patients as weourselves would wish to be treated.

ACHS Medal and ACHS Quality Improvements AwardRECOGNISING ACHIEVEMENT

ACHS Medal Winner 2015 Dr Sahadulla

ACHS International Medal 2015 Citation

The following citation was

given on 29 October, 2015.

ACHS International Medal Citation 2015 –

Winner – Dr Mohammed Sahadulla

Dr Mohammed I Sahadulla, Chairman and MD

of the Kerala Institute of Medical Sciences (KIMS

Group), has been a leader in establishing and

developing hospital quality standards in India.

Initially trained in Internal Medicine at Trivandrum

Government College, India, Dr Sahadulla

migrated to the UK during the 1970s to further

his clinical training. While there, Dr Sahadulla

also studied and obtained a MBM degree from

Hull University, pairing his clinical skills with the

principles of executive management.

From here he moved his family to Saudi Arabia,accepting a position with the Saudi ARAMCOhospitals (the world’s largest oil company) withits own hospital for employees and theirdependants. He was part of the clinicalmanagement team that prepared the hospitalfor accreditation from the US Joint Commission,one of the first hospitals accredited outside theUS. He served as a technical advisor to JCIand helped them understand how MiddleEast patients seek care and how accreditationguidelines should be developed to address theregion’s challenges. This exposed Dr Sahadulla


ACHS Quality ImprovementAwards 2015

Hunter New England Local Health District, MetroSouth Hospital and Health Service – LoganHospital, and The Children’s Hospital atWestmead were announced as winners of the18th Annual ACHS Quality Improvement Awardsat the ACHS / ACHSM Joint Congress inMelbourne in October 2015.

The awards in three categories were presentedfor – Clinical Excellence and Patient Safety, Non-Clinical Service Delivery, and HealthcareMeasurement.

Almost 100 high quality submissions werereceived from Australian and International ACHS member and Clinical Indicator Programorganisations.

Hunter New England Local Health District wonthe Clinical Excellence and Patient Safety Awardfor their Preventing Catheter Associated UrinaryTract Infection (CAUTI) which accounts for 40%of all Healthcare-Associated Infections (HAIs).Metro South Hospital and Health Service – LoganHospital won the Non-Clinical Service DeliveryAward for their Preventing Infection throughCleaner Hospitals (PITCH): An Environmental

L to R: Dr Mark Burgess, ACHS, Christie Graham and AndreaKench, the Children’s Hospital at Westmead – HealthcareMeasurement Award, Mejoree Sehu, Metro South Hospitaland Health Service, Logan Hospital – Non-Clinical ServiceDelivery Award, Michelle Giles and Wendy Watts, HunterNew England Local Health District – Clinical Excellence and Patient Safety Award, Mr Brendan Cummins, DirectorHealthcare Solutions Baxter, Ms Linda O’Connor, ACHS.

Ms Kae MartinDr Laurence Lai (International)Christopher Brook PSMProfessor Robert ‘Bob’ GibberdProfessor Jeffrey BraithwaiteProfessor Bruce BarracloughDr Michael (Taffy) Jones AMAssociate Professor Christine Kilpatrick

Cleaning Bundle project to reduce HAIs and alsoreform and enhance hospital cleaning practice.This includes the introduction of ultraviolet gelauditing to assist in the visual review of cleaning.

The Healthcare Measurement Award was won by The Children’s Hospital at Westmead, forSustaining Improvements in Cystic Fibrosis (CF)Nutrition Outcomes for patients aged 2-18 years.

Competition within each of the three categorieshad increased in recent years, with each onehaving at least one ‘Highly Commended’ asrunner-up to the winners. The judges were onceagain impressed by both the scope and the veryhigh level of entries submitted.

A full list of Quality Initiatives entries received by ACHS was published in “Quality Initiatives –entries in the 18th Annual ACHS QualityImprovement Awards 201”’ which can bedownloaded from the ACHS website atwww.achs.org.au

Professor William RawlinsonProfessor Ross HollandDr Lisa HarveyMr Michael DooleyDr Ian O’RourkeDr John GreenwellMrs Phyllis NewnhamMr Brian Lewis

Mr Trevor PickeringMr Kevin DoddDr Lindsay ThompsonMr Brian CollopyMr Murray ClarkeDr Myles KehoeMs Doreen MooreDr Lionel Wilson

Previous ACHS Medal and ACHS International Medal recipients

MacauA gap analysis was conducted for the Centro SanJanuario General Hospital in January and this willbe their second EQuIP membership cycle.

The People’s Republic of ChinaThe University of Hong Kong – Shenzhen Hospitalunderwent their OWS in September 2015 and reachieved ACHSI accreditation, recognised by acertificate presentation in November.

SingaporeA total of 10 Fresenius Medical Care Clinicsare ACHSI accredited in Singapore with sevenundergoing their OWS for the EQuIP5 DayProcedures Centres program, receiving threeyear accreditation.

MalaysiaA total of five Fresenius Medical Care clinicsare ACHSI accredited in Malaysia with twoundergoing the EQuIP5 Day Procedure Centresprogram, receiving accreditation for three years.

TaiwanThe Sense & Beauty Dental Center and twoFresenius Medical Care Clinics in Taiwan havejoined the EQuIP membership program.

IndonesiaBIMC International Hospital, Bali underwent their Periodic Review in June 2016, receivingcontinuing accreditation.

Middle East Region

United Arab EmiratesEmirates Airlines Medical Services held an OWSin May 2016 and are in their third EQuIP cycle.

Kingdom of BahrainBahrain Defence Force Military Hospitalunderwent an OWS as part of their third EQuIPcycle, achieving accreditation for four years. Aspecialty topic workshop on Risk Managementwas held at the Bahrain Defence Force MilitaryHospital in May 2016.

Kingdom of Saudi ArabiaThe Abdul Latif Jameel Hospital held theirscheduled PR in December 2015 and wereaccredited.

State of QatarKIMS Qatar Medical Centre underwent their OWSin December 2015 and received full accreditation.The Al-Ahli Hospital held their OWS in April 2016and also received continuing accreditation.

ACHS International (ACHSI) extendsthe mission and vision of ACHSinternationally. Since 2007 it has aimedto create a strong presence in boththe Middle East and the Asia Pacificregions and it continues to grow.

Highlights of 2015 - 2016

z ACHSI approved by Dubai Healthcare City Authority to be an approved accreditor, amongst three organisations, for conducting accreditation of hospitals in Dubai Healthcare City (DHCC).

z Successful completion of the Accreditation Scheme Project of the Hospital Authority, Hong Kong, with all 15 hospitals achieving full accreditation status. ACHS awarded a third contract for the for this Project to accredita further 11 public hospitals.

z Commencement of activities for the Ministry of Health, Sri Lanka to establish a local accrediting body.

z Memorandum of Understanding (MoU) signed with the Korean Institute for Healthcare Accreditation (KOIHA) to collaborate with ACHS/I.

z ACHSI continued to host several international delegations from various countries such as United Arab Emirates, Korea, Japan, Vietnam and China.

A summary of activities and outcomes in 2015 –2016 are provided based on the two maingeographical areas of operation:

Asia Pacific Region

Hong KongACHSI was awarded the contract to provideaccreditation services to the Department ofHealth, School Dental Care Services’ nine dental centres.

A total of 20 on-site events comprising of acombination of Organisation-wide Surveys(OWS), Periodic Reviews (PR) and gap analyseswere held in the private and public sector duringthe 2015 - 2016 period.

The Dental Implant & Maxillofacial Centre(DIMFC) achieved ACHSI accreditation under theEQuIP5 for Day Procedure Centres standards.


ACHS InternationalDIVISION REPORTS

Sultanate of OmanKIMS Oman Hospital also successfully achievedACHSI accreditation with a certificate presentationwas held in January 2016.

The Muscat Laser Eye Center also underwent a gapanalysis in May 2016 and is preparing for theirOWS, in early 2017.


1. Survey team at work during the Periodic Review of thePamela Youde Nethersole Eastern Hospital, Hong Kong in June 2016.

2. Staff and survey team at the Periodic Review of the Matilda International Hospital, Hong Kong.

3. Left to right: KOIHA President Dr Suk, ACHS/I President Mr John Smith PSM and Dr Desmond Yen at the KOIHA premises in Seoul, South Korea.

4. Staff and survey team at the Organisation-wide Survey of the Dental Implant & Maxillofacial Centre (DIMFC), Hong Kong.

5. Periodic Review team of the Adventist Hospital – Tsuen Wan, Hong Kong.

6. Periodic Review team of the Adventist Hospital – Stubbs Road, Hong Kong.

1. 2.

3.

5.

4.

6.

Standards and ProductDevelopment

Standards and Product Development (SPD) isresponsible for the generation and maintenanceof ACHS quality improvement programs includingEQuIPNational, EQuIPNational Day ProcedureCentres, EQuIPNational Corporate HealthServices, EQuIP6, EQuIP6 Day Procedure Centresand EQuIP Corporate Services. This section alsodevelops associated resources and specialistpublications to support these programs.

In addition to the maintenance of existing

programs, this section develops new products

for ACHS including a proposed program to

recognise exemplary performance in healthcare

organisations. SPD also collaborates with

national and international organisations to

develop specialised healthcare programs

including EQuIP6 Hong Kong, EQuIP6 Oral

Health (international market) and EQuIP6 Dialysis

(international market). SPD works in consultation

with key internal and external stakeholders to

ensure program development reflects current

health priorities and contemporary best practice.

SPD coordinates the ACHS annual QualityImprovement (QI) awards, which acknowledgesand encourages outstanding quality improvementactivities, programs or strategies that have beenimplemented in healthcare organisations.

Key achievements 2015 – 2016

z Development of EQuIP6 Standards

ACHS completed the development of EQuIP6.

EQuIP is the core ACHS accreditation programs

and the basis of all such programs and products

offered to members. EQuIP6 will inform future

program updates. Member organisations locally

and internationally are thanked for their have

assistance, through their attendance on Working

Groups, at open consultations, onsite pilot

surveys and desktop audits.

Customer Services

During 2015 - 2016 the focus of the CustomerServices Managers (CSMs) was on businessretention.

Nearly 50% of accreditation program member-ships were due for renewal during the past yearand Customer Services is pleased to report thatwith support from Accreditation AdministrationServices the target set for membership renewalswas exceeded. During this same period ACHSalso exceeded its set target for obtaining newmemberships.

Throughout the year the CSMs also focussed on customer support and introduced newmethods, such as targeted newsletters and group presentations, for delivering support to our accreditation members.

Performance and OutcomesService

The Performance and Outcomes Service (POS)has been responsible for the ACHS ClinicalIndicator Program since 1989. More than 800healthcare organisations currently submit data fora range of Clinical Indicators every six months viathe web-based Performance Indicator ReportingTool (PIRT). In 2015 - 2016, POS providedhealthcare organisations with 314 ClinicalIndicators across 21 Clinical Indicator sets.

ACHS Clinical Indicators are developed by working parties comprised of practising cliniciansof relevant Australian and New Zealand medicaland nursing colleges, associations and societies,consumer representatives, statisticians and ACHSstaff. Clinical Indicator sets are regularly reviewedto ensure they are relevant for clinicians, that theycontinue to reflect today’s healthcare environment,that there is a consensus on collection andreporting requirements and that the set is regarded as useful for quality improvement.


z Publication of the Australasian Clinical

Indicator Report 2007 - 2014, 16th edition,

z Publication of five Clinical Indicator user manuals including Emergency Medicine (version6), Hospital in the Home (version 5), Intensive Care (version 5), Mental Health (version 7) and Pathology (version 4), Healthcare organisations from Sri Lanka and Sultanate of Oman commenced participation in the Clinical Indicator Program, joining other international members from Indonesia and Hong Kong.

Customer Services and DevelopmentDIVISION REPORTS


DIVISION REPORTS

Adapted from the Health Foundation - Inspiring Improvement:Building Capability to improve safety. Event Report, August 2014)

Lead LevelThe Lead group are employed in roles within organisation to lead change and improvement. They need a highskill level and expertise in patient safety and quality improvement; in particular they are expert in improvementscience and collaborative improvement methods. They understand human factors and reliability theories andcan begin to work with front line teams to prospectively design and redesign care to prevent harm. They sit onconsumer councils within organisations to ensure changes meet the needs of patients and families. They aresenior within the organisation working closely with the executive and board to drive continuous improvement.

Practitioner LevelThis level is applicable to a wide range of staff with different roles. Most likely they will be middle managerswith direct responsibility for patient care. This level can also include finance and other administrative servicessuch as informatics. Their work should be informed by a clear understanding of the principles and practice ofcontinuous improvement in healthcare. They should actively encourage and support the professionaldevelopment of other members of their team. This level reflects a leadership role in quality improvement. This group should role model and champion change and innovation within their own local environment..

Foundation LevelAll staff working in health care settings who should have a raised awareness of principles that underpin qualityimprovement to drive patient safety and higher levels of service delivery. In addition the foundation levelshould include patient and carer. It is recommended that staff new to the organisation receive an introductionto quality improvement at induction programs.


In October 2015 ACHS took theopportunity to redevelop itseducation offerings to both theAustralian and internationalmembers. Ms Bernie Harrison wasbrought into the organisation to develop training programs to meetinternational best practice in qualityand safety. The vehicle for doing thisis through the development of anImprovement Academy.

The vision of the Academy is to build the

capability of frontline clinical and executive

teams to best meet the challenges of health

care provision in the 21st Century and to

increase the alignment of continuous

improvement as contiguous with accreditation

and benchmarking through clinical indicators.

From October 2015 through to its launch in

March 2016, the Improvement Academy worked

on developing a suite of offerings using the

curriculum framework in the diagram below.

The Improvement Academy

Two programs were developed at the lead level;

The Patient Safety Lead (PSL) and the Quality

Improvement Lead (QIL) Training Programs. Both

these programs run for 12 months and are made

up of 4x2day face-to-face teaching modules. In

addition, participants undertake a work-based

patient safety or quality improvement project and

are supported through webinars, emails and

peer-to-peer support.

ACHS was able to identify an international and

local faculty who possessed both the theoretical

and practical real world experience in patient

safety and quality improvement, combined with

excellence in adult learning teaching methods.

For example: Dr Brent James - Intermountain

Health Care USA, Professor Lynne Maher - Ko

Awatea NZ, Professor Maxine Power - Salford

Royal Foundation Trust UK, Mr Peter Hibbert -

Macquarie University NSW, Dr Stephen Walker -

Cognitive Institute QLD, Dr Tim Smyth - Holman

Webb, NSW and Ms Bernie Harrison as Director

ACHS Improvement Academy.

On 3 March the Improvement Academy launched

these two programs in Melbourne at the Park

Royal Melbourne Airport. The launch was

opened by the President of ACHS, Mr John

Smith, PSM. Attendees were by invitation only

and included ACHS Board Members, Chief

Executives, ACHS Surveyors and other senior

leaders from member organisation. The keynote

speakers at the event were: Dr Brent James,

Chief Quality Officer and world renowned expert


in clinical quality improvement from

Intermountain Health Care USA, Dr John

Wakefield, Deputy Director General Queensland

Health who is a recognised expert in patient

safety; and Ms Bernie Harrison Director ACHS

Improvement Academy who is a recognised

expert in patient safety and quality improvement.

Dr James was able to join the launch and

provide his presentation via a live video link.

The launch was a great success and was closed

by ACHS CEO Dr Christine Dennis.

Since the launch the ACHS Improvement

Academy has commenced Lead programs in

Sydney and in Melbourne. Both these sets of

programs will complete next year. The

attendance at these programs has vastly

exceeded our early expectations. We currently

have nearly 120 participants enrolled in these

programs. They are made up of medical and

nursing clinicians and patient safety and quality

managers and directors of clinical governance.

The session feedback has been extremely

positive and complimentary.

At the practitioner level we have offered one day

programs in; clinical incident management / root

cause analysis, clinical practice improvement,

executive masterclasses, business planning

and risk management and preparing for ACHS

Accreditation Surveys. To date 30 one day

workshops have been held across Australia,

with more than 500 participants.

The new Quality Safety Lead course started successfully inJune 2016 and was followed shortly by the first Patient Leadcourse, held at the UTS Sydney campus, also in June.

Corporate and Surveyor Workforce Unit

DIVISION REPORTS


Corporate and Surveyor WorkforceUnit comprises five core sections:

1. Information Technology (IT)2. Finance and Human Resources

Administration3. Business Support Services (BSS)4. Accreditation Administration

Services (AAS)5. Surveyor Workforce (SW)


z Electronic Assessment Tool (EAT) 6 upgrade,

z Performance Indicator Reporting Tool (PIRT)

upgrade,

z Customer Relationship Management (CRM)

system upgrade,

z Server infrastructure upgrade,

z Redesign surveyor workforce allocation

and performance management system.

Information Technology (IT)

ACHS IT governance is concerned with the

strategic alignment between the goals and

objectives of the business and the utilisation

of its IT resources to effectively achieve the

desired results. ACHS IT is committed to

providing IT related business solutions and

systems integration in line with best practice

and consistent with the strategic direction of the

ACHS and ACHS International to ensure optimal

services to both internal and external customers.

Finance and Human ResourcesAdministration

The two main functions of this unit are the

management of finance and the management

of human resources.

z Finance plans, directs and coordinates the

formulation, preparation, execution, review

and analysis of the ACHS and ACHS

International’s operating budget and

monitors budget appropriations and actual

expenditures. The Finance unit works closely

with all department heads and gathers

information to create and maintain the annual

operating and capital budget. Financial

performance to budget is reported monthly to

the ACHS and ACHS International Board of

Directors to ensure that the organisations are

financially stable and to flag any potential

financial risks.

The review of corporate contracts such as

travel, accommodation and insurance are also

the responsibility of Finance together with

determination of pricing for ACHS products,

tenders and projects.

z Human Resources Management (HRM) has

generic functions which include:

z ensuring efficient human resource

information systems,

z administration of policies, programs and

practices,

z developing and running with a strategic

approach to human resources,

z monitoring compliance with legal

requirements as well as administering

award and corporate wellness

management, such as the development

and communication of policies and

procedures with regard to the

management of wellbeing;

z workplace health and safety including

the Employee Assistance Program and

health promotion programs such as free

influenza injections for staff as well as

ergonomics audits.

Business Support Services (BSS)

BSS is the repository of the ACHS and ACHS

International accreditation data, and it

collaborates with various departments and

university research partners on a variety of

projects. The BSS unit is responsible for data

extraction, data cleaning and reporting on the

data trends to stakeholders, jurisdictions,

members and surveyors.

BSS provides user support to all ACHS and

ACHS International members, surveyors and

staff in relation to the accreditation Assessment


Recording Tool (ART), Electronic Assessment

Tool (EAT) and the in-house Customer

Relationship Management (CRM) system. These

services range from access; telephone and email

support; training and education; presentations;

help manuals; meetings and site visits.

BSS also administers, maintains and rehabilitates

the ACHS premises, including the office building

as well as the assets therein. The BSS strives to

ensure a safe working environment for the ACHS

staff, clients and visitors. Its responsibilities

include, amongst others, taking the necessary

steps to identify and mitigate the potential

hazards or risks in the working environment

from both health and hygiene aspects.

Surveyor and Survey Coordinator Development

Days are compulsory training days held annually

to ensure currency of knowledge of the surveyor

workforce. This training is required as part of

the reappointment process of the Surveyor

Workforce. These informative training days are

also structured to provide an opportunity for

skills development; additionally they provide

the opportunity for dialogue and peer support

between surveyors. The BSS team is responsible

for the management of these events.

State Advisory Committee (SAC) meetings are

held every six months in each state via face-to-

face meetings and/or teleconference. The role

of the SAC is to provide a forum for increasing

the engagement, as well as the dissemination

of information between the ACHS and its

stakeholders. The SAC meetings are vital for the

ACHS to enable it to be informed of and address

the issues that impact stakeholders in their local

environment. The BSS unit is responsible for all

aspects of organisation for these meetings as

well as the regulation of appointments and

re-appointments and measuring performance

of the committees against a set of agreed key

performance indicators.

The BSS also oversees Finance, IT and Surveyor

Workforce functions and related projects.

Accreditation AdministrationServices (AAS)

The core function of the AAS is to provide

administrative support to the Customer

Services Unit, accreditation administration

and education support services to member

organisations and surveyors to ensure the

success of the accreditation programs. This

includes participation in the review of business

processes at management and staff levels. The

AAS also has responsibility for management of

member records, their accreditation phases

and monitoring and reporting of membership

renewals and invoicing through the CRM.

Surveyor Workforce

The Surveyor Workforce Unit has responsibility

for selecting appropriate teams for on-site

surveys to ensure the credibility of the ACHS

accreditation programs and the satisfaction

of its members. These teams are now based

on skills and proficiency processes that lead

to more suitable surveyors being chosen

for surveys.

In addition, this unit is responsible for ensuring

surveyors are kept up to date with the latest

information via a dedicated surveyor newsletter

and regular updates to the surveyor section

of the ACHS website. Face-to-face education

is provided at an annual surveyor development

day in each state and additionally for

coordinators at a separate annual development

day. The development days are structured to

provide an opportunity for skills development

and for dialogue and peer support between

surveyors. Further education is provided via

eLearning, webinars and quarterly mandatory

competency quizzes.

The Surveyor Workforce Unit also provides

training for newly recruited surveyors as

required. The training program uses a mixture

of didactic and interactive learning and was

re-accredited this year. The interactive sessions

are structured to provide a simulated version

of the survey environment, and are presented

by experienced ACHS staff and survey

coordinators.


The Surveyor Workforce Unit also has responsibility

for training and selecting appropriate surveyors

for projects. This year the team has worked with

various members of the surveyor workforce on

the following projects:

z Queensland Health Audit,

z Trauma Recovery Programme accreditation,

z Deepening our Understanding of Quality in

Australia (DUQuA) research together with

Macquarie University,

z Joint Accreditation Project with the Aged Care

Quality Agency;

z Short Notice Surveys.

Appropriate surveyors have also been selected

for consultancies for 23 organisations.

The unit monitors the performance of the

surveyor workforce on an ongoing basis to

ensure customer satisfaction and compliance

with requirements of the Australian Commission

on Safety and Quality in Health Care and

accreditation by the International Society for

Quality in Health Care (ISQua).

1. ACHS Staff and Surveyors at the SA Surveyor Development day, August 2015.

2. NSW Surveyor Inductee day, May 20163. ACHS Staff and Surveyors at the WA Surveyor Development day

September 2015.4. Keynote speaker Mr Peter Capp at the Vic Surveyor Development

day September 2015.

1. 2.

4.3.

ACHS Councillors 2016, as at 30 May 2016, was 29 Councillors, including three life members

Associate Professor Peter Bland

Royal Australian and New Zealand College of

Obstetricians and Gynaecologists (RANZCOG)

Ms Samantha Carney

Australian Day Hospital Association (ADHA)

Dr Margaret Cowling

MBBS, FFARACS, FANZCAAustralian and New Zealand College of Anaesthetists

(ANZCA)

Professor Geoff Dobb

BSc(Hons), MBBS, FRCP, FRCA, FANZCA, FCICM, FAMAAustralian Medical Association (AMA)

Ms Helen Dowling

BPharm, DipHospPharm (Admin), GradDipQlinHCare,CHP, FSHP, AICD Allied Health Professions Australia Ltd

Dr Iain Dunlop

MBBS(Hons), FRANZCO, FRACSAustralian Medical Association (AMA)

Associate Professor Brett Emmerson

MBBS, MHA, FRANZCP, FRACMAThe Royal Australasian College of Medical

Administrators (RACMA)

Dr Roger Jonathan Garsia

MBBS, PhD, FRACP, FRCPAThe Royal College of Pathologists of Australasia (RCPA)

Dr Michael Hodgson AM

FAMA, MBBS, FANZCA, FRCALife Member of ACHS Council

Dr David Hutton

MBBS, GradDipEconNSW Ministry of Health

Mr Mark Kearin

RN, ADCNS (Geront Nurs), BHSc (Mgt), MHSc (Mgt)Australian Nursing Federation (ANF)

Clinical Associate Professor Peter Kendall

MBBS, DA, FRACP, FCCPThe Royal Australasian College of Physicians (RACPS)

Mr Tony Lawson

BA, BSoc.Admin, FIPAA, FAIM, CPMgrConsumers’ Health Forum of Australia Ltd (CHF)

Adj Associate Professor Karen Linegar

RN, RM, MHA, BAppSc (Nursing), BBus, Dip.CommLaw, FRCNA, JPThe Australian College of Nursing (ACN)

Dr David Lord

MBBS, DPM, FRANZCPRoyal Australian and New Zealand College of

Psychiatrists (RANZCPS)

ACHS Council Members

OVERVIEW

Ms Angela Magarry

BHA, MPS, CGFNS, FCHSM Australasian College of Health Service Management

(ACHSM)

Dr Sally McCarthy

MBBS, MBA, FACEMAustralasian College for Emergency Medicine (ACEM)

Dr Roderick McRae

FAMA, MBBS (Hons), BMedSC (Hons), MBioeth, JD,PGDipPCCEAustralian Medical Association

Dr Jon Mulligan

MBBS, MHA, FRACP, FRACMA, GAICDLife Member of ACHS Council

Prof Leonard Notaras AM

AFCHSE, LLB, BA (Hons), DipComm, BMed, MHA, MAVice-President

Northern Territory Department of Health and Community

Services

Dr Eva Raik AM

MBBS, FRCPA, FRACPLife Member of ACHS Council

Mr Michael Roff

Grad Cert MgtAustralian Private Hospitals Association (APHA)

Dr Paul Scown

MMBS, BHA, FRACMA, AFACHSM, MAICDAustralian Healthcare & Hospitals Association (AHHA)

Mr John Smith PSM

MHA, GradDip HSM, AFACHSM, CHE, FAHSFMA,AFAHRI, AFAIM, FAICDPresident

Australian Healthcare & Hospitals Association (AHHA)

Ms Fiona Tito-Wheatland

BA (Hons) LLBHealth Care Consumers’ Inc.

Dr Phillip Truskett AM

MBBS, FACS, FRACS, FASCBI (Hons)The Royal Australasian College of Surgeons (RACS)

Ms Alison Verhoeven

BA, GradDipEd, MLitt, MBA, FAIM, GAICDThe Australian Healthcare & Hospitals Association (AHHA)

Mr Stephen Walker

AssDip.Eng, B.Bus, GradDipAcc, AFCHSE, MAICD Treasurer

Australian Private Hospitals Association (APHA)

Dr Noela Whitby AM

MBBS, GradDipHumNut, DPD, FRACGP, FAICDThe Royal Australian College of General Practitioners

(RACGP)

ACHS was still awaiting nominations from ACT Health, QldHealth and the Australasian Association for Quality in HealthCare at the time of publication.


DIRECTORS’ REPORT

The Board of Directors (the Board) of The Australian Council on Healthcare Standards Limited (“ACHS”) in office at the date of this report present the results of The Australian Council on Healthcare Standards Limited and itscontrolled entities (collectively referred to as “the Group”) for the financial year ended 30 June 2016 and theIndependent Auditor’s Report thereon.

Directors and meeting attendanceAt the date of this report, the names of the members of the Board, the meetings of the Board and meetings of theBoard Finance Audit and Risk Committee (BFARC), and the number of meetings attended by each of the Boardmembers during the financial year are listed and summarised in the table below:

Mr Michael RoffAdj Assoc Prof Karen Linegar Mr John Smith PSM (Chair)Mr Stephen Walker (BFARC Chair)Ms Helen DowlingMs Jennifer BakerDr David LordProf Michael Cleary PSMProf Geoffrey DobbDr Noela Whitby AMMr Anthony LawsonProf Leonard Notaras AMA/Prof Brett Emmerson

Name Date appointed Date of Cessation

Board

Meetings

BFARC

MeetingsAttendance at ACHS Board MeetingsJuly 2015 – June 2016

2 Feb 200425 Nov 200424 Nov 200523 Nov 200627 Nov 200826 Nov 200926 Nov 200925 Nov 201025 Nov 201024 Nov 201124 Sep 201222 Nov 201225 Nov 2015

-----

25 Nov 2015-

30 Mar 2016

---

A B

9989839367885

9999949799995

A B

-2222-------

-2222-------

A I Number of meetings attended B I Number of meetings held during the time the director held office during the year

Directors have been in office since the start of thefinancial year to the date of this report unless otherwisestated. Details of directors’ qualifications, experienceand special responsibilities can be found on pages 24 to 25 of this report.

Company secretaryDr Christine Dennis has held the role of CompanySecretary since October 2014. Dr Christine Dennis is also the Chief Executive Officer of the ACHS.

Mission and strategyThe Group’s mission is to strengthen safe, qualityhealthcare by continuously advancing standards andeducation nationally and internationally.

The Group’s strategy for accomplishing its missioninclude:

z Expand our business reachz Grow our membershipz Build strategic alliancesz Inspire organisational performancez Ensure sustainability z Share our knowledge.

Principal activitiesThe principal activities of the Group during the financialyear remained unchanged and were dedicated toimproving the quality of healthcare in Australia throughcontinuous review of performance, assessment andaccreditation.

Review of operationsThe Group’s net surplus of $1,324,513 has beenachieved mainly due to savings in operational and on-sitesurvey costs. The Group has no loans or borrowings toany financial institution as at 30 June, 2016.

During the year a large number of accreditationmemberships were up for renewal with a high percentagerenewing their membership. On renewal, the majorityhave retained their existing accreditation program witha few changing to another ACHS accreditation program.

Performance measuresThe Group measures its performance through themonitoring of key performance indicators:

z To assess the cost effectiveness of the provision of product and services

z To ensure revenue derived is effectively directed back to servicing customers

z To assess member and stakeholder satisfaction with the programs and services received

z To assess the take up of programs and services z To assess the effectiveness of support and services

provided to customersz To assess and manage risks.

Risk Management The ACHS is committed to the effective management of risks. At the ACHS the ownership of the day-to-daymanagement of risks remains the responsibility of theChief Executive Officer with the support of ACHS staff.


The Board Finance Audit and Risk Committee (BFARC)has the primary oversight of risk management practicesacross the ACHS.

Its responsibilities include assisting the Board throughperiodic review of the operation of the ACHS RiskFramework, through review of reports from the CEO.The BFARC meets at least twice a year to endorse allrisk monitoring, compliance, financial reporting,budgeting and forecasts for the Group. During the yearexisting controls are in place to ensure all identified risks are managed within an acceptable level consistentwith our risk appetite.

Members’ guaranteeACHS is incorporated as a company limited byguarantee. In accordance with the company’sconstitution each member of the company is liable tocontribute $50 if the company is wound up during thetime he/she is a member or within one year thereafter.As at 30 June, 2016 the total amount those members of the company were liable to contribute if thecompany is wound up is $1,500.

AUDITOR'S INDEPENDENCE DECLARATION

A copy of the auditor's independence declaration as required under section 307C of the Corporations Act 2001 is

set out on the following page.

Auditor

This report is made in accordance with a resolution of directors.

On behalf of the directors

Mr John Smith PSMPresident

Mr Stephen WalkerTreasurer

Sydney – 22 September 2016


AUDITOR’S INDEPENDENCE DECLARATION TO THE DIRECTORS OF THE AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS

In accordance with the Section 307C of the Corporations Act 2001, as lead auditor of The Australian Council on

Healthcare Standards for the year ended 30 June 2016, I declare that, to the best of my knowledge and belief,

there have been:

z no contraventions of the auditor independence requirements as set out in the Corporations Act 2001 in

relation to the audit; and

z no contraventions of any applicable code of professional conduct in relation to the audit.

Pitcher Partners Sydney

Melissa AlexanderPartner

Dated in Sydney this 22nd day of September 2016


Mr John Smith PSM (President)MHA, Grad Dip HSM, FAICD,FAHSFMA, AFACHSM, AFAHRI,AFAIM, CHE,z ACHS President from 2015z ACHS Vice President, 2011-2015z ACHS Treasurer, 2007-2011z ACHS Board member from 2005z ACHSI Treasurer, 2009-2012z ACHSI President from 2015z ACHSI Board member from 2008z ACHS Councillor (Australian Hospital

and Healthcare Association representative) from 2000

z National Councillor, AHHA from 2000z Director Victorian Healthcare

Association, 1997-2004z Board member, The Victorian

Hospitals Industrial Association Limited from 1994

z Vice Chairman, The Victorian Hospitals Industrial Association Limited

z Chief Executive Officer, West Wimmera Health Service

Professorr Len Notaras AM (Vice President)AFCHSE, LLB, BA (Hons), DipComm,BMed, MHA, MAz ACHS Vice-President from 2015z ACHS Board member from 2002z ACHSI Board member from 2009z ACHS Councillor (Northern Territory

Health representative) from 2002z Chief Executive Officer (CEO), NT

Department of Healthz Region #1 Top End Medical Disaster

Coordinatorz Executive Director National Critical

Care and Trauma Response Centre from 2009

z Medical Director of the NT Medical Administration Network from 2005

z Medical Superintendent Royal Darwin Hospital, 1994-2007

z NT Principal Medical Consultant, 1996-2002

z General Manager, Royal Darwin Hospital, 1995-2009

z Deputy CEO NT Health, 2000-2001z Senior Lecturer NT Clinical School,

1995-presentz Member NT Medical Board,

1996-2012z Chair NT Radiographers Board,

1997-2006z Chair NT Pharmacy Board,

1997-2006z Chair NT Radiographers Board,

1997-2006z Council Member National Council

for Safety and Quality in Healthcare,1999-2002

z Senior Superintendent NT Acute Care Network, 2003-2007

z Clinicians Involvement Working Group Chair, 2003-2004

z NT President ACHSE, 2003-2006z Chair NT Acute Care Quality

Committee, 2003-2008z Appointed Professor Fellow,

Flinders University SA, July 2015

Mr Stephen Walker (Treasurer)Ass DipEng, BA Bus, GradDipAcc,AFCHSE, MAICDz ACHS Treasurer from 2012z ACHS Board member from 2006z ACHSI Board member from 2011z ACHS Councillor (Australian Private

Hospital Association rerpresentative)from 2006

z Chief Executive Officer, St Andrew’s Hospital, Adelaide from 2001

z Member, SA Clinical Training Council

z Past Vice President, SA branch Australian College of Health Service Management (ACHSM)

z Past ACHS and Quality Health New Zealand Surveyor

Ms Jennifer Baker (ceased November 2015)

BHSc (Mgt), BBus (IR), MLegSt, MIR,FCHSM, CHEz ACHS Board member from 2009z ACHS Councillor (ACHSM

representative) from 2007z ACHSM Board member 2005-2012z Member, Australian Institute of

Radiographyz Fellow of the Australian College

of Health Services Managementz Fellowship Examiner ACHSM

Dr Michael Cleary PSM (ceased March 2016)

MBBS, MHA, FACEM, FRACMA, AFACHSMz ACHS Board member, from 2011z ACHS Councillor (QLD Health

representative) from 2011z Chief Operations Officer,

Department of Health and Deputy Director-General, Health Services and Clinical Innovation Division

z Member Medical Services Advisory Committee

z Chair and Deputy-Chair of the Australian Casemix Clinical Committee

z Treasurer and Councillorfor the Australasian College for Emergency Medicine

z Fellow of the Australasian College for Emergency Medicine

z Fellow of the Royal Australasian College of Medical Administrators

Professor Geoffrey DobbBSc (Hons), MBBS, FRCP, FRCA, FANZCA,FCICM, FAMAz ACHS Board Member from 2011z ACHS Councillor (Australian Medical

Association representative) from 2011z Chair, Advisory Council, Australian

Organ and Tissue Authorityz Board Deputy Chair, Child and

Adolescent Health Service, WA z Director, Australian Medical

Association Ltd

BOARD OF DIRECTORS

Adj Assoc ProfessorKaren Linegar

Mr John Smith PSM(President)

Mr Stephen Walker(Treasurer)

Ms Jennifer Baker Dr Michael Cleary PSM Ms Helen Dowling

Associate ProfessorBrett Emmerson

Mr Anthony (Tony) Lawson

Dr David Lord

Prof Len Notaras AM

Mr Michael Roff

Professor Geoffrey Dobb

Dr Noela Whitby AM


z Head of Department, Intensive Care, Royal Perth Hospital

z Clinical Professor, School of Medicine and Pharmacology, University of WA

z Consultant in Intensive Care, Mount Hospital, Perth, WA.

z Consultant in Intensive Care, St John of God Hospital, Subiaco, WA

Ms Helen DowlingBPharm, DipHospPharm (Admin),GradDipQI in HCare, FSHP, AICDz ACHS Board member from 2008z ACHS Surveyor from 2009z ACHS Standards Committee

member from 2003z Chair, ACHS Standards Committee,

2007-2012z ACHS Councillor (Allied Health

Professional representative) from 2001

z Pharmacist Consultant Contractor, Australian Commission on Safety & Quality in Health Care from 2015

z Chief Executive Officer, The Society of Hospital Pharmacists of Australia from 2012-2015

z Director of Pharmacy, Hunter New England Local Health District, 2008-2012

z Director of Pharmacy, Greater Newcastle Sector, Hunter New England Health, 2001-2008

z Member ACSQHC Health Services Medication Expert Advisory Committee from 2012-2015

z Member ACSQHC Clinical Care Standards Advisory Committee from 2013

z Member NSW Health Caring Together Independent Panel, 2009-2011

z Member NSW Health Medication Safety Strategy Steering Committee, 2009-2012

z Member and President, Pharmacy Council of NSW, 2010-2015

z Vice President, Pharmacy Board of NSW, 2008-2010

z Federal President, The Society of Hospital Pharmacists of Australia (SHPA), 1999-2002

z SHPA GlaxoSmithKline Medal of Merit recipient 2005

Associate Professor Brett EmmersonMBBS, MHA, FRANZCP, FRACMAz ACHS Board Member from 2015 z ACHS Councillor, (RACMA

Representative) from 2009z Councillor, RANZCP 2000–2009z Chair, Central Queensland Mental

Health Clinical Network, 2007 - currentz Chair, Queensland Mental Health

Clinical Collaborative, 2005 - currentz Member, Queensland Health Medicine

Advisory Committee, 2000

z Executive Director, Metro North Mental Health from 1997 – current

z Stepping Stones Club House Board Member from 1995

z Member, ACHS Standards Committee from 1994 to current

z ACHS Surveyor from 1994 to currentz Director, Logan Mental Health Service,

1994-1997z Queensland Chief Psychiatrist,

1990-1994

Mr Anthony (Tony) LawsonBA, BSoc.Admin, FIPAA, FAIM, CPMgrz ACHS Board Member from 2012z ACHS Councillor (Consumers Health

Forum of Australia representative) from 2012

z ACHS Surveyor z Chair, CHF Ltdz Member, St Andrew’s Hospital

Consumer Reference Groupz Member, Australian Atlas of

Healthcare Variation Advisory Group - Australian Commission on Safety and Quality in Health Care

z Fellow, Institute of Public Administration Australia

z Fellow, Australian Institute of Management

z Managing Director, Tony Lawson Consulting

z Executive Director, Institute of Public Administration of Australia, SA Division (IPAA SA)

z Former CEO City of Mitchamz Former Commissioner for Consumer

Affairs SAz Former Chair, Health Consumers

Alliance of SA Incz Former member, Central Adelaide

Local Health Network Governing Council

Adjunct Associate Professor Karen LinegarRN, RM, MHA, BAppSc (Nursing), B Bus,Dip Comm Law, FACN, JPz ACHS President, 2011-2015z ACHS Vice President, 2008-2011z ACHS Board member from 2004z ACHSI Board member from 2008z ACHS Surveyor from 2005z ISQua Board Member, 2013-15z ACHS Councillor (Australian College of

Nursing / Australian Nursing Federation representative) from 2004

z Appointed ISQua expert 2013 z Acting Chief Executive Officer

Tasmanian Health Organisation - North West, 2010-2011

z Executive Director of Nursing, Midwifery and Care Redesign - Tasmanian Health Organisation - North West 2009–current

z Director of Nursing - North West Regional Hospital, Burnie, 1994-2009

z Chair ACHS Tasmanian Advisory Committee from 2005

z President, Royal College of Nursing, Australia, 2002-2004

z Board member, Royal College of Nursing, 2002-2007

z Chair, Nursing Board of Tasmania, 2000-2003

Dr David LordMBBS, DPM, FRANZCPz ACHS Board member from 2009z ACHSI Board member from 2011z ACHS Councillor (Royal Australian and

New Zealand College of Psychiatrists representative) from 2009

z ACHS Surveyor from 2007z Retired (2008) psychiatrist

Mr Michael RoffGrad Cert Mgt.z ACHS Board member from 2004z ACHS Councillor (Australian Private

Hospital Association representative) from 2004

z Chief Executive Officer, APHA from 2000z Member, National Health Performance

Committee, 2000-2008z Member, Private Health Industry Quality

& Safety Committee, 2000-2004z Director, Australian Centre for Health

Research, 2006-2010z Member, Private Hospital Sector

Committee (ACSQHC) from 2013z Member, Clinical Trials Advisory

Committee, 2014-2016z Member, National Health Performance

Authority Advisory Committee for Private Hospitals, 2014-2016

Dr Noela Whitby AMMBBS, Grad Dip HumNut, DPD, FRACGP,FAICDz ACHS Vice-President, 2005–2007z ACHS Board member, 2000–2009;

2012-presentz ACHS Councillor (RACGP representative),

2000–2009; 2012-presentz ACHSI Board member, 2006–2009z Deputy Chair RACGP Queensland

Faculty Board from 2013z Chair, National Expert Committee on

Standards of RACGP, 2002–2005z Member, National Expert Committee on

Standards of RACGP from 1994z Chair, AGPAL, 2003–2006z Director, AGPAL, 2000–2006z Director, Quality in Practice Pty Ltd,

2003–2006z Director, National Asthma Council

Australia, 2005-2014z Chair, National Asthma Council

Australia, 2008-2014z Member, Medical Services Advisory

Committee, Australian Government, from 2014

z General Practice Principal, Carindale Medical Clinic, Brisbane from 1979

z Associate Professor of General Practice,Bond University, 2006-2007

z Past ACHS Surveyorz Fellow of the AICD

Ms Helen Dowling


ACHS Board Members I representing consumers, governments and the Australian healthcare industry

CONSOLIDATED STATEMENT OF PROFIT OR LOSS AND OTHER COMPREHENSIVE INCOME FOR THE YEAR ENDED 30 JUNE 2016

CONSOLIDATED STATEMENT OF FINANCIAL POSITION AS AT 30 JUNE 2016


CONSOLIDATED STATEMENT OF CHANGES IN EQUITY FOR THE YEAR ENDED 30 JUNE 2016

CONSOLIDATED STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 30 JUNE 2016


NOTES TO THE FINANCIAL STATEMENTS


THE AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS

A.C.N. 008 549 773

DIRECTORS’ DECLARATION FOR THE YEAR ENDED 30 JUNE 2016

1. In the directors’ opinion:

a) the financial statements and notes set out on pages 9 to 19 are in accordance with the Corporations Act 2001,

including:

i. complying with Accounting Standards, and the Corporations Regulations 2001; and

ii. give a true and fair view of the consolidated entity’s financial position as at 30 June 2016 and

of its performance for the financial year ended on that date; and

b) there are reasonable grounds to believe that the company will be able to pay its debts as and when they

become due and payable.

This declaration is made in accordance with a resolution of the directors.

Mr John Smith PSMPresident

Mr Stephen WalkerTreasurer

Sydney – 22 September 2016


INDEPENDENT AUDITOR’S REPORT

TO THE MEMBERS OF THE AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS

Report on the Financial Report

We have audited the accompanying financial report of The Australian Council on Healthcare Standards (‘the Group’) which

comprises the statement of financial position as at 30 June 2016, the statement of comprehensive income, statement of

changes in equity and statement of cash flows for the year then ended, notes comprising a summary of significant

accounting policies and other explanatory information, and the directors’ declaration of the consolidated entity comprising

The Australian Council on Healthcare Standards and the entities it controlled at the year’s end or from time to time during

the financial year.

Directors’ Responsibility for the Financial Report

The directors of the company are responsible for the preparation of the financial report that gives a true and fair view in

accordance with Australian Accounting Standards – Reduced Disclosure Requirements (including Australian Accounting

Interpretations) and the Corporations Act 2001 and for such internal control as the directors determine is necessary to

enable the preparation of the financial report that is free from material misstatement, whether due to fraud or error.

Auditor’s Responsibility

Our responsibility is to express an opinion on the financial report based on our audit. We conducted our audit in accordance

with Australian Auditing Standards. Those standards require that we comply with relevant ethical requirements relating to

audit engagements and plan and perform the audit to obtain reasonable assurance about whether the financial report is

free from material misstatement.

An audit involves performing procedures to obtain audit evidence about the amounts and disclosures in the financial report.

The procedures selected depend on the auditor’s judgement, including the assessment of the risks of material misstatement

of the financial report, whether due to fraud or error. In making those risk assessments, the auditor considers internal

control relevant to the entity’s preparation of the financial report that gives a true and fair view in order to design audit

procedures that are appropriate in the circumstances, but not for the purpose of expressing an opinion on the effectiveness

of the company’s internal control. An audit also includes evaluating the appropriateness of accounting policies used and

the reasonableness of accounting estimates made by the directors, as well as evaluating the overall presentation of the

financial report.

We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our audit opinion.

Independence

In conducting our audit, we have complied with the independence requirements of the Corporations Act 2001.


Opinion

In our opinion, the financial report of The Australian Council on Healthcare Standards and its controlled entities is in

accordance with the Corporations Act 2001, including:

c) giving a true and fair view of the consolidated entity’s financial position as at 30 June 2016 and of its performance

for the year ended on that date; and

d) complying with Australian Accounting Standards – Reduced Disclosure Requirements (including Australian

Accounting Interpretations) and the Corporations Regulations 2001.

Pitcher Partners NSW

Chartered Accountants

Melissa AlexanderPartner

Dated in Sydney this 22nd day of September 2016



z ISQua Conference Doha

QUALITY IMPROVEMENT INITIATIVES

TACKLED BY HEALTHCARE ORGANISATIONS -

A 5 YEAR REVIEW OF ACHS ANNUAL QUALITY

IMPROVEMENT AWARDS.

M. W. Burgess, L. O'Connor, K. Linegar,

This abstract focussed on areas healthcare

organisations prioritise for quality improvement

by analysing ACHS Quality Improvement Awards,

both winning and highly commended

submissions, over 5 years.

Presentations and Submissions

PROFILE

Public recognition of achievement by a healthcare organisation, of requirements ofnational healthcare standards

A measure of the clinical management and outcome of care; a method of monitoringconsumer / patient care and services which attempts to ‘flag’ problem areas,evaluate trends and so direct attention to issues requiring further review

Contains the 10 NSQHS Standards and the 5 additional standards derived fromEQuIP5

A health professional trained by ACHS to assess the performance of healthcareorganisations against EQuIP standards and other quality improvement programs

Accreditation

Clinical Indicator

EQuIPNational

Surveyor

Definitions in this glossary are for use in the context of this Report

Glossary of terms

The Australian Council on Healthcare Standards (ACHS)

5 Macarthur Street Ultimo NSW 2007 Australia

T. 61 2 9281 9955 F. 61 2 9211 9633 E. [email protected]

www.achs.org.au

2015/2016 - achs · profile publications and presentations 42 glossary of terms inside back cover...

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