ACHSNEWS The Australian Council on Healthcare Standards

The official newsletter from ACHS to communicate to all member organisations and our stakeholders

ACHSNEWS

See Inside For: ACHS Annual Dinner ACHS 2014 QI Awards ACHS Accreditation Forums

No. 49 Summer 2015

The ACHS Board of Directors

is about to undertake

significant work related to

setting its strategic direction for

the next three years. The

process will provide the ACHS

with an opportunity to reflect

and report on the achievement

of previous goals; to review the

national and international

business context in which it

operates; and, to develop

future orientated strategies that

enable the identification of priorities and allocation of

resources.

Strategic planning would be familiar to many in the public

and private health sector and, while some may gasp in

horror at the thought of attending such a session, as a

confessed ‘planning zealot’, I am looking forward to the

opportunities it will present.

For those who would not be so enthusiastic, perhaps I

may suggest that the overuse of ‘strategy language’

combined with minimal evidence of outcome are

impacting negatively on the perceived usefulness and

value of planning as an approach to establishing

organisational direction and strategic change. Additionally,

past experiences of planning and its capacity to change

systems and processes confirms the perceptions of many

that most plans are destined to the shelf of dreams.

What is strategic planning?

Strategic planning has been promoted in the management

literature as an approach to improve organisational

outcomes with promises of highly structured, future

orientated management techniques adopted from the best

-run business operations (Berry and Wechsler, 1995;

Begun and Kaissi, 2005; Duncan, Ginter and Swayne,

2002). Strategic planning is an example of one of the

many tools that the health sector has adopted from

business in an attempt to set direction, ensure

accountability and manage an extremely complex and

financially constrained system; which often exists in

conflict with political and professional pressures.

The health care industry has been described as one of the

heaviest users of such management tools however it

could be argued that there is little evidence of the

effectiveness of such significant input into business

planning and futures thinking in a complex and ever

changing health environment

Begun and Kaissi (2005) state that complexity theory

argues that strategic planning is not useful in complex

adaptive systems (including health care delivery systems).

They suggest that adherence to a plan can actually harm

an organisation that should be focusing on learning and

creativity in response to emergent strategic opportunities.

For your consideration: suggestions regarding strategy

and planning in the health sector;

ACHS Strategic Planning

Dr Christine Dennis

ACHSNEWS 2

a. Recognising the complexities of the environment and

acknowledging its unpredictability; this requires the

need to incorporate flexibility and emergent strategy in

planning processes and being prepared to adjust or

‘change with the wind’ while keeping the destination

as a clear focus. Responsiveness replaces

preparation.

b. Consideration of the timeframes for strategic plans;

Smith (2005) argues that long range planning in

complex organisations is impossible. While this should

not be interpreted as dismissing any possibility that

organisations can influence their futures, it suggests a

balance needs to exist between being able to

influence and, an over confidence in being able to

control through planning. The timeframe therefore in

which healthcare organisations plan, needs to be

realistic and acknowledge the complexity of the

environment including the influence of politics and

funding and, emergent opportunity.

c. Avoiding strategic planning that leads to an immediate

restructure without clearly understanding the root

cause of problems. Moving lines around on the

organisational chart seems the most frequent and

obvious change strategy however; there is minimal

evidence that such an approach delivers the intended

outcome. Instead it often causes disruption, confusion

and usually is costly to implement.

d. Avoiding strategic plans that have too much going on.

Plans need to be simple and easily understood. They

need to ensure people have clarity regarding how the

plan is going to be implemented and what their part is

in delivering the strategies. The plans need not only to

be measurable, but measured and reported – the

successes, challenges and those strategies that

failed. Important lessons can be learnt from what

didn’t work and why.

e. Supplementing data and information with intuition or

tacit knowledge; less quantitative and more qualitative

analysis.

f. Recognising that people need to be engaged and not

feel disenfranchised from the process. However, given

that there is no one size fits all approach and as

evident from this research, healthcare systems can

vary from serving populations of 250,000 to those

exceeding three million; it will be necessary to

consider the reasonableness of purporting to engage

everyone or, as an alternative, providing opportunity to

be engaged and ensuring effective communication.

Such processes need to acknowledge also that

consultation will not always result in consensus and

expectations will need to be managed.

g. Operationalisation of strategy: There is little to be

gained from developing a plan per se. There is

everything to be gained from the thinking that lies

behind the plan and the action that follows it (Wilson

2004, cited in Conway 2004). A strategic plan that

remains a theoretical concept and is never actualised

serves only to add to cynicism about the intent of

planning. The operationalisation of strategy requires

identification of priorities, leadership, communication

and resourcing. It requires a commitment to change

management and reporting of both the successes and

failures. The monitoring of planning outcomes should

not be artificially compressed into what can be easily

collected and measured as clearly defined Key

Performance Indicators (KPI). Caution should be

applied in taking this path as the KPIs can quickly

become the drivers while the strategic intent and

emerging opportunities are lost.

Copyright Update on ACHS Website Information

As part of its goal to continuously improve, ACHS has recently reviewed the copyrighting of its

own website information and has introduced a new procedure to ensure that copyright

conditions are understood by users.

Both ACHS members and authorised people are able to access the information, but need to

indicate that they understand the terms and conditions of being able to access such

information when doing so.

Under copyright law, all materials on the ACHS website are owned or licenced by ACHS and this limits what the

user may do with the materials, as some of the information is confidential to ACHS.

Agreeing to the conditions of usage is now necessary before proceeding to access information.

Dr Christine Dennis

ACHSNEWS 3

Dr Christine Dennis, Ms Kate Spurway, Mr Tony Lawson Prof Chris Baggoley AO Mr Rick Tocchetti, Ms Merrilee Clark

Adj Assoc Prof Karen Linegar

Dr Christine Dennis, Prof Chris

Baggoley AO

Dr Taffy Jones AM

Ms Kae Martin, Adj Assoc Prof Karen

Linegar Adj Assoc Prof Karen Linegar, Mr John Smith

Ms Bronwen Ross, Mr Robin Mead, Ms Melissa Harvey

Ms Sandy Thomson, Ms Ros Pearson

Dr Lawrence Lai, Ms Susan Chiu, Ms Manbo Man, Mr

Wayne Singh, Mr Hobby Cheung

ACHS Annual Dinner

2014

ACHS celebrated its Annual Dinner on Thursday 27 November 2014.

ACHSNEWS 4

Congratulations to the

2014 Quality Improvement Award Winners

Central Coast Local Health District,

Country Health South Australia Local

Health Network and Melbourne

Health were all announced as

winners of the 17th

Annual ACHS

Quality Improvement Awards at the

ACHS Annual Dinner in November.

ACHS received approximately 100

high quality submissions from

Australian and international ACHS

members and Clinical Indicator

Program organisations in 2014 for the

three categories – Clinical Excellence

and Patient Safety, Non-Clinical

Service Delivery, and Healthcare

Measurement.

Central Coast Local Health District

won the Clinical Excellence and

Patient Safety Award for their

Children and Young People’s Mental

Health Project “The Keep Them Safe

Whole Family Team Gosford Pilot

Project”, aimed at addressing child

protection concerns when the family

unit’s health and social well-being is

at risk.

Country Health South Australia Local

Health Network’s Safety and Quality

Unit won the Non-Clinical Service

Delivery Award for their

“BloodMove” project to implement a

novel red blood cell wastage

minimisation program across 62

regional hospitals with and without on

-site laboratories and a multiple

transfusion laboratory network. The

project has been so well accepted it

is now part of normally accepted

practice in country SA.

The Healthcare Measurement

Award was won by Melbourne

Health’s Influenza Vaccination

Working Party for their “Taking staff

influenza vaccination rates to a

record level” which did as it said -

lifting rates from 45 % in 2012 to

80%, and achieving 95% compliance

with documentation.

ACHS Executive Director of

Customer Services and

Development, Linda O’Connor

said the awards went to

outstanding organisations from

different geographical settings

on very broad and contemporary

health topics.

“Innovation in health care quality

and safety is being successfully

showcased through these

awards, with the submissions

received, including overseas

ones, being of an outstandingly

high level.” she said.

Central Cost Local Health District,

winners for Clinical Excellence & Patient

Safety, Domeniek Coates and Deborah

Howe.

Melbourne Health’s Influenza

Vaccination Working, winners for the

Healthcare Measurement Award, Peta

Green and Penny Birchmore.

Non-Clinical Service Delivery, Country Health South Australia Local Health Network, Safety and Quality

unit, L to R: Lucas Semmler, Roslyn Chataway, Rick Tocchetti, Merrilee Clark, David Rosenthal.

If you have any questions regarding the 2014 ACHS QI Awards please contact Dr Mark Burgess on +61 2 8218 2776

or email him at mburgess@achs.org.au.

ACHSNEWS 5

ACHS Medal Winners

ACHS Medal Winner 2014 and

the ACHSI 40 Year Anniversary Medal Winner

ACHS has

awarded its

prestigious 2014

ACHS Medal to

South Australian

Kae Martin for

outstanding

achievement in

maintaining a

continuous quality

improvement focus

in healthcare delivery systems.

In presenting the award, ACHS President, Adjunct

Associate Professor Karen Linegar said “We are

delighted to recognise Kae Martin for her clinical

experience combined with her extensive career in senior

executive roles in metropolitan and country health

settings,” she said.

“What is clearly evident in the positions she has held over

many years, is her unrelenting passion for ensuring that

the safest and best quality health services are delivered

to patients and communities.”

For the first time ever

ACHS also announced a

second medal winner with

the new ACHS

International 40 year

Anniversary Medal being

bestowed upon Dr

Lawrence FM Lai from

Hong Kong in recognition

of his ‘outstanding

contribution at an international level to improving quality

and safety in health services’.

“Dr Lai is highly respected in Hong Kong for the various

roles he has held and his contribution to promoting

hospital accreditation and improving quality and safety at

the local, regional and international level.” Adj Assoc Prof

Linegar said.

“He is a highly influential person who, until his retirement

in December 2009 was the Cluster Chief Executive of

Hong Kong West Cluster, comprising Queen Mary

Hospital and six other hospitals.

“He is currently appointed Honorary Senior Advisor of the

Hong Kong Hospital Authority and has recently guided

the Hong Kong-Shenzhen Hospital to undertake ACHS

accreditation which is a major milestone as it will be the

first hospital in the People’s Republic of China to be

awarded ACHS accreditation status.

“The ACHS International 40 Year Anniversary Medal,

presented in our 40th Anniversary year, acknowledges an

individual who has made an outstanding contribution, and

one that also furthers the work and profile of ACHS

internationally. Dr Lai is a worthy recipient of this award.”

And in another first for the awards, a ‘Highly

Commended’ recognition was given to a ACHS Medal

nominee from Queensland – Ms Cheryl Burns, Patient

Safety and Quality Manager, Torres and Cape Hospital

and Health Service in Far

North Queensland.

The ACHS Board was

impressed with the depth of

quality that had been

specifically demonstrated in

Cheryl’s leadership to assist

the Torres and Cape Hospital

and Health Service (TCHHS)

achieve accreditation.

“Overall this has been a strong

year for nominees and the ACHS Board is proud of the

winners and the difference they have made throughout

their careers,” Adj Assoc Prof Linegar said.

Dr Christine Dennis, Ms Kae Martin, Ms

Roslyn Chataway

Dr Lawrence Lai, Adj Assoc Prof Karen Linegar, Ms Kae Martin

Dr Lawrence Lai and Adj Assoc

Prof Karen Linegar

Ms Cheryl Burns

ACHSNEWS 6

ACHS Education Update

Webinars: ACHS 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. Upcoming topics for 2015 include:

Standard 5, Patient ID and Procedure Matching

Tuesday 17 March 2015 @ 1400 AEDT

For further details and registration options click here.

Audits for Small Hospitals Standards 1-3

Friday 20 March 2015 @ 1400 AEDT

For further details and registration options click here.

Ask a Surveyor (for hospitals >300 beds)

Tuesday 31 March 2015 @ 1400 AEDT

For further details and registration options click here.

All details of upcoming workshops and webinars are available at: http://www.achs.org.au/education

-services/achs-calendar-workshops-and-webinars/

ACHS eLearning is also available for ACHS members at: http://www.achs.org.au/education-

services/achs-elearning/

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: educate@achs.org.au

The new ACHS Patient-centred care workshop is now available to run on-site in your organisation. This workshop,

presented by Stephanie Newell, will help you to understand the value of Patient-centred care approaches in

healthcare organisations and how to commence and evaluate workforce training on Patient-centred care and the

engagement of patients. All details are at: click here

Please contact us if you are interested in finding out more: educate@achs.org.au

New in 2015!

ACHS Root Case Analysis (RCA) Education Workshops:

A great opportunity to increase or refresh the RCA skills base across your organisation! Details available at click here

Register Your Interest for 2015!

Leading patient safety: Change Management for Health Care Professionals

ACHS is calling for expressions of interest from individuals and groups who are interested in attending this one day

workshop in 2015. This workshop will be added to the calendar in 2015, and the decisions around workshop locations

and number of workshops run will be based on the response to this expression of interest.

Who should attend? The program is suitable for anyone involved in change, including – but not limited to: Unit

Managers, Clinical Managers, Executive Team Members, Quality Coordinators and Quality and Risk Managers,

ACHS Surveyors and Healthcare Consumer Representatives. Program Facilitator: Bernie Harrison.

Click here for more information

Education events up to June 2015 are now available on the ACHS website at:

http://www.achs.org.au/education-services/achs-calendar-workshops-and-

webinars/

Have your say in the future planning of education for ACHS members! ACHS online education needs survey open till 20 February 2015. Click here to complete the survey and add your input – the survey will take only 5-10

minutes to complete.

ACHSNEWS 7

Newly Revised CI Manuals

The Performance and Outcomes Service has released four

user manuals for the 1st half of 2015 data collection period.

These include Hospital-Wide, Internal Medicine, Anaesthesia

and Perioperative Care, and Medication Safety. Clinical

Indicator sets are regularly updated to support clinicians in

providing evidence-based patient care, and flag areas in need

of quality improvement initiatives. ACHS would like to thank the

members of these Working Parties for their contribution in the

process of developing these revised Clinical Indicator sets.

Hospital-Wide (v12) will focus

on:

1. Hospital readmissions

2. Return to the operating room

3. Pressure injuries

4. Inpatient falls

5. Patient deaths

6. Blood transfusion

7. Thromboprophylaxis

8. Minimum standards for rapid

response system (RRS) calls

9. Surgery

Anaesthesia and

Perioperative Care (v6)

will focus on:

1. Pre-anaesthesia period

2. Intraoperative period

3. Patient recovery period

4. Postoperative period

5. Management of acute

pain

6. Obstetric anaesthesia

care

Internal Medicine (v6)

will focus on:

1. Cardiovascular

disease

2. Endocrine disease

3. Acute stroke

management

4. Care of the elderly

5. Respiratory disease

6. Gastrointestinal

disease

7. Oncology

Medication Safety (v4)

will focus on:

1. Antithrombotic therapy

2. Antibiotic therapy

3. Medication ordering

4. Pain management

5. Continuity of care

6. Hospital-wide policies

FREE: ACHS Accreditation Forum – Lessons learned: Queensland – Friday 6 March 2015.

Limited spaces available, Registrations close on Monday 23 February 2015

The Queensland ACHS Accreditation Forum will be held at Royal Brisbane and Women’s Hospital, Brisbane on the

morning of 6 March 2015. The range of topics and the depth of discussion will allow attendees to gain valuable

insight on lessons learned by the organisations represented. All healthcare professionals are invited to attend this

session free of charge.

Click here for more information and to register

Two very successful ACHS Member Forums were held

in Sydney and Melbourne in late 2014, covering a

range of lessons that have been learned since the

introduction of EQuIPNational. The forums have been

enthusiastically received by participants who value the

opportunity to network, share and discuss their

experiences.

Links to copies of previous Forum presentations are

available on the ACHS website

Click here to access

ACHS Accreditation Forums

ACHSNEWS 8

Consultation on ACHS Draft EQuIP6 Standards,

criteria and elements

ACHS is currently undertaking a review of EQuIP5, its

core ACHS accreditation program and the basis of all

accreditation programs and products offered to

members both across Australia and internationally.

The ACHS Evaluation and Quality Improvement

Program (EQuIP) was launched in 1996. EQuIP was

developed by ACHS to assist healthcare organisations

to strive for excellence and was designed to be used by

all types of organisations which provide health care.

The current edition, EQuIP5, was introduced in January

2011 and implemented July 2011.

The review of EQuIP5 will inform future updates of all

related accreditation programs, including the

EQuIPNational programs and EQuIP 6th edition.

The review of EQuIP5 commenced in February 2014,

with input from staff of Australian and international

member organisations providing the breadth of

experience necessary to revise the Standards.

Volunteers from a broad cross-section of Australian and

international healthcare organisations formed eight

working groups to review the EQuIP5 standards, criteria

and elements and have created the first draft of

EQuIP6.

Field review of the revised EQuIP5 standards

commenced on 10 February 2015 and will close 23

March 2015. Emails will be sent to alert member

organisations when the field review process begins,

however, if you do not receive an email, please check

the ACHS website to access the draft Standards and

the survey.

The invitation to provide comment is open to all staff of

ACHS member organisations, ACHS surveyors, key

stakeholders, consumers and carers, and any other

interested individual or representative group, so please

notify your colleagues about the review.

“The aim of the review is to ensure that the

content of this core accreditation program

is up-to-date, evidence-based, and

relevant to member organisations.”

The last quarter of 2014 was a busy time for ACHS International and saw a flurry of activities across Hong Kong, Korea, Indonesia, Malaysia, India and the Middle East region.

International Accreditation Activity

Organisations that undertook a survey during the period were:

Hong Kong: Hong Kong Baptist Hospital, Queen Mary Hospital, Princes Margaret Hospital and Yan Chai Hospital

Malaysia: Fresenius Medical Care Malaysia Sdn Bhd - Pusat Dialisis The Kidney Dialisis Centre Jalan Ipoh and Fresenius Medical Care Malaysia Sdn Bhd - Pusat Dialisis NephroCare – Bukit Piatu.

India: Kerala Institute of Medical Sciences and KIMS Kochi

State of Qatar: KIMS Qatar Medical Centre

Sultanate of Oman: KIMS Oman Hospital

United Arab Emirates: Dubai London Clinic and Speciality Hospital

Kingdom of Bahrain: American Mission Hospital, Royal Bahrain Hospital, KIMS Bahrain Medical Centre and RBH Medex Medical Centre

Kingdom of Saudi Arabia: International Medical Center, Dr Soliman Fakeeh Hospital and Al Hammadi Hospital.

International Medical Center Hospital Building, Kingdom of Saudi

Arabia

Staff and Survey Team, International

Medical Center, Kingdom of Saudi

Arabia

Staff and Survey Team, Dubai

London Clinic and Speciality

Hospital