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ACHSNEWS

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

ACHSNEWS The Australian Council on Healthcare Standards

No. 43 Autumn 2013

EQuIPNational – number one choice for ACHS members

Preparations for change with the implementation of the National Safety and Quality Health Service (NSQHS) Standards on 1 January 2013 have occupied our thoughts and energies for some time and the strong results of these efforts are now apparent. ACHS is delighted at being appointed by the ACSQHC as an approved accreditation agency and with the level of trust many of our members have shown by nominating to remain with us. Aligning the needs of members to the requirements of the new NSQHS Standards has its complexities and our goal has been to continue to provide leadership and expertise throughout this period of change. We have created a high level of personalised support to make this a seamless transition for our members, with the first organisation accredited to Interim Accreditation to the new NSQHS Standards in February 2013. Our members have the option of selecting the ACHS NSQHS Standards or EQuIPNational programs for accreditation. Many of our members have opted for EQuIPNational which was developed by ACHS to provide both an inclusive assessment to the NSQHS Standards together with a further five EQuIPNational Standards, derived from key elements of the ACHS EQuIP program. This meets the needs of those members who wish to have a comprehensive organisation-wide assessment with the monitoring and reporting of clinical and non-clinical systems and processes. As mentioned previously, when I wrote in February to ACHS members, 2013 is a year of transition to these new standards. The Australian Commission on Safety and Quality in Health Care (ACSQHC) is emphasising the importance of taking a flexible approach – specifically, looking at how the organisation has risk-assessed issues, and seeing issues in the overall context of the health service. The ACSQHC has also increased the number of developmental actions in the Standards, and there are seven actions where minimum requirements have been prescribed for 2013. The introduction of the Guide for Small Hospitals is another example of a flexible initiative being introduced in a period of transition that will mean changes for some of our members.

ACHS Surveyors take “washing machine” for a spin

Surveyors, Ros Pearson and Dr Philip Hoyle along with Central Australian Hospital Network Acting Executive Director, Sharon Sykes and Quality Manager, Gillian Wright on the tarmac in Tennant Creek in temperatures of 48°, preparing to alight the Cessna, locally known as the “washing machine” due to summer thermals.

From left to right: Dr Philip Hoyle (surveyor), Gill Wright (CAHN Quality Manager), Sharon Sykes (Acting Executive Director CAHN) and Ros Pearson (Contracted Coordinator)

On behalf of the Board, I would like to advise that the ACHS farewelled Mr Brian Johnston on 22 February following the completion of his contract as Chief Executive. The Board thanks Brian for his service over the last 12 years. Dr Lena Low, Executive Director Corporate Services and with more than 17 years’ service at the ACHS will be the Acting Chief Executive in the interim until a new Chief Executive is appointed. I would like to take this opportunity to express the Board’s appreciation for your continuing support. As a not-for-profit organisation, ACHS remains determined to be the independent advocate supporting safety, quality and performance in the Australian health care accreditation industry we serve – and your support counts. Adj. Assoc. Professor Karen Linegar FRCNA President

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ACHSNEWS

The use of the new generation Assessment Recording Tool (ART) for the ACHS NSQHS Standards and EQuIPNational Programs has already begun with members preparing for survey in 2013 now using it.

The early feedback from members has been positive with a smooth transition from the previous EQuIP5 Electronic Assessment Tool (EAT5) to ART which includes migration of the organisation’s background information and previous recommendations from EAT5 with positive feedback around a more streamlined self-assessment compared to EQuIP5 surveys. Positive feedback has also been received from surveyors who pilot tested the ART and those who commenced using ART in the last week of January 2013.

ART is an online database that allows members to enter all of their essential survey data and track their quality improvement activities – assisting them to get ready for survey by having a record of their progress.

The three most notable benefits of ART are: It can be used by members throughout the accreditation cycle to track their progress against the standards and present their self-assessment in a consistent format with the ability to easily extract reports for use both within the organisation and as required during the accreditation process. As an online tool, ART is both accessible and

portable for both members and survey teams. It

contains all necessary information about each

accreditation cycle event including survey dates,

submission dates of current and future surveys as

well as a history of each survey completed within

the tool.

Administrators can assign any staff of their

organisation with access to specific data entry

sections of the tool allowing the most relevant

staff to enter data for a particular section of the

self-assessment.

One of the features of the ART is that members cannot submit their self-assessment until all required data for the current survey phase has been entered. This ensures there is a complete assessment presented at the time of submission. Each step of the process has been designed to be straightforward. ART is easy to navigate with a similar structure of a left hand navigation tree to that used by Windows Explorer and is compatible with multiple browsers, including Safari for those using Macintosh desktop or laptop systems. For members familiar with EAT5, ART will be especially easy to navigate with a familiar layout but new design to suit the new standards and accreditation process. Compared to EAT5, there is less data required to complete a self-assessment in ART. Organisations are only required to submit:

A summary of evidence for each of the 10 standards in the overall “Quality Measures” section, Tick a rating for each action,

Progressive migration of information from EAT to ART will take place over the coming months according to each member’s survey timetable. Once your membership under either the EQuIPNational Program or the ACHS NSQHS Standards Program has been established, users with current access authorised by their organisations will be able to access ART from the ACHS website as usual. For first time users, please complete the online registration available at www.achs.org.au/register-for-access to establish your login details (all access must be approved by your organisation’s ACHS primary contact). A ‘Frequently Asked Questions’ with troubleshooting information and instructions around the basic functionalities is available on the ART login page together with the help manual. Support staff can be contacted via ACHS reception or at art@achs.org.au

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The extensive program continues on from the NSQHS Standards with an additional five standards derived from EQuIP5 Day Procedure Standards, ensuring a comprehensive performance assessment program.

Specific areas included in the EQuIPNational Day Procedure Centres Standards which build on the 10 NSQHS Standards include:

Service and Care Delivery Workforce Planning and Management, Information Management, Organisational Systems and Systems for Safety.

With up to 60% of Australian operative procedures currently being undertaken as day patient procedure there is a strong need for an assessment program that meets the specific requirements of this growing sector. By adopting a wider range of standards, day procedure centres will have the opportunity to grow and expand their capabilities and maintain contemporary performance strategies directed at assuring safety and quality in the delivery of services. ACHS consulted widely within the industry to ensure a thorough review of its existing knowledge, with careful consideration given to the selection of the new Standards, as well as

the range of criteria and actions that they incorporate.

If you are interested in learning more about the EQuIPNational Day Procedure Centres Standards please click on the link below:

http://www.achs.org.au/publications-

resources/equipnational-day-procedure-centres/

ACHS has released the new EQuIPNational Day Procedure Centres Standards written specifically for Australian Day Procedure Centres. The new Standards have been developed to complement and support the Australian Commission on Safety and Quality Health Care (ACSQHC)’s new National Safety and Quality Health Service (NSQHS) Standards. They encompass all major components of a healthcare provider’s assessment program. The new program commenced from 1 January, 2013. in line with implementation of the NSQHS Standards. In keeping with the formatting of EQuIPNational to seamlessly integrate with the new NSQHS Standards, the EQuIPNational Day Procedure Standards have also been developed in a similar style to provide a consistent approach for both members and surveyors.

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ACHSNEWS

Are you interested in improving the quality of health care in Australia?

ACHS WANTS YOU! Are you a medical practitioner, nurse, or mental health professional?

Consider becoming an ACHS Surveyor and making a difference.

ACHS is seeking health professionals who have five years of senior management experience to join our team of surveyors and play a collaborative role during onsite accreditation surveys. You will provide education and information both formally and informally, enabling the organisation seeking accreditation to better understand how to improve quality performance.

This is a valuable opportunity to make a lasting contribution. Becoming a surveyor will enhance your knowledge and skills in management of health services. Currently there are approximately 400 experienced, senior health practitioners surveying for ACHS.

Training is provided to new surveyors through a comprehensive induction program with ongoing education and information. If you are a health professional experienced in:

medical practice mental health private hospitals or day procedure centres

Then please contact Laurie Leigh, Executive Director, Customer Services, ACHS on (02) 8218 2766, mwang@achs.org.au or go to www.achs.org.au/achs-surveyors/

History in the making ACHS surveyors give one of the last OWS under EQuIP5 in December at Royal Darwin Hospital, in the prelude to the introduction of the new National Safety and Quality Health Care Standards in 2013.

From left to right: The team from the left (front row) are: Peter Fahy, Heather Brown, Sharon Kendall, Ros Pearson (back row): Janine Holland, Dr John Reilly, and Jane Newcomb (trainee surveyor) oversaw a successful OWS.

Keeping you informed

Keeping up-to-date with a constant flow of information in a changing environment is all part of being a surveyor.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) has released a new policy introducing NSQHS Standards Advisories. A NSQHS Standards Advisory is a formal communication to Accrediting Agencies from the Commission to provide guidance and direction on the interpretation and/or assessment of the NSQHS Standards.

One of the goals of releasing these advisories is to ultimately improve inter-rater reliability across providers, and ensuring there is a move towards measureable improvement across the industry.

The first advisory, concerning the national hand hygiene initiative, was released in January and all ACHS surveyors have been advised of this communication.

ACHS will continue to keep surveyors updated through emails, State Advisory Council meetings and stories in ACHS News.

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ACHSNEWS

ACHS’ Seventh Annual Executive Masterclass Series

Patient-based care: the challenge of a new paradigm

Presenters:

Professor Jeffrey Braithwaite (Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, Australia)

Professor Cliff Hughes (Clinical

Excellence Commission, New South Wales, Sydney, Australia)

Invitation:

We are delighted to announce the Seventh ACHS Annual Executive Masterclasses. Each year we choose a contemporary, useful and interesting topic.

This year the topic is Patient-based care: the challenge of a new paradigm. This responds to the increasing need to be able to design and manage in a new world order in health care: one which demands that we are much more responsive to patients’ needs, and we build care around those needs.

To learn more about this exciting opportunity, please go to:

http://www.achs.org.au/education-support/executive-masterclass-2013/

Sydney, NSW Monday 20 and Tuesday 21 May 2013

Adelaide, SA Thursday 23 and Friday 24 May 2013

Melbourne, VIC Monday 27 and Tuesday 28 May 2013

Locations:

Enter this year’s QI Awards! Watch the ACHS website for submission details on how your organisation can tell us about a successful quality initiative.

Big Data 2013 is following on from the success of HISA's Data Governance conferences of 2011 and 2012. HISA will be hosting 'Big Data' at the Rydges Melbourne on 18 -19 April 2013. Big Data 2013 is Australia's first Big Data in biomedicine and healthcare conference. For more information visit www.hisa.org.au/bigdata2013

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ACHS launched its new website in September 2012. We are keen to find out what you think of the new ACHS website design and functionality to ensure our site is user friendly, as well as any other comments you would like to share that could help us make any further improvements. The survey is anonymous and will only take a few minutes of your time to complete. Please click on the link below if you wish to participate in our online survey: https://www.surveymonkey.com/s/achssurvey The closing date for this survey is Friday 15 March 2013.

The new Blackwood River Clinic in Nannup, WA made history on 7 February as the first facility in Australia to be surveyed by ACHS to the new National Safety and Quality Health Service (NSQHS) Standards. Set in a picturesque 85 acres, a three-hour drive south of Perth, the standalone mental health day hospital which is yet to formally open its doors to patients also became the first ACHS member organisation to be surveyed to the new accreditation requirements. ACHS Survey Co-ordinator Sandy Thomson said the smoothness of the interim accreditation process benefited from the support of an associated ACHS member organisation – Abbotsford Private Hospital – who provided guidance on requirements as well as providing good framework for sound, evidence-based policies and procedures, and good governance. “This was certainly one of the more unusual interim accreditation surveys I have done, but the staff were able to demonstrate how the policies and procedures will operate in the near future,” Sandy said. The facility will operate day therapy programs for up to 30 patients who will benefit from the planned therapeutic model of care. “The interim accreditation was timed to coincide with the licensing inspection by the Dept. of Health, both of which are needed in order to commence admitting patients,” Sandy explained.

“The survey also enabled additional advice to be provided for licensing, noting that many of the requirements under the ACHS EQuIP program are required for licensing, with fire and safety being a key example.” “This value-add was really appreciated by the organisation. Even though the new accreditation model is largely clinically focussed, surveyors should still provide advice on corporate and support areas where a risk might be identified. This is where being an experienced EQuIP surveyor really helps,” she said. Chair of the Board of Blackwood River Clinic, Mrs Rose Moroz, said that the national standards and the process constructed by ACHS were very helpful in guiding the establishment of the Clinic and thanked the Assessors and ACHS for their approach and assistance. “It is a rare event to accredit a new facility that has yet to admit patients, yet Blackwood has started with very strong foundations and in 12 months’ time they should have worked through all the survey team’s recommendations,” Sandy Thomson said. “Having worked with organisations to assist them in their preparation for National Standards has also been a great experience and it is evident that everyone is keen to do well in 2013 and showcase their achievements under this new model,” she concluded.

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ACHSNEWS

ACHS Education Update

March 2013

All details of the ACHS Education Workshop calendar for January to June 2013 are now available on the ACHS website at: http://www.achs.org.au/education-support/education-workshop-calendar/ All workshops on the ACHS Education calendar are also available as customised ‘on-site’ workshops in your own organisation. ACHS also offers an on-site consultancy service. Please do not hesitate to contact us if you would like to find out more about these options.

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

ACHS Education:

eLearning for ACHS Members

NEW FREE eLearning lesson now available:

Introduction to EQuIPNational for ACHS Members

This eLearning lesson will give Members a clear understanding of the ACHS EQuIPNational program, including the cycle, structure and ratings for EQuIPNational and the National Safety and Quality Health Service Standards

http://www.achs.org.au/education-support/achs-elearning/

If you do not have a password, it is easy to go online and apply via the ACHS website at:

http://www.achs.org.au/register-for-access/

Available at:

eLearning

for ACHS Surveyors National Safety and Quality Health Service (NSQHS) Standards The first in this series of eLearning lessons is now available: ‘Standard 10, Preventing Falls and Harm from Falls’

This eLearning lesson will give ACHS Surveyors the knowledge to:

Describe the structure and core concepts covered in the NSQHS Standard 10

List the Developmental actions for NSQHS Standard 10

Understand the key role of the Safety and Quality Improvement Guide for NSQHS Standard 10 as a reference

Understand the flexible requirements in place during the 2013 introductory period

As part of surveyors’ professional development, it is required that all surveyors successfully complete this and the lessons for all the NSQHS Standards. These are currently under development and will be available soon.

http://www.achs.org.au/education-support/achs-elearning/

Available at:

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ACHSNEWS

The reality of performing to the new National Safety and Quality Health Service (NSQHS) Standards is dawning for all ACHS member organisations as 2013 gets underway. Judging what the real expectations of the 10 NSQHS Standards and the large number of action items required to be met is presenting a challenge for many. Indecision and procrastination are not options - action is required, but the extent and level of depth required to ensure you meet all the requirements is a testing exercise. ACHS has re-introduced On-Site Consultancy Options to assist you with cutting through the confusion with the help of our experienced and knowledgeable health professionals. ACHS Consultancy services are available in a several areas. See below:

A high level consultancy against the NSQHS Standards, which involves an experienced surveyor visiting the organisation and sampling across the standards and providing a consultancy report at the ‘standard’ level, which outlines the issues identified, plus any recommendations for future improvements

A detailed gap analysis against

the NSQHS Standards which

involves a number of experienced

surveyors making an onsite review

of the organisation’s progress

toward meeting the 10 NSQHS

Standards is undertaken. The

review of evidence is conducted at

the action level. A detailed report is

produced providing Action

comments and rating and Standard

summaries.

ACHS also offers a wide range of

other consultancy services,

addressing matters such as:

A pre-survey consultation,

A planning session for a new

organisation,

A review of directional signage

issues in a new building,

To provide advice following an

Advanced Completion (AC)

recommendation,

Working with an organisation to

develop a new risk management

system.

N.B. Only experienced surveyors are offered as consultants. The advice provided by the consultant is no guarantee that the sponsoring organisation will automatically be accredited if the advice of the consultant is accepted. Who is the ACHS contact? The Education Manager, ACHS, Ms Joy Brumby. Please click here if you would like more information on ACHS Consultancy services.

ACHS Consultancy Services:

Get to know the new requirements with help from the experts

5 Macarthur Street Ultimo NSW 2007

P: 02 9281 9955 W: www.achs.org.au