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: ACHSM/ACHS Joint Congress ACHSI Medal QI Awards ACIR 2007-2014 ART Update

No. 52 Spring 2015

The joint hosting by ACHS, together with the Australasian

College of Health Service Management (ACHSM) of the Asia

Pacific congress – “Health leadership: odds-on favourite” in

Melbourne (October, 2015) was an enormous success, for

the delegates attending, the speakers invited and both

organisations.

With a timely spring racing carnival theme, the congress

attracted a range of international and local speakers keen to

share their views on some of the more confronting and testing

aspects of contemporary leadership in the health industry.

Some of the main highlights from the congress held at the

Sofitel Melbourne on Collins from 28 to 30 October included:

The plenary session with invited panel guests Prof Chris

Ham (Chief Executive, The King's Fund, London), Ms

Bronwyn Pike (Chair Western Health Board), Dr Stephen

Duckett, (Health Program Director, Grattan Institute),

Assoc Professor Chris Carter (CEO North Western

Melbourne Primary Health Network) and Dr Brendan

Murphy (CEO, Austin Health).

Facilitated by ABC journalist and presenter, Dr Norman

Swan, his goal was to get the panel to determine what our

actual handicaps in leadership might be, leading to some

thought-provoking discussions. A feature of this session

was a mobile polling app, allowing the audience to share

their perspectives on a number of key topic areas and to

get an understanding of where different views lay.

Some of the polling results were:

1. In order of importance, the key problems facing the health

system = lack of investment in primary care (rated 3.5 out

of 5) fragmentation (rated 3.4 out of 5); waste (3.4 out of

5); failure to ration (2.3 out of 5) and fee for service (2.3

out of 5).

2. Flexibility and willingness to innovate =

3. To what extent do you think the current discussions about

health reform are at such a high level that they have no

impact on the work that you do or are likely to do?

4. Are you confident we have strong leadership and goals?

ACHSNEWS 2

Dr Christine Dennis

5. The biggest problem we have is implementation of reform?

Key discussions centred on the role of leadership in

determining the success or otherwise of delivering health

service reform noting that one of the biggest obstacles was the

ongoing high-turnover of CEO’s; diluting their chance to deliver

successful and sustainable change and destabilising

leadership throughout the organisation.

It is clear from the results of the poll that the issues of

leadership and implementation are both critical now and in the

years ahead. The ACHS and ACHSM plan to revisit this in

2016 and to explore how both organisations can continue to

support building leadership capability and strategies to

implement and embed change.

Keynote addresses were also made by:

Christopher Rex, CEO Ramsay Health, who gave a

revealing overview of the Ramsay’s business ethos which

has led to their stunning success in recent years. George

Saviddes, Managing Director of Medibank, shared his view

on the fortunes of Medibank in recent years and the

prognosis for the future.

Kym Peake (Acting Secretary Department of Health and

Human Services, Victoria) and Nicole Feely (Director

General, ACT Health), spoke of managing health

expectations with declining resources.

Further keynote addresses were given on Day 2 by Chris Ham

and Eric de Roodenbeke (Director General of the International

Hospital Federation) who had an internationalist worldview on

what it takes to implement leadership. Professor Munjed Al

Muderis presented a compelling story on his life until now, from

refugee to osteo-integration surgical specialist.

One of the biggest crowd-pleasing sessions was the ‘Out of the

Barriers – courage, determination and will to succeed’ plenary,

with four keynote addresses by Dale Fisher (CEO, Peter

Macallum Cancer Centre), Diane-Smith Gander (Chair,

Spectrum Group, formerly Transfield), Barbara Henry, (Chief

Executive Derbarl Yerrigan Health Service, Perth, WA) and

Adjunct Professor Debra Thoms (Chief Nursing and Midwifery

Office, Commonwealth Dept of Health). Four very different

views on what it takes to arrive at the top, and to stay there

and ensure that the leadership provided is what is actually

required for the organisation.

Key announcements on Day 2 included the awarding of the

ACHS International Medal to Dr Mohammed Sahadulla,

principal of the KIMS group of hospitals in India, the Middle

East and the Gulf region, awarded for his outstanding

contribution to the area of quality and safety, as well as the

announcement of the ACHS Quality Initiatives Awards – see

page 4 for the winners.

More than 35 individual speakers presented throughout the

concurrent sessions held on the Wednesday and Thursday on

a range of topics covering: quality and safety, health service

leadership and management, stakeholder engagement,

practical solutions to patient safety problems and a host of

health-related ideas.

Coming up the home straight on the last day was a special

treat for all congress delegates, a delightful, ‘tell-it as it is‘

session with the woman voted as the most trusted person in

Australia - Prof Fiona Wood AM. Her highly-engaging style

and firsthand knowledge of how to make a breakthrough in the

health system and her experience of demonstrating leadership

qualities under duress was certainly one of the congress’s

highlights.

Anyone in the room who hadn’t previously heard of

inspirational speaker Michael Crossland will never forget his

openness and charisma as he relayed his life story from being

a one-year old having his first of many surgeries for cancer, to

growing up to represent the Australian baseball team in

America, and the many medical hardships suffered along the

way. Keeping a very firm grip on what are mostly ‘first world’

problems, Michael’s attitude to overcoming adversity and his

simple assessment of what is required to stay ‘above the line’

had everyone’s attention.

With nearly 430 delegates attending in Melbourne, the

overwhelmingly positive feedback has been the congress was

a great success. Thank you to all of the speakers who took

part in travelling to Melbourne to make the congress such a

strong event. Planning is now underway for the 2016 Asia

Pacific Joint Congress, to be held in Brisbane from Wednesday

26 – Friday 28 October – Save the dates Now!!!

ACHSNEWS 3

Sandy Thomson Dr Cathy Balding

Plenary session facilitated by Norman Swan and featuring Prof Chris Ham, Bronwyn

Pike, Nicole Feeley, Dr Stephen Duckett, Adj A/Prof Chris Carter, Dr Brendan Murphy

Some of the 428 registrants on Day 1.

L to R: Neal Fong, Eric de Roodenbeke, A/Prof Munjed

Al Muderis, Prof Chris Ham, Dr Christine Dennis Welcome to Country

Adj A/Prof Karen Linegar

Dr Brian Collopy

L to R: Dr Christine Dennis, Adj Prof Debra Thoms, Dale Fisher,

Diane Smith-Gander, Barbara Henry, Catherine Chaffey

ACHSNEWS 4

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

ACHS / ACHSM Joint Congress in Melbourne on 29 October.

ACHS Executive Director of Customer Services and

Development Ms Linda O’Connor together with Baxter

Director Healthcare solution, Mr Brendan Cummins

presented the awards in three categories – Clinical

Excellence and Patient Safety, Non-Clinical Service Delivery,

and Healthcare Measurement.

This year ACHS received approximately 100 high quality

submissions from Australian and international ACHS member

and Clinical Indicator Program organisations.

Hunter New England Local Health District won the Clinical

Excellence and Patient Safety Award for their Preventing

Catheter Associated Urinary Tract Infection (CAUTI) which

accounts for 40% of all Healthcare-Associated Infections

(HAIs).

Metro South Hospital and Health Service – Logan Hospital

won the Non-Clinical Service Delivery Award for their

Preventing Infection through Cleaner Hospitals (PITCH): An

Environmental Cleaning Bundle project to reduce HAIs and

also reform and enhance hospital cleaning practice. This

includes the introduction of ultraviolet gel auditing to assist in

the visual review of cleaning.

The Healthcare Measurement Award was won by The

Children’s Hospital at Westmead, for Sustaining

Improvements in Cystic Fibrosis (CF) Nutrition Outcomes for

patients aged 2-18 years.

Ms O’Connor said the competition within the three categories

had increased in recent years, each one having at least one

‘Highly Commended’ as runner-up to the winners. “The

judges were impressed by both the scope and the very high

level of entries submitted,” she said.

“Each of the winners have identified an area of improvement

in health, and set about to deliver a project that will bring

measurable results. The Quality Initiative Awards are all

about showcasing practical innovation projects where the use

of imagination to challenge standard practices and provide

more creative problem-solving is leading to stronger

initiatives.”

“Patients around the country will benefit in the long-term from

these initiatives as they are adopted by other health practices

looking to improve patient safety,” Ms O’Connor said.

L to R: Christie Graham and Andrea Kench, The Children’s Hospital at Westmead - Healthcare Measurement Award, Marjoree Sehu, Metro South Hospital and Health Service, Logan Hospital - Non-Clinical Service Delivery Award, Michelle Giles and Wendy Watts, Hunter New England Local Health District - Clinical Excellence and Patient Safety Award.

Long-time ACHS surveyor Val Smith is used to expecting anything can happen when it comes to

going on survey. Putting all her skills, wit and determination into action on a recent survey, Val

found herself changing a tyre en route to the survey, proving that whenever something can go

wrong – it will go wrong. Val made it safely to her destination and impressed the members with

stories on her tyre-changing prowess.

ACHSNEWS 5

Bernie Harrison is the

inaugural Director of the

ACHS Improvement

Academy. She has over

30 years experience in

health care, with 15 years

of that in the areas of

safety measurement and

the improvement of health

care processes. Her

previous positions include:

Executive Director of

Hospital Performance for

the National Health

Performance Authority for

the Commonwealth

Government and Director

in the Clinical Excellence Commission with responsibilities for improvement

in blood transfusion practice across NSW, clinical leadership and clinical

practice improvement development in public hospitals in NSW. For the last

18 months she has run her own company, Peloton Healthcare

Improvement Consulting, providing workshops in patient safety, change

management and health care improvement. Her background includes:

Awarded the 2001 Australian American Fulbright Scholar professional

awardee and spent nine months in the USA studying at Intermountain

Healthcare with Dr Brent James and with Dr Don Berwick at the Institute

for Health Care Improvement and Project Manager. She was project

manager and one of the authors of the Quality in Australian Health Care

Study which was published by the MJA 1995, this publication was

recognised by the MJA in 2014 as the most cited paper in the journal’s 100

year history.

She has a clinical nursing background, training in the NHS England where

she worked in neurosurgical intensive care and as a labour floor sister.

In her role as Director, Improvement Academy she will be bringing

contemporary content and training approaches to the field of safety and

quality. Her focus will be particularly on building capability across the

system in all facets of quality and safety, from Boards and Executives to

frontline clinicians. Patient safety is increasingly moving to the prospective

design and redesign of health care processes to prevent harm using:

reliable systems thinking; human factors engineering; patient

empowerment, lean production and improvement science. There will be

continued focus on supporting preparation for surveys and the Australian

National Standards.

As Director, one of her first jobs will be to consult with stakeholders around

planned programs and activities. Offering training opportunities that reach

both national and international ACHS members that advance quality and

safety is a very exciting prospect she says. The Improvement Academy will

have its launch early in 2016.

I’ve been fortunate in recent months to travel

to Victoria to present accreditation

certificates to two member organisations;

Hesse Rural Health Service and the Victorian

Aboriginal Health Service (VAHS) for their

Dental Standards.

Both services have fairly individualised

offerings for their respective local

communities, but at the same time they have

a great similarity in their respect for the

consumer and their passion for including

them in a range of planning and service

activities.

I was surprised and delighted at the work and

effort that has gone into making dementia

patients at Hesse’s 10 bed unit feel

comfortable with a beautiful outdoor country

garden and shed setting called ‘The Werruna

Project’. And equally I am impressed by the

level of work that has gone into ensuring that

VAHS continues to meet the needs of its

growing community.

Congratulations again to both services for

being awarded their accreditation; the first for

VAHS. It is a very important marker on their

continuous journey towards patient safety

and quality, and is something each staff

member can take pride in.

Dr Christine Dennis

Victorian Aboriginal Health Service (VAHS)

Hesse Rural Health Service

ACHSNEWS 6

Australia’s most statistically-

detailed, national report on the

performance of 807 healthcare

organisations (HCOs) over an

eight year period was launched in

Melbourne on October 29.

The Australasian Clinical Indicator

Report 2007 – 2014 (16th edition),

published by ACHS, presents a

rich analysis of data and current

healthcare trends in Australia.

ACHS President, Adjunct

Associate Professor Karen Linegar

said this report presents a

compelling picture of the ongoing

changes in levels of performance

in 2014 for the 490 public and 317

private HCOs who contributed

32,637 data submissions to

present an overview on their

performance.

“With more than a 10% increase in

the number of contributing HCOs

from 689 in 2007 to 807 in 2014,

the statistical integrity of the data

has also improved over time,” she

said.

“As Australia’s leading healthcare

accreditation agency, ACHS is

grateful for the strong level of

commitment from more than 40

medical colleges, specialist

societies and associations.

Through their ongoing

contributions of data, the Clinical

Indicator (CI) program gives a

comprehensive understanding of

where improvements in patient

care has occurred, and most

importantly, where the potential for

future improvement lies.”

“The 22 sets contain 328 individual

CIs that constitute a broad range of

clinical specialty areas. These CIs

are related to inpatient, outpatient

and community facilities, and were

developed by specialist clinicians.”

Notable improving trends over the

eight year period include:

Emergency Medicine -

Australasian Triage Scale

(ATS) categories 2 to 5

improved, as did the rate for

admitted critical care patients

waiting more than four hours in

emergency,

Intensive Care - the three CIs

relating to access block

improved significantly, however

rapid response calls to adult

ICU patients within 72 hours of

discharge has almost doubled

over the last four years,

Mental Health - 50% reduction

in the number of patients

discharged on psychotropic

medication and in attempted or

actual suicide.

In 2014 there were 46 CIs

which showed statistically

significantly undesirable trends,

including:

Mental Health Inpatient - the

rate of seclusion for greater

than four hours deteriorated

from 44.1 to 55.1 per 100

inpatients,

Ophthalmology – the

readmission rate following

retinal detachment surgery

deteriorated from 2.1 to 4.2 per

100 patients, and

Internal Medicine - the rate of

documentation of swallowing

screen prior to food/fluid intake

deteriorated from 85.4 to 58.1,

a change of 27.3 per 100

inpatients.

Please contact 02 9281 9955 or

send an email at pos@achs.org.au

if you would like a copy.

The Performance and Outcomes Service have

released three new Clinical Indicator User

manuals for the first half of 2016 data collection

period. These include:

Mental Health User Manual

version 7 - endorsed by The

Royal Australian and New Zea-

land College of Psychiatrists

(RANZCP) and will focus on:

1. Diagnosis and care planning

2. Physical examination of patients

3. Prescribing patterns

4. Electroconvulsive therapy

5. Use of seclusion and restraint

6. Major critical incidents

7. Length of stay

8. Mental Health Act status

9. Continuity of care

10. Community care

Pathology User Manual

version 4 - endorsed by The

Royal College of Pathologists of

Australasia (RCPA) and will

focus on:

1. Chemical pathology

2. Haematology

3. Anatomical pathology

4. Microbiology

5. Whole of service

Intensive Care User Manual

version 5 - endorsed by the

Australian and New Zealand

Intensive Care Society

(ANZICS) and will focus on:

1. Access and exit block

2. Intensive care patient management

3. Intensive care patient treatment

4. Central line-associated bloodstream infection

5. Utilisation of patient assessment systems

6. Empathetic practice

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.

To download these User Manuals, please visit

the Clinical Indicator Program page on the ACHS

website.

ACHSNEWS 7

The fourth APAC forum, held

recently in Auckland (NZ)

included a wide range of ACHS

members and surveyors. The

forum attracted more than 1,500

registrants from over 60

countries.

The forum offered a range of specifically designed pre-

conference ‘intensives’, four keynote sessions and two days of

targeted information-sharing sessions. More than 150 posters

were submitted - describing innovative quality improvement

solutions in a variety of settings.

The complimentary work undertaken by a number of our well-

known quality-focused organisations, for example, the Clinical

Excellence Commission and the Agency for Clinical Innovation

in NSW, was the focus of a number of sessions.

ACHS members were well represented on the program,

presenting their experience and improvements at various

sessions over the two days. Many of these organisations had

either recently been through the survey accreditation process

or are currently in the pre-survey planning phase.

The mood at the forum was one of energy, excitement, and

enthusiasm and was great for networking. Collaboration

opportunities were realised across teams, states and countries.

Participants were encouraged to turn their new knowledge and

inspiration into real system changes for the health frontline.

Improving the experience for patients and their families/carers

and the health benefits to the community was the focus of

many discussions.

The ‘buzz’ at the end of the forum was palpable.

Date for your diary – APAC 2016 will be held in Sydney from

12–14 September.

The Australian Council on

Healthcare Standards (ACHS)

has awarded the ACHS

International Medal 2015 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’. This is the second

time ACHS has presented the

award.

“Dr Sahadulla is highly respected in India as a leader in

establishing and developing hospital quality standards and

making a substantial difference at all levels,” said ACHS

President, Adjunct Associate Professor Karen Linegar.

“The ACHS International Medal acknowledges an individual

who has made an outstanding contribution to the area of

quality and safety, and one that also furthers the work and

profile of ACHS internationally. Through his commitment to

quality improvement, Dr Sahadulla is a very worthy recipient

of this award.”

“As the owner of KIMS Group (which has six Indian hospitals,

as well as three in the Middle East, and five polyclinics

throughout the Gulf region) has had a major impact in

improvement of quality standards over the last decade.

“He has been a quality pioneer throughout India with a focus

on good clinical practices to ensure patient safety. This

includes prioritised access to care, and championing the

development of Indian emergency medicine, a new and under

-developed specialty. He regards the Emergency Department

as the hospital’s “welcome door” and focuses on ensuring

that clinical staff properly triage and treat patients within

international guidelines.

Trained at Trivandrum in India, Dr Sahadulla migrated to the

UK in the 1970s and obtained a MBM degree at Hull

University.

ACHS President Linegar said in the citation for Dr Sahadulla,

“His philosophy about quality is at the core of all KIMS

decisions.”

“Dr Sahadulla’s has a strong record as an advocate for quality

and safety and we are delighted to give him the ACHS

International Medal 2015,” Adj Assoc Prof Linegar said.

Ros and Helen in Auckland.

Dr Sahadulla and his family who travelled from India to accept the award.

ACHSNEWS 8

ART NEWS Feedback Phase 2 of the Feedback upgrade is now well underway and

Surveyor Feedback Forms will be made available through ART

at the 7 November Monthly Maintenance update. Surveyors

can now visit the information and news page in the Surveyor

Section of the ACHS Website for detailed instructions on how

to use the feedback forms.

ART improvements implemented since June 2015 Since the winter edition of the ACHS News

published in June, the following changes have

been implemented in the Assessment Recording

Tool (ART) based on user Feedback.

1. DRGs are now automatically sorted by order

of highest number of cases to lowest;

2. Action descriptions are now included in the

survey report for improved readability;

3. Criterion headings are now included in action

rating summary report for improved

readability.

Under Construction Phase 2 of the feedback upgrade will

conclude with the implementation of the

Surveyor Feedback forms into EAT5 in

early 2016. This will be followed by the

final Phase in which Organisation

feedback forms will be added to the

feedback module in ART.

MAJOR ART UPDATE COMPLETED

Enhancements for the colour vision impaired The following enhancements to make the tool useable for the colour vision impaired has been implemented:

Pink and Blue magnifying glasses will be replaced with pencil and notepad with pencil icons;

Green and grey submit icons will be replaced with new icons and clear text;

Upload Feedback but-

tons have been intro-

duced to reduce con-

fusion between up-

loading completed

feedback and sub-

mitting the reviewed

survey in ART;

The Submit Survey

page will be upgrad-

ed from the current 3

tab format in which

Red and Blue text is

used to indicate the

completion status of

each data entry sec-

tion. Following the

upgrade, a list of in-

complete items will

be displayed making

it very clear which

areas require atten-

tion in order to sub-

mit your survey.

B. Data Missing

Data Ready

Submitting

Reviewed Survey

Received by

ACHS

Incomplete NEW!

OLD…

OLD…

NEW! Send to ACHS

OLD…

NEW! Received ACHS

A.

Data Entered

No Data En-

tered

Action Comment

Data Entry

OLD…

NEW!

OLD…

NEW!

C. Uploading

Feedback

Data Missing

NEW!

OLD…

Data Ready

OLD…

NEW!

Received by

ACHS

OLD…

NEW!

Incomplete

Upload to ACHS

Received ACHS