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The Australian Council on Healthcare Standards
ACHSNEWS
The official newsletter from ACHS to communicate to all member organisations and our stakeholders
No. 49 Summer 2015
ACHS Strategic Planning
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
Dr Christine Dennis
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;
See Inside For:  ACHS Annual Dinner  ACHS 2014 QI Awards  ACHS Accreditation Forums
ACHSNEWS
a. Recognising the complexities of the environment and e. Supplementing data and information with intuition or
acknowledging its unpredictability; this requires the
tacit knowledge; less quantitative and more qualitative
need to incorporate flexibility and emergent strategy in
analysis.
planning processes and being prepared to adjust or
f. Recognising that people need to be engaged and not
‘change with the wind’ while keeping the destination
feel disenfranchised from the process. However, given
as a clear focus. Responsiveness replaces
that there is no one size fits all approach and as
preparation.
evident from this research, healthcare systems can
b. Consideration of the timeframes for strategic plans;
vary from serving populations of 250,000 to those
Smith (2005) argues that long range planning in
exceeding three million; it will be necessary to
complex organisations is impossible. While this should
consider the reasonableness of purporting to engage
not be interpreted as dismissing any possibility that
everyone or, as an alternative, providing opportunity to
organisations can influence their futures, it suggests a
be engaged and ensuring effective communication.
balance needs to exist between being able to
Such processes need to acknowledge also that
influence and, an over confidence in being able to
consultation will not always result in consensus and
control through planning. The timeframe therefore in
expectations will need to be managed.
which healthcare organisations plan, needs to be
g. Operationalisation of strategy: There is little to be
realistic and acknowledge the complexity of the
gained from developing a plan per se. There is
environment including the influence of politics and
everything to be gained from the thinking that lies
funding and, emergent opportunity.
behind the plan and the action that follows it (Wilson
c. Avoiding strategic planning that leads to an immediate
2004, cited in Conway 2004). A strategic plan that
restructure without clearly understanding the root
remains a theoretical concept and is never actualised
cause of problems. Moving lines around on the
serves only to add to cynicism about the intent of
organisational chart seems the most frequent and
planning. The operationalisation of strategy requires
obvious change strategy however; there is minimal
identification of priorities, leadership, communication
evidence that such an approach delivers the intended
and resourcing. It requires a commitment to change
outcome. Instead it often causes disruption, confusion
management and reporting of both the successes and
and usually is costly to implement.
failures. The monitoring of planning outcomes should
not be artificially compressed into what can be easily
d. Avoiding strategic plans that have too much going on.
collected and measured as clearly defined Key
Plans need to be simple and easily understood. They
Performance Indicators (KPI). Caution should be
need to ensure people have clarity regarding how the
applied in taking this path as the KPIs can quickly
plan is going to be implemented and what their part is
become the drivers while the strategic intent and
in delivering the strategies. The plans need not only to
emerging opportunities are lost.
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.
Dr Christine Dennis
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.
ACHSNEWS 2
ACHS Annual Dinner
2014
ACHS celebrated its Annual Dinner on Thursday 27 November 2014.
Dr Lawrence Lai, Ms Susan Chiu, Ms Manbo Man, Mr
Wayne Singh, Mr Hobby Cheung
Dr Christine Dennis, Ms Kate Spurway, Mr Tony Lawson
Prof Chris Baggoley AO
Mr Rick Tocchetti, Ms Merrilee Clark
Dr Christine Dennis, Prof Chris
Baggoley AO
Adj Assoc Prof Karen Linegar
Dr Taffy Jones AM
Ms Kae Martin, Adj Assoc Prof Karen
Linegar
Ms Sandy Thomson, Ms Ros Pearson
Ms Bronwen Ross, Mr Robin Mead, Ms Melissa Harvey
Adj Assoc Prof Karen Linegar, Mr John Smith
ACHSNEWS 3
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.
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
Central Cost Local Health District,
winners for Clinical Excellence & Patient
Safety, Domeniek Coates and Deborah
Howe.
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
Melbourne Health’s Influenza
Vaccination Working, winners for the
minimisation program across 62
Healthcare Measurement Award, Peta
regional hospitals with and without on
Green and Penny Birchmore.
-site laboratories and a multiple
transfusion laboratory network. The
80%, and achieving 95% compliance
project has been so well accepted it
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
Non-Clinical Service Delivery, Country Health South Australia Local Health Network, Safety and Quality
high level.” she said.
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 4
ACHS Medal Winners
ACHS Medal Winner 2014 and
the ACHSI 40 Year Anniversary Medal Winner
Dr Christine Dennis, Ms Kae Martin, Ms
Roslyn Chataway
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.
“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.”
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
Dr Lawrence Lai and Adj Assoc
Hong Kong in recognition
Prof Karen Linegar
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.
Dr Lawrence Lai, Adj Assoc Prof Karen Linegar, Ms Kae Martin
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.
Ms Cheryl Burns
“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.
ACHSNEWS 5
ACHS Education Update
Education events up to June 2015 are now available on the ACHS website at:
http://www.achs.org.au/education-services/achs-calendar-workshops-andwebinars/
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.
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
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
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.
Ask a Surveyor (for hospitals >300 beds)
Tuesday 31 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.
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/educationservices/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
ACHSNEWS 6
ACHS Accreditation Forums
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
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
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
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
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
ACHSNEWS 7
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 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 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.
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 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.
International Accreditation Activity
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.
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
International Medical Center Hospital Building, Kingdom of Saudi
Arabia
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.
Staff and Survey Team, International
Medical Center, Kingdom of Saudi
Arabia
Staff and Survey Team, Dubai
London Clinic and Speciality
Hospital
ACHSNEWS 8