Common acronyms included in this Report

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2 Common acronyms incuded in this Report The ACHS strongy acknowedges the generous support provided by Baxter Heathcare for the purposes of pubishing this Annua Report. This support enabes ACHS to pubish and distribute our report to member organisations, ACHS surveyors, heath industry bodies, governments and the community and maintain our profie in the heath community. ACHS ACHSI ACCREDIT AAQHC ACIR ACSQHC AGPAL AHHA AHSSA AICD AIHI AMA APHA The Austraian Counci on Heathcare Standards ACHS Internationa Accreditation Coaborative for the Conduct of Research, Evauation and Designated Investigations through Teamwork Austraasian Association for Quaity in Heath Care Austraasian Cinica Indicator Report The Austraian Commission on Safety and Quaity in Heath Care Austraian Genera Practice Accreditation Limited Austraian Heathcare and Hospitas Association Austraian Heath Service Safety and Quaity Accreditation Austraian Institute of Company Directors Austraian Institute of Heath Innovation Austraian Medica Association Austraian Private Hospitas Association September 2013 The Austraian Counci on Heathcare Standards Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Austraian Counci on Heathcare Standards. The Austraian Counci on Heathcare Standards Annua Report ISBN: (paperback) ISBN: (website) This Report is avaiabe in PDF format via the ACHS website (under the Pubication and Resources menu option) from the homepage: To order a printed copy, pease contact the ACHS at: ART EAT EQuIP EQuIP5 EQuIPNationa HSRG IAP ISQua Assessment Recording Too Eectronic Assessment Too Evauation and Quaity Improvement Program the 5th edition of the ACHS Evauation and Quaity Improvement Program Contains the 10 NSQHS Standards and the 5 additiona standards derived from EQuIP5 Heath Services Research Group Internationa Accreditation Programme The Internationa Society for Quaity in Heath Care NSQHS Standards Nationa Safety and Quaity Heath Service Standards OWS PIRT PR QI QIC QMT Organisation-Wide Survey Performance Indicator Reporting Too Periodic Review Quaity Improvement Quaity Improvement Committee Quaity Monitoring Too 5 Macarthur Street Utimo NSW Austraia 2007 Teephone Facsimie E-mai communications@achs.org.au Website RACGP RHS SAC WHS The Roya Austraian Coege of Genera Practitioners Remote Heath Standards State Advisory Committee Work Heath and Safety

3 About ACHS Vision, Mission and Vaues 1 Our Identity 2 CONTENTS Our Performance Corporate and Strategic Pan 4 President s and Chief Executive s Report 10 Highights of the year 13 Our Organisation Organisationa Chart 15 Our Executive Team 16 Recognising Achievement ACHS Meda and ACHS Quaity Improvement Awards 18 Division Reports ACHS Internationa 21 Customer Services 23 Deveopment Unit 25 Corporate Services 27 Corporate Governance Overview 29 ACHS Counci Members 32 Financia Performance Director s Report ACHS 34 Board of Directors 36 Independent Auditor s Report 39 Notes to the Financia Statements 43 Directors Decaration 50 Listings Our Surveyors 51 Our Members 54 Pubications and Presentations 65 Overview of Products and Services 66 Gossary of Terms Inside back cover

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5 Vaues The foowing words encapsuate how the organisation seeks to behave: Vision Safe, quaity heath care for a Mission To be the eading provider of products and services for accreditation that support performance, exceence in safety and quaity programs for a broad range of heath service providers and consumers Accountabiity Taking responsibiity for and reporting on our performance Consumer focus Appropriatey meeting our cients needs Exceence Striving for exceent performance Integrity Acting professionay, ethicay, confidentiay and with respect in a we do Teamwork Working co-operativey with each other and our stakehoders ACHS ANNUAL REPORT

6 ABOUT ACHS OUR IDENTITY The Austraian Counci on Heathcare Standards (ACHS) is an independent organisation coaborating with heath care professionas, industry bodies and consumers to deveop and impement the accreditation standards and quaity improvement programs used by the majority of Austraian hospitas and heath care organisations. As a not-for-profit organisation, ACHS is governed by a Board of 12 Directors who are eected by a Counci of 31 member organisations, drawn from peak bodies in the heath industry, as we as representatives from governments, consumers and ife members. The ACHS is recognised by The Internationa Society for Quaity in Heath Care (ISQua) for its organisationa framework, its accreditation programs and surveyor training. ACHS, as an organisation, has been a member of ISQua s Internationa Accreditation Programme (IAP) from 1999 when ISQua was aunched, and successfuy met ISQua accreditation in Products and services Since its inception in 1974, ACHS has sought to provide a comprehensive but effective range of accreditation programs to meet the needs of the Austraian heath care industry, most notaby with the introduction of the Evauation and Quaity Improvement Program (EQuIP) in EQuIP provided a recognisabe set of measures by which quaity and safety coud be evauated for heath care organisations. An integra part of EQuIP has been the use of externa and independent peer review to faciitate the journey of improvement surveys as ACHS continues to extensivey use its more than 500 surveyors. As heath-industry professionas and consumers, ACHS surveyors are trained to conduct reviews of heath care organisations against the EQuIP standards. ACHS aunched its new product - EQuIPNationa in September 2012 to compement the introduction of the Austraian Commission on Safety and Quaity in Heath Care s (the ACSQHC s) Nationa Safety and Quaity Heath Service (NSQHS) Standards. ACHS s EQuIPNationa standards and program ensure ACHS members wi meet the requirements to participate in a program incuding the NSQHS Standards, from 1 January The key features of EQuIPNationa incude the ten NSQHS Standards (to which a hospitas and day procedure centres are required to be accredited) and a further five Standards which are derived from key eements of EQuIP5. Offering a seamess integration between the sets of standards, EQuIPNationa aows a comprehensive organisation-wide assessment with the monitoring and reporting of both cinica and non-cinica systems and processes. Deveoped with the input of member organisations, EQuIPNationa is an evidence-based program where survey resuts demonstrate that patient safety and quaity of care can be at risk without a system in pace to monitor and evauate the performance of non-cinica activities. Member feedback during the deveopmenta phase ensured that EQuIPNationa strongy represents the needs of member organisations to meet the Nationa Safety and Quaity Heath Service (NSQHS) Standards, whist aso eiminating any dupication between the standards and EQuIP5. EQuIPNationa now supersedes EQuIP5 in Austraia, except for heath care organisations without acute care faciities. At an internationa eve, both EQuIP5 and EQuIP5 Day Procedure Centres remain the key ACHS products. ACHS wi work cosey with a its members over the next 12 months to ensure there continues to be a smooth transition to EQuIPNationa, or aternativey, to being accredited to the NSQHS Standards. With the deveopment and creation of EQuIPNationa, both the ACHS Day Procedures Centres, and ACHS Corporate Heath products wi be re-visited to refect the appication of the new standards is consistent across our product range. Since the reguation of the heath care industry s accreditation agencies by the ACSQHC, ACHS has continued to meet the ongoing, day-to-day demands in providing industry-wide eadership on standards and processes. ACHS has demonstrated a strong commitment to meeting a the chaenges that have arisen in the first haf of ACHS has provided its members with the resources and expertise gained through its highy-deveoped network of staff and surveyors and ensured that this has been a defining year in the history of accreditation in Austraia. 2 ACHS ANNUAL REPORT

7 OUR IDENTITY Number of EQuIP Fu and Associate members in 2010, 2011 and Note that EQuIPNationa was introduced Sept Some ACHS members have remained with EQuIP5. Not a ACHS Members had advised ACHS of which program they were choosing by end of Dec Sector Private Pubic Tota For more information on ACHS products and services see page 66. ACHS Members Despite strong competition in the market, ACHS has retained the number of members it has, with sma increases in both the number of group organisations (with associates) as we as individua ACHS members. The majority of ACHS members continue to be hospitas, but the many other organisations participating in our accreditation and quaity improvement programs incude: community heath organisations, Medicare Locas, corporate offices of heath services and day surgeries. For a compete ist of ACHS Member organisations see page 54. ACHS Surveyors More than 470 surveyors are trained by the ACHS in evauation techniques to assess organisations against the ACHS standards. The majority of our surveyors sti work fu-time in the heath industry and contribute on a vounteer basis. Most ACHS surveyors are heath professionas with reevant heath care experience such as doctors, nurses, medica administrators and aied heath professionas. For a fu ist of ACHS Surveyors see page 51. Funding EQuIPNationa / NSQHS Standards (as at 31/01/2013) ACHS maintains its status as an independent, not-for-profit organisation, with the majority of funding derived from membership fees. Funding is aso received from tenders and projects undertaken on behaf of government organisations and other industry bodies. We aso receive a specific annua contribution from Baxter Heathcare for our Quaity Improvement (QI) Awards program and the pubication of this Annua Report. Our environment and the future ACHS has spent the ast 12 months preparing to operate in a new environment from 1 January, 2013 and overseeing the smooth transition of our members to this environment. The panned transition phase to the new NSQHS Standards is for the first 12 months, the first six of which have gone we, with many organisations preparing for imminent surveys in the second haf of During the transition phase, ACHS has consistenty communicated with its members as new information has been reeased by the ACSQHC and as ACHS deveops its own position on certain issues. ACHS centra offer in was the choice to meet the new NSQHS Standards, either through EQuIPNationa (covering the ten NSQHS Standards as we as five standards derived from EQuIP5) or aternativey, to accredit to the NSQHS Standards ony. ACHS continues to remain the ony peer-based accrediting agency in the new market, and continues to have a dominant reputation as it is essentiay formed by the industry, for the industry, and uses its infuence and knowedge in the ongoing deveopment of standards today. Partnerships ACHS continues to work strongy with a Austraian States and Territories. ACHS was founded on a number of specia partnerships, many of which thrive today. ACHS s mission is to present a definitive mode of accreditation that continues to meet the compex needs of the member organisations, when exceence in safety and quaity are paramount. As a strategic deveoper of standards for the Austraian heath industry, ACHS ensures a voices and views are considered. With our key activities continuing to be surveying, standards deveopment and the ongoing deveopment of cinica indicator sets, our partnerships are essentia to our success. Without the coaborative contributions of our many member organisations and stakehoders we coud not deiver the continua upgrade to the standards that have had such a critica impact on Austraian and internationa heath standards. ACHS ANNUAL REPORT

8 OUR PERFORMANCE CORPORATE AND STRATEGIC PLAN Our Corporate and Strategic Pan provides the direction to assist the ACHS meet the chaenges in our environment and to achieve our vision and mission. The new Strategic Pan came into effect on 1 January, It is against these goas that this report is structured. Corporate Goa 1 To be the eading provider of accreditation products and services 1Strategic direction Aims Outcomes Future Pans Provide standards and products that compement the nationa safety and quaity requirements and which are appropriate to the needs and expectations of a broad range of heath care organisations and consumers. Markets may incude hospitas, day procedure centres, community and ambuatory care services, Medicare Locas, speciaists medica practices, denta services and aged residentia care settings. Launch and introduce EQuIPNationa to provide a comprehensive, seamess product which incorporates the Nationa Safety and Quaity Heath Service (NSQHS) Standards pus EQuIP compementary criteria for member organisations. Become an approved accrediting agency to the Austraian Commission on Safety and Quaity in Heath Care s (ACSQHC) NSQHS Standards. EQuIPNationa was successfuy aunched at the ACHS 2012 Conference in September Approva was granted by the Commission in eary Continue to deveop products customised to meet the needs of members and specific sectors. Become an approved accrediting agency to the ACSQHC s new Medicare Loca Accreditation Standards. Approva was granted by the Commission in Apri Deveop EQuIPNationa Day Procedure Centres, formatted and surveyed to seamessy integrate with the NSQHS Standards. EQuIPNationa Day Procedure Centres reeased in January Deveop EQuIPNationa Private Hospita Guideines to support the new EQuIPNationa product. Revise EQuIP5 Corporate Member Services for aignment with the EQuIP5 and EQuIP5 Corporate Heath Services programs. EQuIPNationa Resource for Private Hospitas reeased in Apri Revision of EQuIP5 Corporate Member Services competed January Provide fexibe program deivery systems. This may incude the deveopment of new products, aternative deivery systems or the capacity for members to choose components of products and services reevant to their requirements. Ensure the reevancy and fexibiity of programs to assist customers and their organisations meet their needs. A program deivery systems were revised to provide a fexibe base for organisations transitioning to the new nationa accreditation program. This incuded the deveopment of new eectronic toos. Transitiona arrangements were made avaiabe for the impementation of the NSQHS Standards to maintain ACHS accreditation status during Monitor and evauate the customer environment and respond accordingy. Provide support services that are focused on the needs of consumers and customers. Ensure that throughout the transition phase member organisations and stakehoders are provided with accurate written information, as it becomes avaiabe, incuding anaysis of data, and free seminars. Accurate information has been provided to member organisations and stakehoders throughout the transition period using both written communication, anaysis of data and free seminars. Increased support by Customer Services Managers during key transition period. Continue to assess the members environment and review products and services to ensure they meet the market s requirements. 4 ACHS ANNUAL REPORT

9 2 Strategic direction Corporate Goa 2 To provide high quaity performance assessment services for accreditation and certification against recognised standards Aims Outcomes Future Pans Provide high quaity surveyors (based on their experience, knowedge, skis and training) abe to meet the performance assessment requirements for a reevant range of speciaised heath care settings. Ongoing education and review of education needs are a high priority throughout the year of transition, covering reated knowedge requirements for both the NSQHS Standards and EQuIPNationa, as we as the new ACHS Austraian Medicare Locas program. To hod an appropriate number of surveyor workshops to share avaiabe knowedge of reguatory requirements. Participation in the gap anayses to the NSQHS Standards proved to be very vauabe and highy informative. Assist surveyors to ensure they maintain the high eves of competency achieved to date. Ensure that a member organisations are kept abreast of a requirements from the Commission. A tota of 93 gap anayses were hed over a six month period to invove and educate surveyors. The Surveyor induction program was re-designed to accommodate current information needs. Maintain efficient survey systems and toos (incuding eectronic information system, administrative support) targeted at minimising any administrative burden. Deveopment of user-friendy eectronic toos to suit the new environment. Systems and toos have been progressivey revised to suit the new environment. Customer education on the Assessment Recording Too (ART) is avaiabe, as required. Continue to monitor and adapt ACHS resources to meet the needs and requirements of members and key stakehoders. Provide consutancy services that meet the needs of organisations reevant to ensuring high quaity and safe heath services. Provide consutancy services to member organisations when requested. Foowing on from the success of the gap anaysis for member organisations undertaken against the NSQHS Standards in the first haf of , we have continued to offer consutancy services since 1 January, To date there were six consutancies hed to the NSQHS Standards. Continue the gaps anayses program unti December Remediation consutancies to be offered as we as foow up to organisation s undergoing EQuIPNationa or NSQHS Standards programs to ascertain if they require any assistance. Deiver consutancy services and reports to member organisations that opt in for a gap anaysis of the NSQHS Standards together with their Organisation-Wide Survey or Periodic Review. The Education and Support service has coordinated five consutancies (11 consutancy days) in the past year. These have been high-eve consutancies against the Nationa Safety and Quaity Heath Service (NSQHS) Standards, for member organisations who wish to better understand where the gaps are in meeting the NSQHS Standards. These consutancies have a been on the ead-up to the organisation s first NSQHS Standards or EQuIPNationa Survey. Further deveopment of the roe of consutancy provider, and marketing to members. ACHS ANNUAL REPORT

10 Corporate Goa 2 continued Strategic direction Aims Outcomes Future Pans Provide education programs that are taiored to the needs of heath care organisations. Ensure appropriate resources are avaiabe to support educationa activities in the ead-up to and eary years of the impementation of the new mode for accreditation. Educationa programs are to continue to focus on topics reevant to the impementation of the NSQHS Standards together with EQuIPNationa. Free gap anayses were provided to member organisations to enabe an assessment of their progress in impementing the new NSQHS Standards; this offer was very popuar with our members. The progressive resuts provided vauabe feedback to poicy makers. Key areas incude the management of potentia risks, and the strategies deveoped to manage the risk. A poo of senior surveyors, with appropriate heath service eadership experience to be identified as the workforce for the consutancy program. Adapt the educationa programming mode for heath care organisations as required. Conduct an annua review of a needs anaysis from member organisations; as we as review of program fee structures; and, estabish a target number of earning interventions, using new modaities such as eearning and webinars. Launch of the new website in September 2012 to provide a contemporary patform to assist in education. The new website was aunched and has been received we by users. Ensure the website refects the range of ACHS educationa choices avaiabe and provides adequate information and resources for our customers. 6 ACHS ANNUAL REPORT

11 3Corporate Goa 3 The coection and anaysis of performance data and the dissemination of information reevant to the quaity and safety needs of consumers and the heath care industry Strategic direction Aims Outcomes Future Pans Maintain an efficient, resourcefu data coection system that supports a survey activities, faciitates reporting obigations and the generation of required information. Ensure that the new eectronic assessment toos deiver a more efficient system being avaiabe to both members and surveyors. Since the introduction of Assessment Recording Too (ART) there has been positive feedback from members. Ensure the effectiveness of data coection is appropriate to the new reporting requirements for jurisdictions and the ACSQHC, as we as member organisations. In addition, we need to ensure these systems support future new programs. Continue to deveop the cinica indicator program, incuding resources on how to evauate. Provide comparative reports twice yeary to a heath care organisations participating in the Cinica Indicator Program. Comparative reports for Jan-June 2012 provided to 724 heath care organisations in October Maintain the currency and reevance of cinica indicators on a program basis. Where reevant, deveop new indicators. Further enhance the reporting capacity of the program. Comparative reports for Ju - Dec 2012 provided to 704 heathcare organisations in Apri Deveop and maintain a broader range of performance indicators and measures to support the information needs of stakehoders eg. day procedure centres, non-cinica activities and nationa performance indicator reporting requirements. Review and update existing cinica indicator sets. Ensure the Cinica Indicator Program effectivey meets the needs of key stakehoders and member organisations. Day Patient version 5 and Gastrointestina endoscopy version 2 endorsed by coege and ACHS Board Feb 2013 for second haf 2013 coection. Continued growth in participation rates for the ACHS Cinica Indicator Program. Ongoing review and assessment of suitabe areas for performance indicators. Consider opportunities for expanding the range of indicators to other programs. Pubication of information that provides information reevant to the achievement of quaity and safe heath services and supports the socia responsibiity commitments of ACHS. Coate content for the pubication of the Austraasian Cinica Indicator Report Pubish conference presentations as appropriate. Pubish annua ACHS Quaity Improvement Awards. Austraasian Cinica Indicator Report th edition aunched at ACHS conference September Hard copy report maied to a coeges / associations / societies participating in cinica indicator sets, federa / state heath jurisdictions, private sector heath corporations, ACHS Counciors, ACHS survey co-ordinators and ACHS Board members. Presented ACHS achievements at ISQua Internationa Conference, Geneva, September Presented Quaity Improvement Awards at the ACHS Annua Dinner Distribute information to a broad range of stakehoders. Continue to pubish information on heath care quaity and safety reating to cinica indicator information and survey data using a broad range of communication forums. ACHS ANNUAL REPORT

12 4Corporate Goa 4 To be a eading contributor to research into quaity and safety in heath care Strategic direction Aims Outcomes Future Pans Advancement of the research program, particuary where it inks to the deveopment of products and services. Review and make recommendations for the continuing deveopment of the ACHS research agenda. The existing research program wi contribute to buiding the understanding of accreditation and the impact of human resources management systems on the performance of heath care organisations. Support strategicay important and reevant research topics. Continued engagement in research on a coaborative partnership basis. Maintain ongoing coaboration with existing research partners. ACHS continued its active coaboration with its research partners, the Austraian Institute of Heath Innovation (AIHI) at University of New South Waes, and Griffith University. Assess future research partnerships where appropriate, working towards improved research projects into accreditation systems and their effectiveness. Promote the pubication of research particuary in reation to accreditation, its processes and impact. Support externa ACHS research partners in the pubication of research in reation to accreditation. Pubication of the Austraasian Cinica Indicator Report was successfuy achieved. Continue to promote the Cinica Indicator Report as the eading report of its kind in Austraia. The preiminary reports of the impementation of the NSQHS Standards were produced. Whie the reports contained some chaenging information, they were we received and assisted key decisions by ACHS. Continue to contribute to papers through coaboration with research partners. Pubished papers: Medica cinician surveyors in the hospita accreditation process: their motivations for participating, the factors that infuence them and how they dea with those infuences. Low, L. PhD Doctorate: UNSW Dec ACHS ANNUAL REPORT

13 5Corporate Goa 5 Ensure a strong business focus Strategic direction Aims Outcomes Future Pans Expand the marketing program, particuary by using market research, to enhance brand recognition / identity and to guide product and service deveopment. To market ACHS strengths and brand. To enhance overa brand recognition. ACHS has communicated consistent key messages to members to buid its profie and infuence decision-makers. To continue the impementation of a comprehensive marketing program focused on meeting existing and future accreditation requirements of heath care organisations. Continue horizon-scanning of performance assessment programs both nationay and internationay to benefit ACHS activities. To update knowedge of current trends in contemporary performance assessment practice at domestic and internationa eves. ACHS programs and activities refect nationa poicy directions and internationa best practice. Maintain appropriate and competitive assessment programs. Ensure interna business activities are efficient and incude the use of risk management, quaity improvement and externa assessment (such as ISQua accreditation) programs. Ensure efficiency and effectiveness of a business practices to support the maintenance of the organisation s competitive edge. Ongoing assessment of the interna quaity improvement program is aigned to the business pan. It aso forms a key component of the risk management pan. ISQua accreditation for a ACHS standards achieved (EQuIP5, EQuIP5 Day Procedure Centres, EQuIP 4 Hong Kong Guide, EQuIP5 Hong Kong Guide). Constanty expore new opportunities to assist in maintaining a high eve of efficiency. ACHS as a heath care externa evauation organisation to undergo ISQua survey in October 2013, to meet accreditation for Apri Expand reevant internationa business activities for both commercia benefits and to enhance nationa repuation. Continue to grow the voume and range of internationa business secured for both commercia and reputationa purposes. The project in Hong Kong continues to progress extremey we and has resuted in severa additiona business opportunities being taken up. There was sow, but steady growth in other internationa memberships. Continuing expansion of internationa business program. ACHS ANNUAL REPORT

14 OUR PERFORMANCE PRESIDENT S AND CHIEF EXECUTIVE S REPORT This has been a year of achievement in an environment of change and renewa. Significant resuts were achieved across the business. The ACHS continues to maintain a eadership position in the heath care accreditation domain with the retention of the majority of its members. This has been achieved in a highy competitive market with the introduction of a mandatory government accreditation program. Some key factors for this success have been its accreditation expertise gained since 1974, its peer review program utiising experienced surveyors from the heath care industry and its innovative approaches in a changing environment. Governance There were significant changes to the composition of the Board in : The foowing two Counciors were re-appointed, having served previous terms as Board members: Dr Len Notaras AM, representing the Northern Territory Department of Heath and Community Services was re-appointed to the Board, Dr Noea Whitby AM, representing the Roya Austraian Coege of Genera Practitioners (RACGP) was re-appointed to the Board, The foowing Counciors were re-eected to continue their term of appointment. The foowing Counciors were re-eected: Ms Jennie Baker, representing the Austraasian Coege of Heath Service Management (ACHSM) was re-eected, Dr David Lord, representing the Roya Austraian and New Zeaand Coege of Psychiatrists (RANZCP) was re-eected, Mr Stephen Waker, representing the Austraian Private Hospitas Association was aso re-eected, and Mr Tony Lawson, representing the Consumers Heath Forum of Austraia Ltd. was wecomed to the Board. Mr Stephen Murby, the consumer representative on the ACHS Board and Ms Michee McKinnon, a Government representative, eft us this year having both made substantia and constructive contributions to the Board. The Board, in consutation with the Counci has commenced a review of the ACHS Constitution. This document is centra to the ega and governance arrangements for ACHS. It sets out our objectives and in broad terms provides the framework for operationa decision-making. This review wi take into account the changing environment in which we operate and provide a sound basis for effective governance of the organisation in the future. In February 2013, Mr Brian Johnston eft the organisation after 12 years as Chief Executive. At a farewe dinner hosted by the Board in appreciation of his services to ACHS, former Presidents acknowedged the vaue they paced on his contribution to ACHS and his persona support over the years. The President aso acknowedged Mr Johnston s eadership of the ACHS over the past 12 years. Dr Lena Low, Executive Director - Corporate Services was appointed as Acting Chief Executive Officer whie a recruitment search is undertaken. Transitions for our members Accreditation continues to be at the heart of a strongy functioning nationa quaity and safety agenda in heath. Our focus over the year has been directed at making the transition for our members to the new Nationa Safety and Quaity Heath Service (NSQHS) Standards as smooth and seamess as possibe. This has incuded the ongoing adaptation of existing programs to meet the new requirements. The re-design of existing toos and the strong support service from our Customer Services Managers, communication and education innovations to our customers and surveyors have aso been instrumenta in faciitating the transitions. 10 ACHS ANNUAL REPORT

15 In undertaking this transformative change, ACHS had to become an approved accrediting provider by the Austraian Commission on Safety and Quaity in Heath Care (ACSQHC), of which there are now nine such providers in the country. In the ead-up to the introductory date of 1 January 2013 we were the ony accreditation provider to offer our members a compimentary gaps assessment to the NSQHS Standards in conjunction with their usua accreditation survey. The key goas of this initiative were to assist our members and surveyors prepare for the new standards and to provide ourseves with opportunities to identify possibe issues in the future. This exercise proved invauabe for both ourseves, those members who participated and utimatey a ACHS members who benefited from the knowedge gained. A tota of 161 organisations vounteered for the gaps assessment and the resuts were of immediate vaue, resuting in a weath of information and earning as we became famiiar with specific areas that needed extra attention. We aso took the opportunity to work coaborativey with the ACSQHC by sharing the data from these gaps assessments with the ACSQHC. The support for members has been very targeted, not ony through the gap assessments, but the free information sessions hed in a number of ocations around the country, as we as the deveopment of elearning toos and highy structured educationa programs, created around specific needs. The choices for the majority of our members have been either EQuIPNationa or the NSQHS Standards. There are sti a significant number of our members who are not impacted by the NSQHS Standards and who remain with EQuIP5. The reevancy of the EQuIPNationa program has been demonstrated by a strong uptake, with the majority of our members seecting it. This support has reinforced the need for an organisation-wide assessment program such as EQuIPNationa. This has aso been extended to our other major programs EQuIPNationa Day Procedure Centres Standards, whie the deveopment of the EQuIPNationa Resource for Private Hospitas has been taiored for the needs of a specific audience. Financia performance The ACHS remains in a financiay stabe position and utiises various hypothetica financia modes to predict a range of possibe outcomes in the changing environment. As a not for-profit organisation, we continue to reinvest any surpus back into the organisation for the benefit of our members. This year we have again recorded another sma surpus, subject to the fina audit. Nationa Heath Reform There has been an ongoing momentum of change in the nationa heath reform agenda in recent years, with the roes and responsibiities of the respective agencies becoming more ceary defined. An exampe is the emergence of Medicare Locas and with this the opportunity for pursuing new markets in accreditation. With the commencement phase of the NSQHS Standards we underway, ACHS is in an environment of earning as the program becomes embedded and we adapt to new practices and approaches in conducting accreditation. The immediate impact of having a rating system of substantiay met, not met or met with merit has simpified some aspects, whie others are now more invoved. The feedback to date from our members on how we ACHS has supported them during this period of change has been heartening. They have experienced firsthand the benefits of ACHS eadership and innovation over a period of significant changes in the heath care industry. Research ACHS remains committed to the area of research with invovement in a number of exciting projects. The ACCREDIT project, ed by the Austraian Institute of Heath Innovation (AIHI) at the University of New South Waes is at the forefront of internationa research into accreditation. Now in its third year, the project is at a point where eary indications of the impacts of accreditation are becoming apparent with the concusion of some of the different phases of the 12 projects imminent. The enormous contributions these studies wi make to the ong-term understanding of accreditation and its future perceptions are something with which ACHS remains proud to be invoved. The research has been an investment in our future and the prospects of key dividends of both knowedge and information are now very cose. Projects in coaboration with the Griffith University in Queensand are aso progressing and adding to the knowedge base. The 13th edition of the Austraasian Cinica Indicator Report was pubished and remains a vita document in assisting cinica review processes within organisations. As the pre-eminent report of its type in the country it is a benchmark for how cinica indicators have a roe identifying future quaity improvements in heath care. ACHS ANNUAL REPORT

16 Working in Partnership Throughout the ast 12 months we have sought to engage and coaborate where possibe with the Austraian Commission on Safety and Quaity in Heath Care to provide a strong, authoritative presence that refects our neary 40 years of eadership and expertise, whie remaining an independent voice for our members. Internationa Business Activities Ongoing deveopment of internationa business activities in seected regions continued throughout ACHS has continued to maintain a high profie within Saudi Arabia and the Midde East, and has estabished a strong foothod in Asia, specificay in Hong Kong where the Phase 2 contract is we underway. Other signs of interest by heath care services and hospitas in these regions, as we as in some parts of Europe have signaed a strong interest in the programs offered by ACHS internationay. A number of exporatory meetings and visits have aso taken pace, as we as visits by deegations to Austraia. A Competitive Market In the cimate of increasing competition, the ACHS has focused on an innovative, coaborative and fexibe approach with our members to ensure they eect to remain with us for the vaue-add we provide to their organisations. The same approach is appied to prospective members and our stakehoders. We have aso streamined our business and accreditation processes to ensure that the administrative burden on member organisations is reduced wherever possibe to accommodate the introduction of the NSQHS Standards. We are therefore particuary proud of our Assessment Recording Too (ART) which repaced the Eectronic Assessment Too (EAT) for EQuIP5 and the ease with which our members have adapted to the change. ACHS continues to invest in producing resources and education for our members and surveyors based on their feedback to us. 40 Year Anniversary In 2014 we wi ceebrate our ruby anniversary - 40 years of serving Austraian and overseas heath care organisations through accreditation and the ongoing deveopment of safety, quaity and performance. We very much ook forward to incuding our members and stakehoders as we commemorate the year with events in every state. Acknowedgements It is important to again acknowedge our ong-standing reationship with Baxter Heathcare, our major sponsor for the pubication of this report as we as our nationa quaity awards program, the ACHS Quaity Improvements Awards. We aso recognise and thank members of the Board and Counci, the organisations that nominate representatives to Counci, State Advisory Committee members and our highy respected surveyors. Once again they have shared their professiona expertise and energies enthusiasticay to enabe ACHS to conduct its Vision safe, quaity heath care for a. Finay, we thank our Executive team and their staff for making this a andmark year where their efforts have aunched us further in our own quaity improvement journey. They have deivered and the resuts are a credit to a of them. We commend this report to you. Adjunct Associate Professor Karen Linegar President Dr Lena Low Acting Chief Executive 12 ACHS ANNUAL REPORT

17 HIGHLIGHTS Key highights in the past year were: ACHS continues to pay a key research and educationa roe in the fied of accreditation with its support as a coaborator in the Accreditation Coaborative for the Conduct of Research, Evauation and Designated Investigations through Teamwork (ACCREDIT) project. The coaboration, invoving a tota of 12 research projects wi extend unti ACHS revised its survey requirements for fire, safety and heath buidings, and continues to require fire inspection reports for Cass 9a Heathcare Buidings and buidings where occupants seep. EQuIPNationa Day Procedure Centres was reeased in January It was deveoped to compement the NSQHS Standards for day procedure centres as an assessment program to evauate both cinica and non-cinica systems. More than 400 peope attended the annua Surveyor Deveopment Days hed during August and September, aong with the second round of Co-ordinator Deveopment Days for ACHS in coaboration with the Austraian Heathcare and Hospita Association (AHHA) and the Women s Hospitas and Chidren s Hospita Austraasia (WCHA) hed the Quantum Leap, measurement: redefining heath s boundaries? conference in Sydney in September Neary 290 deegates from around the country and overseas attended this three day conference. EQuIPNationa, the advanced product that incorporates both the 10 NSQHS Standards and a further five EQuIP-derived standards that address additiona content at an organisationa-wide eve was aunched at the Quantum Leap conference. The Austraasian Cinica Indicator Report was aso aunched at the ACHS conference. The 13th edition provides vauabe anaysis on the 353 indicators avaiabe across 22 cinica streams. Competing the trifecta of aunches at the conference, the new ACHS website was deivered and provided a more contemporary and userfriendy too for members, surveyors and stakehoders aike to access vauabe information and receive important news updates. As an added benefit, ACHS offered member organisations a gaps assessment against the NSQHS Standards during their EQuIP5 survey throughout the second haf of A tota of 172 organisations eected to take up the free consutancy reviews in the period between Juy and December Piot testing of new Assessment Recording Too (ART) commenced prior to its aunch on I January, 2013 to assist in recording member information for the NSQHS Standards. Usabiity for members was a key consideration in deveoping it, and to assist them meet the new requirements for data reporting. By 31 June 2013, the take-up of the EQuIPNationa program was at 69% of our tota members, with 23% choosing to do the NSQHS Standards and the remainder (mainy non acute hospitas) staying with the EQuIP5 program. The new EQuIPNationa Resource for Private Hospitas, reeased in Apri 2013, is specificay deveoped to meet the needs of private sector organisations. EQuIP5 Corporate Member Services program is revised to bring the program into aignment with the EQuIP5 and EQuIP5 Corporate Heath Services programs. ACHS is accepted as a registered provider of accreditation for Medicare Locas, aowing it to be abe to offer its new ACHS Medicare Loca program from 3 June, The seventh Annua Executive Mastercass Series was hed in May 2013 in Sydney and Mebourne with presenters Professor Ciff Hughes and Professor Jeffrey Braithwaite, on the topic Patientbased care: the chaenge of a new paradigm. In the first six months of 2013 approximatey 950 members and surveyors received some sort of forma, face-to-face education via workshops at ACHS, onsite workshops and webinars. Additionay, approximatey 1,000 members and surveyors undertook elearning during this time. The EQuIPNationa Accreditation Workbook to assist with EQuIPNationa was reeased in May ACHS updated seven cinica indicator sets in 2013: the Day Patient (previousy Day Surgery), Gastrointestina Endoscopy, Ophthamoogy, Radioogy, Radiation Oncoogy, Paediatrics and Obstetrics sets. The Infection Contro, Hospita- Wide and Gynaecoogy wi be reviewed in the future. In updating these Cinica Indicators (CIs), ACHS coaborated with a wide range of medica coeges, societies and organisations, and has drawn upon the cinica expertise from many speciaist organisations and cinica discipines. It is their knowedge and expertise that makes the Cinica Indicator Program such a successfu resource. ACHS ANNUAL REPORT

18 The Quantum Leap Conference, measurement redefining heath s boundaries (September 24-27, 2013) ACHS Staff in action at the 2012 Annua Conference. 14 ACHS ANNUAL REPORT

19 ORGANISATIONAL CHART ACHS Board of Directors Counci ACHS Internationa Board of Directors Chief Executive Executive Assistant Communications Manager Communications & Events Officer Internationa Business Executive Director Corporate Services Executive Director Customer Services Executive Director Deveopment Unit Executive Director Internationa Business Co-ordinator Administrative Assistant Business Support Services Business Manager Project Officers Executive Assistant Executive Assistant Accreditation Administration Services Manager Senior Admin Assistant Admin Assistants Word Processing Officers Cerica Assistant Receptionist Trainees Education Administration Services Supervisor Admin Assistants Financia Services/ Human Resources Management Administrator Assistant Accountants Accounts Officer Customer Services Team Manager Customer Services Managers Education & Support Services Education Manager Education Consutants Surveyor Workforce Resource Co-ordinator Surveyor Booking Administrator Survey Booking Assistant Standards & Program Deveopment Senior Project Officer Project Officers Performance & Outcomes Service Cinica Director Manager Project Officer Data Anayst Research IT Services IT Manager Senior Anayst Programmer Anayst Programmer Network Engineer IT Support Officer ACHS ANNUAL REPORT

20 OUR ORGANISATION OUR EXECUTIVE TEAM Mr Brian Johnston Dr Lena Low Ms Laurie Leigh Ms Linda O Connor Dr Desmond Yen Mr Brian Johnston Dip Pub Admin (NSWIT), BHA, FCHSE, FAICD, FAIM ACHS Chief Executive unti February 2013 Mr Brian Johnston has been Chief Executive of the ACHS since November He has been professionay invoved with the ACHS since being appointed as a surveyor in 1985 and was aso previousy a member of the Standards Committee for six years. He has quaifications in heath administration from the University of New South Waes and in pubic administration from the NSW Institute of Technoogy (now the University of Technoogy, Sydney). Mr Johnston is a Feow of the Austraasian Coege of Heath Services Management, a Feow of the Austraian Institute of Company Directors (AICD) and a Feow of the Austraian Institute of Management. He hods appointments as Visiting Feow, Centre for Cinica Governance Research, at the Facuty of Medicine, University of New South Waes; Adjunct Associate Professor, Schoo of Heath, Griffith University and is a member of the Management Committee of the Roya Austraasian Coege of Surgeons Austraian Safety and Efficacy Register of New Interventiona Procedures - Surgica. He is a member of the Counci for the IAP provided by ISQua and was the Chair from 2006 to He was awarded Life membership of ISQua in Dr Lena Low PhD, MBA, Grad Dip Mgmt, JP, AFACHSM, FAICD Executive Director - Corporate Services Dr Lena Low has been with the Austraian Counci on Heathcare Standards (ACHS) since November 1995 and ACHS Internationa (ACHSI) since its inception in 2005; she has been invoved in deveoping heath care accreditation systems for more than 15 years. Her portfoio covers finance reporting for both ACHS and ACHSI, information technoogy, human resources management, business deveopment, business support services and organisation wide risk management. She is a reguar presenter of ACHS s heath care accreditation toos to internationa deegations and at training sessions for surveyors both nationay and internationay. Dr Low s quaifications incude: Master of Business Administration, Dipoma Austraian Institute of Company Directors, and Doctor of Phiosophy. Her doctorate speciaisation in pubic heath and community medicine was competed in 2012 and is tited: Medica cinician surveyors in the hospita accreditation process: their motivations for participating, the factors that infuence them and how they dea with those infuences. The doctorate contributes to the groundbreaking research into the correation between accreditation processes and quaity of care undertaken by the Austraian Institute of Heath Innovation, Centre for Cinica Governance Research in Heath, University of New South Waes, Austraia. Dr Low is a Visiting Feow at the UNSW. She is aso a member of the Internationa Society for Quaity in Heath Care (ISQua) Accreditation Counci; an ISQua surveyor who has ed survey teams for ISQua in France, India and New Zeaand. Currenty acting in the roe of Chief Executive of the ACHS, Dr Low is Company Secretary for both ACHS and ACHSI. Ms Laurie Leigh BA (Hons), MA, Dip (Nursing Studies), MA CANTAB, MA HSM, RMN (UK), RN (Aus), AFCHSM, GAICD Executive Director - Customer Services Ms Laurie Leigh commenced with the ACHS in March 2009 in the roe of Executive Director - Customer Services. Her key responsibiities incude the management of program membership and accreditation services, the surveyor workforce and the ACHS education services. Ms Leigh has previousy hed a number of senior heath management positions; most recenty as a nurse manager for menta heath services within a arge area heath service. Having moved to Austraia from the UK in 2003, Ms Leigh s professiona experience is as a menta heath nurse and senior manager for menta heath services within hospita and community settings. Her breadth of experience in the two heath systems is an area of expertise as is change management 16 ACHS ANNUAL REPORT

21 and quaity improvement. Both as a cinician and as a heath service manager, she has a broad experience in impementing the safety and quaity agenda within arge, compex heath service organisations. She has quaifications in socia psychoogy, mathematics, person-centred counseing and menta heath nursing. Ms Leigh has an MA in Heath Services Management with the University of Technoogy, Sydney. She is a graduate of the Austraian Institute of Company Directors (AICD) course. Ms Linda O Connor BAppSc, Grad Dip (Med Utrasound), MA (Org Com), AMS, CPHQ, GAICD Executive Director - Deveopment Ms Linda O Connor joined ACHS in September 2010, and as Executive Director of Deveopment, is responsibe for standards and product deveopment, the ACHS cinica indicator program, and research. Linda has worked in heath care for 20 years, and is a Board Certified Professiona in Heathcare Quaity. Ms O Connor has both nationa and internationa experience. In the senior management team of Harvard Medica Internationa, the internationa consuting arm of Harvard Medica Schoo, she worked between Boston and Dubai to estabish the Center for Heathcare Panning and Quaity, Dubai Heathcare City. As Head of Quaity, she ed numerous heath care education and quaity improvement initiatives, incuding deveopment of heath care poicy and quaity standards, estabishment of the heath care accreditation program, and coordination of an internationa Quaity Counci. Dr Desmond Yen B Com, MBA, DBA, FAICD Executive Director - Internationa Business Dr Desmond Yen joined the ACHS in Juy 1995 and is a key member of the ACHS Executive team. His current portfoio primariy covers a aspects of internationa business. Prior to his current roe, he was responsibe for the ACHS Corporate Services. His mutipe responsibiities have incuded strategy, poicies and systems deveopment, finance, risk management, information technoogy and support services. He has been exposed to a aspects of heath care accreditation requiring interaction with the ACHS Board, Counciors, member organisations and the surveyor workforce. Dr Yen s broad range of experience, mainy within arge muti-nationa organisations, covers a mix of oca and internationa strategic management, finance, and information technoogy roes. Dr Yen is a surveyor for ISQua and has surveyed the South African, Maaysian and Jordanian accreditation agencies. Dr Yen hods graduate quaifications in commerce, a Masters Degree in Business Administration, a Doctorate in Business Administration and is a Feow of the AICD. Ms O Connor has coaborated on projects with the Joint Commission, Internationa Organization for Standardization (ISO) and Accreditation Canada. Her cinica speciaties incude high risk obstetric utrasound and diagnostic medica imaging, and she aso hods a Masters Degree in Organisationa Communication. She was previousy empoyed by Mater Radioogy, Mater Private Hospita Sydney. She has contributed cinicay to the BreastScreen Austraia Program, and is currenty appointed to the BreastScreen Austraia Accreditation Review Committee. Linda is a graduate of the Austraian Institute of Company Directors (AICD) course. ACHS ANNUAL REPORT