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 [email protected]. 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: [email protected] 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: [email protected] 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
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