ACHS Annual Report 2021-2022

ANNUAL REPORT 2021-2022

Common acronyms included in this Report:

ACHS – The Australian Council on Healthcare Standards

ACHSI – ACHS International

ACSQHC – The Australian Commission on Safety and Quality in Health Care

ACIR – Australasian Clinical Indicator Report

EQuIP – Evaluation and Quality Improvement Program

EQuIP7 – the 7th edition of the ACHS Evaluation and Quality Improvement Program

NSQHSS – National Safety and Quality Health Service Standards

SAC – State Advisory Committee

October 2022 © The Australian Council on Healthcare 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 Australian Council on Healthcare Standards.

The Australian Council on Healthcare Standards Annual Report 2021 - 2022

ISBN: 978-1-875544-35-6 (Paperback)

ISBN: 978-1-875544-43-1 (E-book)

This Report is available in PDF format via the ACHS website (under ‘About us’ / Governance menu option) from the homepage: www.achs.org.au

To order a printed copy, please contact Communications at:

The Australian Council on Healthcare Standards

5 Macarthur Street

Ultimo NSW Australia 2007

Telephone 61 2 9281 9955

Facsimile 61 2 9211 9633

E-mail communications@achs.org.au Website www.achs.org.au

CONTENTS

About ACHS

Mission, vision and values ........................................................................................ 2 Strategic goals 3 Facts and figures 4

Who we are: a corporate overview 5 Our history The Council ACHS Assessors Funding Partnerships

Our Performance

President’s message ................................................................................................ 6 Chief Executive Officer’s message ......................................................................... 7 Highlights of 2021 - 22 ............................................................................................ 8

Recognising Achievement

ACHS Medal 2021 12 Quality Improvement Awards 14

Division Reports

ACHS International 16 Customer Services and Development 18 Corporate and Assessor Divisions 22 The Improvement Academy 26

Our Council

ACHS Council members 28

Our Board of Directors

ACHS Board of Directors ..................................................................................... 30

ACHS vision: Inspiring Excellence in Healthcare

Our mission

ACHS provides a partnership approach to continuous improvement tailored to the needs of individual services and health systems using its expertise in standards, accreditation, education and training.

Our vision

“Inspiring excellence in healthcare”

Our vision statement is focused on our core business. We aspire to excellence in all aspects of healthcare and want to inspire others to strive for excellence.

Our values

Values are the key foundation to our organisation. They describe what is important to us and frame how we work.

Collaboration

We work with our stakeholders to achieve goals

Accountability

We take responsibility for our performance

Commitment

We are committed to fostering an innovative and outcomes driven culture

Adaptability

Our flexibility enables us to adapt and embrace change

Responsiveness

We are quick to respond to the needs of our members and the ever-changing health landscape

Excellence

We strive for excellence in everything we do

Strategic goals

The new ACHS Strategic Plan 2022-2025 has been developed by the ACHS Board, Council and Executive through analysis, consultation and feedback with input from key stakeholders including consumers, members, staff, health departments, government safety and quality agencies, professional colleges and international societies.

Our new Strategic Goals for the future are:

Strengthening member engagement and experience

We will strengthen the ACHS through demonstrating value for members and actively growing membership

Enhancing and diversifying our services

We will enhance our current ACHS offerings, develop new products and services and explore new aligned markets

Demonstrating leadership and innovation

We will show leadership by investigating new approaches to safety and quality improvement and external evaluation in the national and international communities

Strengthening member engagement and experience

Within ACHS we will ensure we provide excellence in service delivery and work with our key partners to leverage capability

Who we are: a corporate overview

Our history

The Australian Council on Healthcare Standards (ACHS) is now into its fifth decade having marked its 48th anniversary in 2021.

Since its establishment in 1974, the ACHS has been the pre-eminent, independent, not-forprofit organisation focussing on improving the quality of healthcare through standards and accreditation.

Over the past 17 years it has built its global influence as both a developer of healthcare standards and as a accreditation agency. ACHS has continued to expand its expertise through education, training and consultancy services.

The Council

The Council exists to support Australia’s largest hospital and healthcare accreditation agency.

• In 2021 - 22 there were 23 Council member organisations with 23 Council member representatives, drawn from peak bodies in the health industry, as well as representatives from governments and consumers. ACHS is governed by a Board of nine Directors.

What we do

• We support both the national accreditation system as well as developing our own accreditation programs, suitable for use in a range of countries.

• ACHS has an enviable reputation as an independent, healthcare accreditation provider currently exporting its successful program of accreditation to 17 countries.

ACHS Assessors

ACHS is privileged to have the services of our assessors who enable us to deliver a strong accreditation program nationally and overseas.

• We currently have more than 259 assessors

• ACHS invests in education and developing the assessor cohort to build on their professional knowledge

• The majority of our assessors continue to work in full-time roles as health professionals.

Funding

As a not-for-profit, ACHS is a company limited by guarantee, and as such is recognised by the Australian Securities and Investments Commission (ASIC).

Most of our funding is derived from membership fees.

Our education services attract a broad crosssection of the health community and this supplements our income streams.

Partnerships

As the pre-eminent hospital and healthcare accreditation agency in Australia:

• we work in a range of different partnerships that are either mutually supportive or jointly collaborative in nature.

• we aim to bring value to the different areas that we support.

President’s message

Professor Len Notaras AO President, Board of Directors

ACHS continues to demonstrate an outstanding capability to innovate and support the healthcare community respond to emerging challenges. A testament of our true and admirable capacity, ACHS maintained core and critical functions with minimal disruptions while ensuring staff wellbeing.

In the past year, ACHS has demonstrated the ability to innovate our delivery of service in the accreditation space while upholding standards of excellence in safety and quality in an everchanging healthcare landscape.

The team have put in tremendous effort to help launch a revitalised ACHS website that incorporates the organisation’s new branding. The updated website provides easier navigation and access to information for our members, stakeholders and assessors. A key focus moving forward will be on enhancing the brand’s digital engagement, further streamlining our processes and the way our customers interact with us.

ACHS has continued to offer new products that respond to market demand. The new Rainbow Tick Accreditation Program is now being offered as part of ACHS’ accreditation and standards assessment portfolio. This represents an important milestone for the organisation towards promoting inclusiveness and health equity among our members.

ACHS has also launched new EQuIP7 Standards in a modular program which is tailored with content applicable for individual healthcare service types in support of our international members.

In this year, ACHS welcomes three new Councillors to the ACHS Council, representing the following member organisations: Australasian College for Emergency Medicine, Australian and New Zealand College of Anaesthetists, Consumers Health Forum of Australia.

I wish to congratulate the staff and Executive team at ACHS for their continued resilience and dedication this year. Outstanding leadership and unswerving commitment has been demonstrated at every level and, along with my colleague Directors, I extend our sincerest gratitude to all.

We have seen great achievements and the Board remains committed to achieving its strategic priorities as set out in the ACHS Strategic Plan 2022-2025.

Professor Len Notaras AO President, Board of Directors

Chief Executive Officer’s message

Dr Karen Luxford Chief Executive Officer

It has been an incredible year at ACHS, and I am most impressed by the outstanding leadership and commitment demonstrated by our staff and Members.

ACHS recognises the significant impact COVID-19 continues to have on the provision of health services across Australia and the world. We remain committed to supporting our Members and the wider healthcare community throughout these extraordinary times.

A key focus across the organisation this financial year has been on the implementation of the ACHS Strategic Plan 2022-2025. The plan will guide our strategic development and engagement with stakeholders over the next three years as we focus on our vision of inspiring excellence in healthcare.

This year we recommenced our face-to-face events, namely the Assessor’s training day as well as onsite customer support visits which were led by our devoted Customer Service team. It is always a pleasure to be able to connect with our Members and colleagues in various settings and we welcome future opportunities to participate in face-to-face events.

The Improvement Academy (IA), ACHS’ education and training arm, continued to deliver excellent support to clinicians and healthcare leaders in responding to new demands and challenges. The Academy held a total of 90 days of virtual interactive sessions and Masterclasses, helping to connect healthcare practitioners with industry experts and thought leaders.

I am also delighted to announce that ACHS received outstanding results from the

International Society for Quality in Health Care (ISQua)’s External Evaluation Association (EEA)’s accreditation assessment of our own organisation. This is an accreditation process we must undergo every four years to be able to continue offering quality accreditation services to our Members. Undertaking the accreditation serves as a reminder for our organisation on what it feels like to be assessed. I am very proud of our team for their ongoing dedication to quality improvement and know that this result serves as an affirmation of all their hard work.

I would like to convey my thanks to the Board of Directors for their ongoing support of ACHS’ strategic growth and development. I also would like to acknowledge our fabulous staff and amazing Executive team for all that they have accomplished this year.

Dr Karen Luxford Chief Executive Officer

Highlights

Financial year 2021-2022

ACHS received outstanding results from the IEEA accreditation, which ACHS undergoes every four years. ACHS was commended by IEEA surveyors on the significant work we have done around each Standard over recent years.

In final report, ACHS was acknowledged for its areas of strength including “strong leadership” and “exceptional systems and processes”.

ACHS commenced implementing the 2022-2025 Strategic Plan, including key initiatives such as the Integrated Business Management System project to improve member and assessor support.

ACHS became an independent provider of the Rainbow Tick accreditation. The Rainbow Tick Accreditation is for health and human services organisations seeking to provide a safe and inclusive workplace and services for the LGBTIQ community.

Internationally recognised, Nobel Laureate Professor Peter Doherty AC, was the Guest Speaker at our annual Virtual Awards Ceremony 2021 on 25 November.

Prof Doherty spoke about the COVID-19 pandemic and the work of immunologists and health care workers to build a safer world.

The new ACHS website was developed and launched to provide better user experience and incorporate new branding.

The new website has a user friend portal and streamlined navigation with improved accessibility of information for our Members, stakeholders and assessors.

ACHS was very pleased to welcome back former members, Barwon Health, Children’s Health Queensland, and Toowong Private Hospital. The first hospital accredited by ACHS was Geelong Hospital in 1974, now known as University Hospital Geelong - part of Barwon Health.

ACHS implemented our new Extended Lead Assessor cohort and engaged further new assessors with current health service leadership experience.

ACHS held its first face-to-face Lead Assessor Forum in two years. The Forum was focused on ACHS Strategic Directions, outlining key initiatives that will enhance assessment experience for both members and assessors.

Interactive group sessions included discussions of assessment processes, use of mobile technology and planning to support virtual and hybrid assessment.

Highlights

ACHS

Our Improvement Academy ran a highly successful Masterclass Series, complimentary to our Members.

A highlight, was the discussion between Improvement Academy Director, Adj Assoc Professor Bernie Harrison and President and CEO at the Institute for Healthcare Improvement (IHI), Dr Kedar Mate, on how we use improvement science to address the key challenges in healthcare today.

ACHS launched the 7th Edition of our Evaluation & Quality Improvement Program (EQuIP) Standards: EQuIP7 for use internationally.

The Performance and Outcomes Services Team initiated a project to enhance the analytics and software behind our performance indicator reporting, improving usability and reporting for Members.

partnered with Monash University and Eastern Health on research on new digital models to support health service assessment through a national Digital Health CRC project.

The Australian Private Hospitals Association (APHA) National Congress was the first face to face congress attended by ACHS in two years.

The Congress focused on topics such as new models of care, workforce challenges, virtual hospitals and quality data reporting.

ACHS President, Prof Len Notaras, AO was appointed as Chair of the WHO Emergency Medical Team (EMT) Strategic Advisory Group (SAG). On this 2-year appointment, Professor Notaras will advise on the strategic direction of the EMT Initiative.

Supporting Australia's biggest healthcare expo, the 11th Annual Australian Healthcare Week Expo, CEO Dr Karen Luxford was a panellist discussing the topic: How to Enhance Clinical Governance for an Increasingly Digital Healthcare Service Environment.

After two years of restricted travel, CEO, Dr Karen Luxford joined ACHS International Regional Director, Bassel El Sayegh in a series of meetings across the Middle East to connect with our community.

Recognising Achievement

ACHS Medal

The prestigious ACHS Medal 2021 was awarded to Ms Christine Gee, CEO of Toowong Private Hospital (a private mental health facility), QLD

While her focus has been on mental health and the private health sector, her contribution has been felt across the entire health system, with extensive national leadership positions including:

• Member – Australian Council on Safety and Quality in Healthcare (forerunner to the Australian Commission on Quality and Safety in Healthcare - ACSQHC)

• Commissioner and Board member of the ACSQHC since its inception

• Chair – Private Health Industry Safety and Quality Committee (PHISQC)

• Chair – Private Hospital Sector Committee of the ACSQHC.

Ms Gee was awarded the ACHS Medal as part of the ACHS Virtual Awards Ceremony held on Thursday 25 November, 2021.

In presenting the award, ACHS President Professor Len Notaras, AO said “On behalf of the Board of ACHS, I am delighted to present this award to Christine Gee, whose contribution to safety and quality in Australian health care, with a particular focus on the private sector, is immense.”

“This award recognises an individual’s outstanding contribution to the promotion of quality and safety in Australian health service and Christine is recognised as a leader for her strong advocacy on quality improvement across a range of Standards setting committees and forums,” he said.

“Christine has not only had a direct impact in quality and safety in her own hospital, she has also committed time, energy and her considerable leadership skills in the promotion of safety and quality in health care at a national level, over a sustained period of time.”

Professor Notaras said that in her leadership roles within the Australian Private Hospitals Association (APHA), Christine has been a strong advocate of private hospitals leading the adoption of safety and quality practices. Critical achievements include:

• successfully advocating for amendments to the APHA Constitution to make accreditation a condition of membership, years before accreditation become mandatory,

• as Chair of the PHISQC, led the development of the “Private Sector Quality Criteria” which became a requirement for private hospitals to obtain eligibility for Second Tier Default benefits, thereby boosting quality requirements,

• overseeing a successful national trial of Drug Use Indicators in private hospitals and day facilities,

• involvement on the Private Hospital Sector Committee (PHSC) contributing to general Standards development in Australia being fit for purpose.

M s C h r i s t i n e G e e A C H S M e d a l l i s t 2 0 2 1

Christine Gee’s contribution to safety and quality in Australian health care, with a particular focus on the private sector is impressive.

Christine has not only had a direct impact as a leader but has also committed time, energy and her intellect to promoting safety and quality in healthcare on a national level over 25 years.

Her contributions have been felt across the entire health system with national leadership positions including:

Member Australian Council on Safety and Quality in Healthcare (forerunner to the ACSQHC)

Commissioner and Board member of the ACSQHC since its inception, and ACHS Councillor.

Along with numerous positions as Chair on Committees of or Advisory Groups, she was President of Australian Private Hospitals Association (twice) and Chair of the APHA Safety and Quality Taskforce.

As Chair of the Private Hospitals Health Industry Safety and Quality Committee (PHISQC)(prior to the establishment of the ACSQHC) Christine led the development of the “Private Sector Quality Criteria”, which were subsequently subsumed into existing accreditation standards.

In this role she also oversaw a successful national trial of Drug Use Indicators in private hospitals and day facilities.

Following the establishment of the ACSQHC, Christine successfully advocated for the creation of the Private Hospital Sector Committee (PHSC), providing a bridge between the Commission and the private sector, and ensuring its work in standards development has been fit for purpose.

Christine was responsible for ensuring the alignment of the NSQHS Standards with the National Standards for Mental Health Services and helped develop standards regarding recognition and response to mental health deterioration in acute care settings.

She has been a strong advocate of private hospitals leading the way in the adoption of safety and quality practices, advocating for amendments to the APHA Constitution to make accreditation a condition of membership, years before it become mandatory.

Christine’s personal philosophy has always put patients at the centre of care and this is reflected in her work. Congratulations Christine on your many achievements and being the deserving winner of the ACHS Medal 2021.

Recognising Achievement

ACHS’s 24th Annual Quality Improvement Awards

Illawarra Shoalhaven Local Health District in NSW and two metropolitan Sydney hospitals, Liverpool Hospital, Liverpool and Prince of Wales Hospital, Randwick were the final winners in the 24th annual ACHS Quality Improvement (QI) Awards 2021.

Each health service demonstrated their strong commitment to supporting and developing innovation in different areas of healthcare that individually will impact on patient safety.

Illawarra Shoalhaven Local Health District won the Clinical Excellence and Patient Safety Award for safer, better emergency nursing care with their HIRAID submission: ‘a proven, up-scalable emergency nursing framework’ aimed at ensuring Emergency nurses have an evidence base to their initial assessment and management of patients who enter Emergency.

Liverpool Hospital won the Non-Clinical Service Delivery Award for their ‘12 Books for 12 Months: Enhancing Early Language and Literacy Environments’ – a preventative language and pre-literacy program.

The Healthcare Measurement Award was won by Prince of Wales Hospital, Randwick NSW who undertook a clinical redesign of their clinical pharmacy services with their ‘Improving Access to Medication Review in High-Risk Inpatients’ project.

The Global Quality Improvement Award is a fourth category for ACHS International members. This Award recognises projects that use Australian healthcare standards to strengthen quality improvement frameworks internationally. There were two joint winners of the Global Quality Improvement Award this year:

• Fresenius Medical Care Asia Pacific won for their ‘Implementation of an Electronic Auditing Program Across 10 Countries’ project.

• Hong Kong Baptist Hospital won for their ‘Key to Combat COVID-19 in Hong Kong Baptist Hospital: Agility, Dedication and Passionate Support from All Staff Levels’ COVID-19 response project.

ACHS CEO Dr Karen Luxford presented the Awards in the four categories – Clinical Excellence and Patient Safety, Non-Clinical Service Delivery, Healthcare Measurement, and Global Quality Improvement.

There were a high number of entries this year, with a critical focus on patient safety and quality improvement during a pandemic. For the second year, many submissions focused on COVID-19 response management and adapting practices to meet new circumstances.

The awards promote innovation by introducing considered, timely improvements across the spectrum of health, placing patients at the centre of care. Every submission builds on previous practices by challenging current thinking and exploring new ways to address emerging issues.

ACHS is proud to host these Awards that recognise the strong new innovations that will benefit patients and their families.

Details of QI Awards submissions can be found in the Quality Initiatives publication

Quality Improvement Award Winner: Illawarra Shoalhaven Local Health District

Quality Improvement Award Winner: Liverpool Hospital

Quality Improvement Award Winner: Prince of Wales Hospital

Quality Improvement Award Winner: Fresenius Medical Care Asia Pacific

Quality Improvement Award Winner: Hong Kong Baptist Hospital

ACHS International

ACHS International remains the trusted quality improvement partner to healthcare organisations across 17 countries in the Middle East and Asia Pacific.

We are focused on supporting organisations to continually improve the safety, quality, value, and outcomes of care provided to their patients and community.

After two years of restricted travel, CEO, Dr Karen Luxford joined ACHS International Regional Director, Bassel El Sayegh in a series of meetings across the Middle East to connect with our community. They met with leaders of regulatory bodies, large healthcare groups, other healthcare facilities in all our primary target countries to strengthen relationships.

Here are the key highlights of the ACHS International Team over the last financial year:

Expanded our service offerings and support:

• Launched the 7th Edition of our Evaluation & Quality Improvement Program Standards: EQuIP7

• Held our first face to face Assessor Competency Training in Singapore

• Launched Centre of Excellence program, Patient Centred Systems (PCS) Distinction Program and Safe Hospital Consulting Program

Partnered with like-minded organisations:

• Southeast Asia partner GlobalHealth Quality and Innovation Accreditation (GHQIA)

• ICON Group Singapore

• KIMSHEALTH

• GNP Group

• Nahdicare

• Liberty Dental Clinic

• Successful assessments with new and

existing member organisations including Badr Al Samaa, the largest private hospital group in Oman

Provided continuous learning opportunities and recognition:

• Launched ACHS International online learning platform – Learning Vault

• Member Forums, educational webinars and expert panels

• Awarded the ACHS International Medal 2022 to Dr Jamil Ahmed (Middle East) and Dr Fu-Chan Wei (Asia Pacific)

Participated in key conferences:

• Arab Health in Dubai, UAE

• Knowledge partner at the Consortium of Accredited Healthcare Organisations (CAHO) in Kochi, India

Visited ACHS International Member ICON Cancer Centre in Singapore

Held our first face to face Assessor Competency Training in Singapore

Welcomed new member Nahdicare Group in Jeddah, Saudi Arabia

Awarded accreditation certficates to Badr Al Salma Group of Hospitals in Oman

Connected with ACHS International Member Bahrain Military Hospital

Congratulated GNP Hospital, Saudi Arabia for achieving EQuIP Standards

Customer Services And Development

Customer Services

The Customer Services Managers (CSMs) are responsible for contract and relationship management for all domestic accreditation members (customers). All events during the accreditation cycle are managed within the Customer Services team, with the support of the Accreditation Administration Division. This includes new member enquiries, contract negotiation, contract renewals, scheduling of assessments, providing support pre and post assessment, and quality assurance on assessment reports.

The CSMs support ACHS members in the implementation of accreditation programs, such as keeping the member organisations abreast of updates from the Australian Commission on Safety and Quality in Healthcare (ACSQHC). Customer support is provided via telephone, email, online meetings and onsite visits throughout the entire accreditation contract cycle. Onsite support visits, which were paused due to COVID lockdowns/restrictions, were recommenced during FY22.

Key achievements

• Implementation of new product - Rainbow Tick Accreditation

• Resumption of onsite customer support visits

• Welcomed back Barwon Health, Children’s Health Queensland, and Toowong Private Hospital

• Received the first Day Procedure Centre member (Far North Day Hospital) under the Short Notice Assessment Program

• Completed 230+ quality assurance reviews on assessment reports

• Conducted 875+ support meetings (virtual/ onsite)

Welcomed back member organisation Children’s Health Queensland

Implemented new product: Rainbow Tick Accreditation Program

Presented accreditation certificate to South Australia Ambulance Service

Standards and Product Development

Standards and Product Development (SPD) is responsible for the generation and maintenance of ACHS quality improvement programs including a range of EQuIP Standards and Guides for Hospital, Ambulatory Care, Dialysis, Oral Health, Cancer Care, Telehealth, Residential and Home Care and Primary Healthcare Services.

SPD prepares ACHS responses to Australian Commission on Safety and Quality in Health Care (ACSQHC) submissions for accreditation approval, annual ACSQHC feedback reports, and all other ACSQHC submissions and requests for feedback. This section also develops resources and specialist publications to support ACHS programs. SPD works in consultation with key internal and external stakeholders to ensure program development reflects current health priorities and contemporary best practice.

SPD contributes to various special projects undertaken by ACHS, as well as industry consultations, the development of relevant healthcare standards with Standards Australia and representation on external Committees on behalf of ACHS. The ACHS Annual Quality Improvement (QI) Awards acknowledge and encourage outstanding quality improvement activities, programs or strategies that have been implemented in healthcare organisations. This section coordinates the Awards program.

Key achievements

• ISQua EEA accreditation of EQuIP7 Hospital and EQuIP7 Ambulatory Care Standards

• Finalisation and Board endorsement of EQuIP7 Residential and Home Care Standards

• Finalisation of EQuIP7 Guide for Dialysis Care

• Finalisation of EQuIP7 Guide for Oral Health

• Finalisation of EQuIP7 Guide for Cancer Care

• Finalisation of EQuIP7 Guide for Telehealth

• Presentation of ACHS Quality Improvement Awards at ACHS Virtual Awards Ceremony.

New EQuIP7 publications

Performance and Outcomes Service

The ACHS Performance and Outcomes Unit coordinates the development, collection, analysis and reporting of clinical indicators.

The ACHS Clinical Indicator Program (CIP) is Australia’s longest running clinical indicator program and has more than 347 clinical indicators across 22 specialty medical disciplines.

The program operates by facilitating benchmarking with participating healthcare organisations at an organisational, peer, and national level.

Key achievements

• Assisted more than 614 healthcare organisations reporting 27,725 individual clinical indicators across Australia and international regions.

• Four clinical indicator sets were reviewed and updated (Oral Health, Maternity, Radiology, Radiation Oncology).

• A project to improve the analytics and software behind the Performance Indicator Reporting Tool was commenced.

• Promoted the Clinical Indicator Program through 57 training sessions across Australia and internationally.

Standards Committee

The Standards Committee is a permanent standing committee of the ACHS Board with a pivotal role in guiding and refining development of new ACHS standards and programs, and reviewing proposed changes to existing ACHS Standards. The Committee reports its recommendations directly to the ACHS Board.

The Standards Committee has broad representation from across the health care sector, including members with experience as ACHS assessors. Committee membership is drawn from both the public and private sectors and includes clinicians, consumers, senior health administrators, allied health professionals, and quality managers. Standards Committee membership includes International representation from New Zealand, Asia and the Middle East. International representation is also provided on Standards Committee working groups.

Dr Philip Hoyle Chaired the Committee during the period 2021-2022. Committee membership also includes the President of the ACHS and the ACHS Chief Executive Officer. The Standards Committee is administered by the ACHS Standards and Product Development Unit, led by the Executive Director - Customer Services and Development.

A major focus for the Standards Committee during 2021-2022 was the finalisation of EQuIP7 Standards.

Appointed Prof Stephen Tobin as our new Clinical Advisor to support CIP

The Australasian Clinical Indicator Report 2013-2020 was published in November 2021

Standards Committee Members

Name Representation

Dr Malathi Arshanapalai

Ms Margo Carberry

International Member – UAE / India

Public Sector / Allied Health / Community and Rural Health / ACHS Assessor

Ms Roslyn Chataway Consumer Representative

Ms Cathy Cummings International Member – New Zealand

Ms Helen Dowling

Prof Brett Emmerson AM

Public Sector / Allied Health / Pharmacy / ACHS Assessor

Public Sector / Mental Health / ACHS Councillor / ACHS Board member / ACHS Assessor

Dr William Ho International Member – Hong Kong SAR

Dr Philip Hoyle (Chair)

Public Sector / Clinician / ACHS Assessor

Ms Cathy Jones Private Sector / Aged Care

Ms Joanne Levin Private Sector / Corporate

Adj Assoc Prof Karen J Linegar (to Feb 2022)

Public Sector / Nursing / ACHS Councillor / ACHS Assessor

Dr Karen Luxford (ACHS CEO) ex-officio

Dr Nashat Nafouri International Member – Saudi Arabia

Prof Len Notaras AO (ACHS President) ex-officio

Ms Samantha Sanders

Private Sector / Day Procedure Centres / ACHS Councillor

Dr Nellie Yeo International Member – Singapore

Corporate and Assessor Divisions

The Corporate and Assessor Divisions (CAD) supports the entire organisation and its external stakeholders.

Key responsibilities of the CAD include, management of all aspects of the Assessor cohort, management of the IT infrastructure and software of ACHS, management of ACHS finances, administration of the ACHS State Advisory Committees (SACs), internal and external data reporting and analysis, as well as the administration of the accreditation processes.

Information Technology

• Initiated the Integrated Business Management Solution (IBMS) project with US based software company, NextLOGiK. This is a multi-year data transformation project to implement a new customer interface, revised business processes and back-end system integrations

• Implemented a new Unified Communication System using Zoom Phone to deliver IP based telephony services to staff in the office and working remotely

• Further developed ART2 electronic tool to support the redeveloped EQuIP7 program

• Implemented a new website to deliver a thoroughly revised and modern web experience to our stakeholders

• All staff undertook a 12 month Cyber Awareness training and testing program

• All meeting rooms have been fitted out with video conferencing capability in order to enhance communication and collaboration with our members, assessors, stakeholders and staff

Finance and Human Resources Administration

• Unqualified audit report received

• 7.9 years average length of service for employees

• 100% completion of staff performance appraisals

• 100% new employees completed orientation programs

• Continued to support strategic decisionmaking through increased management and Board reporting focusing on future oriented financial scenario planning

• Enhanced Performance Framework

• Implemented Employee Self Service (ESS) and payroll system to the cloud, increased access, reduced double handling, improved data security, back up and disaster recovery capabilities

• 360 degree performance management system with goals linked to Key Strategic Areas implemented

• ACHS Ultimo office compliant with NSW Health requirements for staff Return to Office

Accreditation Administration Services

• Conversion of National Standards assessments scheduled from 1 January 2022 to NSQHSS 2.1 edition

• Monthly reporting to Australian Commission on Safety and Quality in Health Care (ACSQHC)

• 94% of reports processed within expected time frames

• 98% of new memberships processed within three days

• 97% of accreditation outcomes processed within two working days

Business Services

• NSQHS Standards and NGPA Scheme data and other adhoc reports submission timeframes were met with no negative feedback received

• 100% of data requests were accurate, provided within the requested timeframe and received no negative feedback

• All staff supported through health and safety initiative

• Flu vaccination offered to all staff

Fitted out all meeting rooms with virtual meeting capability

Supported staff through health and safety initiatives - RUOK Day 2021

Assessor Division

Our Assessor Cohort is structured to ensure consistency and support across all levels. Our systems and processes ensure that facilities will be fairly and consistently reviewed.

“Lead Assessor was fantastic and she was able to give us clear directions and feedback. We are really happy with the outcome of this assessment after a very challenging time with the floods.”

“We had great Assessors so I would definitely recommend ACHS”

“Extremely satisfied with the outcome and the way the assessment was conducted. Assessors made it a more relaxed environment and the feedback given by Assessors was valuable and informative.”

Introduction of Extended Lead Assessor Cohort

• Review of reports for consistency

• Observational audits

• Mentoring and education

• Review of Assessor cohort structure and training systems

• Extended Lead Assessor cohort

• Training and performance management focus on consistency / inter-rater reliability

• Implementation of Triage hotline for Assessors in the field

• Review of Assessor Allocation system

• Assessors trained to assess Rainbow Health Australia accreditation program

• Appointment of Director Assessor Division

Assessor Training

First face to face Lead Assessor Forum & Assessor Competency Training since 2019

Our Assessors undergo regular training and performance review ensuring consistency

• Ensuring inter-rater reliability with effective communication for quality and consistency

• All Assessors are compliant to ACSQHC requirements

• Regular Assessor Meetings

• Assessor Newsletters

• Assessor Portal

• Regular Communication

Extended Lead Assessor Mentor, educator, report reviewer, performance management Lead Assessor Leader of assessment teams Assessor Member of assessment teams

Retiring

Ormond Pearson 1991 70 164 31

Peter Johnson 1994 89 214 27

Irene Lake 1995 65 230 26

Paula Hanlon 2000 53 201 21

Peter Renshaw 2001 42 153 21

Margo Carberry 2002 35 99 20

Lynn Ford 2002 45 153 20

Sally Percy 2008 124 324 13

Anna Fletcher 2009 121 324 12

Dianne Gray 2010 58 200 11

Bobbie Carroll 2010 90 325 12

Improvement Academy

The Improvement Academy (IA), continued to deliver the majority of its events as virtual interactive training. There were 90 days of virtual training held with a total of 5,800 registrations.

Virtual Interactive Training

Root Cause Analysis

• Run every month, excellent attendance

• Participants from across the country (& some international participants from NZ) and the health sector – community, acute, mental health, aged care, ambulance services. Including health executives, managers, quality managers, clinicians

• Emphasis on sustained quality improvement in response to clinical incidents

Clinical Incident Analysis (similar to RCA) for QLD Health

• Custom course for QLD Health including reference to QLD legislation and policy

• Managers and clinicians across QLD Health attended

• Very positive feedback from QLD Health Executive and participants

Patient Journey Mapping

• This very popular 3 x 3 session virtual course has had 255 attendees

• Provides a framework to understand process, pressure and pain points experienced by patients and design interventions accordingly

• Practical course with theoretical components intertwined

List of public training FY2021-2022

Quality Improvement Lead Training Program

Root Cause Analysis

Introduction to Patient Journey Mapping

Leadership - It Starts with you

Introduction to Human Factors in Healthcare

Open Disclosure

Comprehensive Care Standard 5

Partnering with Consumers to Improve Health Care Services

Aged CareChange Management

Aged Care - Implementing Recommendations

Aged Care - Open Disclosure

Aged CareSerious Incident Investigation and Response

I never cease to learn something from any event I have attended - so much to learn, share and improve and so much information and expertise provided to help this occur.

Member Masterclass Series

We had the privilege of hosting four renowned international experts on the topic of Quality and Safety in our ACHS Masterclass series in FY 2021-2022. These Masterclasses were free and exclusive to all our Members from across Australia and overseas.

Presenter Title

Peter Lachman

Maxine Power

International approaches to Safety & Quality ImprovementAfter COVID, what have we learnt?

Managing hospital flow at the peak of the COVID pandemic in NHS England

David Gilbert The Rise of Patient-Consumer Leadership

Kedar Mate

The Importance of Quality as we confront disruptors of traditional health systems

The Improvement Academy Director, Adjunct Associate Professor Bernie Harrison conducted our first ‘in conversation’ style Masterclass, with President and Chief Executive Officer at the Institute for Healthcare Improvement (IHI), Dr Kedar Mate (pictured on page 10).

The discussion covered the importance of quality as we confront disruptors of traditional health systems and how we use improvement science to address the key challenges in healthcare today. This conversation was very well received by our members, with a record number of attendees.

Today's Masterclass session was very informative yet concise. I have learnt heaps and looking forward to future sessions!

Masterclass with Dr Peter Lachman

Masterclass with Dr Maxine Power

Masterclass with Mr David Gilbert

Council members

Our Council represents consumers, governments and peak health industry bodies from throughout Australia.

ACHS Council as at 30 June 2022 was 23 Councillors, including two life members.

Dr Patricia Bradd

PhD, B.AppSc (Speech Path), GradCertMgmt, MHlthLeadMgmt, Fellow.SPA NSW Ministry of Health

Ms Roslyn Chataway Consumers Health Forum of Australia

Dr Carmel Crock MD, FACEM, OAM

The Australasian College of Emergency Medicine

Professor Geoff Dobb BSc (Hons), MBBS, FRCP, FRCA, FANZCA, FCICM, FAMA Australian Medical Association (AMA)

Professor Brett Emmerson AM MBBS, MHA, FRANZCP, FRACMA, FCHSM

The Royal Australasian College of Medical Administrators (RACMA)

Dr Roger Jonathan Garsia MBBS, PhD, FRACP, FRCPA

The Royal College of Pathologists of Australasia (RCPA)

Dr Michael Hodgson AM FAMA, MBBS, FANZCA Life Member of ACHS Council

Assoc Professor Gregory Jenkins MBBS, FRANZCOG

Royal Australian and New Zealand College for Obstetricians and Gynaecologists

Mr Mark Kearin RN, ADCNS(Geront Nurs), BHSc(Mgt), MHSc(Mgt), FACN Australian Nursing Federation (ANF)

Clinical Associate Professor Peter Kendall MBBS, DA, FRACP, FCCP The Royal Australasian College of Physicians (RACPS)

Ms Sally Kincaid Allied Health Professionals Australia

Ms Bernadette Loughnane Rn, RM, BaHscN, GDNM, MaHSM, FCHSM, CHE, GAICD

Australasian College of Health Service Management (ACHSM)

Russell McGowan Health Care Consumers’ Inc

Dr Jon Mulligan MBBS, MHA, FRACP, FRACMA, GAICD Life Member of ACHS Council

Prof Leonard Notaras AO (President) AFCHSE, LLB, BA (Hons), DipComm, BMed, MHA, MA Northern Territory Department of Health and Community Services

Ms Robyn Quinn RN, BaHscN, MBA, FACN, FAAP M The Australian College of Nursing (ACN)

Ms Samantha Sanders Day Hospitals Australia

Dr Grant Sara

MB BS, MM, MM (Psychotherapy), FRANZCP, PhD

Royal Australian and New Zealand College of Psychiatrists

Dr Paul Scown

MMBS, BHA, FRACMA, AFACHSM, MAICD Australian Healthcare & Hospitals Association (AHHA)

Dr Phillip Truskett AM

MBBS, FACS, FRACS, FASCBI (Hons) The Royal Australasian College of Surgeons (RACS)

Dr Lakshmi (Nayana) Vootakuru B.Med, MPH, FANZCA Australian and New Zealand College of Anaesthetists

Mr Stephen Walker

AssDip.Eng, B.Bus, GradDipAcc, AFCHSE, MAICD Australian Private Hospitals Association (APHA)

Dr Noela Whitby AM MBBS, GradDipHumNut, DPD, FRACGP, FAICD The Royal Australian College of General Practitioners (RACGP)

Board of Directors

ACHS Board Members: representing consumers, governments and the Australian healthcare industry

Professor Len Notaras AO (President)

FACHSM, AFCHSE, LLB, BA (Hons), DipComm, BMed, MHA, MA

• ACHS President from 2017

• ACHS Vice-President from 2015

• ACHS Board member from 2002

• ACHSI Board member from 2009

• ACHS Councillor (Northern Territory Health representative) from 2002

• Founder National Critical Care and Trauma Response Centre 2004, Executive Director NCCTRC from 2009 - present

• Former Chief Executive Officer (CEO), NT Department of Health

Mr

Stephen Walker (BFARC Chair)

Ass Dip Eng, BA Bus (Health Management), Grad Dip Acc, FACHSM, MAICD

• Chair ACHS Business Finance, Audit and Risk Committee from 2012

• ACHSI Board member from 2011

• ACHS Board member from 2006

• ACHS Councillor (APHA representative) from 2006

• Chief Executive Officer, St Andrew’s Hospital, Adelaide from 2001 - present

• APHA Council Member

• Board Member Prostate Cancer Foundation Australia (SA) and Biotech Advisory Board

• Member, Australian Commission on Safety & Quality in Health Care Private Hospital Sector Committee

Professor Geoffrey Dobb

BSc (Hons), MBBS, FRCP, FRCA, FANZCA, FCICM, FAMA

• ACHS Business Finance, Audit and Risk Committee, and Governance Committee

• ACHS Board Member from 2011

• ACHS Councillor (Australian Medical Association representative) from 2011

• Head of Department, Intensive Care, Royal Perth Hospital from 2005 - present

• Clinical Professor, Faculty of Health and Medical Sciences, University of WA

• Board Deputy Chair, Child and Adolescent Health Service, WA from 2016

• Chair of the CAHS Safety and Quality Committee from 2016

Professor Brett Emmerson AM

MBBS (QLD), MHA (NSW), FRANZCP, FRACMA, FCHSM

• ACHS Board Member from 2015

• ACHS Councillor, (Royal Australasian College of Medical Administrators representative) from 2009

• Member, ACHS Standards Committee from 1994

• ACHS Assessor from 1994

• Executive Director, Metro North Mental Health Brisbane from 1997 - 2022

• Professor, School of Clinical Medicine, University of Queensland

Mr Anthony (Tony) Lawson

BA, BSoc.Admin, FIPAA, FAIM, CPMgr

• ACHS Board Member from 2012

• Member ACHS Board Finance, Audit and Risk Committee, Governance Committee

• ACHS Councillor (Consumers Health Forum of Australia representative) from 2012

• Former ACHS Assessor

• Chair, Consumers Health Forum of Australia Ltd from 2014 - present

• Awarded Professional Life Membership, IPAA (SA Division) 2018

• Member, Palliative Care Research Collaboration Program Advisory Committee

• Chair, Board of Governors, Statewide Palliative Care, The Hospital Research Foundation Group

• Member, CareSearch National Advisory Group

Mr Michael Roff

Grad

Cert Mgt.

• Independent Director appointed to the ACHS Board from November 2019

• ACHS Board member from 2004 to 2019

• ACHSI Board member from 2017

• ACHS Councillor (Australian Private Hospital Association representative) from 2004 - 2019

• Chief Executive Officer, Australian Private Hospital Association from 2000 – present

• Member, Australian Commission on Safety & Quality in Health Care Private Hospital Sector Committee, 2013 - present

• Member, Private Health Ministerial Advisory Committee 2016 – 2019

• Chair of the ACHS Governance Committee April 2016 to June 2021

• Chair of ACHS International Board from October 2021

Dr Paul Scown

MBBS (UQ), BHA (UNSW), FRACMA, AFCHSM, MAICD

• ACHS Board member from 2017

• ACHS Councillor from 2006 (AHHA representative)

• Consultant to the Health Education and Research Sectors

• Sid Sax Medal recipient 2018

• Adelaide Primary Health Network (APHN) Board Service & Clinical Governance Committee Member from 2017

• Nexus Primary Health Chair from 2014

• Board of Advice, Deeble Institute for Health Policy Research Member from 2015

Ms Anne Trimmer AO

BA, LLB (ANU) FAAL, FAICD

• Independent Director appointed to the ACHS Board from July 2018

• Secretary General Australian Medical Association 2013 – 2018

• CEO Medical Technology Association of Australia 2006 - 2013

• Barrister and Solicitor

• Chair of the ACHS Governance Committee from October 2021

Dr Noela Whitby AM

MBBS (Qld), Grad Dip HumNut, DPD, FRACGP, FAICD

• ACHS Vice-President, 2005 – 2007

• ACHS Board member, 2000 – 2009; from 2012

• ACHS Councillor, 2000-2009; from 2012

• ACHSI Board member, 2006-2009; from 2018

• Past ACHS Assessor

• General Practice Principal, Carindale Medical Clinic, Brisbane from 1979

• Member, Medical Services Advisory Committee, Australian Government, 2014 - 2017

The Australian Council on Healthcare Standards

5 Macarthur Street

Ultimo NSW Australia 2007

Telephone 61 2 9281 9955 Facsimile 61 2 9211 9633 E-mail communications@achs.org.au Website www.achs.org.au