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ANNUAL REPORT 2022-2023

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 2023 © 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 2022 - 2023 ISBN: 978-1-875544-72-1 (Paperback) ISBN: 978-1-875544-76-9 (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 Marketing 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 marketing@achs.org.au Website www.achs.org.au

CONTENTS About ACHS Mission, vision and values

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Strategic goals

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Facts and figures

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Who we are: a corporate overview

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Our history The Council ACHS Assessors Funding Partnerships

Our Performance President’s message

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Chief Executive Officer’s message

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Highlights of 2022 - 23

Recognising Achievement ACHS Medal 2022

Quality Improvement Awards

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ACHS International

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Customer Services

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Division Reports

Healthcare Standards Assessor Division

Performance and Outcomes Services Corporate Services

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The Improvement Academy

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Our Council ACHS Council members

Directors' Report and Financial Statements Directors' report ACHS Board of Directors

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CONTENTS

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 ACHS Strategic Plan 2022-2025 was 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

Enhancing and diversifying our services

Demonstrating leadership and innovation

Improving our organisational capability

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

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

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

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

Facts and figures Established in

1974

Council represented through

member organisations

ACHSI operates in

More than countries

1,500

members in Australia

A team of

156 Australian assessors and 84 international assessors Nearly

7,400

registrants for Improvement Academy courses and webinars

930

onsite and virtual customer support meetings More than 630 healthcare organisations reported about 27,000 individual clinical indicators

Quality Improvement Awards

'High Commended' commendations

ACHS Medal winner

Who we are: a corporate overview Our history

ACHS Assessors

The Australian Council on Healthcare Standards (ACHS) is now into its fifth decade having marked its 49th anniversary in 2023.

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

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.

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We currently have more than 240 assessors

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

Over the past 18 years it has built its global influence as both a developer of healthcare standards and as an accreditation agency. ACHS has continued to expand its expertise through education, training and consultancy services.

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

Funding

The Council

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).

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

Most of our funding is derived from membership fees.

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

In 2023 there were 22 Council member organisations with 22 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 •

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

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.

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

ACHS has an enviable reputation as an independent, healthcare accreditation provider currently exporting its successful program of accreditation to 20 countries.

President’s

message Professor Len Notaras AO President, Board of Directors

This year has marked a period of strategic growth as we focus on strengthening our organisational governance and capabilities. I am delighted to welcome several new Councillors to our distinguished team. Their professional knowledge and expertise will undoubtedly enrich our strategic discussions and contribute to our shared vision of inspiring excellence in healthcare. Alongside this, we bid farewell to our much beloved Executive Director, Dr Lena Low for her well-deserved retirement, and welcomed Ms Aisling Forrest to this pivotal role. Aisling has brought a wealth of experience, embodying the spirit of fun and innovation that is much valued by the team. In recognising outstanding contributions, we proudly presented the ACHS Inaugural President’s Award to Dr Philip Hoyle, Director of Medical Services, Royal North Shore Hospital and Chair of ACHS Standards Committee. Dr Hoyle has made a remarkable difference to ACHS over the years through his direct involvement in committees, training, and mentoring. It is also with immense pride that we acknowledge our Board Member, Professor Geoffrey J Dobb on being awarded a Member in the Order of Australia in the 2023 Australia Day Honours List. Professor Dobb was recognised for his significant service to intensive care medicine and professional associations. His work continues to inspire us all. I also extend congratulations to Ms Christine Gee, ACHS Medallist 2021 for her recognition as Member in the Order of Australia, a testament for her remarkable impact on healthcare and

the community at large. These achievements serve to reinforce the exceptional work of our community and their unwavering dedication to making a difference. In closing, I wish to extend my appreciation to our esteemed Board, Council, Executive team as well as every individual who contributes to the vision and mission of ACHS. Your dedication and commitment have not gone unnoticed, and I am excited to witness the positive impact we will continue to create as an organisation. Thank you for all your contributions to improving the quality and safety of healthcare in Australia and internationally. I am filled with hope and optimism for the future.

Professor Len Notaras AO President, Board of Directors

Chief Executive Officer’s

message

Dr Karen Luxford Chief Executive Officer

As we continue our commitment to excellence, we remain ever conscious of the importance of our actions in shaping the future of healthcare. This year ACHS took significant strides towards fostering greater inclusivity and cultural awareness in health care and across the organisation. The face-to-face cultural safety training session with ACHS Assessors marked a significant milestone for progress. We welcomed Aboriginal and Torres Strait Islander trainers to facilitate the full-day program, and they provided our Assessors with experiential learning as well as the opportunity for reflection. This training session not only met The Australian Commission on Safety and Quality in Health Care (ACSQHC)’s requirements, but also enriched our Assessor’s understanding and appreciation for the experiences of our stakeholders with Indigenous heritage. ACHS are proud to have officially commenced our Reconciliation Action Plan (RAP) as we remain committed to developing a vision for reconciliation and deepening our relationships with Aboriginal and Torres Strait Islanders. We stand unwavering in our commitment to supporting ACHS Members through times of change. The Commission’s announcement of mandatory Short Notice Assessments this year has prompted our proactive response. The ACHS team have worked tirelessly behind the scenes to help Members navigate this transition. We remain optimistic that these new requirements by the Commission will bring about positive impacts on health services.

We were pleased to continue our ‘value-added’ benefits in FY22-23, with education and training offered exclusively to our Members through our Improvement Academy. With discounted public courses, complimentary, interactive training sessions in Open Disclosure and exclusive access to renowned international speakers in our Masterclass Series. These sessions have supported Members to develop skills, learn from experts in the field and connect with colleagues. Our ACHS Strategy Day involving the management and executive team was a pivotal moment for reflecting on the organisation’s strategic direction and charting the course for progress. Guided by our collective vision to inspire excellence in healthcare, we remain steadfast to steer our organisation to greater heights. As we reflect on our accomplishments this year, I am proud to see the positive impacts that our work continues to have on the broader community. To our dedicated staff, valued Board and Council Members - I extend my deepest gratitude for your unwavering commitment to excellence. In a world of evolving challenges and opportunities, the collective efforts of our team have been nothing short of inspiring.

Dr Karen Luxford Chief Executive Officer

Highlights Financial year 2022-2023

The ACHS Executive and Management teams conducted a successful Strategy Day to discuss improved efficiencies and ideas to support our Members.

ACHS Assessor Forums were held face-to-face, across the country. In addition to providing important updates and education, the Forums are a great opportunity to network, hear feedback as well as share ideas and experiences.

Improvement Academy continued our successful Member Masterclass Series. We heard from international experts such as Chief Sustainability Officer at the NHS in England, Dr Nick Watts about world-class net zero emission health service.

CEO Dr Karen Luxford and Board Member Stephen Walker joined the ACHS Customer Services team at the Australian Private Hospitals Association (APHA) National Congress.

ACHS kicked off our Reconciliation Action Plan (RAP), aimed to embed the principles and purpose of reconciliation within our organisation governance and operations. As we commence the first phase of developing our RAP, we prepare ourselves for scoping and deepening our relationships with Aboriginal and Torres Strait Islander stakeholders.

CEO Dr Karen Luxford lead a panel discussion about the future of safety and quality assessment, with international leaders including Helen Bevan at the IHI BMJ International Forum on Quality and Safety in Healthcare.

The ACHS Improvement Academy launched a selfdriven learning experience supporting online, ondemand education. This exciting new e-learning platform revolutionises the way healthcare workers gain knowledge and CPD Points.

Highlights Financial year 2022-2023 (Cont.)

The Inaugural ACHS President's Award Recipient 2022 was awarded to Dr Phillip Hoyle. ACHS CEO, Dr. Karen Luxford was delighted to present Dr Hoyle with his trophy at The Royal North Shore Hospital and Dr Hoyle was humbled to receive the award.

ACHS Board Chair Prof Len Notaras AO received an Honorary Fellowship of the Royal Australasian College of Medical Administrators RACMA in recognition of his significant and ongoing contribution to improving the delivery of quality healthcare across Australia and for leading critical care and trauma response.

ACHS CEO, Dr Karen Luxford and Customer Service Manager, Caroline Archer greeted colleagues at the 2022 ACHSM Asia Pacific Annual Congress held in Perth. Our Improvement Academy Director, Associate Professor, Bernie Harrison facilitated a successful workshop alongside Mr Anthony Lock, Executive Director Clinical Performance & Systems, St John Ambulance WA.

ISQua’s 38th National Conference brought together 1,500 key decision-makers from over 80 countries, in Australia, to share their expertise and knowledge in health care quality and safety. ACHS President Prof Len Notaras AO and CEO Dr Karen Luxford were present at the ISQua EEA Accreditation Award recognition to ACHS.

The new ACHS International 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.

ACHS welcomed Aisling Forrest as our new Executive Director, Corporate Services, as we farewelled Dr Lena Low for her retirement. Aisling brings significant experience working across healthcare leadership roles.

ACHS engaged Aboriginal and Torres Strait Islander trainers to deliver the mandatory Cultural Safety Training using the training materials provided by the ACSQHC. These successful sessions allowed our Assessors the opportunity of experiential learning in relation to the six specific Aboriginal and Torres Strait Islander actions.

Recognising Achievement ACHS Medal The prestigious ACHS Medal 2022 was awarded to Professor David Pilcher, Clinical Lead at the Victorian Critical Care Network, Safer Care Victoria and Chair, ANZICS Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society.

His contributions have been felt across the entire healthcare system with national leadership positions including: • Clinical Lead Victorian Critical Care Network, Safer Care Victoria • Chair, ANZICS Centre for Outcome and Resource Evaluation Australian and New Zealand Intensive Care Society • Adjunct Clinical Professor Department of Epidemiology and Preventive Medicine, Monash University • Deputy Director of Intensive Care, The Alfred Hospital, Prahran, Melbourne

Professor Pilcher was awarded the ACHS Medal as part of the ACHS Awards Ceremony held on Thursday 23 November 2022. In presenting the award during the ACHS Annual Awards Ceremony 2022, ACHS President Professor Len Notaras AO said, “Professor Pilcher has shown outstanding leadership and has been a strong advocate for the use of data in a clinical setting to support quality and safety improvement,” “The ACHS Medal is in its 38th year and provides a valuable spotlight for an individual’s outstanding contribution to the promotion of quality and safety in Australian health services,” he said. “Professor Pilcher’s utmost dedication to patient safety is strongly reflected in his work. Congratulations David on your many achievements and being the deserving winner of the ACHS Medal 2022.”

Professor Pilcher accomplishments are nothing short of exceptional. He was responsible for the development of successful statistical techniques for feedback and benchmarking of individual ICU’s performance. Professor Pilcher also led the development of a new severity of illness adjustment model which supports hospital level safety and quality assurance as well as state level interventions. Importantly, under his leadership more detailed reports are provided to poorly performing ‘outliers’ with support available to address issues that are identified. Over 250 research articles have been published by Professor Pilcher in the last 10 years, most relating to safety, quality and patient outcomes. Professor Pilcher’s work is recognised both nationally and internationally as world leading and has made a major contribution to our understanding of factors that influence patient outcomes in healthcare.

Recognising Achievement ACHS’s 25th Annual Quality Improvement Awards Wandi Nerida in Queensland, a residential care facility for eating disorders, and two public health services, Hunter New England Local Health District (HNE LHD) in New South Wales and Gold Coast Hospital and Health Service in Queensland, were the final winners in the 25th Annual Quality Improvement (QI) Awards. With judges unable to separate two highquality submissions within the Clinical Excellence and Patient Safety category, there were two winners. Wandi Nerida developed a new residential model of care to treat eating disorders in Australia. The model showed an innovative implementation of inpatient care for individuals affected by eating disorders. It aims to be a proof of concept for the model of care to be implemented nationwide by providing robust clinical and economic evaluation. Hunter New England Local Health District received its first of two awards as the other winner in the Clinical Excellence and Patient Safety category, with its Liver Life randomised controlled trial (RCT) completed by the Chronic Disease Network/Palliative and End of Life Care Stream. Liver Life trialled a transdisciplinary supportive approach to care, embedded within standard care, guided by patient experience optimised health service performance and outcomes for patients living with advanced liver disease (ALD). Gold Coast Hospital and Health Service’s Strategy, Transformation and Major Capital Division, won the Non-Clinical Service Delivery category with their project that focused on embedding a culture of transformation at Gold Coast Health (GCH). The establishment of the Future Focus Transformation Program set out to

achieve the key goals of a sustainable, valuefocused, integrated and digitally enabled Health Service, which resulted in innovation in both practice and process, changing the way GCH works and addresses future challenges. The Healthcare Measurement category was won by Hunter New England Local Health District, Mater Mental Health Pharmacy. The creation of a Virtual Clinical Pharmacy Service (VCPS) for Mental Health (MH) units enabled Tamworth, Manning and Maitland Hospitals within the region access to a Clinical Pharmacy team that was not present on site within their MH units. This allowed pharmacists to be present within MH multi-disciplinary teams (MDTs) virtually, optimising prescription and monitoring of medications, while minimising errors and adverse effects through prevention and early intervention. The 25th Annual QI Awards was the first face-to-face presentation since 2019 due to previous restrictions, which was a welcome change. There were a high number of entries this year, but for the first time in a few years we saw a decline in COVID-19 related health innovations – a sign that many pandemic specific innovations are already in effect. There was a rise in Mental Health focused projects, as well as further inclusion of technological methodologies in the delivery of health-related care. 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, which recognise strong new innovations that will benefit patients and their families.

WINNER, CLINICAL EXCELLENCE AND PATIENT SAFETY: Wandi Nerida, QLD

WINNER, CLINICAL EXCELLENCE AND PATIENT SAFETY: Hunter New England Local Health District NSW, Chronic Disease Network/Palliative and End of Life Care Stream

WINNER, NON-CLINICAL SERVICE DELIVERY: Gold Coast Hospital and Health Service QLD, Strategy, Transformation and Major Capital Division

WINNER, HEALTHCARE MEASUREMENT: Hunter New England Local Health District NSW, Mater Mental Health Pharmacy

ACHS International ACHS International is a trusted leader in healthcare quality improvement, serving healthcare organisations across 25 countries worldwide. Our expanding membership base spans diverse sectors within healthcare, including primary care, residential and home care, hospitals, tertiary facilities, clinics, and specialty services. We are renowned for our transformative impact on healthcare quality improvement, fostering a culture of quality and safety, and providing innovative training and partnership solutions that empower organisations to enhance their overall performance and service delivery. Our global members are increasingly embracing person-centred healthcare, involving patients and families in care design, and taking advantage of our Advanced Person-Centred Module. Additionally, exemplary organisations are proudly demonstrating service excellence through our Centre of Excellence program in various specialties, including cardiac, cancer care, dialysis, orthopaedics to name a few.

Hosted National Kidney Foundation, Singapore delegation to Australia. Meeting with exemplar Australian Healthcare dialysis centres

Here are some key highlights from the ACHS International team over the past fiscal year. These accomplishments underscore our commitment to advancing healthcare quality, safety, and innovation on a global scale. Membership Expansion and Global Reach •

Strengthened our global presence by establishing a strategic partnership in the Republic of Georgia to meet accreditation requirements.

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Expanded our membership base to include some of the largest healthcare services in Saudi Arabia, Bahrain, and the Asia Pacific region.

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Increased the number of assessments conducted with new and renewing members.

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Facilitated member site visits, such as a Singapore delegation visiting Australia.

Launched our new and improved website with member portal

Knowledge Sharing and Engagement in Quality Conferences •

Knowledge partner for the Consortium of Accredited Healthcare Organisations (CAHO) Conference in 2023 and CAHO Tech 2022.

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Participated in important healthcare events, such as Arab Health 2023 and the Thomson Quality Symposium.

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Hosted Member Forums, Expert Panels, and engaged in World Patient Safety Day activities, including masterclasses and webinars.

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Rolled out the QI Tools To Go program to facilitate knowledge exchange and learning within the international healthcare community.

ACHS and ACHSI Group CEO Dr Karen Luxford visits Dubai and presents accreditation certificate to Saudi German Hospital

Diversified Services and Expertise •

Successfully launched the EQuIP7 Residential and Home Care Standards in June 2023.

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Conducted Assessor Competency Training in Bahrain and the United Arab Emirates.

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Introduced the Centre of Excellence program to recognise outstanding healthcare organisations.

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Implemented Telehealth services to enhance healthcare delivery.

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Introduced a Fire and Environmental Safety module as part of our joint Safe Healthcare Environment Advisory Program in Taiwan.

Training of Joint Commission Taiwan surveyors in the Fire Module for Safe Healthcare Environment Advisory Program

Customer Services The Customer Services Managers (CSMs) are responsible for contract and relationship management for all ACHS domestic accreditation members (customers).

Key achievements •

The CSMs are pivotal in the dissemination of information and advice for ACHS accreditation members on the implementation of ACHS and other health industry standards, including the National Safety and Quality Health Service Standards developed by the ACSQHC.

ACHS Short Notice Assessment Webinar provided for free to approximately 500 registrants online

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Implementation of the new products - NSQDMH Standards - NSQPCH Standards - National Clinical Trials Governance Framework - Mandated Short Notice NSQHS Standards

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Welcomed new members to the NSQDMH Standards program - Black Dog Institute - This Way Back - Lifeline Australia

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Welcomed back 34 Members

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Provided 930+ support meetings (online and onsite)

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Supported members with 179+ pre assessment briefings

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Completed 230 quality assurance reviews of assessment reports

FY23 was a period of unprecedented change for accreditation in the domestic health sector; with the implementation of two new sets of standards, the National Safety and Quality Digital Mental Health (NSQDMH) Standards and the National Safety and Quality Primary and Community Healthcare (NSQPCH) Standards, the commencement of Clinical Trials Governance Framework assessments, and the announcement of NSQHS Standards mandated Short Notice Assessments to commence on 1 July 2023. CSMs provide an accessible and responsive point of contact for ACHS Members’ questions. This includes new member enquiries, contract negotiation, contract renewals, scheduling of assessments, providing support pre and post assessment, quality assurance on assessment reports, and keeping the member organisations abreast of updates from the ACSQHC. We continued to provide our high level customer support via telephone, email, online meetings and onsite visits throughout the entire accreditation contract cycle. The many changes introduced by the Commission during FY23 has resulted in an increase in the number of support meetings (online and onsite) being provided to our Members by the Customer Services Managers.

Mandatory Short Notice Assessment ACHS is committed to supporting healthcare organisations in relation to the commencement of mandatory short notice assessments, announced by The Australian Commission on Safety and Quality in Health Care (the Commission).

OUR EXPERTISE IN SHORT NOTICE ASSESSMENT Supporting Short Notice Since 2017 Our expertise is built on years of knowledge while working in partnership with our member organisations and supporting the development of short notice assessments.

Well-established Systems & Processes We have systems and processes in place to specifically cater for short notice assessments. These systems and processes were tested and optimised as we worked with a range of HSOs across Australia.

Knowledgeable Customer Services Team A dedicated Customer Services Manager will work closely with you to assist you with the transition to short notice assessments and provide ongoing support throughout your accreditation process.

Experienced Assessors Our cohort of Assessors and Lead Assessors are experienced in conducting short notice assessments. They will engage with your team to facilitate the assessment process.

Member Resources to support Short Notice Assessments ...valuable support and guidance provided by our Customer Service Manager from the ACHS leading up to and during the event. We found the Assessment Team to be very engaged given this was our first Short Notice Assessment event. - Illawarra Shoalhaven Local Health District (ISLHD) -

To find out more about Short Notice Assessment and how we support you through this transition, contact an ACHS Customer Services Manager today on 02 9281 9955 or email csm@achs.org.au

Healthcare Standards Healthcare Standards (HS), formerly Standards and Products Development (SPD), is responsible for ACHS responses related to all Commission healthcare standards activities, including submissions for approval to assess to Commission standards, general consultations, and responses to annual ACSQHC feedback reports.

Key achievements •

Presentation of 25th Annual ACHS QI Awards at the ACHS Awards Ceremony in November 2022

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Publication of 25th Annual QI Award winning and highly commended projects in November 2022

HS develops resources and specialist publications to support ACHS programs. HS works in consultation with key internal and external stakeholders to ensure programs reflect current health priorities and contemporary best practice. HS also leads activities related to standards developed by other organisations such as Rainbow Health Australia and Royal Australian College of General Practitioners (RACGP).

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ACSQHC approved ACHS to conduct assessments of general practices to the National General Practice Accreditation (NGPA) Scheme from 1 January 2023 to 1 January 2028. Approval was granted in December 2022

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EQuIP7 Hospital and Ambulatory Care Standards’ Progress Report submitted to ISQua in February 2023

HS is responsible for the generation and maintenance of ACHS healthcare standards programs including a range of EQuIP Standards, and Guides for Hospital, Ambulatory Care, Dialysis, Oral Health, Cancer Care, Telehealth, Residential Care and Primary Healthcare Services.

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ISQua EEA accreditation of EQuIP7 Residential and Home Care Standards achieved in March 2023

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EQuIP6 Primary Healthcare Standards Progress Report submitted to ISQua in May 2023

HS 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. HS also coordinates the ACHS Annual Quality Improvement (QI) Awards, which acknowledge and encourage outstanding quality improvement activities, programs or strategies that have been implemented in healthcare organisations.

Publication of the 25th Annual QI Award winning and highly commended projects

Standards Committee

The Standards Committee is a sub-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.

Finalisation of the EQuIP7 Residential and Home Care Standards

Dr Philip Hoyle Chaired the Committee during the period 2022-2023. Committee membership also includes the President of the ACHS and the ACHS Chief Executive Officer. The Standards Committee is administered by the ACHS Healthcare Standards Team, led by the Executive Director – National Business and Development. A major focus for the Standards Committee during 2022-2023 was the finalisation of EQuIP7 Residential Care Standards.

Standards Committee Members Name

Representation

Dr Malathi Arshanapalai

International Member – UAE / India

Ms Roslyn Chataway

Consumer Representative

Ms Cathy Cummings

International Member – New Zealand

Ms Helen Dowling

Public Sector / Allied Health / Pharmacy / ACHS Assessor

Prof Brett Emmerson AM

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

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 (Until Nov 22)

Private Sector / Day Procedure Centres / ACHS Councillor

Dr Nellie Yeo

International Member – Singapore

Assessor Division In July 2022 Darlene Hennessy commenced in the role of Director – Assessor Division. In November, following the retirement of Dr. Lena Low, the Assessor Division executive reporting line moved to Linda O’Connor, Executive Director – National Business and Development. The past year has seen the ACSQHC introduce new requirements which have required further training and updates for assessors in the following areas:

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Digital Mental Health Standards

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Standardised reporting template

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Primary and Community Healthcare Standards

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National Clinical Trials Governance Framework

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Cultural Safety Training

ACHS Assessor Forum in Melbourne, Victoria

“The assessment team were very professional and provided advice for further improvements. Staff reported a positive experience with the whole process.” “Assessors were friendly, provided useful feedback, and were very approachable.” “We would like to thank the assessors for their comprehensive assessment and supportive approach to working with us to ensure the region continues to provide safe, high-quality care to our patients.”

In addition, ACHS Assessor Division has conducted Assessor Forums in Brisbane, Perth, Sydney and Melbourne as well as a Lead Assessor forum in Melbourne. At the Forums, assessors were provided with the latest updates from ACHS as well as the ACSQHC, feedback from assessments and the opportunity to network with one another. The program at the Forums meets the annual training requirements of the ACSQHC, ensuring that ACHS assessors can maintain their registration to continue to assess to the National Safety and Quality Health Service Standards (2nd edition).

In addition to attending annual training, assessors must meet the annual minimum number of days on assessments as required by the ACSQHC in order to maintain their registration. The Assessor Division conducted two assessor competency training programs for internationally based assessors in 2023. The first was held in Bahrain and the second in Dubai. In addition, an online forum for Hong Kong based assessors was conducted in 2023.

Retiring Assessor Acknowledgements: 2022 - 23 Retiring Assessor

Joined

Total Assessments

Total Assessor Days

Total Years as Assessor

Charlie Grugan

2002

175

Jeremy Higgins

2012

Frank Flannery

2000

163

375

Christine Minogue

2000

225

Dianne Norris

1997

159

498

Yvonne McCann

2009

153

Graham Clay

2010

Ben Skerman

1995

145

401

Jacinta Powell

2009

Sharon Godleman

2006

Performance and Outcomes Service The ACHS Performance and Outcomes Service 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 speciality medical disciplines. The program operates by facilitating benchmarking with participating healthcare organisations at an organisational, peer and national level.

The Australasian Clinical Indicator Report (ACIR) 23rd edition 2014-2021 was published in November 2022

The impact of COVID-19 is evident in the Clinical Indicator data as it is both a measure of activity and resource allocation. These impacts are discussed in the Australasian Clinical Indicator Report 2014 2021 (ACIR) to highlight how the COVID-19 pandemic has impacted the delivery of quality healthcare and the maintenance of healthcare improvements through resource setbacks.

Key achievements

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Assisted more than 631 healthcare organisations reporting 27,098 individual clinical indicators across Australia and international regions.

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The project to improve the analytics and software behind the Performance Indicator Reporting Tool (PIRT) is now almost complete and in the final phase of testing.

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Three indicator sets were reviewed and updated (Radiology, Ophthalmology and Infection Control), and there was the creation of a new set (Ambulance Health Services).

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Promoted the Clinical Indicator Program through 52 training sessions across Australia and internationally.

Corporate Services The objective of the Corporate Services Division is to provide efficient and effective support services to allow ACHS to deliver its strategic business goals. The Division’s main aim is to implement cutting-edge systems and procedures to ensure that ACHS aligns with contemporary best practices, ensuring that our members, assessors and staff have the best possible experience with us.

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Professional development plans for all staff recorded in Performance Management System.

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Flu vaccination offered to all staff.

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Trained staff cohort in first aid and emergency evacuation.

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Organised monthly all-staff days to promote staff well-being.

Information Technology

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Quality and accuracy of reports met as per KPIs.

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System redesign to support a range of new assessments such as Short Notice Assessments and Clinical Trials Governance Framework. ACHS maturity level assessed by an independent evaluator, against the Australian Cyber Security Centre's Essential Eight Standard.

Accreditation Administration Services •

Conversion of all assessments to short notice assessments.

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‘Essential Eight’ Action plan developed ensuring ACHS technology and infrastructure remain secure against cyber-attacks.

Revised membership agreements to incorporate short notice requirements.

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Delivered a series of improvement projects to optimise administrative efficiencies.

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Cyber Awareness training for all staff, delivered on an ongoing basis.

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All administrative KPI targets exceeded.

•

Pivoted to the ‘ACHS Hub’ project to deliver a new transformational information system to optimise the assessment experience for members and assessors.

•

Implemented new enterprise grade software solutions to facilitate centralised cyber and security management and monitoring.

•

Finance and Human Resources Administration •

Unqualified audit report received.

•

Facilitated a ‘People and Culture’ workshop for ACHS staff.

ACHS staff participated in the ‘People and Culture’ workshop

Improvement Academy The Improvement Academy (IA) now offers its training as face to face, virtual training and e-Learning. The total number of events (including multi day events) run by the IA was 89 (total days 119). The total number of registrations in all IA events is 7,400.

Member Benefit Series Free Open Disclosure Training: 2,060 registrations A series of two-hour interactive training was offered free to ACHS Members to develop skills in how to conduct an Open Disclosure using evidence-based methods. Free Masterclasses: 2,200 registrations Throughout the year, we invited five international thought leaders to work with us as part of our ACHS Masterclass series. They provided thought leadership on a range of important issues facing healthcare globally.

Custom Training IA provided custom training for a total of 19 organisations which spanned acute, community, mental health, justice health, rural, remote and ambulance services in both the public and private sectors. Top 3 courses requested were: •

Clinical Incident Analysis (Including RCA)

•

Clinical Governance (Standard 1) for Boards and Executives

•

Clinical Incident Report Writing

Established jurisdictional partnerships with QLD Health, Tasmanian Health Service and Northern Territory Health.

Masterclass Presenter

Title

Professor Helen Bevan Strategic Advisor at NHS Horizons, UK

Mobilising for Change and Improvement in Health Systems

Dr Amar Shah Chief Quality Officer at East London NHS Foundation Trust, UK

What does it really take to embed a culture of continuous improvement?

Dr Maxine Power Executive Director of Quality, innovation and improvement at North West Ambulance Service NHS Trust, UK

Improvement Science can Transform Health Organisations

Mr. Simon Kuestenmacher Co-Founder and Director at The Demographics Group, Australia

The future of healthcare in Australia: A demographic outlook

Dr Nicholas Watts Chief Sustainability Officer of the NHS, UK

How challenging climate change will have profound benefits for public health?

New Initiatives e-Learning Platform Launch Delivering Excellence: NSQHS Standards selfpaced eLearning course helps participants gain an understanding in the National Safety and Quality Accreditation Scheme and NSQHS Standards. Access to IA resources including masterclass recordings and quality improvement project abstract booklets. Clinical Incident Report Writing This 3-hour virtual training was developed following feedback from participants of Root Cause Analysis (RCA) training. It provides a structured approach to writing a clinical incident report to meet the needs of multiple stakeholders. The course has been run every month, receiving excellent feedback. Expanding IA offerings for ACHSI members IA provided complimentary training for ACHS International members in QI Tools To Go. A total of 145 members participated in the 2x3 hr sessions.

Virtual Quality Improvement Lead (V-QIL) Training Program IA flagship V-QIL training is a 9-month program, providing a deep immersion in improvement science, reliability science, transformative leadership for improvement and clinical governance for improvement. A total of 57 work-based quality improvement projects were completed by participants from across Australia. Northern Territory Health sponsored 35 staff to participate in the V-QIL program.

Public training topics FY2022-23, available to all health care systems across Australia Comprehensive Care Delivering Excellence: NSQHS Standards e-Learning Course – new course Introduction to Human Factors in Healthcare Introduction to Patient Journey Mapping Leadership for Improvement- new course Open Disclosure Partnering with Consumers to Healthcare Services QI Tools to Go – new course Report Writing – new course

“The QIL Program’s strengths are in the practical application of the theories and science of improvement. I am really enjoying this program and would recommend it to quality leads and clinicians alike.” Clinical Governance Coordinator

Root Cause Analysis Virtual Quality Improvement Lead Training Program

Council Members

Our Council represents consumers, governments and peak health industry bodies from throughout Australia. ACHS Council as at 30 June 2023 was 22 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 AM

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)

Professor Christian Gericke

MD PhD MPH (Cantab) MSc MBA FRACP FAFPHM AFRACMA FRCP (Edin) FEAN FAAN The Royal Australasian College of Physicians (RACP)

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)

Ms Bernadette Loughnane

RN, RM, BaHscN, GDNM, MaHSM, FCHSM, CHE, GAICD Australasian College of Health Service Management (ACHSM)

Clin. Prof 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)

Ms Amanda Shand

Day Hospitals Australia

Dr Phillip Truskett AM

Mr Russell McGowan

Health Care Consumers’ Inc

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

Dr Jon Mulligan

Dr Lakshmi (Nayana) Vootakuru

MBBS, MHA, FRACP, FRACMA, GAICD Life Member of ACHS Council

Prof Leonard Notaras AO (President)

B.Med, MPH, FANZCA Australian and New Zealand College of Anaesthetists

AFCHSE, LLB, BA (Hons), DipComm, BMed, MHA, MA Northern Territory Department of Health and Community Services

Mr Stephen Walker

Ms Robyn Quinn

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

RN, Bachelor Health Science (Nursing), MBA, FACN, FAAP M The Australian College of Nursing (ACN)

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

Dr Noela Whitby AM

Directors’ Report The Board of Directors (the Board) of The Australian Council on Healthcare Standards Limited (“ACHS”) in office at the date of this report present the results of The Australian Council on Healthcare Standards Limited and its controlled entities (collectively referred to as “the Group”) for the financial year ended 30 June 2023 and the Independent Auditor’s Report thereon.

Directors and meeting attendance At the date of this report, the names of the members of the Board, the meetings of the Board and meetings of the Board Finance Audit and Risk Committee (BFARC), and the number of meetings attended by each of the Board members during the financial year are listed and summarised in the table below:

A: Number of meetings attended B: Number of meetings held during the time the Director held office during the year

Board Meetings

BFARC Meetings

Name

Date Appointed

Date of Cessation

Mr Michael Roff

2 Feb 2004

Mr Stephen Walker (BFARC Chair)

23 Nov 2006

Prof Geoffrey Dobb AM

25 Nov 2010

Dr Noela Whitby AM

24 Nov 2011

Mr Anthony Lawson

24 Sep 2012

Prof Leonard Notaras AO

22 Nov 2012

Prof Brett Emmerson AM

25 Nov 2015

Dr Paul Scown

23 Nov 2017

Ms Anne Trimmer AO

1 July 2018

Directors have been in office since the start of the financial year to the date of this report unless otherwise stated. Details of Directors’ qualifications, experience and special responsibilities can be found on pages 31 to 32 of this report.

Governance

Risk management

Mr Michael Roff was reappointed as a Board Appointed Director for a term of up to three years, to commence following the Annual General Meeting on 24 November 2022.

The Board Finance Audit and Risk Committee (BFARC) has the primary oversight of risk management practices across the ACHS. Its responsibilities include assisting the Board through periodic review of the operation of the ACHS Risk Framework and through review of reports from the Chief Executive Officer.

A call for nominations was sent out to Council for one Member-elected position to the Board. One nomination was received, and in accordance with the ACHS Constitution, a ballot was not required. Professor Geoffry Dobb AM was appointed to the position unopposed at this Annual General Meeting on 24 November 2022.

Company Secretary

Dr Karen Luxford has held the role of Company Secretary since July 2019, she is also the Chief Executive Officer of the ACHS.

Mission and strategy

The Group’s mission is to provide 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. The Group’s strategy for accomplishing its mission include: •

Strengthening member engagement and experience

•

Enhancing and diversifying our services

•

Demonstrating leadership and innovation

•

Improving our organisational capability

The ACHS is committed to the effective management of risks. At the ACHS the ownership of the day to day management of risks remains the responsibility of the Chief Executive Officer with the support of ACHS staff.

The BFARC meets three times a year, to endorse all risk monitoring, compliance, financial reporting, budgeting and forecasts for the Group. During the year existing controls are in place to ensure all identified risks are managed within an acceptable level consistent with our risk appetite.

Members’ guarantee

ACHS is incorporated as a company limited by guarantee. In accordance with the company’s constitution each member of the company is liable to contribute $50 if the company is wound up during the time he/she is a member or within one year thereafter. As at 30 June 2023 the total amount those members of the company were liable to contribute if the company is wound up is $1,100.

Principal activities

The principal activities of the Group during the financial year remained unchanged and were dedicated to improving the quality of healthcare in Australia through continuous review of performance, assessment and accreditation.

Review of operations

The Group’s net surplus of $2,093,742 was mainly attributable to net gains and fair value movements in financial assets. The Group has no loans or borrowings to any financial institution as at 30 June 2023.

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 AM BSc (Hons), MBBS, FRCP, FRCA, FANZCA, FCICM, FAMA • ACHS Business Finance, Audit and Risk Committee, and Governance Committee • ACHS Board Member from 2010 • ACHS Councillor (Australian Medical Association representative) from 2011 • Head of Department, Intensive Care, Royal Perth Hospital from 2005 - 2022 • 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 2017 - 2023 • Nexus Primary Health Chair 2014 - 2022 • 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 Limited

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

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Auditor’s Independence Declaration To the Responsible Entities’ of The Australian Council on Healthcare Standards ABN 90 008 549 773

I declare that to the best of my knowledge and belief, during the year ended 30 June 2023 there have been no contraventions of: i. the auditor’s independence requirements as set out in the Australian Charities and Not-for-profits Commission Act 2012 in relation to the audit; and ii. any applicable code of professional conduct in relation to the audit.

This declaration is in respect of The Australian Council on Healthcare Standards and the entities it controlled during the year.

SYLVIA WALLACE

Partner PITCHER PARTNERS Sydney 13 October 2022

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