Improving the survey report review process of the Australian Council on Healthcare Standards

Raman Dhaliwal Customer Services Manager The Australian Council on Healthcare Standards, NSW

Background

Hundreds of accreditation surveys are conducted by the Australian Council on Healthcare Standards (ACHS) annually, and it is always looking to improve its services. At the conclusion of the onsite survey at the member organisation, the survey report is submitted to the ACHS by the survey coordinator via an online assessment reporting tool (ART). This is a requirement of the National Safety and Quality Health Service (NSQHS)/EQuIPNational (EN) programme. In addition, the key performance indicators (KPIs) as directed by the Australian Commission on Safety and Quality in Health Care (ACSQHC) regarding the turnaround time for submission of the draft survey report need to be met. The first draft submission to the organisation for review and finalisation is 30 business days from the last day of the survey. Any delay in the turnaround time leads to decreased customer satisfaction and KPIs, and requirements by the jurisdiction not being met, as well as increased accountability for the customer services manager (CSM).

Problem/Aim

The aim of this project was to provide the member organisation with a comprehensive completed survey report in a timely manner to enable the organisation to progress its quality journey efficiently, and to ensure that the ACHS meets its KPIs and requirements as prescribed in the accreditation scheme.

Measures

Feedback was taken from the CSMs and consumers (ACHS members), and the project team performed a causeand-effect analysis of delays in sending draft survey reports to the organisation for review. The most common cause of delays was incomplete reports being submitted to the ART because of the ACHS survey report submission rules not being followed. Several core actions from the NSQHS standards (3.10.1, Training in aseptic technique; 9.6.1, Training in basic life support; and 3.16.1, Compliance with relevant national or international standards and manufacturer’s instructions for cleaning, disinfection and sterilisation of reusable instruments and devices regularly monitored) require comments in the survey report by the coordinator. The aim is to provide evidence of the organisation’s compliance as per the requirements specified by the ACSQHC advisories (A13/08 and A16/03). Data were collected for the total number of surveys conducted during the survey period January 2016 – June 2017. Data were extracted from survey reports submitted to the ACHS that had comments regarding the three core actions mentioned above. In addition, data were collected regarding survey reports that were not sent to the organisation for review within 30 business days from the last day of the survey.

Conclusion

Initial interventions were effective in improving the turnaround time for submission of the draft survey report to the organisation within 30 business days, achieving the target of 100% in the following 4 months. However, these interventions need further review to ensure that the target of 100% completed survey reports submitted to the ART is achieved by December 2017.

Next steps

The designated intervention was tested using the Plan-Do-Study-Act (PDSA) process and is currently in the second test cycle.

Design

From 1 July 2017, the information technology (IT) team at the ACHS created mandatory fields in the ART (ACHS online tool) for Actions 3.10.1, 9.6.1 and 3.16.1 so that no survey report can be submitted to the ART by the survey team without providing comments regarding these three core actions. Pop-up screen alerts were set in the ART for the coordinator, indicating that the requisite actions have missing comments.

Results

Completed survey reports submitted to the ART from January to October 2017 improved for Action 3.10.1 from 38% to 98% (60% improvement), for Action 3.16.1 from 23% to 100% (77% improvement) and for Action 9.6.1 from 24% to 97% (73% improvement). Turnaround time for submission of the draft survey report to the organisation (within 30 business days from the last day of the survey) from January to October 2017 improved from 74% to 100% (26% improvement) in the 4 months following implementation of the first intervention.