ACHSNEWS The Australian Council on Healthcare Standards

The official newsletter from ACHS to communicate to all member organisations and our stakeholders

ACHSNEWS

See Inside For: ◊ Fond Farewell to two Surveyors ◊ QI Awards ◊ Jason Leitch Guest Speaker

No. 62 Autumn 2018

September 10-12 Melbourne Exhibition and Convention Centre

Connect. Co-create. Communicate.

(… continued on page 2 )

ACHS is proud to partner with two international

organisations – Institute for Healthcare Improvement (IHI)

and the British Medical Journal (BMJ) to present the 2018

International Forum on Quality and Safety in Healthcare.

The forum is the premier bi-annual international gathering

of healthcare professionals in quality improvement and

patient safety. It supports and energises the movement

for healthcare improvement and connects healthcare

leaders and practitioners worldwide to improve outcomes

for patients and communities.

Our 2018 theme is Connect. Co-create. Communicate.

Join with 1,000 other healthcare practitioners and leaders

from more than 35 countries for three outstanding days.

The program looks at how supporting connections

between patients, frontline staff and management leads

to a culture of collaboration where everyone in a

workforce is empowered to make a difference. We will

also explore how, through the use of effective

communication, ideas can be translated into global

improvements in patient care.

Photographer - David Foote, Auspic

ACHS President Professor Len

Notaras AM hosted a very

successful site visit for His Royal

Highness Prince Charles, Prince

of Wales to the National Critical

Care and Trauma Response

Centre during his visit to Darwin in

April as part of the royal tour of

the Northern Territory. “I can’t tell

you how impressed I am” said the

Prince as he was shown a ‘pop-

up’ surgical theatre, as well as

vital life-saving equipment that

can easily be transported abroad.

ACHSNEWS 2

Key highlights include:

• Keynotes from influential figures in the quality

improvement landscape as well as perspectives from

other industries

• More than 40 sessions with presenters from across

the world

• Skill- based training workshops with internationally-

renowned experts in quality improvement

• The opportunity to visit outstanding organisations and

experience first-hand how they deliver exceptional

care during our off-site experience days

• More than 50 speakers

• Networking: We will have a dedicated space for you to

meet up with colleagues, make new connections and

begin work on future collaborations with delegates.

Keynote speakers include:

Donald M Berwick MD, MPP, President

Emeritus and Senior Fellow, Institute for

Healthcare Improvement; Former

Administrator, Centers for Medicare and

Medicaid Services; USA

Recognised as a leading authority on

health care quality and improvement,

Dr Berwick has received numerous

awards for his contributions. In 2005, he was appointed

“Honorary Knight Commander of the British Empire” by

the Queen of England in recognition of his work with the

British National Health Service. The author or co-author

of more than 160 scientific articles and five books, he

also serves as Lecturer in the Department of Health Care

Policy at Harvard Medical School, and is an elected

member of the American Philosophical Society. A

pediatrician by background, Dr Berwick has served on

the faculty of the Harvard Medical School and Harvard

School of Public Health, and on the staffs of Boston’s

Children’s Hospital Medical Center, Massachusetts

General Hospital, and the Brigham and Women’s

Hospital. He served two terms on the Institute of

Medicine’s (IOM’s) Governing Council, and served on

President Clinton’s Advisory Commission on Consumer

Protection and Quality in the Healthcare Industry.

Derek Feeley, IHI Executive Vice

President since September 2013

He has executive level responsibility for

driving IHI’s strategy across five core

focus areas; Patient Safety; Patient and

Family Centred Care; Quality, Cost and

Value; Population Health; and

Improvement Capability. He assists in

delivering IHI’s mission to improve health and care

across the world.

Prior to joining the IHI, Derek had been Director General

(DG) Health and Chief Executive of the National Health

Service (NHS) in Scotland since November 2010. From

January 2011, the DG role was extended to cover Health

and Social Care. He was the principal adviser to Scottish

Ministers on health and care issues and he provided

direction to the work of NHS Boards in ensuring the

delivery of high quality health and healthcare.

Gary Kaplan, Chairman and CEO,

Virginia Mason Health System; USA

Dr Kaplan’s leadership at Virginia

Mason has been recognised by the

Harvard Business School as a standard-

setting approach to improving cost and

quality; he is widely recognised as one

of the most influential physician

executives in health care. He has developed and led

national “market-place collaboratives” with key employers

to reduce health costs and dramatically improve both

employee productivity and corporate competitiveness.

Alvin Shang Ming Chang, Senior

Consultant, Department of Neonatology,

KK Women’s and Children’ Hospital;

Singapore

Dr Alvin Chang is a Neonatologist and

Paediatrician. His interest includes

neonatal pulmonology, neonatal

transport, healthcare quality and patient

safety. Using quality improvement methods, he

introduced changes within the NICU, KK Women’s and

Children’s Hospital, resulting in at least 50% reduction of

chronic lung disease of infancy.

Amanda Reeves, Improvement

Manager, Redesign, The Royal

Children’s Hospital; Melbourne,

Australia

Amanda Reeves is an Improvement

Manager for Redesign at the Royal

Children’s Hospital, Melbourne. She

enjoys using her background as a

Service Designer and Futurist to identify emerging trends,

prototype solutions, and craft strategies that help deliver

quality care for patients as we face increasing demand

and complexity of care.

Visit: https://internationalforum.bmj.com/

melbourne/ for more information

ACHSNEWS 3

Australia’s premier quality improvement awards for

the health sector – the ACHS Quality Improvement

Awards are now officially open for 2018.

Designed to keep quality improvement and

innovation critical to the healthcare safety agenda,

the Awards recognise organisations’ advancing

excellence in healthcare.

“Now in their 21st year, the ACHS Quality

Improvement (QI) Awards have ensured there is a

strong emphasis on putting innovation at the

forefront of improvements to quality in healthcare,”

Dr Christine Dennis, ACHS CEO said.

“For more than two decades the awards have made

a strong contribution to the promotion of healthcare

quality by recognising outstanding quality

improvement activities implemented by ACHS

member organisations, here and overseas.

The Awards retain the same three categories:

Clinical Excellence and Patient Safety, Non-Clinical

Service Delivery and Healthcare Measurement:

Clinical Excellence and Patient Safety

This Award recognises innovation and

demonstrated quality improvement in the delivery of

safe, effective consumer / patient care.

Non-Clinical Service Delivery

This Award acknowledges a demonstrated outcome

in improvement and innovation to patient /

consumer services and organisation-wide practice

including services provided by community and

allied health.

Healthcare Measurement

This category recognises organisations which have

measured an aspect of clinical management and or/

outcome of care, taken appropriate action in

response to that measurement, and demonstrated

improved consumer / patient care and

organisational performance upon further

measurement.

Healthcare measurement can include data

collected from the ACHS Clinical Indicator program

or other methods of monitoring consumer / patient

care processes or outcomes. Both quantitative and

qualitative data can be used, however this category

must describe the initial measurement, the analysis

of that measurement, the action(s) implemented,

and the improved measurement(s).

Recognising quality improvements in health

ACHS PRINCIPLES

The guiding principles behind the awards are:

• A consumer focus

Organisations demonstrate this in their care provision

• Effective leadership

Organisations demonstrate responsibility and commitment

to excellence in care provision, quality improvement and

performance

• Continuous improvement

Management and staff demonstrate how they continually

strive to improve the quality of care in assisting the

organisation.

• Evidence of outcomes

Organisations depend on the measurement and analysis of

performance. Indicators of good care processes or,

wherever possible, outcomes of care, demonstrate a

commitment to maintaining quality and striving for ongoing

improvement.

• Striving for best practice

The organisation compares its performance with, or learns

from others and applies best-practice principles.

Judges will also assess additional criteria, including:

Improvement in patient safety and care, measured

outcomes, applicability in other settings

Innovation in patient care and/or processes, and

Relevance to the QI Awards category

The closing date for the

awards is: electronic version –

Friday 7 September, 2018,

5,00pm, hard copy version,

Friday, 14 September 2018,

5.00pm. Winners will be

announced at the ACHS

annual dinner in Sydney on

Thursday 22 November, and

winning entries published in

the “Quality Initiatives”

publication. For more

information visit

www.achs.org.au or contact

Dr Mark Burgess on (02) 8218 2776.

ACHSNEWS 4

The ACHS Improvement Academy recently welcomed

Professor Jason Leitch from Scotland as a visiting

speaker with a reputation as a quality improvement expert

from his long stint in the Scottish Government as National

Clinical Director Healthcare Quality and Strategy.

An Honorary Professor, a dentist, and a facial-cranio

fracture surgeon for 15 years, Jason went to the States to

get a public health degree, and has since studied quality

and safety.

The Academy proudly hosted Professor Leitch as a

speaker at the ACHS offices in Sydney in early April, and

as guest speaker at the New Royal Adelaide Hospital in

Adelaide for an informative learning session.

The transformation of NHS Scotland began in January

2008 with the launch by the Scottish Government of the

Scottish Safety Programme. It was initially a five-year

program with an early aim to reduce Hospital

Standardised Mortality ratios by 20% by the end of 2015.

By December 2014 mortality had reduced by 16.1 %

across NHS Scotland.

The Acute Adult programme, which is one of four main

programmes, is now organised into nine priority areas for

improvement:

Venus Thromboembolism (VTE); Sepsis; Pressure Falls,

Catheter Associated Urinary Tract Infections (CAUTI);

Deteriorating Patients: Heart Failure, Surgical Site

infections; Safer Use of Medicines.

The other three programs are: Maternity and Children,

Mental Health and Primary Care. These programmes

continue as a joint initiative of the Scottish Government’s

Healthcare Quality and Improvement Directorate and

NHS Scotland’s public health body - Healthcare

Improvement Scotland.

Here is a summary of points he made:

• Prof Leitch noted that in April 2016 Scottish Health

had their first re-structure in 11 years. “Over the last

decade I have told politicians to stop restructuring.

Evidence supports that almost all restructuring in

health is a waste of time, and in the long term, money

won’t be saved,” he said. “You are not going to solve

the problem. You are just replacing it with another,

and it is tempting as it is easier work than taking what

you’ve got and actually fixing it.”

• “Politicians seek simplicity from figures, where

simplicity doesn’t exist, but you have to raise the

dialogue to a much higher approach – is the system

safer than it was yesterday?” he said. “Just because

they think the ED wait number is the right figure to be

questioning, doesn’t mean that it is.”

• Communication is critical, particularly in healthcare

which consists of microsystems and is not linear. Prof

Leitch discussed Joseph Juran’s (from 1950-60s)

theory, who said you need three things: Quality

Control, Quality Improvement, and Quality Planning.

• In 2008, 20% of patients seen by Scottish Health were

harmed by the care they received. Following the

deaths of 37 people from infection control harm in an

aged care nursing home near Glasgow, a Ministerial

decision was made to tackle safety and quality, above

everything else.

• As a result of that program, a quality strategy for NHS

(the first ever), was published in 2010. Quality was to

be the organising principle by which the health service

would be re-established. In 2008 they launched 43

interventions for hospitals to do, taking the very best

of clinically-best practices from around the world and

importing into their health system.

• After the Safety Programme started, the graph started

to move in the right direction. By years four and five,

infections were falling by 90%, (peripheral cannulas

were now only put in 40% of the patients, previously it

was all who visited an ED). They stopped inserting

IDCs in elderly patients, and there was a whole lot of

culture changes with respect to thinking about patient

safety. They are now sharing quality improvement

science with other sectors including police, social

work, domestic violence and prisons to affect change

in a raft of areas that impact on health issues.

Prof Jason

Leitch and ACHS

Improvement

Academy

Director Bernie

Harrison visit

the New Royal

Adelaide

Hospital

ACHSNEWS 5

First AAGP Survey Held The first induction program for the new ACHS Accreditation

for General Practices program was held in February and

resulted in the successful appointment of three GP

surveyors and four non-GP surveyors.

Since the induction ACHS has successfully undertaken an

on-site survey, with further surveys booked for 2018.

“We are delighted to have started accrediting to the new

program and will be looking to make our mark in a number

of states in the short terms,” said ACHS CEO, Dr Christine

Dennis.

The AMA have recently released a Position Statement

(General Practice Accreditation – 2005 Revised 2018)

supporting; “a profession-led voluntary general practice

accreditation system that encourages and supports

practices to not only meet a minimum set of standards, but

to continuously pursue improvement”.

Congratulations to SA Ambulance Service

(SAAS) on becoming the first ever ambulance service in

Australia to be accredited to the NSQHS Standards!

At a SAAS State Leadership Team Briefing held in Adelaide

in February, attended by a wide range of operational staff

as well as a variety of non-operational personnel, SA

Ambulance Service was formally presented with its

NSQHSS Certificate of Accreditation by ACHS CEO Dr

Christine Dennis, to SAAS CEO Jason Killens and

Executive Director Clinical Performance & Patient Safety,

Keith Driscoll.

This celebration is a milestone event for SA Ambulance

Service and its team members, validating the professional

attention to detail which has characterised the SAAS

approach to the accreditation program, and to ongoing

safety and quality.

The presentation was held at SA Ambulance’s newly

commissioned and operational Rescue Retrieval and

Aviation Services (RRAS) base at the Adelaide Airport;

after which a tour of the remarkable new facility was given

to the ACHS visitors.

ACHS has conducted a series of State Advisory

Committee (SAC) meetings in the first quarter of

2018 across the country to keep our members up-

to-date and informed.

The purpose of the bi-annual meetings is to

ensure that representatives of our members in all

states have the opportunity to hear the latest

information on industry and Council changes

regarding accreditation.

The first one was held in WA on 11 January,

followed by the QLD and NT SAC on 18 January,

and the SA and TAS meetings held in February,

and Victoria and NSW in March.

Key issues covered included:

• NSQHS Standards (second edition) and

resources

• ACHS Mapping of EQuIPNational to NSQHS

Standards (second edition)

• Revised AHSSQA Scheme

• AAGP (General Practitioner) Program

• Development of a new International market

program – ACHS Aged Care Program

• Contract renewal and new memberships 2017

• Membership trends 2014 - 2017

• Ongoing Customer Support through transition,

and other ACHS updates covering the surveyor

workforce, ACHS Improvement Program and

the ACHS Constitution.

“Once again we have had a range of valuable

conversations with key representatives and the

opportunity to find out more about their concerns,

and where we can assist our members in the

future,” said Dr Christine Dennis.

Mid-year meetings will be held in July and August.

ACHSNEWS 6

Rosemary Snodgrass

We were blessed to have

Rosemary as part of our ACHS

family for many years. She was a

generous mentor, and a wonderful

friend and colleague to so many of

us. Dr Christine Dennis, ACHS

CEO

Extremely sad news. Rosemary is

not only a loss to her family and

friends, but a huge loss to the

greater Health Community, not the

least ACHS. Along with the Board

and your own Executive and ACHS staff, I pass on my

sincerest condolences. Rosemary has left a significant space

… one that will not soon be filled. Professor Len Notaras AM

She was a great person and strong ACHS supporter. A/Prof

Brett Emmerson AM

Incredibly sad news. Tony Lawson

Vale Rosemary, a legendary stalwart and ambassador. Dr Paul

Scown

Such sad news! My thoughts are with all of her family and

friends and all of the team at ACHS. Stephen Walker

Am on survey at Eastern Health. All team members very sad to

hear of Rosemary's death. We will miss her very much.

Christine, please pass on my condolences to Rosemary's

family and to ACHS colleagues. Dr David Lord

That is very sad news, she is in my thoughts and prayers. God

bless her and her family and friends …. these small acts of

kindness were so characteristic of Rosemary as a colleague

and a friend. I had personally known her for 30 years, first

meeting when she was my DON at RNSH. It was so nice to

reconnect with her at ACHS, we had some great catch ups and

wonderful conversations. She will be greatly missed. Bernie

Harrison

I am saddened by the news … in my ignorance I did not

perceive such a precipitous pathway since Rosemary advised

us of her ailment. Her passing will impact on many. I hope you

are travelling ok. My sympathy is with you all in there. Alex

Bennie

I am so very sorry - really loved Rosemary as she always

showed me great kindness. Julie Cartwright

This is very sad news, Rosemary was a wonderful mentor

throughout all the years we worked together and she will be

sadly missed. Please pass on my condolences. Sandy

Thompson

I will remember Rosemary very well. We had lots of survey and

other memories together. Marilyn Sneddon

I am on survey in Lismore. Very sad news and similar thoughts

and sentiments have been expressed by the survey team.

Condolences to Rosemary’s family. Helen Dowling

It’s very sad to hear the news about Rosemary. If you are

passing surveyor condolences on to the family, could you send

them on behalf of Graham Clay and myself. Thank you. Ros

Pearson

With great sadness, ACHS lost two of its longest-ever serving surveyors in early March, our esteemed colleagues and friends

Rosemary Snodgrass and June Graham who passed away within days of each other. Rosemary Snodgrass passed away on

Tuesday 6 March after a long illness, having relinquished her most recent full-time role at ACHS as the Manager, Surveyor

Workforce, in mid-2017 after being brought out of retirement in 2014.

Rosemary’s commitment to ACHS was exemplary, and she was awarded the ACHS Gold Medal at last year’s annual conference

for her considerable contributions over time to the improvements of quality in healthcare. Rosemary participated in a total of 269

surveys (of 676 surveyor days in her 22 years as a surveyor). Her last survey was in mid December 2016.

June Graham started as a surveyor with ACHS in 1999 and produced a similarly long record of commitment, participating in 181

surveys (totalling 529 surveyors days) and was also held in esteem by many ACHS surveyors and members for her knowledge

and commitment to sharing this with others. June passed away on Saturday 10 March.

ACHS records its affection and regard for both ladies, and sends condolences to both families during this time of sadness. We

remember both Rosemary and June for their contributions not only as surveyors, but for their qualities as healthcare professionals

providing a strong example of leadership for others to follow.

(The following messages were received by the ACHS as spontaneous reactions to the email announcements to the

Board and fellow surveyors of the news)

We remember them …

ACHSNEWS 7

Thank you for letting us know about Rosemary’s death. I was

on survey at the time with Cheryl Burns and we dedicated the

survey to Rosemary. I worked with Rosemary at RNSH from

1990 to 1996. During her tenure as Director of Nursing she

epitomised leadership. She coached and lead all of us as

NUMs. She advocated for her nurses, our patients and the

health system at all times. Her leadership style was exemplary

and she set the standards for others to emulate. As a surveyor

she demystified some of the complexities for both surveyors

and those being surveyed. I did one survey with Rosemary and

her wisdom experience, humour and leadership were very

valuable. Vale Rosemary. Bernadette Loughnane

Rosemary was, above all a lifelong practitioner and advocate

for healthcare and healthcare improvement in Australia – from

youth, through many settings from the remote outback to senior

metropolitan management positions, to years of accreditation

assessment surveying right up to retirement, short as it was.

And now she has let us. We remember Rosemary now, and

not just what she did, but also the legacy she left us – a

passion for healthcare quality and rigour, balanced with

equanimity and fairness. Robin Mead

My fondest memories of Rosemary as a Quality Manager:

Rosemary came to my hospital when I was a very young and

new Quality and Risk Manager at the end of the 1990’s. She

interviewed me along with some other staff and was gentle in

her enquiring and was not in the least intimidating, as I had

heard surveyors could be (yes, nothing has changed!) She told

me she was disappointed with the “lack of data” with the 3

months’ worth of data the organisation had available, the first

point being June (EOFY) followed by July and August. She

said she felt this did not tell a story. I asked her, and she gave

me permission to retrieve some data from my office. I showed

her “my trended data over time” to demonstrate not only our

achievement over the past two years but also the three years

prior, demonstrating that we had been able to sustain the

change over time. She helped me with my project of

presenting trended data over time at the summation and for

that I was eternally grateful. Rosemary will be sadly missed by

me and everyone she worked with and touched in her own

special way. May you rest in peace lovely lady … Marrianne

Beaty

June Graham

Oh my. What a shock. I so

enjoyed working with June. She

is a huge loss and on top of

losing Rosemary you must be

reeling. I am so sorry.

Sincerely, Wendy Wood

What an awful week. I am very

sorry (and shocked) to hear

this. I don’t know what to say.

Another loss of a wonderful

lady with a wicked sense of

humour and great

knowledge. My thoughts are

with you all. Sue Colley

Very sad news. Do you have contact details of June’s next of

kin as would like to express my condolences? Garrett Hunter

I am sorry and shocked to hear about June. Could you pass on

my condolences to her family? Kind Regards, Ros Pearson

That was very unexpected. I will miss June and her funny

stories of experiences as a nurse and as a surveyor.

Condolences to her family and friends at ACHS. Kind regards,

Marion Holden

Thanks for letting me know; June was one of my most favourite

coordinators and I can’t believe this especially as I only saw

her a couple of weeks ago. I will really miss her great style and

approach. Thanks, Sandy Thomson

This is so sad. Many surveys with June – she will be missed.

Best regards, Mark Diamond

This is just so very sad, I have worked with June several times

and always enjoyed her company, her attention to detail, her

dry wit and her directness – I have seen her manage difficult

situations and remember one time when a surveyor played a

practical joke and the way June’s face smiled once she

realised she had been set up. Vale June Graham, taken too

early. Di Knight

I feel so very sad about Rosemary and now June. I am

shocked by the news about June's passing and I feel very sorry

for her family. This is indeed a very sad time for all. Tracey

Hynes

Oh my God. I can’t believe it, this is too much. We only all

caught up at the coordinator’s (day) update last month. I did

my very first survey with June, in Gove Qld. We went crocodile

sightseeing! Didn't spot any thank goodness. Fond memories.

My thoughts and prayers are with her family. Regards, Tonia

Easton

Oh my goodness. This is a real surprise. Please pass on my

condolences. Lorraine Stevenson

And now you're really shocked me! Too close to home. My

condolences to all staff who have worked closely with June

over the years. Frank Flannery

Thanks for letting me know. I knew June from Hunter New

England days. Sad times to have yet another great loss to the

safety and quality collective. My thoughts are with June’s

family and friends. Best, Helen Dowling

I am extremely saddened to hear this news I have such deep

respect for June. What a loss to everyone. Kind regards,

Amanda Ginger

Oh my god, how sad ... this is awful for all of you ... take care

of yourselves! June was a bit of a character! Chris Coombs

Good gracious ... June was sitting on our table at the

Coordinator’s Update day just on four weeks ago in Melbourne.

Helen Milne

Sorry to hear. I also surveyed with her a few times. Regards

Karen Becker

Thank You for advising of the passing of both June and

Rosemary, knew them both for many years … both will be very

much missed … Regards, Di Norris

ACHS has a long history of

providing a variety of

accreditation programs here

and overseas. Our

dedicated team will provide

the personalised spur

necessary to ensure the

General Practice

accreditation process occurs

smoothly, without fuss.

Contact us on (02) 9281

9955 for more information.

ACHSNEWS 8

The ACHS Improvement Academy is delighted to have

been successful in gaining the contract for providing

Quality Improvement Lead (QIL) Training to 30 senior

Health staff, in Melbourne Victoria.

The QIL Program has already gained success through

its public courses which have run in Sydney, Melbourne

and Brisbane. This is the first QIL program to be run

within a whole organisation, as part of

its capability building in improvement

science for senior clinicians, clinician

managers and patient safety and

quality improvement staff.

The program commenced in early

April and all participants will undertake

an improvement project that has

strategic importance for the

organisation.

The goal of the program is to provide this lead group

the core skills and competencies to address issues

such as clinical variation, patient safety concerns and

improve patient experience.

This is an exciting opportunity for Austin Health and

we are delighted to be working with the ACHS

Improvement Academy on providing a uniform

approach to quality improvement at Austin Health” said

CEO Ms Sue Shilbury.

The training program will assist Austin Health staff to

adopt process improvement methodologies to improve

and standardise care processes and as a method for

introducing innovations in models of care.

Austin staff undertaking the training have leadership

responsibility for quality and safety, including dedicated

quality and safety managers.

“These key personnel require Lead

Level training as they are employed

in roles that lead change and

improvement across the services to

our community,” said Ms Shilbury.

“As the major provider of tertiary

health services and health

professional education and research

in the northeast of Melbourne, Austin

Health is the largest Victorian provider

of training for specialist physicians and surgeons.”

“We have a responsibility to ensure clinicians get the

best Lead training in the country that will improve their

understanding of the improvement science behind quality

and safety, and understand how this will make a

difference to our many patients,” she said.