ACHS Accreditation Presentation to GPDV March 2004

2. ACHS Accreditation Presentation to GPDV March 2004 Dr Lee Gruner ACHS surveyor and committee member

3. What is ACHS? • Australian Council on Healthcare (Hospital) Standards established 1974 • Initially set up due to concerns with medical records and credentialing in hospitals • Has evolved over 30 years to assess public and private sector hospitals and day surgeries, community health, health corporate offices, other health organisations • Process of survey has evolved from ticking compliance to a consultative process based on clear organisational criteria and promoting quality and safety in health care

4. What is EQuIP? • EQuIP represents the Evaluation and Quality Improvement Program designed by ACHS and the Australian health care industry to provide a framework for improvement in safety and quality • The framework consists of functions, standards, criteria and elements that describe achievement against the criteria • The framework has been designed to assess both organisations and clinical care

5. EQuIP 3- why the change? • Aim is to provide framework for health service organisations to continuously improve standards and service delivery • Need to reflect current standards • Need to encourage further improvement • Need to build in improved consistency • Need to challenge thinking • Many organisations just going through the motions with EQ2

6. Accreditation –what’s changed? • Meaning of the ratings • 19 mandatory criteria • Elements for each rating • Draft report • Presentations • Importance of leadership involvement

7. Meaning of the ratings • LA- awareness • SA- implementation • MA- evaluation • EA- benchmarking • OA- best practice • To date- only 32% of organisations have obtained MA in all mandatory criteria

8. Mandatory Criteria • 19 including SP&E • Results • 65% with 2 years accreditation (7% in EQ2) • 4% HPR (3%) • 30% full accreditation (90%) • 1%-no accreditation • Major issues for HPR– fire safety • Most common SA: policies/ legislative requirements/ risk management policy/ consumer rights and responsibilities • EA ratings still rare

9. Elements for ratings • Guide for organisations to understand the key areas of importance in health service delivery • Developed by a large group of peers • Have brought structure and process back into the assessment • Checked by surveyors to see how the organisation carries out its business • Missing elements will not necessarily decrease the rating

10. Draft report • Provided to the organisation to correct any errors of fact • Great majority have not required any corrections • Some organisations have wanted to use this to change the report- generally because no understanding of EQ3

11. Functions • Continuum of Care • Leadership and management • Human resource management • Information management • Safe practice and environment • Improving performance

12. Example of a criterion • Standard 2: The governing body leads the organisation’s strategic direction and establishes an operational framework to ensure the provision of quality safe services • 2.1.3 Credible and transparent governance is assisted by formal structures within the governing body and an operational framework within the organisation

13. Example of a criterion Elements- examples: • Awareness: there is informal orientation of newly appointed members to the governing body • Implementation: there is formal orientation to the governing body • Evaluation: self evaluation by individual members of the governing body occurs • Benchmarking: comparison with external systems to improve processes and systems • Leader: organisation recognised as a leader for credible transparent governance

14. Process of accreditation • Structure: 4 year cycle- OWS each cycle with a PR in between • Process: • Organisations complete self assessment • Multidisciplinary survey team of surveyors working in health care, over 1 to 5 days depending on the size of the organisation • Outcomes: full accreditation, 2 years with HPR, 2 years for less than “evaluation” on mandatory criteria, non accreditation

15. Benefits of ACHS accreditation • All surveyors have been senior managers in health with both clinical and non clinical backgrounds • Specifically developed for the health care sector with broad consultation with the industry, government, consumers and other stakeholders followed by extensive piloting·     • Ongoing structured support and education on and off site • Almost 900 health care services throughout Australia accredited • Over 90% of health care organisations registered with ACHS as members

16. Benefits of ACHS accreditation • Consultative process, with clear guidelines for achievement • Easy to follow elements to provide evidence to surveyors • Trained coordinator workforce to ensure professionalism

17. Who does ACHS accreditation make a difference for? • Consumers / patients • Carers • Health care professionals • Hospitals • Private health insurers • Federal and state/territories governments • Ministers

18. What difference does ACHS accreditation make? • Trust and confidence for consumers • Opportunity to obtain funding for urgent requirements • Independent benchmarking • Strategic performance analysis • Impact on the working life of health care staff

19. How does ACHS accreditation make a difference? • Standards are explicit about how care and services are delivered, managed and organised • Requires demonstration of health care organisation structures, processes and outcomes, details of activities they are reviewing and evaluating and improvements made • Encourages self-assessment, continual improvement, promotes enhanced team work and compliance with standards

20. Does accreditation make a difference? Past research projects: • An evaluation of the ACHS Accreditation Program: its effect on the achievement of best practice • Literature Review to support a study to test the theory that Involvement in ACHS Accreditation increases health care organisations’ ability to facilitate change • The Southern Cross University Institute for Action Research survey of EQuIP members highlighted issues which were addressed in the development and implementation of EQuIP 3 • Lee Gruner’s MBA

21. Current research projects • Relationship between accreditation and organisational and clinical performance • The clinical indicator program • Co - supervision of 2 PhD students • Study on EQuIP of the views of medical practitioners • Evaluation of implementation of EQuIP 3 • Ongoing evaluation of each stage of the EQuIP process.