The Australian Council on Healthcare Standards ANNUAL REPORT

08-09 SAFETY QUALITY PERFORMANCE

The Australian Council on Healthcare Standards (ACHS) would like to thank the management, employees, consumers and visitors at the following organisations who participated in the photography for this Annual Report: ÂÂ Concord Repatriation General Hospital, Concord ÂÂ Greenwich Hospital, Greenwich ÂÂ Liverpool Hospital, Liverpool ÂÂ Prince of Wales Private Hospital, Sydney ÂÂ Prince of Wales Public Hospital, Sydney ÂÂ Sydney Southwest Private Hospital, Liverpool The ACHS seeks to treat indigenous cultures and beliefs with respect. In many areas of indigenous Australia, it is considered offensive to publish photographs or names of indigenous people who are recently deceased. Readers are warned that this publication may inadvertently contain such photographs.

The ACHS would like to acknowledge the generous support provided by Baxter Healthcare for the purposes of publishing this Annual Report. This support enables us to publish and distribute our report to ACHS member organisations, ACHS surveyors, health industry bodies, governments and the community. October 2009 © 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.

Common Acronyms included in this Report: ÂÂ AAQHC – Australasian Association for Quality in Health Care ÂÂ AC60 – Advanced Completion in 60 days ÂÂ ACHS – The Australian Council on Healthcare Standards The Australian Council on Healthcare Standards Annual Report 2008–2009 ÂÂ ACHSI – The Australian Council on Healthcare Standards International Pty Ltd ISBN: 1 921265 47 7 (paperback) ÂÂ ACSQHC – Australian Commission on Safety and Quality in ISBN: 1 921265 48 5 (website) Health Care This Report is available in PDF format ÂÂ AIHW – Australian Institute of Health and Welfare via the ACHS website (under the Publications and Resources menu ÂÂ APS – Agreed (accreditation) Performance Statement option) from the homepage: ÂÂ EAT – Electronic Assessment Tool www.achs.org.au ÂÂ EQuIP – Evaluation and Quality Improvement Program To order a printed copy, please contact ÂÂ EQuIP 4 – the 4th edition of the ACHS Evaluation and Quality the ACHS: Improvement Program 5 Macarthur Street ÂÂ IAP – International Accreditation Programme Ultimo NSW Australia 2007 ÂÂ ISQua – International Society for Quality in Health Care Telephone 61 2 9281 9955 Facsimile 61 2 9211 9633 ÂÂ PIRT – Performance Indicator Reporting Tool E-mail [email protected] ÂÂ RACMA – Royal Australasian College of Medical Administrators Website www.achs.org.au

B ACHS ANNUAL REPORT 2008–2009 CONTENTS

About ACHS Division Reports Financial Performance 03 18 36 Vision, Mission and Values Customer Services Directors’ Report 04 22 38 Our Identity Development Financial Statements

Our Performance 25 40 Corporate Services Notes to the Financial Statements 06 Corporate and Strategic Plan 28 48 ACHS International Directors’ Declaration 09 President’s and Corporate Governance 49 Independent Auditor’s Report Chief Executive’s Report 29 12 Overview Listing Highlights of the year 31 50 Our Organisation ACHS Board of Directors Our Members 34 60 13 ACHS Council Members Our Surveyors Organisation Chart 63 14 Publications and Presentations Our Executive Team 64 Recognising Overview of Products and Services Achievement 16 Index ACHS Medal and ACHS Quality Improvement Awards 64 Glossary of Terms Inside back cover

ACHS ANNUAL REPORT 2008–2009 1

ABOUT ACHS

Vision To be recognised nationally and internationally as the leading Australian organisation that independently assesses performance and promotes and improves the quality and safety of healthcare Mission To improve the quality and safety of healthcare Values The following words encapsulate how the organisation behaves: Excellence Transparency To strive for excellent performance in all that we do To be clear and visible in all matters Leadership Teamwork To demonstrate leadership and support the leadership role To work cooperatively with each other and all stakeholders of stakeholders Consumer focus Commitment To look at health system issues through the eyes of consumers To consistently demonstrate our commitment to the achievement of safety and quality in the provision of all Cultural responsiveness health services To respond to the various beliefs, traditions and customs that are reflected in Australian society Integrity To be professional, truthful and reliable in all our actions

ACHS ANNUAL REPORT 2008–2009 33 About ACHS Our Identity

The Australian Council on Healthcare Standards (ACHS) is an independent, not-for-profit body; collaborating with consumers, healthcare professionals, industry bodies and the broader community to develop the accreditation standards and quality improvement programs used by the majority of Australian hospitals and healthcare organisations.

ACHS is governed by a Board of Directors elected by a Council drawn from peak bodies in the health industry, representatives of governments and consumers. ACHS full and associate memberships by state and sector as at 31 December 2008 We are recognised by the International Society for Quality in Health Care (ISQua) for our organisational framework, our 350 accreditation standards and our surveyor training. 331 Private Public Our products and services 300 External and independent peer review is considered international best-practice for many industries, including healthcare. ACHS 250 Surveyors are health-industry professionals and consumers trained to conduct reviews of healthcare organisations against the standards of the ACHS Evaluation and Quality Improvement 200 Program (EQuIP). The current edition of this program’s standards, EQuIP 4, was

introduced in January 2007 and has increased the focus on 150 140 129 consumer participation in healthcare and the need to provide 127 103 evidence of clinical and organisational outcomes. 106 100 101 The purpose of accreditation is not to review against a checklist but to provide a thorough and realistic roadmap for improvement and 60 to help organisations establish a culture that strives for excellence. 50 38 Regularly consulted by other countries, ACHS has relationships 34 13 9 7 6 throughout the world in relation to standards development, 6 accreditation systems and clinical indicator programs. 0 1 NSW VIC SA TAS WA NT QLD ACT For more information on ACHS products and services see page 64.

Our Members Over 1200 individual healthcare organisations are members of ACHS quality improvement programs. Number of ACHS full & associate members by sector: 2005–2008* Hospitals, community health organisations, divisions of general practice, corporate offices of health services and day surgeries Sector 2005 2006 2007 2008 are some of the types of organisations participating in ACHS Private 481 435 417 431 accreditation and quality improvement programs. Public 555 613 675 780 For a complete list of ACHS Member organisations see page 50. Other – Public/Private 17 0 0 0 Total 1053 1048 1092 1211

* Restructuring of a membership contributes to changes in membership figures.

4 ACHS ANNUAL REPORT 2008–2009 Our Surveyors This is exemplified by the inclusion of accreditation requirements in government policy/legislative initiatives and from within the Over 400 surveyors are trained by the ACHS in evaluation industry. The Australian Commission on Safety and Quality techniques to assess organisations against the EQuIP 4 in Health Care has completed a review of accreditation and standards. Many of these surveyors still work full time in the Australian Health Ministers have given ‘in principle’ approval health industry and contribute on a volunteer basis. to the implementation of a new model. ACHS has strongly In addition to the growing number of consumer surveyors, the supported the review and endorses its conclusions. majority of ACHS surveyors are professionals with recent and With an ageing population and the increasing cost of funding broad healthcare experience such as doctors, nurses, medical healthcare there is also a growing emphasis on population and administrators and allied health professionals. preventative health, culminating most recently (September 2009) For a full list of ACHS Surveyors see page 60. in the release of the National Preventative Health Strategy by the Commonwealth Preventative Health Taskforce. Our funding In 2007 the ACHS introduced a health promotion standard into As an independent, not-for-profit organisation, the majority the EQUIP 4 Program encouraging organisations to promote of funding is from membership fees. Funding is also received ‘better health and wellbeing for consumers’. During our review of from tenders and projects undertaken on behalf of government EQuIP 4 we are working with experts in the preventative health organisations and other industry bodies. We also receive a specific field to further develop this standard. contribution from Baxter Healthcare for our Quality Improvement Our Corporate and Strategic Plan provides direction for Awards program and the publication of this Annual Report. meeting the challenges in our environment (page 6).

Our environment and our future Our partnerships The quality agenda for the Australian healthcare industry for There is a range of governance models among the Australian more than a decade has been focused on ensuring patient States and Territories as well as across public and private safety and high quality performance. The Australian Health healthcare; each presenting its own unique strengths and Ministers in 2001 adopted a National Health Performance challenges. Understandably, there is also a variety of interests Framework which includes nine dimensions of “health system and views around the best approaches to improving quality and performance”. EQuIP reflects this framework. safety in healthcare. Patient safety remains a significant concern to health system From surveying to standards development and clinical indicator operators, clinicians, the public and politicians. working groups, our philosophy and operational model is built on There is an increased usage of standards-based performance industry collaboration and partnerships. assessment (accreditation) programs across the health industry. For example, we continue a close working relationship with the Australian Commission on Safety and Quality in Health Care to provide input in the development of the new model for accreditation programs in Australia.

ACHS Members (full & associates) by bed size as at 31 December 2008 (n1,211)

59% (n709)

14% (n168)

13% (n154) 0-49 beds 50-99 beds 10% (n117) 100-199 beds 5% (n63) 200-499 beds > 500 beds 0% 10% 20% 30% 40% 50% 60%

ACHS ANNUAL REPORT 2008–2009 5 Our Performance Corporate and Strategic Plan*

Our Corporate and Strategic Plan provides direction to meet the challenges in our environment and achieve our Vision and Mission (page 3).

Strategic Goal 1 Be the leading organisation providing products and services that promote and improve quality and safety in the provision of health services, including standards development, performance assessment, accreditation and education

Objective 2008–2011 Aims 2008–2009 Outcome 2009–2010 Outlook Be provider Pursue potential growth Membership growth in: Grow memberships in target of choice; markets through yy Diagnostic Imaging Accreditation markets by: maintaining, and comparison of AIHW yy exploring options for injury where possible, yy Mental Health Services (Tasmania) data against our member management services and allied growing the yy NSW alcohol and other drug agencies database health services membership base through partnership with Network for Implement recruitment Alcohol and Drug Agencies (NADA) yy reviewing product for stand-alone strategy to increase the day hospitals to improve service number of allied health Publication of a Methadone Resource Tool Increase recruitment of clinical specialty clinician surveyors to support NSW Health facilities and mental health surveyors and Strategy implemented with several allied survey coordinators to meet member health clinicians joining the ACHS as requirements surveyors Implement 3 part-time contracted Conducted comprehensive and survey coordinator positions to improve independent survey of ACHS member inter-rater reliability satisfaction with ACHS activities and program support Evaluate 2009 member survey and recommend strategies to improve program support and satisfaction Provide relevant Commence an effective Over 140 healthcare professionals Field review of the revised EQuIP 4 evidence-based consultative framework for (Working Groups and Reference Groups standards, August 2009 products and the review of EQuIP 4 for EQUIP 4 Review) represented a broad Introduce a quality improvement services cross-section of member organisations program for day hospitals based on and provided expert advice. industry feedback Maintain Maintain ISQua IAP Accreditation of ACHS Surveyor training ACHS undergoing ISQua survey for international accreditation program achieved ongoing organisational accreditation, recognition of September 2009 the organisation, Review of EQuIP 4 program continues standards and the within the principles and objectives surveyor training program set out by ISQua Increase Assess methodologies for Appointment of a consumer Develop resource tool to support consumer including consumer input representative to the ACHS Standards consumer surveyors participation in Achieve 10% of Committee Continue to promote consumer survey program Organisation-Wide Surveys 10% target still to be achieved surveyors on teams. Review with a consumer surveyor information given to members on the team regarding this option Promote Promote ACHS through Attendance targets (around 600 Promote ACHS when planning 2010 ACHS through National Forum on Safety registrants) exceeded for the National National Forum on Safety and Quality publications and Quality in Health Care Forum (698). Evaluation conducted in Health Care and conference (Adelaide, October 2008) online (226 evaluations collected). Overall presentations feedback was very positive For full publications and presentations listing see page 63

* Acronyms included in this Plan are detailed on the inside front cover of this Report.

6 ACHS ANNUAL REPORT 2008–2009 Strategic Goal 2 Develop and sustain collaborative links with key stakeholders

Objective 2008–2011 Aims 2008–2009 Outcome 2009–2010 Outlook Maintain Further implement Collaborated with ACHS Council, State Continue consultation for EQuIP 4 liaison with consultation processes Advisory Committees and Surveyors program through field review and industry-leading for the review of EQuIP 4 Communication with stakeholder groups ACHS communication channels organisations program for review of EQuIP 4 Implement recommendations from and be Strengthen collaborative Consultations with EQuIP members the ACHS Member Survey and responsive to links with member communicate progress their needs conducted in Perth, Newcastle, organisations Adelaide, Melbourne, Brisbane, Canberra, Hobart and Ballarat Conducted ACHS Member Survey with independent consultants to evaluate EQuIP programs and member services 53% of member organisations responded to the electronic member satisfaction survey via the ACHS website Consultations conducted with industry stakeholders in relation to program for day hospitals Interact with key Continue partnerships in the Partnered with key industry bodies such Collaboration with key stakeholders in stakeholders, development of the premier as ACSQHC and RACMA to deliver the planning for 2010 National Forum including annual health industry National Forum on Safety and Quality in Health Care participation conference in Australasia ACHS represented on ACSQHC Pursue opportunities to partner with on significant Maintain effective Accreditation Implementation AAQHC for a 2011 conference committees, in relationship with ACSQHC Reference Group key events and and other key bodies at conferences Continued representation in the National Indicators Advisory Group developing a proposed set of national clinical indicators

Strategic Goal 3 To be recognised as a leading contributor to research into quality and safety in healthcare

Objective 2008–2011 Aims 2008–2009 Outcome 2009–2010 Outlook Advance the Consolidate the activities Collaborative research activities Progress identified projects and collaborative of the ACHS Research undertaken with established research source funding research Advisory Panel entities, for example Griffith University and Establish working groups to review program Develop collaborative Centre for Clinical Governance Research in the Day Surgery, Emergency Medicine partnerships for research Health, UNSW and Intensive Care Clinical Indicator into accreditation and Established working groups to review sets quality management in Clinical Indicator sets for Anaesthesia, healthcare services Medication Safety and Mental Health Community-based Indicators Publish research Publish annual ACHS Papers on research into quality Continue to develop and release Australasian Clinical improvement submitted to national and research papers Indicator Report and international journals Progress demonstrated by meeting papers on research into Published ACHS Australasian Clinical targets for publications using ACHS data quality improvement Indicator Report sources and research Publish biennial National Report on Health Services Accreditation Performance

ACHS ANNUAL REPORT 2008–2009 7 Our Performance Corporate and Strategic Plan

Strategic Goal 4 Promote and publish information in relation to the quality and safety of healthcare

Objective 2008–2011 Aims 2008–2009 Outcome 2009–2010 Outlook Promote public Agreed Performance 93% compliance of eligible members Pursue 100% compliance of APS disclosure of Statement (APS) percentage publishing their APS on the ACHS website published performance of compliance in line with Data analyses and production of NAR Publish NAR information contractual obligation commenced for November 2009 Prepare biennial National publication Accreditation Report (NAR) on EQuIP 4 performance information Implement Assist the effective collection Developed web-based data reporting Continue development of PIRT Online effective usage of and analysis of ACHS Clinical system PIRT Online to streamline and to expand functionality clinical indicator Indicator data with the improve business processes related to data Review the content of the ACHS information introduction of a web-based submission and reporting clinical indicators Australasian Clinical Indicator Report PIRT program, 2009 Established working groups to review 2001–2008 Continued review of current Clinical Indicator sets for Anaesthesia, ACHS Clinical Indicator sets Medication Safety and Mental Health and introduction of new Community-based Indicators ACHS indicator sets on Developed and distributed Trend Reports behalf of medical colleges for individual organisations and health associations Published indicator report Publish national clinical indicator report Increase utilisation of clinical indicator data by surveyors Ensure website Implement second web Second server implemented Website utilisation rates monitored, facilitates access server to improve access PIRT online available (see above and evaluated and demonstrating of information by and minimise disruption for page 23) improvement over time all stakeholders users Review website content and structure Ensure Awards Increase participation rates Participation rates levelled Review viability of QI Awards program Review collection systems for Introduced standardised summation form Review eligibility criteria for the recognises submissions and expand the for submissions to the ACHS QI Awards QI Awards excellence in information provided in the 2008 Review submission categories for performance accompanying publication Improved access to website-based QI Awards (Quality Initiatives) QI Awards information and published submissions

Strategic Goal 5 Maintain effective internal systems that enable business goals to be efficiently achieved Objective 2008–2011 Aims 2008–2009 Outcome 2009–2010 Outlook Deliver effective Meet budget targets Budget targets met Meet budget targets financial Ensure audit report Audit report unqualified Ensure audit report unqualified performance unqualified The software integration reduced process Integrate payroll management into the Implementation of new duplication and resource requirements SAP Business One accounting software and A comfortable and safe working integration with the existing environment maintained; measured corporate database through staff satisfaction survey and absence of workplace incidents Ensure business Maintenance of ISQua IAP Accreditation of ACHS Surveyor training ACHS undergoing ISQua survey for systems accreditation program achieved ongoing organisational accreditation, externally September 2009 accredited Ensure effective Strategy targets measured Media and communications targets Review 2005–2010 Communications communications through media references exceeded for National Forum 2008 Strategy and planning to extend to and media and stakeholder feedback Corporate Editorial and Visual Style 2011 aligning with updated Corporate strategy in place Guides updated and Strategic Plan 8 ACHS ANNUAL REPORT 2008–2009 Our Performance President’s and Chief Executive’s Report

This report summarises the major points of another productive and positive year for the ACHS. The organisation continues to grow and evolve its services in response to quality and safety agendas nationally. There is a heightened national focus on quality and safety that has not unexpectedly resulted in challenges and some tensions. While international business growth has continued to be positive it has been impacted by the international financial crisis. However, our success in winning a major tender to work with the Hong Kong Hospital Authority was an impressive way to celebrate our overseas business activities in the latter part of the financial year.

Governance There have been several significant changes among Executive Staff. In response to our expanding international activities, Dr Michael Hodgson AM completed his term as President, and an international business unit was created within the parent having reached the maximum term allowed as a Director also organisation in October 2008 and Dr Desmond Yen was appointed left the Board, and was succeeded by Associate Professor Executive Director – International Business. Desmond had been Peter Woodruff. Dr Hodgson’s contribution to ACHS has been leading the growth of international business for several years prior exemplary by any measure. He enthusiastically filled a number of as part of his previous role as Executive Director – Corporate key positions whilst on the Board. His leadership and thoughtful Services. As a consequence of the dedicated international position contributions will be missed. Ms Lena Low was promoted to Dr Yen’s former position. Both Ms Karen Linegar, who represents the Royal College of Lena and Desmond are long-term employees of ACHS and Nursing, Australia on the Board, was elected as Vice President. continue to make highly valued contributions in their new roles. Ms Linegar continues to have a distinguished nursing career Ms Heather McDonald resigned from the position of Executive and those experiences have already proven to be of substantial Director – Customer Services in November 2008 after more benefit to the Board’s deliberations and the exercise of its than six years in that position. She guided the Service through responsibilities. Mr John Smith PSM was re-elected as an evolutionary phase and we wish her well in her future career. Treasurer. He has brought vast experience and diligence to the Ms Laurie Leigh was appointed to the position and commenced performance of that role. in March 2009. She has brought a substantial range of Ms Helen Dowling, who represents Allied Health Professions experience at both clinical and operational management levels, Australia on the Council, was elected to fill the vacancy on the together with a passion for quality. Board. She brings the knowledge and experience gained in her The Board approved of ACHS strengthening its capacity for continuing career as a senior pharmacist in the health system. externally commissioned consultancy work and a major study Her appointment is most welcome. Ms Dowling is also the Chair of governance arrangements at the Royal Darwin Hospital was of the Board’s Standards Committee. successfully undertaken at the request of the Minister for Health The Board consolidated the role of the Financial Review Advisory in the Northern Territory. ACHS intends to extend its consultancy Group. This is now a formal component of its governance activities in the future. framework and, in part, reflects the growth in business as well as the continuing challenges of sound financial stewardship, Financial performance especially in the current adverse financial conditions. Another positive financial result has been achieved, continuing a The organisation’s Corporate and Strategic Plan was revised. pattern established over a decade ago. The details are available It provides a concise statement of organisational direction. elsewhere in this report (see page 38). A number of cost The planning process was undertaken under the auspices of pressures continue to impact on the organisation particularly the Board and involved the Council, other stakeholders and with respect to the operational requirements of delivering the staff. The planning period was limited to three years due to the accreditation programs. The organisation remains financially dynamic environment around quality and safety in healthcare. very sound. The membership continues to grow and expand its reach, but none of this can be taken for granted.

ACHS ANNUAL REPORT 2008–2009 9 Our Performance President’s and Chief Executive’s Report 2008–2009

Maintaining performance A similar picture has emerged in relation to the credentialling of health professionals. On balance the health system has moved As part of our existing commitment to external validation of our a long way on this issue. However, significant adverse events in activities, ACHS extended its involvement in the accreditation recent years have raised its importance and there are variations programs provided by the International Society for Quality in the level of performance despite the national standard being in Health Care (ISQua). The ACHS surveyor training and published in 2004. Again time has been spent documenting the development program was awarded accreditation in April 2009. various approaches partly to ensure a consistent approach by This is a new accreditation program offered by ISQua and was surveyors, but also to draw attention to the need for a single developed in response to increasing international requests given recognised standard that is adhered to, especially as we move the importance placed on surveyor performance in accreditation towards national registration of health professionals. processes. ACHS was the second organisation to be accredited internationally. We now participate in all three of ISQua’s Disappointingly we saw the loss of some day surgery members, programs encompassing standards development and review, mainly on the basis that they found the EQuIP requirements, our organisation and now the surveyor development program. especially in relation to survey processes, burdensome given the typically small organisation size and the limited resources During 2009 an important, independent review of member and available. The Board has responded by determining that the stakeholder organisation’s satisfaction of the products and program requirements for this group be revised and a sector- services provided by ACHS will be undertaken. This is the first specific version is expected by the end of 2009. review since 2001 and we look forward to sharing the results with you later in the year. The National Safety and Quality Agenda This year has seen us return, with some regret, to a long- term issue, namely fire safety. The variation in compliance We have continued the close working relationship with the requirements and guidance information across Australia seems Australian Commission on Safety and Quality in Health Care. to have become more marked in recent years. This has led Several Board members, Councillors and Executive staff to situations where surveys identified significant risks in some have active roles within the organisational framework of the locations despite appropriate certificates of compliance being Commission. The Chief Executive continues as a member of the provided. Whilst these situations have been rare, the variation in Commission’s Accreditation Implementation Reference Group practice has resulted in ACHS seeking to document the specific that provides advice on the development of the new model for requirements across each jurisdiction to ensure surveys produce accreditation programs in Australia. consistent and sound advice relevant to each location. ACHS was awarded two contracts to undertake studies that were instigated as part of the revision of accreditation. They were the Piloting of Short Notice Surveys (sometimes described as unannounced surveys) and Piloting of Patient Journey Methodologies (also known as tracer methodology). Both projects were completed on time and to the satisfaction of the Commission. They reflect well on our emerging recognition as a respected researcher. It is appropriate to observe that whilst very good progress has been achieved with the national agenda, each stage points to the need for an authoritative and nationally consistent framework to be put in place. This remains the dominant challenge.

Prince of Wales Hospital and Community Health Services, Sydney

10 ACHS ANNUAL REPORT 2008–2009 Research Thank you At the time of writing this report, the major paper from the Firstly, the continuing contribution of Baxter Healthcare Australian Research Council Linkage Grant study into the is gratefully acknowledged. Their support for the Quality broadly described value of accreditation is awaiting publication. Improvement Awards program and in the production of this The project was led by Professor Jeffrey Braithwaite, Director Annual Report over many years has been most generous. of the Centre for Clinical Governance Research, University of The stability and commitment of the Board, the contributions New South Wales and included ACHS and Ramsay Healthcare by members of Council and the organisations they represent all as collaborators. Several other research proposals directed at serve to enrich this organisation. However, none of the positive extending the evidentiary base behind accreditation are now outcomes for the year in review would have been possible being developed. without the contributions of staff in all their differing roles. The In addition, we have been delighted to join with the Business final word of thanks goes to the surveyors whose continuing School, Griffith University, Queensland in its study into human contributions have been highly respected. resource management in Australian hospitals. This work is in its early stages but looks very promising. The results will have Looking forward importance for ACHS standards development and elsewhere. For ACHS the next year will see us adopting the next version of our standards. The working parties have already completed Partnerships initial drafts and we are now entering into the field review A very successful National Forum on Safety and Quality in and pilot testing phases. The work of the Commission on Health Care was held in Adelaide in October 2008 attracting the development of National Health Standards and survey approximately 700 delegates. The Forum was held in partnership methodology will be reflected in the end product. It will be with the Australian Commission on Safety and Quality in important to strike the correct balance between compliance Health Care, the South Australian Department of Health and checking and the promotion of a continuous quality improvement the Royal Australasian College of Medical Administrators. The philosophy. These are often the two major competing forces international plenary speakers came from the United Kingdom, impacting accreditation programs. It is ground that can, and The Netherlands and Canada. The Forum provided opportunities does, provoke emotional debate and where the essence of for the sharing of knowledge and experience and for the our common goals, a safe patient environment with effective establishment of networks. It is regretted that the Australasian outcomes, can become clouded. Association for Quality in Health Care decided not to co-partner The establishment of clear national directions, consistently this event as it had done for the previous two years. ACHS looks articulated by leaders and supported by respected powers to forward to re-establishing this partnership in the future. direct performance will be essential to maximise patient safety in a high-quality health system provided by skilled and motivated International business activities health professionals. The exciting development has been our success in winning a major tender to work with the Hong Kong Hospital Authority Thank you to pilot a hospital accreditation scheme in Hong Kong. Work commenced in May 2009 and excellent progress has already been made. The project is planned to take 30 months and may well lead to a more substantial partnership with the Hospital Authority. This achievement is a wonderful reflection on the reputation of ACHS and everyone associated with it.

In other regions, slow but steady growth has been achieved in expanding membership of the accreditation program.

Associate Professor Mr Brian Johnston Peter Woodruff Chief Executive President

ACHS ANNUAL REPORT 2008–2009 11 Our Performance Highlights of the Year

In the past year we:

Achieved a 93% satisfaction rating with the Were awarded a Hong Kong Hospital Authority cohesiveness of the survey team (from our tender to assist with the development and members who completed a post-survey implementation of a pilot scheme of hospital questionnaire), see page 18 accreditation, see the ACHS International report, page 28 Improved the timeframe for turnaround of accreditation survey reports moving from 54% Maintained a modest financial surplus of of reports outside the turnaround benchmark $27,698, ensuring the ongoing viability of our to 16% outside the benchmark, see page 20 services, see page 36

Commenced the review of our Evaluation and Grew our membership base, see page 50 Quality Improvement Program (EQuIP 4) to Increased our surveyor workforce including ensure our standards remain current, continue several allied health clinicians, see page 60 to reflect industry and community expectations and are evidence-based, see page 22 Exceeded attendance and evaluation targets for the National Forum on Safety and Quality in Health Care, October 2008, see below

ACHS, in partnership with the Australian Commission on Safety and Quality in Health Care and the South Australian Department of Health (and in conjunction with the Royal Australasian College of Medical Administrators), hosted the National Forum on Safety and Quality in Health Care in Adelaide, 29–31 October 2008. With international and local speakers and facilitators, the Forum addressed the theme: Safety and Quality is Everyone’s Business. Almost 700 attendees ensured attendance targets were exceeded and overall the online evaluations were extremely positive.

Above: Panel session at the National Forum, Adelaide, October 2008. Pictured from left to right: Professor Chris Baggoley, Professor Ross Baker, Ms Christine Gee, Professor Michael Ward, Professor Richard Grol, Professor Martin Marshall and Dr Normal Swan

12 ACHS ANNUAL REPORT 2008–2009 Our Organisation Organisation Chart

ACHS Council Board of Directors ACHS International Board of Directors Chief Executive Communications Manager

Executive Assistant Communications & Events Officer

International Business Corporate Services Customer Services Development Executive Director Executive Director Executive Director Executive Director

International Business Business Services Administrative Assistant Administrative Assistant Coordinator Business Manager

Customer Services Project Officer Business Support Services Team Leader Senior Project Officer Customer Services Managers Project Officers Standards & Program Accreditation Administration Services Education Support Development Team Leader, Senior Admin Assistant, Services Senior Project Officer Admin Assistants, Word Processing Officers, Education Manager Project Officer Receptionist, Clerical Assistant, Trainees Education Consultant Administrative Assistant

Education Administration Services Performance & Surveyor Supervisor, Admin Assistant, Clerical Assistant Outcomes Service Workforce Clinical Director Resource Coordinator Coordinator Financial Services Surveyor Bookings Data and Admin Accountant, Assistant Accountant, Accounts Officer Administrator Assistant Surveyor Bookings IT Services Assistant IT Manager, Programmers, Support Officer Research Principal Consultant

From left to right: Ms Laurie Leigh, Ms Darlene Hennessy, Mr Brian Johnston, Ms Lena Low, Dr Desmond Yen

ACHS ANNUAL REPORT 2008–2009 13 Our Organisation Our Executive Team

Mr Brian Johnston Ms Darlene Hennessy Dip Pub Admin (NSWIT), BHA, FCHSE, FAICD, FAIM B Nursing, Grad Dip Adv Nursing, MHA, Grad Cert Marketing ACHS Chief Executive Executive Director – Development Brian Johnston has been Chief Executive of the ACHS since Darlene Hennessy joined the ACHS in August 2006 as November 2000. He has been professionally involved with the Executive Director – Development. Her key responsibilities ACHS since being appointed as a surveyor in 1985 and was include developing and maintaining industry standards, leading also previously a member of the Standards Committee for six the organisation’s programs in performance and outcomes years. He has qualifications in health administration from the measurement and research. University of New South Wales and in public administration Prior to joining the ACHS, Darlene most recently held a position from the NSW Institute of Technology (now the University of in a private health insurance organisation as manager of a Technology, Sydney). contracting team. In this role her responsibilities included the Mr Johnston is a Fellow of the Australian College of Health negotiation and management of contracts with Australian private Service Executives, a Fellow of the Australian Institute of hospitals and day surgeries. Company Directors and a Fellow of the Australian Institute of Darlene has worked with the New South Wales Department Management. He holds an appointment as Visiting Fellow, of Health in the Performance Management Division and has Centre for Clinical Governance Research, at the Faculty of previously been a member of the Education service of the ACHS. Medicine, University of New South Wales, and is a member of the Management Committee of the Royal Australasian College With undergraduate studies in Nursing, Darlene has of Surgeons’ Australian Safety and Efficacy Register of New postgraduate qualifications in Advanced Nursing, Health Interventional Procedures – Surgical. He is the current Chair Administration and Marketing. of the Council for the International Accreditation Programme In her role as Executive Director Development, Darlene has provided by the International Society for Quality in Health conducted presentations at major international conferences Care (ISQua). and was appointed to provide consultancy on standards Mr Johnston’s professional career has been wholly in the development to the Kuwait Ministry of Health. As an ISQua health industry and includes experience at both departmental surveyor she has participated in the evaluation of healthcare and senior health service management levels. He has been organisations internationally. involved mainly in the operational management of public health services and facilities, particularly teaching and referral centres since 1977.

ACHS employee analysis as at 30 June 2009

2001 2002 2003 2004 2005 2006 2007 2008 2009 No. of full-time employees 34 35 36 36 44 48 41 43 53 No. of part-time employees 11 8 8 9 9 7 7 7 6 Total no. of employees 45 43 44 45 55 55 48 50 59 Full-time equivalent 43 41 42 41 50 50 48 47 56 Average years in service 3.59 3.72 4.06 4.74 4.60 6.18 5.27 5.14 5.11

14 ACHS ANNUAL REPORT 2008–2009 From left to right: Mr Brian Johnston, Ms Darlene Hennessy, Ms Laurie Leigh, Ms Lena Low, Dr Desmond Yen

Ms Laurie Leigh Dr Desmond Yen BA (Hons), MA (CANTAB), Dip Nursing (Mental Health), RMN (UK), RN B Com, MBA, DBA, FAICD Executive Director – Customer Services Executive Director – International Business Laurie Leigh joined ACHS in March 2009 as Executive Desmond Yen joined the ACHS in July 1995 and is a key Director – Customer Services from a senior management member of the ACHS Executive team. His current portfolio position within a large area health service. Her portfolio covers primarily covers all aspects of international business. Prior to the EQuIP membership, the surveyor workforce and the ACHS his current role, he was responsible for the ACHS corporate education program. services. His multiple responsibilities have included strategy, policies and systems development, finance, risk management, She has qualifications in Social Psychology and Mathematics, information technology and support services. He has been Person Centred Counselling and Mental Health Nursing; and exposed to all aspects of healthcare accreditation requiring is completing an MA in Health Services Management with the interaction with the ACHS Board, Councillors, member University of Technology Sydney. organisations and the surveyor workforce. Ms Leigh moved to Australia from the UK in 2003 and brings His broad range of experience, mainly within large multi-national to the ACHS professional experience as a mental health nurse organisations, covers a mix of local and international strategic and senior manager for mental health services within hospital management, finance, and information technology roles. and community settings in both countries. Her areas of interest include change management and quality improvement as well Desmond is a surveyor for the International Society for Quality as an international perspective in health service delivery. She has in Health Care (ISQua) and has surveyed the South African and a broad experience both as a clinician and as a health service Malaysian accreditation agencies. Desmond has recently been manager in implementing the safety and quality agenda within appointed as the Deputy Chairman Research Committee for the large complex health service organisations. Asian Society for Quality in Health Care (ASQua). He holds graduate qualifications in commerce, a Masters Ms Lena Low degree in Business Administration, a Doctorate in Business MBA, Grad Dip Mgmt, FAICD Administration and is a Fellow of the Australian Institute of Executive Director – Corporate Services Company Directors. He is also a contributor to an Australian Lena Low has been with the ACHS since November 1995 and Research Council Linkage project titled ‘Examinations of the has been involved in developing healthcare accreditation systems relationship between accreditation, clinical and organisational for over ten years. Her portfolio covers finance, information performance’, being undertaken by the Centre for Clinical technology, human resources management, accreditation Governance Research in Health, University of New South Wales administration services and business support services. in conjunction with industry partners. Her postgraduate qualifications in business management He is currently completing a PhD doctorate on a prospective combined with work experience has enhanced her skills and retrospective study of the organisational influence of peer in business finance, statistical analysis and reporting, accreditation surveyors. His hypothesis is that the presence organisational management, behaviour change management and influence of surveyors in an organisation has a positive and product development. Her qualifications and experience association with health service performance in the ACHS in healthcare accreditation and the industry facilitates the accreditation program and organisational culture. development, management and evaluation of systems to enable accreditation. She is also a surveyor for the International Accreditation Program provided by the International Society for Quality in Health Care (ISQua) and a Fellow of the Australian Institute of Company Directors. Ms Low is completing her PhD on medical clinicians and their role as accreditation surveyors. This study contributes to the groundbreaking research into the correlation between accreditation processes and quality of care undertaken by the Centre for Clinical Governance Research in Health, University of New South Wales in conjunction with the ACHS and other industry partners.

ACHS ANNUAL REPORT 2008–2009 15 Recognising Achievement ACHS Medal and Quality Improvement Awards

ACHS Medallist: 2008 Associate Professor Christine Kilpatrick At the November 2008 Annual Dinner in Sydney, our highest honour was awarded to Associate Professor Christine Kilpatrick for her outstanding achievement and dedication to the promotion of quality and safety in healthcare. “Professor Kilpatrick’s most significant contribution has been as a key member of the Victorian Quality Council (VQC), the expert strategic advisory council established in 2001 to lead the quality and safety agenda for Victorian healthcare services,” commented ACHS President, Dr Michael Hodgson AM. Professor Kilpatrick has been a member of the VQC since its inception in 2001, initially as the inaugural Deputy Chair and from 2005 as Chair during its second term. In this capacity, she demonstrated outstanding leadership in the implementation of a number of significant State and national initiatives that resulted in the VQC becoming a major force in the quality and safety arena, developing resources and programs that are trusted and well known throughout the Australian healthcare setting. One of the key VQC initiatives overseen by Professor Kilpatrick was the development and dissemination of Better Quality, Better Health Care: A Safety & Quality Improvement Framework for Victorian Health Services.

ACHS Medal Recipients ACHS Quality Improvement Awards 2008 ººDr Lionel Wilson The Quality Improvement (QI) Awards were launched by ACHS in 1996 and have been supported by Baxter Healthcare since 1998. ººMs Doreen Moore ººDr Myles Kehoe ººMr Murray Clarke Open to all EQuIP member organisations, the QI Awards are ººMr Brian Collopy an annual recognition of achievement and encouragement for ººDr Lindsay Thompson quality improvement activities, programs or strategies that have ººMr Kevin Dodd been implemented into healthcare organisations. ººMr Trevor Pickering The judging of the QI Awards is conducted externally during August and September, with separate panels for each of ººMr Brian Lewis the three categories, made up of an ACHS Councillor, an ººMrs Phyllis Newnham ACHS Surveyor and a representative from an EQuIP member ººDr John Greenwell organisation. ººDr Ian O’Rourke There were 105 entries in the 2008 QI Awards, with 66 in the Clinical Excellence and Patient Safety category, 31 in the Non- ººMr Michael Dooley Clinical Service Delivery category and eight in the Healthcare ººDr Lisa Harvey Performance Indicators category. Ms Darlene Hennessy, Executive Director – Development presented the winners of ººProfessor Ross Holland the awards at the ACHS Annual Dinner. ººProfessor William Rawlinson ººAssociate Professor Christine Kilpatrick

16 ACHS ANNUAL REPORT 2008–2009 Category: Clinical Excellence and Patient Safety Winner – Liverpool Hospital, Liverpool NSW, for their submission, Interventional Nephrology – A new horizon in dialysis access management. The aims of this project were to reduce unnecessary admissions, better utilise inpatient beds, reduce waiting time for dialysis access surgery and to reduce access-related bacteraemia by 40% over 18 months. The project introduced a very innovative method for gaining dialysis access for patients without the need for operating theatres. This new process has demonstrated a reduction in access surgery waiting time and access-related bacteraemia fell by 44.8%. There have been no major adverse events with any of the procedures and benefits have been identified for both the patient and the organisation.

Category: Non-Clinical Service Delivery Winner – Dungog Community Hospital, Dungog NSW, for their submission, Laundry consortium: Smart Cost Benefits to the Community. The project involved setting up a modern well-equipped laundry for use by various community volunteer groups in order to deliver a free and cost effective linen service to the community in the Hunter, Lower Hunter and New England areas. The project enabled palliative care patients to remain at home and also provided a cost-effective, affordable linen service to the aged community at large. To achieve this project, support and commitment was gained from all levels of government, Hunter New England Health (HNE Health), Dungog Shire Council, non-government organisations such as NeighborCare (the lead agent), the community, palliative care volunteer groups and corporate organisations.

Category: Healthcare Performance Indicators Winner – St Vincent’s Private Hospital, Darlinghurst NSW, for their submission, Warfarin Anticoagulation Safety Project. Through the use of best practice guidelines, education initiatives for staff and patients and the use of ACHS Clinical Indicators, a dedicated multidisciplinary team was able to improve medication management for all patients on warfarin within eight months. Significant results were achieved including a 23% improvement in compliance with warfarin initiation protocols and a 48% improvement in patients receiving warfarin education prior Top: Winners of the Clinical Excellence and Patient Safety category (from left to discharge. to right) Associate Professor Michael Suranyi, Associate Professor Josephine View the winning and highly commended QI Award entries Chow, Dr Jeffery Wong and Dr Tim Spicer in full in the Quality Initiatives 2008 publication, available via Middle: Winners of the Non-Clinical Service Delivery category (from left to the ACHS website: www.achs.org.au by selecting ‘Honours right) Yvonne Patricks, Charmain Bridge, Margaret Jones and Kerry Muddle and awards’ (under ABOUT US) from the homepage. Bottom: Winners of the Healthcare Performance Indicators category (from left to right) Professor Kim Walker, Karen Dewsnap, Jed Duff and Janet Evatts-Gale

ACHS ANNUAL REPORT 2008–2009 17 Division Reports Customer Services

The Customer Services division supports As at June 2009, our surveyor workforce our members to improve the safety and totals over 400 dedicated health quality of care. professionals and several consumers from

ACHS accreditation programs provide a framework for members both Australia and overseas. Over half of to improve the safety and quality of care and service. In order to achieve and maintain accreditation, our EQuIP members the surveyor workforce is supported by the participate in a four-year cycle of quality improvement activities, organisation that employs them, allowing culminating annually in either a self-assessment or an onsite survey. Those members participating in the Quality for Divisions Network them to volunteer their time for surveying. accreditation program participate in a three-year cycle. Customer Services is managed by the Executive Director – 3. Surveyor Workforce Customer Services with the assistance of the Team Leader, Customer Services. Customer Services consists of four The surveyor workforce consists of experienced, senior main areas: healthcare workers with recent and broad experience in healthcare. In addition to several consumer surveyors this 1. Customer Services Managers includes medical practitioners, nurses, administrators and allied 2. Surveyor Bookings health clinicians. As at June 2009, our surveyor workforce totals 3. Surveyor Workforce over 400 dedicated health professionals from both Australia and overseas. Over half of the surveyor workforce is supported by 4. Education and Support Service the organisation that employs them, allowing them to volunteer their time for surveying. Honoraria are paid to surveyors and 1. Customer Services Managers (CSM) coordinators who are not remunerated by an organisation for their The Customer Services team is responsible for implementing time during the survey. There is also a full-time surveyor directly and operationalising accreditation processes in conjunction with employed by the ACHS who has completed over 282 surveys other ACHS departments such as Business Services. throughout Australia since becoming a surveyor. The recruitment process is ongoing for clinical surveyors due to the strong clinical The CSMs provide a link between ACHS, our members, component in EQuIP 4. surveyors and various stakeholders. They are responsible for the promotion and management of ACHS quality improvement Eighteen Australian surveyors resigned during the reporting programs, such as EQuIP, Quality for Divisions Network (QDN) period. Retention strategies are being implemented to ensure and Home and Community Care (HACC) reviews for existing and that we are able to maintain our surveyor workforce. new members. Please see page 60 for a full list of our surveyors. They coordinate and support the entire survey process, including Recently there has been an increase in withdrawals of volunteer the review and finalisation of survey reports and accreditation surveyors from surveys due to the current work climate; as outcomes. most are in full-time positions within the healthcare industry. The management of member contracts is another responsibility Honorarium surveyors have been replacing and assisting the of the team and is the key to ensuring that each member teams at short notice. organisation is matched with the most appropriate accreditation Our members complete a questionnaire at the conclusion of program; and that the survey meets their needs with respect to their survey process. During the year 93% of customers who size and surveyor expertise. completed the questionnaire were ‘satisfied’ or ‘very satisfied’ with the cohesiveness of the survey team at their onsite survey. 2. Surveyor Bookings Below are some examples of comments from the feedback forms: The Surveyor Bookings team works in consultation with the “Both Surveyors were very approachable and had CSMs to ensure surveyors are allocated to survey teams excellent suggestions.” according to the scoping for the relevant organisation. “A comprehensive survey that can only improve the Surveyors have the option to nominate for surveys and the quality of the service..” most appropriate surveyors, based on their experience and specialties, are invited to join the survey teams.

18 ACHS ANNUAL REPORT 2008–2009 “This was a very positive experience for an organisation EQuIP 4 Standards, accreditation processes, survey report and the way the survey was conducted and the writing, AC60 recommendations, our Electronic Assessment Tool recommendations given made it a pleasurable and and surveying biomedical services. encouraging experience.” The reviewed feedback from the Surveyor Satisfaction Survey “They didn’t try and compare us to other health services changed the February and March Coordinator Development or States rather surveyed as an individual organisation days to only occur in New South Wales (NSW) and South meeting the standards in a way that is appropriate for us.” Australia (SA) instead of NSW, Queensland, Victoria, SA In July 2008 a Surveyor Satisfaction Survey was carried out and Western Australia. The result was extremely positive as to assess how satisfied the surveyors are with the support coordinators were able to network with a greater number and they receive from the ACHS. The surveyors also reviewed their wider range of coordinators. It added more diversity of input and impression of ACHS resources, survey issues, the benefits of a boarder national perspective on surveying. one full-time surveyor and the surveyor development days. The During July 2008 to June 2009 we held three inductions in NSW results were collated and reviewed by the Board and an Action and trained 57 health professionals in surveying techniques. Plan implemented. The Australian inductees included five medical practitioners, Below are some comments from the Surveyor Satisfaction survey: 14 nurses, 12 administrators and one allied health professional. Due to demand our surveyor inductions continue to include “I always find the CSM very helpful if I need any additional international professionals from areas such as Hong Kong, information or help. This applies to all the staff.” Bahrain and Dubai. “I would like to be available for more surveys; however my work commitments prevent this..” Education for members “I find the feedback that I receive from the facility, the We offer an annual program of education workshops to our coordinator and fellow surveyors as well as the CSM members. Topics include: very helpful in pointing out any areas which require ººApplying the EQuIP Standards improvement. Thank you!” ººClinical Audit “I really enjoy this aspect of my professional life and ººA Practical Approach to Quality to Achieve Broad-based development and would hope to increase in the future..” Participation 4. Education and Support Service ººEQuIP for Non-Clinicians ººChanging Organisation Culture Education for surveyors ººHealth Record Audit To contribute to the ongoing education of our surveyors ººFrom Quality Manager to Quality Consultant Customer Services conducts Coordinator Development days and Surveyor Development days for all of our surveyors across ººSelf-assessment reporting and the Electronic Assessment Tool. Australia. Active surveyors are required to attend at least one We continued to offer customised onsite programs which are full development day session of training per year and the increasing in demand. programs change each year depending on surveyor and ACHS requirements. During 2008–2009 the education focused on

Distribution of Surveyors in Australia ACHS Surveyor Workforce by Experience and Background

Australian Capital Territory 10 International 51 New South Wales 138 Administration 112 Northern Territory 4 Allied Health 12 Queensland 67 Consumer 13 South Australia 30 Medical & Dental 95 Tasmania 9 Nursing 144 Victoria 87 As at 30 June 2009 Western Australia 31 As at 30 June 2009

ACHS ANNUAL REPORT 2008–2009 19 Division Reports Customer Services

In addition to the activities described on the Network of Alcohol and Drug Agencies Membership previous page, the Customer Services team is In 2008 ACHS was endorsed by the Network of Alcohol and responsible for and has been involved in the Drug Agencies (NADA) as the preferred provider of accreditation following projects: services to its members. NADA members include NSW Health funded Non-Government Alcohol and Other Drug Treatment Mental Health Consumer Surveyors Services. Current NADA EQuIP membership stands at 30. Benefits for this membership include the provision of customer To develop and support our consumer surveyors we held two support and onsite education and the development of a specific mental health teleconferences to review the National Mental resource tool for NADA members. ACHS is currently developing Health Standards, discussing which standards should be a memorandum of understanding with NADA. assigned to Mental Health Consumer Surveyors and gained feedback on their surveying experiences. From these meetings Accreditation Program for Tasmanian Mental all the consumer surveyors have been invited to attend the NSW Health Services development day in September 2009 and a specific evening session will be conducted. In March 2009, the ACHS won a tender to accredit Tasmanian Mental Health Services. This involves seven new memberships State Advisory Committees including a Corporate EQuIP membership for the State Office. An education package has also been negotiated to support the State Advisory Committee meetings are conducted twice a year implementation of the accreditation framework across the mental across all States and are coordinated by Customer Services. The health services. State Advisory Committees provide support to members and key stakeholder groups. In addition the Committees enable the ACHS to consult with members and stakeholders and obtain feedback Significant activities and outcomes during regarding State and Territory issues relating to quality, safety and 2008–2009 accreditation and ACHS products, services and activities. ººThe Education curriculum has been expanded to help State Advisory Committee membership includes surveyors, improve knowledge and use of Clinical Indicators. Since its EQuIP members and other jurisdictional stakeholders. inception, uptake of the ‘Clinical Audit’ workshop has been excellent; 17 workshops have been run across Australia, with Home and Community Care 196 health professionals in attendance. Throughout 2009 the ACHS has continued to assess ººThere has been continued involvement of surveyors in ACHS compliance with Home and Community Care (HACC) Standards education, their contextual and current knowledge continues and Criteria, for organisations in Victoria with HACC services that to be well received by members. They have included: Health are also undergoing an EQuIP 4 survey. Conducting the HACC Record Audit (led by Marilyn Sneddon), EQuIP for Non- review at the same time as the EQuIP survey reduces the burden Clinicians (led by Wesley Carter) and From Quality Manager of participating in two separate surveys. to Quality Consultant (led by Cathy Balding). ººThe ‘From Quality Manager to Quality Consultant’ workshop Diagnostic Imaging Accreditation Scheme which was facilitated in three capital cities in 2008 is being In 2008 ACHS was one of four organisations that successfully run again in 2009. tendered to accredit Diagnostic Imaging Practices across Australia as part of Stage One of the Commonwealth ººExecutive Masterclasses, facilitated by Professors Jeffrey Department of Health and Ageing Diagnostic Imaging Braithwaite and John Øvretveit, were run in three major Accreditation Scheme. Diagnostic Imaging Practices were capital cities on the topic ‘Making Clinical Governance Work’. required to register with an accrediting body by 30 June 2008 ººDuring 2008 a formal application process occurred for part- to be eligible for deemed accreditation. ACHS accepted 320 time ‘Contracted Coordinators’. The contact is an agreement initial registrations for its program. Once registered with ACHS, between the coordinator and the ACHS around the number the Diagnostic Imaging Practices were required to submit a of surveys and survey days that the individual can do Self-Assessment for desktop review to determine compliance as a coordinator or surveyor on a team. The contracted with four Standards set by the Commonwealth. Practices coordinators have been appointed and will begin in 2010. that successfully meet the standards are awarded with full The project will be trialled for a period of two years. accreditation. ACHS membership of this program currently ººConcerns were raised by members and other stakeholders stands at 369. regarding the delays in processing accreditation survey The Commonwealth is currently consulting with stakeholders reports. ACHS reviewed the survey report process and to develop and implement Stage Two of the Diagnostic initiated a quality improvement project. Initial changes have Imaging Accreditation Scheme. It is anticipated that the current resulted in an improvement from 54% outside the turnaround Standards will be expanded and the scheme broadened to benchmark to 16%. Additional changes are planned. include other Diagnostic Imaging Services not currently required to participate.

20 ACHS ANNUAL REPORT 2008–2009 Outlook for 2009–2010 Commonwealth Department of Health and Ageing and its members regarding Stage Two of the Diagnostic Imaging ººAn updated surveyor reappointment process started Accreditation Scheme. from July 2009. The reappointment procedure is based on a surveyor activity report obtained from our database. ººFeedback from members and surveyors suggests that Surveyors will be evaluated with regards to the following: better information regarding the requirement and conduct of Conditional and Alignment Surveys and Advanced yy Survey report evaluation Completion in 60 days (AC60) review is required. Customer yy Surveyor performance gleaned from evaluations Services will develop appropriate guidelines for members – organisational, coordinator and fellow surveyor and surveyors. yy Attendance at the Surveyor Development Days ººIn response to feedback from new NADA organisations, a yy Availability and continued commitment to the ACHS new workshop ‘EQuIP for Drug and Alcohol Programs’ has yy Employment status been developed, commencing in July 2009. yy Customer services input. ººAssessment of the feasibility of utilising e-learning packages Reappointment is conditional on the surveyor’s ability to will be conducted to provide additional support for members, continue to meet the criteria. consumers, the surveyor workforce and staff. ººTo complement the review of the EQuIP 4 Standards, Customer Services is reviewing some key processes associated with EQuIP, such as the ‘rules’ for determining the level of accreditation awarded following survey. ººMember post-survey feedback is essential for informing and driving improvement to ACHS programs and services. Strategies for improving the member organisation’s post- survey feedback questionnaire response rate are currently under consideration. ººImprovements are being made to the guidelines and processes associated with In Depth Mental Health Reviews. Members and surveyors report confusion with the current requirements. ººReview of Self-Assessment submitted by Diagnostic Imaging Practices in accordance with Stage one accreditation continues. ACHS will continue to consult with the

Sydney Southwest Private Hospital Hope Healthcare, Greenwich Hospital, Sydney

ACHS ANNUAL REPORT 2008–2009 21 Division Reports Development

The primary roles of the ACHS Development division are the Through a process of issues review and discussion, the development and review of ACHS Standards and its accreditation working groups considered each EQuIP 4 standard, criteria and programs as well as the monitoring and measurement of element. At the end of the process, a set of draft standards and performance by member organisations. associated issues for discussion was prepared for the Standards Development provides secretariat support to the ACHS Committee and the Board of the ACHS. Standards Committee and the unit is also responsible for initiating A field review of the first in a series of draft revised standards and managing ACHS research activities into accreditation and was completed in October 2009. Comments were received from quality improvement processes. over 300 respondents. For an update on the progress of the Special project development in collaboration with Federal and standards review, visit www.achs.org.au State/Territory health services is undertaken by the Development unit, which also develops support publications and resource 2. Performance and Outcomes Service tools for the EQuIP program. The ACHS annual Quality Improvement (QI) Awards are also Membership of the ACHS Clinical Indicator administered by the Development unit. program has grown in 2008–2009 The three service areas are: with over 730 healthcare organisations 1. Standards and Program Development 2. Performance and Outcomes Service across Australia and New Zealand now 3. Research. participating in the program.

1. Standards and Program Development The Performance and Outcomes Service develops, collects, Review of the EQuIP 4 Standards analyses and reports ACHS Clinical Indicators. The Clinical The key area of responsibility for Indicator program was established by the ACHS in 1989 to Standards and Program Development facilitate the measurement of important aspects of health service during 2008–2009 has been to direct the delivery for members of the ACHS EQuIP program. review of the EQuIP 4 standards. The ACHS Clinical Indicator program currently collects over 380 A review of the EQuIP program and its standards is conducted indicators across 23 different clinical areas. It is a national system by the ACHS every four years in collaboration with industry and that allows healthcare organisations to benchmark against stakeholders, to ensure the program remains current, evidence- similar organisations. based and reflects best-practice. The Performance and Outcomes Service works with Australian and Nine working groups were established between March and June New Zealand medical colleges and societies to develop reliable 2009 to undertake the review. Representation on the working indicators that will reflect variations in care delivery processes groups is voluntary and drawn from consumers and the ACHS or outcomes. The Performance and Outcomes Service also EQuIP membership. From a total of almost 300 applications, collaborates with clinicians, consumers, the National Centre for members were selected to ensure representation of the Classification in Health at the University of Sydney and the Health geographic, professional and service diversity of our membership. Services Research Group (HSRG), University of Newcastle. Each working group, chaired by a member of the ACHS The Performance and Outcomes Service reports the clinical Standards Committee, focused on a subset of related EQuIP indicator data in several ways: standards and criteria: ººComparison Reports are generated six-monthly following Group 1: Continuum of Care submission of data by healthcare organisations. Separate Group 2: Access, Appropriateness and Effectiveness reports are provided to individual healthcare organisations and compare the organisation’s results with national aggregated Group 3: Safety Management and national peer results for each six-month time period. Group 4: Consumers and Risk Management ººAustralasian Clinical Indicator Report is published annually Group 5: Human Resources for general distribution. The report summarises clinical indicator data provided to the ACHS by healthcare organisations. Group 6: Information Management ººIndividual Hospital Trend Reports are provided to Group 7: Governance individual organisations and show trended comparative data Group 8: Workplace and Environment from 2001. Group 9: Health Promotion ººCustom Reports are generated to meet the needs of corporate members or members at an area health service level.

22 ACHS ANNUAL REPORT 2008–2009 Review of indicator sets 2008–2009 The Performance and Outcomes Service coordinated the review The Introduction of PIRT Online and release of three revised indicator sets in January 2009: Development of the online version of the Performance Internal Medicine, Hospital-Wide and Mental Health Inpatient. Indicator Reporting Tool (PIRT) to submit data to the A review of the Hospital-Wide Clinical indicators was timely, Clinical Indicator program commenced in 2008 with the given the announcement by the Federal Government in objective of converting the existing CD-ROM based tool April 2008 of plans to introduce a set of mandatory national to a web-based application. performance indicators for the health system. Some of the The web-based Performance Indicator Reporting Tool, proposed national indicators for the acute sector are common PIRT Online, went live in January 2009. All members to indicators included in the ACHS Hospital-Wide indicator set, of the program will be migrated to PIRT Online for the such as the indicators for hospital readmissions, unplanned reporting of the First Half data collection period 2009. return to operating theatre, medication errors, pressure ulcers, patient falls and venous thromboembolism prophylaxis. The ACHS is currently developing new features which The Working Party agreed to align the Hospital-Wide clinical can be added to PIRT Online such as trended data and indicators with the national performance indicators where there graphic displays of indicator data. was overlap. There are several benefits for ACHS and for members of the ACHS Clinical Indictor program in moving to an Membership online data collection and reporting system. Such as: Membership of the ACHS Clinical Indicator program has grown ººno need for members to install updates and new in 2008–2009 with over 730 healthcare organisations across versions of the PIRT application (this will now be Australia and New Zealand now participating in the program managed centrally) on a six-monthly basis. The ACHS welcomed the entry of greater accessibility for multiple users and from three private hospitals from Indonesia into the Clinical Indicator ºº multiple locations program in July 2008. ººability to add additional new functionality and features 3. Research over time, and The focus of ACHS research is to collaborate with established ººgreater interactivity. research bodies and government agencies in the investigation of quality management initiatives and accreditation. In 2008–2009, the ACHS was invited to undertake two research Short-Notice Surveys projects administered by the Australian Commission on Safety and Quality in Health Care, forming a part of the Commission’s The study to pilot the short-notice method of accreditation investigations into accreditation processes. survey commenced in November 2008 and was undertaken by the ACHS in partnership with the Centre for Clinical Governance Patient-Journey Methodology Research in Health, University of New South Wales and Australian General Practice Accreditation Limited (AGPAL). In response to a tender from the Commonwealth Department of Health and Ageing, administered by the Australian Commission Organisations that did not have an imminent survey were invited on Safety and Quality in Health Care, the ACHS undertook a to participate. The organisations that volunteered to participate study into the patient journey accreditation survey method in in the study were given two days notice of their survey, which conjunction with the Centre for Clinical Governance Research in was then performed using a limited number of criteria from Health, University of New South Wales. the relevant accreditation agency’s standards (the selection of criteria reflected the Commission’s current priorities for The patient-journey methodology traces the patient journey national consideration and action). The organisation’s level of through a facility, documented by the record, in order to review performance was then compared with its previous assessment performance. This methodology was tested as an accreditation ratings for the same criteria in their most recent survey. method in parallel with the normal EQuIP accreditation survey method. Eighteen ACHS EQuIP member organisations were Twenty ACHS members participated in the project. A small team surveyed using the patient-journey methodology alongside the of survey coordinators undertook all the surveys and reported usual scheduled EQuIP accreditation survey. Ratings against their findings. The results of this study were reported to the the accreditation standards and criteria of each organisation Commission in May 2009. were compared. The project commenced in October 2008 and results were reported to the Commission in February 2009.

ACHS ANNUAL REPORT 2008–2009 23 Division Reports Development

Griffith University Research Advisory Panel The ACHS collaborated with Griffith University, Queensland The ACHS established the Research Advisory Panel in 2005. in providing de-identified survey data from EQuIP 3rd edition The panel is co-chaired by Darlene Hennessy, Executive Director surveys 2003–2007 for a study: Improving Human Resources – Development and Professor Jeffrey Braithwaite, Director, and Employee Engagement in Australian Hospitals. Centre for Clinical Governance Research in Health, University of The study, led by Dr Keith Townsend, investigated the possible New South Wales. correlations between the level of accreditation performance Members of the ACHS Research Advisory Panel 2008–2009: in the EQuIP 3rd edition Continuum of Care function against ººDr Rosalie Boyce the four other EQuIP 3rd edition functions – Leadership and Management, Human Resources Management, Information ººProfessor Jeffrey Braithwaite (co-chair) Technology and Safe Practice and Environment. ººProfessor Don Campbell The preliminary findings from the study were presented by ººAssociate Professor Robert Gibberd Dr Townsend to the ACHS Council meeting in June 2009. ººMs Darlene Hennessy (co-chair) ººMr Brian Johnston (ACHS Chief Executive) ººMs Laurie Leigh (ACHS Executive Director – Customer Services) ººProfessor Sandy Middleton ººMs Sally Nathan ººDr Sue Phillips ººProfessor Sally Redman

Sydney Southwest Private Hospital Liverpool Hospital, Maternity Ward, Sydney

24 ACHS ANNUAL REPORT 2008–2009 Division Reports Corporate Services

The Corporate Services division incorporates support services and operational functions, utilising specialised knowledge and technology to serve internal and external stakeholders. This includes financial services/human resource management, information technology services, business support services, accreditation administration services and education administration services.

Key Performance Indicators Board reporting ººAccurate and timely financial reporting ººBoard financial reports now show current year-end budget review and the previous year’s actual year-end figures to ººOrganisation-wide risk management enable comprehensive comparative analysis to support ººInformation systems development and support for board and management planning. the organisation ººBank reconciliation is also a new item reported to the Board. ººA comfortable and safe working environment ººACHS has also implemented a Board-approved financial ººProvision of stable workforce and sound support services delegations policy. ººComprehensive, accurate and accessible information on Work environment the past performance and current status of the business ACHS ensures that the health and welfare at work of all ºº Corporate policies and procedures to support operations employees is top priority. In support of this, the following ººAnalysis and trending of reports from customer evaluations initiatives have been undertaken: to ensure client satisfaction ººFlu vaccinations available to all staff paid by ACHS ººEvaluation reports on issues such as information ººIntroduction and implementation of criminal checks policy on technology (IT), Occupational Health & Safety (OH&S) and new staff the working environment. ººRegular OH&S meetings to monitor and review incidents Financial services/human resource management ººIncident data/OH&S Quality Monitoring Tool issues aggregated for trend analysis to enable quality improvements The financial services/human resource management unit is ººOccupational Health and Safety Committee responsible for accurate and efficient accounting/financial Compliance training services and the management of matters relating to ACHS staff. ººAll staff trained in fire safety as required by legislation The business planning process provides planning and budgeting principles for unit managers to ensure a consistent, organisation- ººComprehensive insurance programs wide approach and is supported by key objectives for the period, The average length of service of staff at ACHS as at 30 quality improvement activities and key performance indicators. June 2009 is over five years. Key achievements of this division over the past year are: New accounting software package SAP Business One ººImplemented and integrated with current customer relationship management (CRM) database system, this allows improved custom financial reports and other business intelligence data and integrated invoicing, accounts receivable and accounts payable. All of the above ensures more control, accurate information, and better long and short-term strategic decision making capabilities. ººThe new system will cater for the expanding requirements of ACHS well into the next decade. ººThe next step is to integrate payroll management into SAP Business One.

ACHS ANNUAL REPORT 2008–2009 25 Division Reports Corporate Services

Investment in Human Resources Key achievements of this division over the past year are: Staff development is encouraged. The following internal and Review of IT strategic and business plan external further education and training is supported: ººDisaster recovery plan reviewed and updated, strategies ººAs at 30 June 2009 ACHS has four trainees completing their implemented this year include data mirroring for increased data Certificate III in Business compared to three in previous years. protection, availability and the minimisation of downtimes ººACHS also provides support for staff undertaking external ººPurchased and installed dedicated security hardware which study. Currently there are: provides intrusion detection and prevention, anti-virus, content filtering and continuous data protection backup yy five staff in postgraduate university courses (PhD and MHealth) ººUser manuals and disaster recovery procedure manuals yy two staff in professional courses (CPA and IT). developed and tested ººEducation and training also extends to Board Members and ººCost effective change from analog to digital telephone Executive Directors. Provision for training revolves around contracts Governance and Directorship issues. ººAudit of office equipment resulting in replacement of all ººAnnual training for all surveyors is held nationwide. machines with expired warranties. The annual business plan provides that approximately 7% Implementation of systems for Quality Health New Zealand from the salaries and wages budget is allocated to training ººThis project involved development and implementation of IT and development. Multiskilling and cross training of staff is applications, implementation and maintenance of disaster encouraged within the organisation. recovery management systems, continually improving the IT infrastructure and resources, and aiming towards Information Technology (IT) Services standardisation of infrastructure and maximum integration of The IT division supports and manages all computer-based all systems. information systems used at the ACHS. This includes design and Electronic Assessment Tool (EAT) development of ACHS custom software applications, purchase ººEAT v4 is in its third year since the 2007 release to all and replacement of hardware, monitoring of system performance member organisations and ACHS surveyors as the main and the conversion, storage and secure retrieval of data. data collection tool used for the accreditation process. The number of EAT users has increased to over 3,000 and continuous improvements have been made to the online and offline versions of the tool based on user feedback. ººThe new ‘Data protect’ function was developed to minimise data loss due to network connection dropouts.

Performance Indicator Reporting Tool (PIRT) PIRT is a Windows-based application provided to organisations that participate in the ACHS Clinical Indicator Program. The tool is used to capture and submit Clinical Indicator data. Development of the first stage of a web-based application has been completed and pilot tested. The functionality and access is similar to the web-based EAT. Planning on the second stage of development, which will include graphical display of results, is in progress.

Prince of Wales Private Hospital, Sydney

26 ACHS ANNUAL REPORT 2008–2009 Business Services Accreditation administration services and education The Business Services area includes business support administration services services, accreditation administration services and education The two units provide all administrative operational services for administration services. the accreditation program and education services. These business units provide multiple services to customers, Some key initiatives over the past year include: surveyors and staff. ººThe review of survey report processes introduced in January 2009 resulting in the improvement of turnaround times of Business support services survey reports Responsible for: ººCentralisation of work processes performed by the ººdata collection, analysis, evaluation and benchmarking of Administrative Assistants team resulting in efficient workflows operational functions and survey reports to support and improved support for both internal and external customers decision-making ººDevelopment of procedure manuals for all work groups in the ººAnalysis of accreditation data to enable promotion, research accreditation and education administration services to enable and publication of information in relation to quality in healthcare cross training and multiskilling amongst the teams ºº IT support to internal and external users on ACHS ººAudit of customer correspondence files conducted to ensure customised software applications. that all information is relevant and accurate.

Some key initiatives over the past year include: ººKey Performance Indicator reports – ensuring that information is accurate, timely and relevant to assist with strategic directions and reporting to the Board ººEnsuring that IT applications are user friendly by understanding and negotiating the end-user requirements and seeking solutions to meet those needs ººProviding end-user technical support, education and training for optimal utilisation of IT resources ººAudit on data integrity relating to membership fields in the ACHS database ººReview of Corporate policies and procedures to ensure currency and areas of potential risk are eliminated and managed.

Sydney Southwest Private Hospital

Other activities in 2008–2009 included:

ººIn-house computer-based training programs made available to all ACHS staff, who are also encouraged to identify training needs at staff meetings or submit requirements via the electronic Quality Monitoring Tool ººComprehensive insurance programs covering directors and officers; industrial special risks; professional indemnity; public/ products liability and corporate travel are current to February 2010 ººRisk management plan and framework reviewed together with risk management register ººProvision of business intelligence and operational support for ACHS and ACHSI ººComplaints management system developed and implemented.

ACHS ANNUAL REPORT 2008–2009 27 Division Reports ACHS International

ACHS International (ACHSI) experienced continuous growth in the year 2008–2009. Interest in the ACHS accreditation program has significantly increased resulting in several successful outcomes and projects and reaffirming our position as a credible international accreditation body.

Some key achievements and activities over the year include: ººCommencement of the Hong Kong Hospital Authority (HKHA) Project ººA Memorandum of Understanding (MoU) signed with Dubai Health Authority (DHA) followed by a proposal to provide assistance establishing a local accreditation agency ººAn agreement signed with five organisations (two in India and three in the Middle East) to act as an “ACHSI Certified Consulting Agent/Trainer” ººAn increase of the membership base in the Middle East and India Australian Project Team at the Tuen Mum Hospital during the Engagement Component of the HKHA project ººParticipation in an accreditation symposium in Jeddah and Arab Health 2009 in Dubai. We continue to maintain our relationship with Quality Council of ACHSI continues to focus on the service delivery of our India (QCI) and National Accreditation Board for Hospitals and accreditation programs and education/consultancy services in Healthcare Providers (NABH) as per the MoU signed in July 2006. the target markets – the Middle East, India and Hong Kong/ Two organisations in India were appointed as an “ACHSI China. Interest from other Asia-Pacific countries has compelled Certified Consulting Agent/Trainer”. ACHSI to expand its area of operations. During the past year ACHSI also hosted numerous delegations to Australia, from Hong Kong countries including Vietnam, China and the United Arab Emirates. ACHSI was awarded a contract by the Hospital Authority (HA) to assist with the development and implementation of a Pilot International activities 2008–2009 Scheme of Hospital Accreditation for five public and three private hospitals in Hong Kong. Work on the project commenced on Middle East 18 May 2009. The project will run over the next three years. An MoU was signed with DHA and a proposal to deliver assistance in establishing a local accreditation agency was provided. ACHSI Overseas Surveyors will conduct educational training workshops for DHA in preparation During the reporting period a total of 25 international attendees for them to establish an accreditation agency using the ACHS participated in the Surveyor Induction Workshop, out of which EQuIP model. Additionally, three agreements were signed with two seven were from the Middle East and 18 were from Hong Kong. organisations in Dubai and one in Bahrain to act as an “ACHSI To date, a total of 55 attendees have participated in the Surveyor Certified Consulting Agent/Trainer”. These organisations will assist Induction Workshop. Three overseas surveyors were formally ACHSI in developing market research and programs for selected appointed ACHS Surveyors. organisations in the region. Following participation at an accreditation symposium held in Outlook for 2009–2010 Jeddah, a proposal was provided for assistance in supporting the Central Board of Accreditation for Healthcare Institutions The outlook for the 2009–2010 financial year appears positive (CBAHI) in Saudi Arabia. despite the global recession and strong competition. A number of organisations are in the process of preparing for ACHSI and Quality in Practice (QIP) also jointly participated in accreditation survey and several proposals are in progress. Arab Health 2009 in Dubai. International recognition of the Australian model of accreditation has generated strong interest from other Asia-Pacific countries India including Korea and Singapore. Five Manipal Cure and Care centres – two in Bangalore and one each in Mumbai, Ahmadabad and Pune, were awarded accreditation status in 2008.

28 ACHS ANNUAL REPORT 2008–2009 Corporate Governance Overview

The ACHS, a company limited by guarantee, is governed by a Board of 12 directors, elected by Council members and supported by a corporate management system.

Introduction The Board maintains currency of its understanding of ACHS operations through monthly meetings. In preparation the The Board is responsible to the Council for the direction Board receives: and oversight of ACHS activities and provides a report on performance at the ACHS Annual General Meeting. ººMonthly reports from the Chief Executive and executive team on financial, human resources, quality, risk management and Both bodies are guided by the Corporations Law and the industry performance Constitution of the Australian Council on Healthcare Standards, adopted in 1974 and regularly reviewed. ººFeature reports from ACHS staff regarding initiatives of strategic interest Functions and responsibilities of the Board ºº Monthly and quarterly reporting of key performance indicators related to the strategic goals of the organisation. The Board has adopted statements of vision and mission which are designed to determine the organisation’s strategic direction, The President and Chief Executive communicate regularly on and has endorsed organisational values and behaviours to issues and performance. ensure its operations are conducted to meet high standards of The Board has procedures in place so that its members may service and professionalism, see page 3. seek independent professional advice on any ACHS matter During 2008–2009 the organisation’s Corporate and Strategic at the organisation’s expense, subject to the prior approval of Plan was revised (see page 6). It provides a concise statement the President. of organisational direction. The planning process was undertaken The Board is assisted in its deliberations on issues relating to the under the auspices of the Board and involved the Council, other ACHS standards by the Standards Committee. stakeholders and staff. The planning period was limited to three years due to the dynamic environment around quality and safety in healthcare. Stakeholders Whilst the Board reviews and approves the organisation’s The State Advisory Committees (SACs) include representatives strategic plan and guiding policy, day-to-day management of the from the health industry, governments and consumers. The ACHS and implementation of the strategic plan are delegated to SACs are a collaborative forum providing advice to ACHS staff the Chief Executive with the assistance of executive directors. and Council on issues of strategic interest. During 2008–2009 the SACs meetings were very successful. SAC members During 2008–2009 the Board consolidated the role of the join the councillors at twice yearly meetings to ensure that Financial Review Advisory Group. This is now a formal there is a dynamic mix of ideas and representation for the component of its governance framework and, in part, reflects the combined meeting. growth in business as well as the continuing challenges of sound financial stewardship especially in the current adverse financial conditions. Structure of the Board The functions and responsibilities of the Board include: The experience and areas of expertise of each member of the Board is set out on pages 31, 32 and 33. ººThe strategic direction of the ACHS, including approval of the corporate strategic plan and guiding policies The ACHS Board consists of 12 representatives voted on at the Annual General Meeting in November by the ACHS ººEstablishing policies to safeguard the ACHS and to monitor Council. The ACHS Council includes 35 representatives for performance in achieving its goals through requiring consumers, peak health industry bodies and governments from regular and timely reporting on a comprehensive set of throughout Australia. performance issues Given the Board’s representational make-up, at the ººApproval of the annual financial report and budget commencement of each Board meeting, members are asked ººSatisfying itself that a robust and sound system of issue and to declare any conflict of interest arising from agenda items and risk management exists, with the executive responsible for withdraw from the relevant discussion. identifying and managing issues and risk ººAccountability; and ººRepresentation of the ACHS. The Board undertakes regular evaluation of its own performance every two years.

ACHS ANNUAL REPORT 2008–2009 29 Corporate Governance Overview

Annual General Meeting: November 2008 The Development unit provides secretariat support to the Standards Committee under the guidance of the Executive Outgoing President, Dr Michael Hodgson AM, completed Director – Development. his maximum allowable term on the Board (under the ACHS Constitution). Associate Professor Peter Woodruff, who The committee Chair is ACHS Board member, Ms Helen Dowling represents the Royal Australasian College of Surgeons and who has been a member of the committee since 2004. The chair is the Director of Vascular Surgery at the Princess Alexandra of the editorial sub-committee is Dr Philip Hoyle. Hospital in Queensland, was elected as the President. Ms Karen The key responsibilities for the Standards Committee during Linegar, representing the Royal College of Nursing, Australia, 2008–2009 were overseeing the development of the principles was elected as the Vice-President. Mr John Smith PSM, one for the review of the EQuIP 4 standards and the commencement of three Councillors representing the Australian Hospitals and of the review as well as assessing the applicability of the EQuIP 4 Healthcare Association, was re-elected Treasurer. Ms Helen standards for day procedure centres. Members of the Standards Dowling, representing the Allied Health Professions Australia Ltd, Committee chaired each of the Working Parties which were was elected to the Board. established to undertake the review of EQuIP 4. The committee also made recommendations to the ACHS Internal committees and guiding policies Board on the development of specialty standards by Our internal Occupational Safety and Maintenance Committee external organisations. continued its important work throughout the year meeting The membership of the Standards Committee 2008–2009 and four times and ensuring compliance with relevant regulations attendance at meetings were as follows: and legislation. No significant workplace injuries were reported during the year. A B Ms Helen Dowling (Chair 2008–) NSW 4 4 Human resources Pharm, Dip Hosp Pharm (Admin), Grad Dip QI Hlth C, CHP, FSHP The conditions offered to staff from our human resources Dr Michael Hodgson AM (Chair 2001– TAS 1 1 principles and policies exceed the minimum legal and 2008) FAMA, MBBS (Qld), FANZCA, FRCA, regulatory requirements. AFCHSE Our executive appointments are approved by the Board. Ms Jackie Bullock WA 4 4 RN, BA (Govt Studies) Ecowan Remuneration Ms Margo Carberry NSW 4 4 RN, C&FHN, AFAAQHC Maintaining our staff remuneration policies and conditions to remain comparative to market and industry benchmarks is an Assoc Prof Brett Emmerson QLD 4 4 ongoing challenge. MB BS (Qld), MHA (NSW), FRANZCP, FRACMA Our Board’s travel and accommodation expenses are covered, Dr Philip Hoyle NSW 4 3 MB BS, MHA, FRACMA however no honorarium is paid. Mr John Kenny NZ 4 4 BSc, Grad Dip QA Standards Committee Ms Leith MacMillan QLD 2 – The Standards Committee is a standing sub-committee of the RN ACHS Board and takes its direction from, and advises, the Board on all matters relating to EQuIP program standards. The Ms Sue McKean QLD 4 4 MHSc (Risk Management), Grad Dip (OHS), President of the ACHS is a member of the Standards Committee. Dip OHS The Standards Committee plays a significant role within the Ms Alison McMillan VIC 4 2 governing structure of the ACHS providing expert and independent RN, BEd, MBA guidance and direction in the development of new standards or Ms Sandra Miller WA 3 3 revisions to existing standards and programs. The Committee BHSc (MRA), Grad Dip HSc (Epi & Bio) oversees the development of resources and support material for ACHS programs and provides guidance on any proposed Mr Stephen Walker SA 4 2 BBus, Grad Dip (Acc), Dip Eng amendments to resources through an editorial sub-committee. Ms Patricia Warn NSW 3 3 Membership of the Standards Committee is drawn from across BA the healthcare industry and includes consumers, administrators, quality coordinators, clinicians and allied health professionals. A Meetings held during the period of office of the member Along with the ACHS President, the Chief Executive, Executive B Meetings attended by the member Director – Customer Services and Executive Director – Development are also members of the Standards Committee.

30 ACHS ANNUAL REPORT 2008–2009 Corporate Governance ACHS Board of Directors Representing consumers, governments and the Australian healthcare industry. As at 30 June 2009 Photograph: Milk & Honey

Front row seated from left to right: Associate Professor Peter Woodruff (President), Mr Brian Johnston (ACHS Chief Executive), Ms Karen Linegar (Vice President), Mr John Smith (Treasurer), Ms Helen Dowling Standing from left to right: Dr Robert Porter, Mr Michael Roff, Ms Kae Martin, Mr Stephen Walker, Mr Russell McGowan, Dr Noela Whitby, Dr Dana Wainwright, Dr Len Notaras

Associate Professor Peter Woodruff Ms Karen Jane Linegar President Vice President MBBS, ChM, FRCS, FRACS, FACS RN, RM, Ba AppSc (Nursing), Ba Bus, MHA, Dip. Comm. Law, JP, FRCNA n ACHS Board member since 2002 n ACHS Vice President 2007–2008 n ACHS Board member since 2004 n Board member – ACHS International, 2008 n ACHS Vice President since 2008 n National Advisory Committee Chair, 2002–2003 n ACHS Councillor (RCNA representative) since 2004 n Honorary Treasurer, Royal Australasian College of Surgeons, n Executive Director of Nursing , Midwifery and Care Redesign 2000–2002 – North West Area Health Service 2009 n Chairman and Director of Vascular Surgery, Princess n Director of Nursing – North West Regional Hospital, Burnie Alexandra Hospital, Qld since 2003 1994–2009 n Vice President, Royal Australasian College of Surgeons, n President Royal College of Nursing, Australia 2002–2004 2003–2005 n Board member Royal College of Nursing, Australia n Member of Medical Board, Qld since 2005 2002–2007 n President, Australian and New Zealand Society for Vascular n Chair Nursing Board of Tasmania 2000–2003 Surgery , 2006–2008 n ACHS surveyor since 2005 n Court of Honour Royal Australasian College of Surgeons n Chair ACHS Tasmanian Advisory Committee since 2005

ACHS ANNUAL REPORT 2008–2009 31 Corporate Governance ACHS Board of Directors

Ms Helen Dowling Dr Len Notaras AM BPharm, Dip Hosp Pharm (Admin), Grad Dip QI in HCare, CHP, AFCHSE, LLB, BA (Hons), DipComm, BMed, MHA, MA FSHP, AICD n ACHS Board member since 2002 n ACHS Board member since 2008 n Clinicians Involvement Working Group Chair, 2003–2004 n Chair, ACHS Standards Committee since 2007 n General Manager, Royal Darwin Hospital since 1994 n Area Director of Pharmacy, Hunter New England Health n Senior Superintendent NT Acute Care Network since 2003 since 2008 n Member NT Medical Board since 1996 n Director of Pharmacy, Greater Newcastle Sector, Hunter New n Chair NT Radiographers Board since 1997 England Health, 2001–2008 n Senior Lecturer NT Clinical School since 1995 n Member and currently Vice President, Pharmacy Board of NSW since 2006 n Council Member National Council for Safety and Quality in Healthcare, 1999–2006 n Member NSW Health Caring Together Independent Panel since 2009 n NT President ACHSE since 2003 n Member NSW Health Medication Safety Strategy Steering n Chair NT Acute Care Quality Committee since 2003 Committee since 2009 n Medical Director of the NT Medical Administration Network n Federal President, The Society of Hospital Pharmacists of since 2005 Australia (SHPA), 1999–2002 n Region #1 Top End Medical Disaster Coordinator n SHPA GlaxoSmithKline Medal of Merit recipient 2005 n Executive Director, National Trauma and Critical Care Response Ms Kae Martin RN, RM, BHSc (Nursing), MHA, LLB, ACHSE Dr Robert Porter MBBS, FRACGP, FRACMA, AFCHSE n ACHS Board member since 2003 n Executive Director, Business Development, Planning & n ACHS Board member since 2003 Performance, Central Northern Adelaide Health Service n ACHS Councillor since 1998 since 2004 n ACHS Surveyor since 1992 n Director, Acute Care & Clinical Services, SA Department of n Councillor, Royal Australasian College of Medical Health, 2000–2004 Administrators, 1997– May 2006 n Marathon runner n Area Director of Clinical Services, Mid North Coast Area Health Service, 2001–2005 Mr Russell McGowan n Project Manager Medical Workforce and Director of Medical BA (Adelaide) Services Maitland Hospital, Hunter New England Area Health Service, 2005–2007 n ACHS Board member since 2001 n Medical Advisor, Internal Audit Hunter New England Health n ACHS Consumer Surveyor since 2001 Service 2007 n National Advisory Committee Chair, 2003–2005 n Area Director of Medical Services Greater Western Area n Consumer Commissioner, Australian Commission on Safety Health Service 2007–2008 and Quality in Health Care since 2008 n Consultant in Medical Administration since 2007 n Director, Australian Divisions of General Practice since 2003 n Member, ACT Health Council since 2003 Mr Michael Roff n Governing Committee Member, Consumers Health Forum Grad Cert Mgt since 2002 n ACHS Board member since 2003 n Community Member, National Blood Authority Board, 2003–2007 n Chief Executive Officer, Australian Private Hospitals Association since 2000 n Consumer representative on numerous local and national healthcare committees n Member, National Health Performance Committee since 2000 n Member, Private Health Industry Quality & Safety Committee, 2000–2004 n Member, National Centre for Classification in Health, Management Advisory Committee since 2000 n Director, Australian Centre for Health Research since 2006

32 ACHS ANNUAL REPORT 2008–2009 Mr John Smith PSM Dr Noela Whitby AM Treasurer MBBS (Qld), Grad Dip HumNut, DPD , FRACGP, FAICD

MHA, Grad Dip HSM, AFACHSE, CHE, FAHSFMA, AFAHRI, n ACHS Board member since 2000 AFAIM, FHFM, FAICD n ACHS Vice-President 2005–2007 n ACHS Board member since 2005 n Board member – ACHS International since 2006 n Chief Executive Officer, West Wimmera Health Service n Chair, National Expert Committee on Standards of RACGP, n ACHS Treasurer since 2007 2002–2005 n Board member – ACHS International, 2008 n Member, National Expert Committee on Standards of RACGP n ACHS Councillor since 2000 since 1994 n National Councillor – Australian Healthcare and Hospitals n Chair, Australian General Practice Accreditation Limited, Association since 2000 2003–2006 n Director Victorian Healthcare Association 1997–2004 n Director, Australian General Practice Accreditation Limited, 2000–2006 n Board Member, The Victorian Hospitals Industrial Association Limited since 1994 n Director, Quality in Practice Pty Ltd, 2003–2006 n Director, National Asthma Council since 2005 Dr Dana Wainwright n Chair, National Asthma Council Australia since 2008 MBBS, FRACP n General Practice Principal, Carindale Medical Clinic, Brisbane since 1979 n ACHS Board member since 2003 n Associate Professor of General Practice, Bond University n VMO Royal Brisbane Hospital 2006–2007 n Past Chair, AMA Federal Council 2003–2008 n Fellow of the Australian Institute of Company Directors n President of AMA Queensland 1998–1999 n Chairman of Medical Staff Association Royal Brisbane Hospital since 2006 n Adverse Drug Committee of TGA since 2000 n Australian Medical Council member since 2004 n Deputy Chairman, Medical Assessment Tribunal, Workers Compensation Regulatory Authority since 2004

Mr Stephen Walker As Dip Eng, B Bus, Grad Dip Acc, AICD, AFACHSE Attendance at ACHS Board Meetings July 2008–June 2009 n ACHS Board member since 2006 A B n Chief Executive Officer, St Andrew’s Hospital, Adelaide since 2001 A/Prof Peter Woodruff 9 8 n Board member, Australian Private Hospitals Association Ms Karen Linegar 9 8 (APHA) since 2005 Ms Helen Dowling 9 9 n President, SA Branch APHA since 2004 Mr Russell McGowan 9 9 n Chairman, APHA National Safety and Quality Committee since 2007 Ms Kae Martin 9 6 n Member, Private Hospital Sector Committee, Australian Dr Len Notaras AM 9 9 Commission on Safety and Quality in Health Care since 2007 Mr Michael Roff 9 9 n Past Vice President, SA branch ACHSE Dr Robert Porter 9 8 n Past ACHS and QHNZ Surveyor Mr John Smith PSM 9 9 Dr Dana Wainwright 9 6 Mr Stephen Walker 9 8 Dr Noela Whitby AM 9 8

A Meetings held during the period of office of the Board member B Meetings attended by the Board member

ACHS ANNUAL REPORT 2008–2009 33 Corporate Governance ACHS Council Members

As at 30 June 2009 The ACHS Council’s powers and duties include: ººElection of the Board, President, Vice-President and Treasurer at the Annual General Meeting ººAppointment of Council committees ººConsideration and recommendation to the Board regarding the acceptance of other organisations as members of the Council ººContribution to and support of the ACHS and assistance in determining the strategic direction of the ACHS ººParticipation in the determination of accreditation status, where appropriate ººConsideration and monitoring of Board performance.

ACHS Council members, their qualifications and Ms Jenny Duncan bodies represented were: RN, RM, Grad Cert Occ Ther, BAdmin (Nurs), FCN, FRCN Catholic Health Australia Ms Jennie Baker BHSc (Mgt), BBus (IR), MLegSt, MIR, FCHSE, CHE Ms Tanya Gawthorne Australian College of Health Service Executives BSc, Grad Dip Ed, Grad Dip Pub Hlth, MAppEpid Department of Health, Western Australia Mr Richard Bartlett BA, PhD, Grad Dip IT Ass. Prof. Deborah Green Commonwealth Department of Veterans’ Affairs BSocStud (resigned 04/2009) Australian Healthcare and Hospitals Association (resigned 07/2008) Dr Patrick Bolton MBBS, Grad Dip Comp Stud, MBA, PhD, EMBA, FRACGP, FRACMA, Dr Michael Hodgson AM (President) FACHI MBBS, FAMA, FANZCA, FRCA, AFCHSE Australian Healthcare and Hospitals Association Australian Medical Association (appointed 12/2008) (resigned 11/2008) Mr Ken Campbell Mrs Alice Jones BSc (Chem Econ), RN, Grad Dip Prof Mgt, AFCHSE RN, RM, CHCNS, BAppSc (Nurs) Department of Health and Human Services, Tasmania ACT Health (resigned 12/2008) Mr Mark Kearin Dr Margaret Cowling RN, ADCNS (Geront Nurs), BHSc (Mgt), MHSc (Mgt), MBBS, FFARACS, FANZCA Australian Nursing Federation Australian and New Zealand College of Anaesthetists Ass. Prof. Peter Kendall Prof. David Davies MBBS, DA, FRACP, FCCP BSc, MBChB, MD, FRCPA Royal Australasian College of Physicians The Royal College of Pathologists of Australasia (appointed 05/2009) Dr Paul Devenish-Meares Ms Karen Linegar (Vice President) MBBS, FRANZCOG, FRCOG RN, RM, BAppSc (Nurs), MHA, Dip Comm Law, FRCNA, JP Royal Australian and New Zealand College of Obstetricians and Royal College of Nursing Gynaecologists Dr David Lord Dr Stuart Dorney MBBS, DPM, FRANZCP MBBS, FRACP Royal Australian and New Zealand College of Psychiatrists NSW Health (appointed 04/2009) (appointed 01/2009) Ms Kim Loveday Ms Helen Dowling Department of Veterans’ Affairs BPharm, Dip Hosp Pharm (Admin), Grad Dip QI HCare, CHP, FSHP, AICD (appointed 05/2009) Health Professions Council of Australia

34 ACHS ANNUAL REPORT 2008–2009 Dr Sally McCarthy Ms Kathleen Ryan MBBS, MBA, FACEM FAAQHC Australasian College for Emergency Medicine Australasian Association for Quality in Health Care Mr Russell McGowan Dr Paul Scown BA (Adelaide) MBBS, BHA, FRACMA, AFCHSE, CHE Consumers’ Health Forum of Australia Australian Healthcare and Hospitals Association Ms Alison McMillan Mr John Smith PSM (Treasurer) RN, BEd, MBA MHA, Grad Dip HSM, AFACHSE, CHE, FAHSFMA, AFAHRI, AFAIM, Department of Human Services, Victoria FHFM, FAICD Australian Healthcare and Hospitals Association Ms Leith MacMillan Australian Day Surgery Council Dr Dana Wainwright (resigned 07/2008) MBBS, FRACP Australian Medical Association Ms Kae Martin RN, RM, BHSc (Nurs), MHA, LLB, ACHSE Mr Stephen Walker Department of Human Services, South Australia Ass Dip Eng, BBus, Grad Dip Acc, AFCHSE, AICD Australian Private Hospitals Association Ms Maralyn Masters RN, Op Cert, Grad Dip HSM Dr Noela Whitby AM Australian Day Surgery Council MBBS, Grad Dip Hum Nut, FRACGP, FAICD (appointed 08/2008) Royal Australian College of General Practitioners Dr Jon Mulligan Professor Andrew J Wilson MBBS, MHA, FRACP, FRACMA, AFCHSE, FAIM, FAICD BMedSci, MBBS, PhD, FRACP, FAFPHM Council Life Member Queensland Health Dr Leonard Notaras AM Dr Ian Woodforth LLB, BA, Dip Comm, BMed, MHA, MA, AFCHSE, MBBS, FANZCA Northern Territory Department of Health and Australian Medical Association Community Services (appointed 12/2008) Dr Robert Porter Associate Professor Peter Woodruff (President) MBBS, FRACGP, FRACMA, AFCHSE MBBS, ChM, FRCS, FRACS, FACS Royal Australasian College of Medical Administrators Royal Australasian College of Surgeons Dr Eva Raik AM Dr Choong-Siew Yong MBBS, FRCPA, FRACP MBBS, Grad Cert CAPsych, FRANZCP Council Life Member Australian Medical Association Mr Michael Roff Grad Cert Mgt 5 Resigned; 7 Appointed Australian Private Hospitals Association 1 Nomination pending as at 30 June 2009: Department of Health and Human Services, Tasmania

Sydney Southwest Private Hospital

ACHS ANNUAL REPORT 2008–2009 35 Financial performance Directors’ Report

The Board of Directors of The Australian Council on Healthcare Standards Limited in office at the date of this report presents the results of The Australian Council on Healthcare Standards Limited and its controlled entity for the financial year ended 30 June 2009.

The names of the members of the Board in office during the The parent entity is exempt from the payment of income tax. reporting year are: The subsidiary, ACHS International Pty Ltd, which was formed to ººMs Helen Dowling – (appointed 27 November 2008) extend the mission of Australian Council on Healthcare Standards (ACHS) internationally, is subject to Australian income tax. ººDr Michael Hodgson AM ººMs Karen Linegar Dividends paid or recommended ººMs Kae Martin The Australian Council on Healthcare Standards Limited is a ººMr Russell McGowan not-for-profit organisation, and accordingly no dividends were paid or recommended. ººDr Leonard Notaras AM ººDr Robert Porter Share capital ººMr Michael Roff The company was incorporated on 4th December 1979 as a ººMr John Smith PSM company limited by guarantee. ººDr Dana Wainwright Review of operations ººMr Stephen Walker During the year, ACHS International Pty Ltd (ACHSI), a wholly ººDr Noela Whitby AM owned subsidiary of the ACHS, continued to expand its strategic ººAssociate Professor Peter Woodruff collaborative links internationally. ACHS was awarded a contract by Directors have been in office since the start of the financial year the Hong Kong Hospital Authority to assist with the development to the date of this report unless otherwise stated. and implementation of a Pilot Scheme of Hospital Accreditation. A Memorandum of Understanding was signed with Dubai Company Secretary Health Authority followed by a proposal to provide assistance in establishing a local accreditation agency. The following person held the position of company secretary at the end of financial year: A total of five organisations, two in India and three in the Middle East, were appointed as “ACHSI Certified Consulting Mr Brian Johnston – Fellow of the Australian College of Health Agent/Trainer”. Service Executives, the Australian Institute of Company Directors and the Australian Institute of Management. He has over Financial assistance by way of grants was received from 30 years of Australian health industry experience. New South Wales Department of Health and Australian Trade Commission. Principal activities State of affairs The principal activities of the Company during the financial year remained unchanged and were dedicated to improving the In the opinion of the Directors, there were no significant quality of healthcare in Australia through continual review of changes in the state of affairs of the Company that occurred performance, assessment and accreditation. during the financial year under review or any significant changes likely to affect the state of affairs of the Company in future There was no significant change in the nature of the Council’s financial years. activities during the 2008–2009 period. Future developments Operating results Likely developments in the operations of the Company and The consolidated net profit for the financial year ended 30 June the expected results of those operations in future financial 2009 before extraordinary items was $27,698. The company is years have not been included in this report as the inclusion of exempt from the payment of income tax. such information is likely to result in unreasonable prejudice to the Company.

36 ACHS ANNUAL REPORT 2008–2009 Environmental issues financial statements by reason of a contract entered into by the Company that was related to the Company when the contract The directors believe that the operations of the company are not was made or when the director received or became entitled to subject to any specific or significant environmental regulation receive, the benefit with: under either Commonwealth or State Legislation. Accordingly, the directors do not anticipate any effect on the operations ººa director, or of the Company, or on its operating results, as a result of ººa firm of which a director is a member, or environmental regulations. ººan entity in which a director has a substantial financial interest. Events subsequent to balance date Non-audit services There are no matters or circumstances that have arisen since the The board of directors report that there was no non-audit end of the period which significantly affected or may significantly services provided during the year. affect the operations of the economic entity, the results of those operations or the state of affairs of the economic entity in subsequent years. Auditor’s independence declaration The auditor’s independence declaration for the year ended Proceeding on behalf of company 30th June 2009 has been received and can be found directly below the directors’ report. No person has applied under Section 237 of the Corporations Act 2001 to bring proceedings on behalf of the company or The report of the Directors, incorporating the Remuneration intervene in any proceedings to which the company is a party Report, is signed in accordance with a resolution of the Board for the purpose of taking responsibility on behalf of the company of Directors. for all or any part of those proceedings. The company was not a party to any such proceedings during the year.

Indemnification and insurance of officers and auditors Associate Professor The Company has not, during or since the financial year, in Peter Woodruff Mr John Smith PSM respect of any person who is or has been an officer or auditor of President Treasurer the company or a related body corporate: Sydney – 24th day of September 2009 ººindemnified or made any relevant agreement for indemnifying against a liability incurred as an officer, including costs and Auditor’s independence declaration expenses in successfully defending legal proceedings; or Auditor’s independence declaration under section 307C of the ººpaid or agreed to pay premium in respect of a contract Corporations Act 2001 to the Directors of Australian Council on insuring against a liability incurred as an officer for the costs Healthcare Standards Limited and controlled entities. or expenses to defend legal proceedings; with the exception The directors received the following declaration from the auditor of the following matters: of Australian Council on Healthcare Standards Limited. ººDuring the period the Council paid an insurance premium I declare that, to the best of my knowledge and belief, during the indemnifying each of the Directors and Officers of the year ended 30 June 2009 there have been: economic entity against all liabilities to another person that may arise from the position as Directors or Officers of the ººno contraventions of the auditor independence requirements Council, except where the liability arises out of criminal or set out in the Corporations Act 2001 in relation to the audit; dishonest conduct or behaviour involving a lack of good faith. and ººThe Company maintained its Professional Indemnity and ººno contraventions of any applicable code of professional Directors and Officers insurance policy through OAMPS conduct in relation to the audit. Insurance Brokers Limited to which the directors are not obliged to contribute.

Remuneration report TALBOTS S A HOLLIER During or since the financial year no director of the Company Chartered Accountants Partner has received or become entitled to receive a benefit, other than Level 6 a benefit included in the aggregate amount of emoluments 379 Kent Street received or due and receivable by the Directors shown in the Sydney NSW 2000 Sydney – 25th day of September 2009

ACHS ANNUAL REPORT 2008–2009 37 Financial performance Financial Statements

Income Statements for the year ended 30th June 2009 Consolidated Parent Note 2009 2008 2009 2008 Sales revenue 2 9,880,880 8,952,627 9,772,321 8,570,069 Cost of sales (3,723,776) (3,323,105) (3,631,061) (3,111,900) Gross profit 6,157,104 5,629,522 6,141,260 5,458,169 Other revenues from ordinary activities 412,698 520,300 288,178 455,028 Marketing, promotional and publication expenses (203,270) (153,876) (86,592) (44,318) Occupancy expenses (94,820) (106,705) (94,820) (106,705) Administration expenses (1,056,617) (879,814) (1,037,813) (867,185) Human resources expenses (4,739,801) (4,334,993) (4,739,804) (4,333,905) Depreciation (292,539) (281,058) (292,539) (281,058) Other expenses (155,057) (314,578) (153,158) (244,388) Profit from operation 3 27,698 78,798 24,712 35,638 Retained profit/(loss) at the beginning of the year 808,566 729,768 770,143 734,505 Retained profit at the end of the financial year 836,264 808,566 794,855 770,143

Balance Sheets as at 30th June 2009 Consolidated Parent Note 2009 2008 2009 2008 Current assets Cash 4 3,615,323 2,989,233 3,443,744 2,815,140 Trade receivables 5 1,694,580 1,514,011 1,694,580 1,506,511 Total current assets 5,309,903 4,503,244 5,138,323 4,321,651 Non-current assets Plant and equipment 6 452,779 477,424 452,779 477,424 Land and building 7 2,542,202 2,629,169 2,542,202 2,629,169 Intangible assets 8 616 1,230 – – Investments 9 3,078 2,837 3,078 2,837 Total non-current assets 2,998,675 3,110,660 2,998,059 3,109,430 Total assets 8,308,578 7,613,904 8,136,382 7,431,081 Current liabilities Trade payables 10 1,520,321 1,429,375 1,495,321 1,404,375 Provisions 11 1,455,904 1,103,381 1,455,904 1,103,381 Unearned income 12 4,496,089 4,272,582 4,390,302 4,153,182 Total current liabilities 7,472,314 6,805,338 7,341,527 6,660,938 Total liabilities 7,472,314 6,805,338 7,341,527 6,660,938 Net assets 836,264 808,566 794,855 770,143 Equity Retained earnings 836,264 808,566 794,855 770,143

38 ACHS ANNUAL REPORT 2008–2009 Statement of Changes in Equity Note Retained Profit Balance as at 30 June 2007 729,768 Profit attributable to members parent entity 78,798 Balance as at 30 June 2008 15 808,566

Balance as at 30 June 2008 808,566 Profit attributable to members parent entity 27,698 Balance as at 30 June 2009 15 836,264

Statement of Cash Flows Consolidated Parent Note 2009 2008 2009 2008 Cash flows from operating activities Receipts from customers net of payments to suppliers and employees 209,090 490,259 211,603 409,387 Interest received 163,837 99,934 163,837 99,933 Net cash provided in operating activities 13 372,927 590,193 375,440 509,320

Cash flow from investing activities Prepayment of expenses 33,867 (13,558) 33,867 (13,559) Acquisition of property, plant and equipment (124,119) (119,490) (124,119) (119,490) Acquisition of investment and short term deposits (241) 6,272 (241) 6,272 Net cash provided from investing activities (90,493) (126,776) (90,493) (126,777)

Cash flow from financing activities Proceeds from borrowings (movement in unearned income) 14 343,656 784,894 343,656 692,593 Net cash provided by financing activities 343,656 784,894 343,656 692,593 Net increase/(decrease) in cash held 626,090 1,248,311 628,603 1,075,137 Cash at the beginning of financial year 2,989,232 1,740,922 2,815,140 1,740,003 Cash at the end of financial year 16 3,615,322 2,989,233 3,443,743 2,815,140

ACHS ANNUAL REPORT 2008–2009 39 Financial performance Notes to the Financial Statements

Note 1: Statement of significant accounting policies Plant and equipment The financial report covers the economic entity of The Australian Plant and equipment are measured on the cost basis. Council on Healthcare Standards Limited and controlled entities, The carrying amount of property, plant and equipment is and The Australian Council on Healthcare Standards Limited as reviewed annually by the Board to ensure it is not in excess of an individual parent entity. The parent entity is a company limited the recoverable amount of these assets. by guarantee, incorporated and domiciled in Australia. ºº The recoverable amount is assessed on the basis of the a) Basis of preparation expected net cash flows which will be received from the assets employment and subsequent disposals. The financial report is a general purpose financial report that has been prepared in accordance with: ºº The expected net cash flows have not been discounted to present values in determining recoverable amount. ºº Corporations Act 2001 ºº Applicable Australian Accounting Standards Depreciation The depreciable amount of all fixed assets excluding freehold ºº Australian Accounting Interpretations, and property are depreciated on a straight line basis over their ºº Other authoritative pronouncements of the Australian estimated useful lives to the entity commencing from the time Accounting Standard Board (AASB). the asset is held ready for use. Australian Accounting Standards include Australian equivalents The useful lives used for each class of depreciable assets are: to International Financial Reporting Standards (AIFRS). Compliance with AIFRS ensures that the consolidated financial Class of fixed assets Depreciable rate statements and notes comply with International Financial Office equipment 5 years Reporting Standards (IFRS). Computer and IT equipment 3 years Except as described below, the accounting policies have been Furniture and fittings 10 years applied to all periods presented in these financial statements and have been applied consistently. Freehold building 40 years

The financial report has been prepared in Australian dollars on an The assets’ residual values and useful lives are reviewed and accrual basis and is based on historical costs and does not take adjusted if appropriate at each balance date. into account changing money values or, except where stated, current valuations of non-current assets. Cost is based on the An asset’s carrying amount is written down immediately to its fair values of the consideration given in exchange for assets. recoverable amount if the asset’s carrying amount is greater than its estimated recoverable amount. b) Basis of consolidation d) Impairment of assets All inter-company balances and transactions between entities in the economic entity, including unrealised profits or losses, At each reporting date, the group reviews the carrying values have been eliminated on consolidation. Accounting policies of of its tangible and intangible assets to determine whether there subsidiaries have been changed where necessary to ensure is any indication that those assets have been impaired. If such consistencies with those policies applied by the parent entity. an indication exists, the recoverable amount of the asset, being the higher of the asset’s fair values less costs to sell and value in Where controlled entities have entered or left the economic use, is compared to the asset’s carrying value. Any excess of the entity during the year, their operating results have been included/ asset’s carrying value over its recoverable amount is expensed to excluded from the date control was obtained or until the date the income statement. control ceased. A list of controlled entities is contained in Note 9 to the financial e) Financial Instrument statements. All controlled entities have a June financial year-end. Financial instruments are initially measured at cost on trade date, which includes transaction costs, when the related contractual c) Property, plant and equipment rights or obligations exist. Subsequent to initial recognition these Property, plant and equipment are brought to account at instruments are measured as set out below. cost, less, where applicable, any accumulated depreciation, Financial assets at fair value through profit and loss impairment losses plus costs incidental to acquisition. A financial asset is classified in this category if acquired principally Property for the purpose of selling in the short term or if designated Freehold land and buildings are shown at their original costs by management and within the requirements of AASB139: plus costs incidental to acquisition less subsequent depreciation Recognition and Measurement of Financial Instruments. for buildings.

40 ACHS ANNUAL REPORT 2008–2009 Derivatives are also categorised as held for trading unless they are i) Cash and cash equivalents designated as hedges. Realised and unrealised gains and losses Cash and cash equivalents include cash on hand, deposits held arising from changes in the fair value of these assets are included in at call with banks, other short-term highly liquid investments with the income statement in the period in which they arise. original maturities of six months or less, and bank overdrafts. Held-to-maturity investments Bank overdrafts are shown within short-term borrowings in current liabilities on the balance sheet. These investments have fixed maturities; and it is the group’s intention to hold these investments to maturity. Any held-to- The Company has no short-term borrowings. maturity investments held by the group are stated at amortised cost using the effective interest rate method. j) Leases Lease expenditure relating to leases deemed to be “operating Fair value leases” is expensed as incurred. Operating lease commitments Fair value is determined based on current bid prices for all outstanding at balance date include guaranteed residual values. quoted investments. Valuation techniques are applied to determine the fair value for all unlisted securities, including recent k) Unearned revenue arm’s length transactions, reference to similar instruments and option pricing models. The income held in advance at Note 12 of the accounts will be brought to account on a “time pro rated” basis over the period f) Income tax of the contract concerned. Sales revenue is also recognised on this basis. The Company has not adopted tax effect accounting. The Parent Company has received confirmation from the l) Interests in joint venture Australian Taxation Office that its income is exempt from income tax pursuant to Section 50-5 of the Income Tax Assessment Act The Company’s share of the assets, liabilities, revenue and 1997 and accordingly the Company does not have any liability expenses of joint ventures are included in the appropriate items for income tax. of the balance sheet and income and expenditure account. Details of the joint venture are shown at Note 9, as shares in Where a controlled entity is a taxable entity the charge for current associated companies. tax expense is based on the profit for the year adjusted for any non-assessable or disallowed items. It is calculated using the tax m) Goods and Services Tax (GST) rates that are applicable during the financial year. Revenues, expenses and assets are recognised net of the g) Employee benefits amount of GST, except where: Liabilities for wages and salaries, annual leave and related on- ºº the amount of GST incurred by The Australian Council on costs are recognised and measured as the amount unpaid at Healthcare Standards as a purchaser that is not recoverable the reporting date at current pay rates in respect of employees’ from the Australian Taxation Office is recognised as part of the services up to that date. cost of acquisition of the asset or as part of an item of expense; Long Service Leave provision is based on the remuneration rates ºº receivables and payables are stated including the amount at year end for all employees with five or more years of service. It of GST. is considered that this measurement technique produces results not materially different from the estimate determined by using the n) Comparative figures present value basis of measurement. Comparative figures have been reclassified where necessary for consistency with the current period’s financial statements and The outstanding amounts of workers’ compensation insurance other disclosures. premiums and fringe benefits tax, which are consequential to employment, are recognised as liabilities and expenses where the o) Revenue and income recognition employee entitlements to which they relate have been recognised. Sales revenue comprises revenue earned (net of returns, Contributions are made by the Company to employee discounts and allowances) from the business activities and is superannuation funds and are charged as expenses recognised at point of sale or lodgement. when incurred. ºº EQuIP membership fees are brought to account on a “time h) Provisions pro rated” basis over the period of the contract concerned. Provisions are recognised when the group has a legal or ºº Interest received is recognised as it accrues. constructive obligation, as a result of past events, for which it is Revenue from the sale of goods is recognised upon the delivery possible that an outflow of economic benefits will result and that of goods to customers. outflow can be reliably measured. All revenue is stated net of the amount of goods and services tax (GST).

ACHS ANNUAL REPORT 2008–2009 41 Financial performance Notes to the Financial Statements

p) Trade and other creditors s) Critical accounting estimates and judgements Liabilities are recognised for goods or services received prior to the The Directors evaluate estimates and judgements incorporated end of the reporting period and which are unpaid. The amounts are into the financial report based on historical knowledge and best unsecured and are usually paid within 30 days of recognition. available current information. Estimates assume a reasonable expectation of future events and are based on current trends and q) Interest revenue economic data, obtained both externally and within the group. Interest revenue is recognised on a proportional basis taking into account the interest rates applicable to the financial assets. t) New accounting standards for application in future periods r) Government grants The AASB has issued new, revised and amended standards and Government grants are recognised at fair value where there interpretations that have mandatory application dates for future is reasonable assurance that the grant will be received and all reporting periods. The Board of Directors has decided against grant conditions will be met. Grants relating to expense items early adoption of these standards. are recognised as income over the periods necessary to match the grant to the costs they are compensating. Grants relating to assets are credited to deferred income at fair value and are credited to income over the expected useful life of the asset on a straight-line basis.

Note 2: Operating revenue comprises revenue from the following operating activities Consolidated Parent 2009 2008 2009 2008 Membership fees 8,215,367 7,773,046 8,111,003 7,393,988 Education workshops 414,825 580,504 414,825 577,504 Projects 776,798 478,473 776,798 478,473 Publications 38,707 63,863 38,707 63,363 Other 435,183 56,741 430,988 56,741 Revenue from ordinary activities 9,880,880 8,952,627 9,772,321 8,570,069 Grants received 209,220 147,872 84,700 82,600 Interest revenue: Interest received from financial institutions 163,837 99,934 163,837 99,934 Other income 39,641 272,494 39,641 272,494 Total operating revenue 10,293,578 9,472,927 10,060,499 9,025,097

Note 3: Profit from ordinary activities Consolidated Parent 2009 2008 2009 2008 Profit from ordinary activities has been determined after: Cost of sales 3,723,776 3,323,105 3,631,061 3,111,900 Depreciation – plant and equipment 205,573 196,802 205,573 196,802 – buildings 86,966 84,256 86,966 84,256 Remuneration of auditors 30,360 25,000 30,360 24,300 Total 4,046,675 3,629,163 3,953,960 3,417,258

42 ACHS ANNUAL REPORT 2008–2009 Note 4: Cash Consolidated Parent 2009 2008 2009 2008 Cash on hand 1,300 1,000 1,300 1,000 Cash at bank 3,614,023 2,988,233 3,442,444 2,814,140 Total cash 3,615,323 2,989,233 3,443,744 2,815,140

Note 5: Receivables and other assets Consolidated Parent 2009 2008 2009 2008 Trade debtors 1,783,734 1,469,300 1,783,734 1,461,800 Less: Provision for doubtful debts (130,000) (30,000) (130,000) (30,000) Other debtors and prepayments 40,846 74,711 40,846 74,711 Total receivables 1,694,580 1,514,011 1,694,580 1,506,511

Note 6: Plant and equipment Consolidated Parent 2009 2008 2009 2008 Furniture and fittings – at cost 224,146 222,586 224,146 222,586 Less: Accumulated depreciation (181,510) (169,850) (181,510) (169,850) Net book value 42,636 52,736 42,636 52,736 Office equipment – at cost 179,788 177,719 179,788 177,719 Less: Accumulated depreciation (123,397) (148,496) (123,397) (148,496) Net book value 56,391 29,223 56,391 29,223 Information technology – at cost 1,201,418 1,080,928 1,201,418 1,080,928 Less: Accumulated depreciation (888,834) (741,601) (888,834) (741,601) Net book value 312,584 339,327 312,584 339,327 Motor vehicle – at cost 74,851 74,851 74,851 74,851 Less: Accumulated depreciation (33,683) (18,713) (33,683) (18,713) Net book value 41,168 56,138 41,168 56,138 Net book value, plant and equipment 452,779 477,424 452,779 477,424

ACHS ANNUAL REPORT 2008–2009 43 Financial performance Notes to the Financial Statements

Note 6: Plant and equipment (continued) Movement in carrying amounts for plant and equipment, land and buildings

Freehold Furniture Office Information Motor land Buildings & fittings equipment technology vehicle Total Consolidated group Balance at 1 July 2007 380,000 2,333,424 47,390 49,101 385,590 71,109 3,266,614 Additions – – 16,464 1,992 101,035 119,490 Disposals – – – – – – Additions through acquisitions – – – – – – Revaluation increments/(decrements) – – – – – – Depreciation expense – (84,256) (11,118) (21,870) (147,298) (14,970) (279,511) Capitalised borrowing cost and depreciation – – – – – – Balance at 30 June 2008 380,000 2,249,168 52,736 29,223 339,327 56,139 3,106,593 Additions – – 1,560 2,069 120,490 124,119 Disposals – – – 56,808 – 56,808 Additions through acquisitions – – – – – – Revaluation increments/(decrements) – – – – – – Depreciation expense – (86,967) (11,660) (31,709) (147,233) (14,971) (292,540) Capitalised borrowing cost and depreciation – – – – – – Disposal of assets on sale of subsidiary – – – – – – Write-off of assets destroyed during flood – – – – – – Balance at 30 June 2009 380,000 2,162,201 42,636 56,391 312,584 41,168 2,994,980

Note 7: Land and building Consolidated Parent 2009 2008 2009 2008 Land – at cost 380,000 380,000 380,000 380,000 Building – at cost 1,425,454 1,425,454 1,425,454 1,425,454 Less: Accumulated depreciation (374,182) (338,545) (374,182) (338,545) Net book value 1,051,272 1,086,909 1,051,272 1,086,909 Building improvements – at cost 1,589,238 1,589,238 1,589,238 1,589,238 Less: Accumulated depreciation (478,308) (426,978) (478,308) (426,978) Net book value 1,110,930 1,162,260 1,110,930 1,162,260 Net book value, land and building 2,542,202 2,629,169 2,542,202 2,629,169

Note 8: Intangible assets Consolidated Parent 2009 2008 2009 2008 Formation costs 3,072 3,072 – – Less: Amortisation (2,456) (1,842) – – Total unearned income 616 1,230 – –

44 ACHS ANNUAL REPORT 2008–2009 Note 9: Investment in controlled and non-controlled entities Consolidated Parent 2009 2008 2009 2008 Investment in non-controlled entities Shares in listed companies Shares in SAI Global Ltd 3,078 2,837 3,078 2,837 Total investment non-current 3,078 2,837 3,078 2,837 Investment in controlled entities Shares in ACHSI – At Cost – – 10,000 10,000 Total investment non-current – – 10,000 10,000

Note 10: Trade payables Consolidated Parent 2009 2008 2009 2008 Accounts payable 635,984 706,258 635,984 706,258 Accrued expenses 95,437 54,366 95,437 54,366 Work in progress 788,900 668,751 763,900 643,751 Total trade payables 1,520,321 1,429,375 1,495,321 1,404,375

Note 11: Provisions – current Consolidated Parent 2009 2008 2009 2008 Employee entitlements 652,194 545,925 545,925 545,925 Provision, overseas market development 30,000 60,000 60,000 60,000 Provision, future costs 65,000 65,000 65,000 65,000 Provision, research and development 120,000 60,000 120,000 60,000 Provision, standards development 8,731 80,000 8,731 80,000 Provision, EQuIP printing/pilot printing and national report 251,000 80,000 251,000 80,000 Provision, external evaluation 24,523 70,000 24,523 70,000 Provision, salaries 78,978 55,978 55,978 55,978 Provision, strategic initiatives 31,478 56,478 31,478 56,478 Provision, board education and training 26,000 30,000 26,000 30,000 Provision, ISQua accreditation and survey 35,000 – 35,000 – Provision, archive scan and RACMA 53,000 – 53,000 – Provision, eLearning and QI benchmarking 80,000 – 80,000 – Total provisions 1,455,904 1,103,381 1,455,904 1,103,381

Note 12: Unearned income Consolidated Parent 2009 2008 2009 2008 EQuIP membership fees and education service fees 4,496,089 4,272,582 4,390,302 4,153,182 Total unearned income 4,496,089 4,272,582 4,390,302 4,153,182

ACHS ANNUAL REPORT 2008–2009 45 Financial performance Notes to the Financial Statements

Note 13: Reconciliation of cash flow from operations with operating profit/(loss) after income tax Consolidated Parent 2009 2008 2009 2008 Operating profit/(loss) after income tax 27,698 78,798 24,712 35,638 Non-cash flows in operating profit Depreciation and loss on disposal of asset 236,345 280,125 236,345 279,511 Charges to provision 452,522 435,918 452,522 435,918 Changes in assets and liabilities Increase in trade and term debtors (314,435) (28,031) (314,435) (20,531) Increase/(decrease) in trade creditors and accruals 151,327 (176,617) 156,825 (221,216) Total cash flows from operating activities 553,457 590,193 555,969 509,320

Note 14: Proceeds from borrowings 2009 2008 Movement Work in progress 120,149 611,322 (491,173) Future income 223,507 173,572 49,935 Net movement 343,656 784,894 (441,238)

Note 15: Retained profits Consolidated Parent 2009 2008 2009 2008 Retained profits at the beginning of the year 808,566 729,768 770,143 734,505 Profit attributable to members for the year 27,698 78,798 24712 35,638 Retained profits at the end of the financial year 836,264 808,566 794,855 770,143

Note 16: Reconciliation of cash flow from operations Consolidated Parent 2009 2008 2009 2008 For the purposes of this statement of cash flows, cash includes: (i) Cash in hand and in deposits with banks or financial institutions, net of bank overdrafts (ii) Investments in money market instruments with less that 14 days to maturity Cash at the end of the year as shown in the balance sheet is: Cash on hand 1,300 1,000 1,300 1,000 Cash at bank 3,614,023 2,989,233 3,442,444 2,814,140 Total cash flows from operations 3,615,323 2,989,233 3,443,744 2,815,140

Note 17: Members’ guarantee Note 18: Remuneration of Board members and The Council is incorporated as a company limited by guarantee. other Councillors In accordance with the Constitution of the Company, every The Board of Directors and Councillors of The Australian Council member of the Company undertakes to contribute an amount on Healthcare Standards Limited during the financial year are limited to $50 per member in the event of the winding up of the listed in the Annual Report of the Board. Company during the time that he/she is a member or within one Apart from amounts received by way of reimbursement for year thereafter. expenses incurred in the attendance at various Executive and Committee Member’s meetings, and fees received (for example, honoraria) by Councillors for services in connection with Surveys and the Educational programs, no amounts were received by a Committee Member or Councillor in connection with the management of the affairs of the Company. 46 ACHS ANNUAL REPORT 2008–2009 Note 19: Related party transactions Foreign currency risk Apart from the transactions referred to in the Annual Report The Company is not exposed to fluctuations in foreign currencies. of the Board there have been no transactions between the Liquidity risk Company and related parties of the Company which require separate disclosure. The Company manages liquidity risk by monitoring cash flows and ensuring that adequate unutilised borrowing facilities are maintained. Note 20: Segment reporting The economic entity operates in one business segment being Credit risk the healthcare industry where it supports organisations in The maximum exposure to credit risk, excluding the value of their implementation of quality improvement through EQuIP to any collateral or other security, at balance date to recognised develop and continually review quality standards and guidelines financial assets, is the carrying amount, net of any provisions for in consultation with the industry. impairment of those assets, as disclosed in the balance sheet and notes to the financial statements. Note 21: Financial instruments The Company does not have any material credit risk exposure to any single receivables or group of receivables under financial Financial risk management instruments entered into by the Company. The Company’s financial instruments consist mainly of deposits with banks, accounts receivable and payable. Price risk The main purpose of non-derivative financial instruments is to The Company is not exposed to any material commodity raise finance for Company operations. The Company group price risk. does not have any derivative or any financial instruments at Interest rate risk 30 June 2008. Interest rate risk is managed by minimising the extent of long- Treasury risk management term interest bearing debt. For further details on interest rate risk Directors and the senior executive meet on a regular basis refer to treasury risk management above. to consider the extent of interest rate exposure and where The Company’s exposure to interest rate risk, which is the necessary evaluate treasury management strategies in the risk that a financial instrument value will fluctuate as a result context of the most recent economic conditions and forecasts. of changes in market interest rates and the effective weighted average interest rates on those financial assets and financial Financial risks liabilities, is as follows: The main risks the Company is exposed to through its financial instruments are interest rate risk, liquidity risk and credit risk.

Fixed interest maturing Weighted average effective Floating Non-interest interest rate interest rate On call More than 1 year bearing 2009 2008 2009 2008 2009 2008 2009 2008 2009 2008 % % $ $ $ $ $ $ $ $ Financial assets Cash at bank 4.0 7.9 315,406 530,659 3,299,917 2,458,574 – – – – Receivables – – 1,763,358 1,469,300 Total financial assets 315,406 530,659 3,299,917 2,458,574 – – 1,763,358 1,469,300 Financial liabilities Accounts payable 726,249 706,256 Provisions 1,455,904 1,103,381 Total financial liabilities 2,182,153 1,809,637 Net financial assets 315,406 530,659 3,299,917 2,458,574 – – (418,795) (340,337)

Note 22: Company details The registered name of the company is The Australian Council on Healthcare Standards Limited located at: No. 5 Macarthur Street, Ultimo, NSW 2007, Australia

ACHS ANNUAL REPORT 2008–2009 47 Financial performance Directors’ Declaration

The directors of the Company declare that: 1) The financial statements and notes set out on pages 36 to 47 are in accordance with theCorporations Act 2001: a) comply with Accounting Standards and the Corporation Regulations 2001; and b) give a true and fair view of the financial position as at 30 June 2009 and of the performance for the year on that date of the company and economic entity. 2) In the Directors’ opinion, there are reasonable grounds to believe that the company will be able to pay its debts as and when they become due and payable. 3) The Chief Executive and the Executive Director – Corporate Services have each declared that: a) the financial records of the company for the financial year have been properly maintained in accordance with section 286 of the Corporations Act 2001; b) the financial statements and notes for the financial year comply with the Accounting Standards; and c) the financial statements and notes for the financial year give a true and fair view. Signed in accordance with a resolution of the Directors, made pursuant to Section 295(5) of the Corporations Act 2001.

On behalf of the Directors

Associate Professor Peter Woodruff Mr John Smith PSM President Treasurer Sydney – 24th day of September 2009

48 ACHS ANNUAL REPORT 2008–2009 Financial performance Independent Auditor’s Report to the Members of the Australian Council on Healthcare Standards Limited

Report on the Financial Report We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our audit opinion. We have audited the accompanying financial report of The Australian Council on Healthcare Standards Limited and controlled Independence entities (the consolidated entity), which comprises the balance sheet as at 30 June 2009; and the income statement, statement In conducting our audit, we have complied with the of changes in equity and cash flow statement for the year ended independence requirements of the Corporations Act 2001. on that date, a summary of significant accounting policies and We confirm that the independence declaration required by other explanatory notes and the directors’ declaration of the the Corporations Act 2001, provided to the directors of The consolidated entity comprising the company and the entities at the Australian Council on Healthcare Standards on 25th September year’s end or from time to time during the financial year. 2009, would be in the same terms if provided to the directors as at the date of this auditor’s report. Directors’ responsibility for the financial report The directors of the company are responsible for the preparation Audit 2009 Opinion and fair presentation of the financial report in accordance with In our opinion: Australian Accounting Standards (including the Australian Accounting Interpretations) and the Corporations Act 2001. a) the financial report of The Australian Council on Healthcare This responsibility includes establishing and maintaining internal Standards Limited and Controlled Entities is in accordance control relevant to the preparation and fair presentation of the with the Corporations Act 2001, including: financial report that is free from material misstatement, whether yy giving a true and fair view of the company’s and due to fraud or error; selecting and applying appropriate consolidated entity financial position as at 30 June 2009 accounting policies; and making accounting estimates that are and of their performance for the year ended on that date; reasonable in the circumstances. In Note 1, the directors also and state, in accordance with Accounting Standards AASB 101: yy complying with Australian Accounting Standards Presentation of Financial Statements, that compliance with (including the Australian Accounting interpretations) and the Australian equivalents to International Financial Reporting the Corporations Regulations 2001 Standards (IFRS) ensures that the financial report, comprising b) the financial report also complies with International Financial the financial statements and notes, complies with IFRS. Reporting Standards as disclosed in Note 1; and Auditors’ responsibility c) the remuneration disclosures that are contained in the Our responsibility is to express an opinion on the financial report directors report comply with Accounting Standard AASB 124. based on our audit. We conducted our audit in accordance with Australian Auditing Standards. These Auditing Standards Inherent Uncertainty Regarding require that we comply with relevant ethical requirements relating Accounting Estimates to audit engagements and plan and perform the audit to obtain Without qualification to the opinion expressed above, attention reasonable assurance whether the financial report is free from is drawn to the following matter. As indicated in Note 12 to the material misstatement. financial report, The Australian Council on Healthcare Standards An audit involves performing procedures to obtain audit evidence has included as liabilities $4,496,089 as unearned income and about the amounts and disclosures in the financial report. Note 10 $788,900 as Work in Progress. These relate to the The procedures selected depend on the auditor’s judgment, Evaluation and Quality Improvement Program (EQuIP) and the including the assessment of the risks of material misstatement progressive recognition of income and expenses throughout the of the financial report, whether due to fraud or error. In making contract cycle based on estimation of each phase completed. As those risk assessments, the auditor considers internal control the figures taken into account are estimates their accuracy cannot relevant to the entity’s preparation and fair presentation of the presently be determined with an acceptable degree of reliability. financial report in order to design audit procedures that are appropriate in the circumstances, but not for the purpose of expressing an opinion on the effectiveness of the entity’s internal control. An audit also includes evaluating the appropriateness of accounting policies used and the reasonableness of accounting TALBOTS S A HOLLIER estimates made by the directors, as well as evaluating the Chartered Accountants Partner overall presentation of the financial report and the remuneration disclosures in the directors’ report. Level 6 379 Kent Street Sydney NSW 2000 Sydney – 25th day of September 2009

ACHS ANNUAL REPORT 2008–2009 49 Listing Our Members As at 30 June 2009

ACHS accredits the majority of Allowah Presbyterian Children’s Hospital Hirondelle Private Hospital healthcare organisations in Australia. Armidale and District Home Nursing and Hunter Valley Private Hospital The organisations participating in ACHS Home Help Service Pty Ltd Hurstville Private quality improvement and accreditation Armidale Private Hospital Hyperbaric Health Sydney programs range from hospitals, corporate Ashbrooke Cosmetic Surgery Insight Clinic Private Hospital offices of private health companies, day Berkeley Vale Private Hospital Junee Correctional Centre – Health Centre surgeries, nursing agencies, community Bondi Junction Private Hospital Kamira Farm Inc health centres, mental health services to Brunswick Private divisions of general practice. Kareena Private Hospital Byrne Surgery Kedesh Rehabilitation Services Below is a list of organisations that are Calvary Health Care Riverina Ltd Kinder Caring Home Nursing Services members of ACHS quality improvement xx Calvary Alcohol and Other Drugs Services and accreditation programs. Lady Davidson Hospital xx Calvary Day Procedure Centre Lawrence Hargrave Hospital For a more current list of ACHS member xx Calvary Health Care Riverina Ltd Lingard Private Hospital organisations as well as their accreditation xx Calvary Health Care Riverina Ltd Lismore Private Day Surgery status, please visit the ACHS website: – O’Connor House Lithgow Community Private Hospital www.achs.org.au and select the ‘Member xx Calvary Health Care Riverina Ltd organisation list’ option (under the ACHS – The Peppers Liverpool Day Surgery MEMBERS tab on the homepage). Castlecrag Private Hospital Lyndon Community, The Caswell Health Care Manly Drug Education and Counselling Centre (MDECC) ACT Private City West Day Surgery Marie Stopes International, NSW Absolute Home Care Pty Ltd Crows Nest Day Surgery xx Marie Stopes International – Fairfield Dee Why Endoscopy Unit Calvary John James Hospital xx Marie Stopes International – Homebush Diagnostic Endoscopy Centre Canberra Eye Hospital xx Marie Stopes International Diaverum Pty Ltd Canberra Surgicentre, The – Kingswood Centre Marie Stopes International, ACT xx Lindfield Dialysis Unit xx Westmead Day Surgery Centre xx St Andrew’s Toowoomba Renal Dialysis Unit Mugga Wara and Brindabella Marsden Eye Surgery Centre xx Diamond Valley Dialysis Unit Endoscopy Centres Mater Hospital, North Sydney, The Dubbo Private Hospital National Capital Private Hospital, The Mayo Healthcare Group Dutiful Daughters Salvation Army, The – Recovery Services, Mercy Community Services Eastern Heart Clinic Canberra Mercy Health Service Albury Ltd xx Sutherland Health Clinic Metwest Surgical Epping Surgery Centre ACT Public Miranda Eye Surgical Centre Excel Endoscopy Centre ACT Health Mosman Private Hospital Forster Private Hospital and North Coast xx ACT Health – Community Health National Day Surgery – Sydney Pty Ltd Community Care xx Canberra Hospital, The Nepean Private Hospital Foundation House xx Mental Health ACT Newcastle Private Hospital Calvary Health Care ACT Garden Court Clinic North Shore Private Hospital xx Calvary Health Care ACT Private Gosford Private Hospital Norwest Private Hospital xx Calvary Health Care ACT Public Griffith Nursing Service Nowra Private Hospital xx Calvary Health Care ACT Public Day Griffiths Road Day Surgery Odyssey House McGrath Foundation Surgery Unit GROW Community ONE80TC Department of Defence, ACT/SNSW Area Hawkesbury District Health Service Ltd Oolong Aboriginal Corporation, The Health Service, Defence Health Service Haymarket Foundation Limited, The Ophthalmic Surgery Centre (North Shore) HCF Dental Centres Preterm Foundation NSW Private xx HCF Dental – Blacktown Dental Centre ADF – Kathleen York House (Alcohol/Drug xx HCF Dental – Bondi Junction Dental Centre Primary Health Care Day Surgeries Foundation, NSW) xx HCF Dental – Brookvale Dental Centre xx Bankstown Primary Health Care Day Surgery Adori Day Clinic xx HCF Dental – Chatswood Dental Service xx Sydney Day Surgery ahm Dental and Eyecare Practice xx HCF Dental – Hurstville Dental Centre xx Warringah Mall Day Surgery Albury Wodonga Private Hospitals xx HCF Dental – Parramatta Dental Centre xx Western Plains Day Surgery xx Albury Wodonga Private Hospital Healthways Australia Pty Ltd Prince of Wales Private Hospital xx Murray Valley Private Hospital Healthwoods Specialist Centre Quality Health Care

50 ACHS ANNUAL REPORT 2008–2009 Regal Health Services NSW Public GSAHS – Western Sector Regional Imaging Cardiovascular Centre xx Berrigan War Memorial Hospital Balmain Hospital Riverina Cancer Care Centre xx Corowa Hospital Bankstown Hospital Rosebery Day Surgery xx Deniliquin Hospital Bowral and District Hospital Rosemont Endoscopy Centre xx Finley Hospital Bulli District Hospital Salvation Army, The, Recovery Services xx Griffith Base Hospital Calvary Health Care Sydney – Blue Mountains xx Hay Hospital, The Calvary Mater Newcastle Salvation Army, The, Recovery Services xx Hillston District Hospital – Alf Dawkins Detox Unit Campbelltown and Camden Hospitals xx Jerilderie District Hospital Salvation Army, The, Recovery Services xx Camden Hospital xx Leeton District Hospital – Central Coast xx Campbelltown Hospital xx Narrandera District Hospital Salvation Army, The, Recovery Services Canterbury Hospital xx Tocumwal Hospital – Lake Macquarie Central Coast Health xx Urana and District Health Services Salvation Army, The, Recovery Services Children’s Hospital at Westmead, The GWAHS Bathurst Base Hospital – Newcastle Concord Repatriation General Hospital GWAHS Broken Hill Health Service Salvation Army, The, Recovery Services Fairfield Hospital GWAHS Cowra and Grenfell Health Service – William Booth House Family Drug Support xx Cowra District Hospital and CHS Skin & Cancer Foundation Westmead Greater Western Area Health Services, xx Grenfell Multipurpose Service Day Clinic Mental Health Services (Eastern and xx Quandialla CHC South Coast Home Health Care Pty Ltd Southern Clusters) xx Woodstock CHC South Pacific Private Hospital xx Bloomfield Hospital GWAHS Dubbo Base Hospital South West Area Nursing Service Swans GSAHS – Central Sector GWAHS Mental Health, Drug and Alcohol Pty Ltd xx Batlow District Hospital, The Services – Central and Castlereagh Clusters Southern Suburbs Day Procedure Centre xx Boorowa Hospital GWAHS Mudgee Health Service Pty Ltd xx Coolamon Ganmain Hospital GWAHS – Oral Health Service Springboard Health & Performance Pty Ltd xx Cootamundra Hospital, The Hope Healthcare St George Private Hospital xx Culcairn District Hospital xx Braeside Hospital St John of God Health Services xx Gundagai District Hospital Hornsby Ku-ring-gai Hospital and CHS xx St John of God Hospital – Burwood xx Henty District Hospital Hunter New England Health xx St John of God Hospital – Richmond xx Holbrook Hospital and Community – Upper Hunter Cluster St Luke’s Care Health Service xx Denman Hospital xx Junee District Hospital and CHS St Vincent’s Health & Community Services xx Merriwa District Hospital xx Lockhart and District Hospital St Vincent’s Hospital – Lismore xx Muswellbrook District Hospital xx Murrumburrah-Harden District Hospital St Vincent’s Private Hospital – Sydney xx Premer Community Health Centre xx Temora and District Hospital Surry Hills Day Hospital xx Quirindi Community Hospital xx Tumbarumba District Hospital Sydney Clinic for Gastrointestinal xx Scott Memorial Hospital xx Tumut District Hospital Diseases, The xx Tambar Springs Community Health Centre xx Wagga Wagga Base Hospital and AHS Sydney Clinic, The xx Walhallow Community Health Centre xx Wyalong and District Hospital Sydney Southwest Private Hospital xx Werris Creek Community Hospital xx Young District Hospital Tamara Private Hospital xx Wilson Memorial Hospital GSAHS – Cross Border Sector The Buttery Hunter New England Health – Greater GSAHS – Eastern Sector Toronto Private Hospital Newcastle Acute Hospital Network xx Bega and Pambula Hospitals and CHS United Gardens Clinic xx Belmont District Hospital xx Bombala Health Service Vista Laser Eye Clinic of NSW xx John Hunter Children’s Hospital xx Braidwood Multi Purpose Services Kaleidoscope Warners Bay Private Hospital xx Burke Street Health Service xx John Hunter Hospital Watershed Drug & Alcohol Recovery & xx Cooma Hospital xx Royal Newcastle Hospital Education Centre Inc xx Crookwell District Hospital Hunter New England Health Waverley Drug and Alcohol Centre xx Crossroads Methadone Clinic – Greater Newcastle Cluster Wayback Ltd xx Delegate District Hospital Hunter New England Health Wayside Chapel, The xx Goulburn Base Hospital – Lower Hunter Cluster We Help Ourselves (WHOS) xx Moruya District Hospital xx Cessnock District Hospital Youth off the Streets Ltd – Dunlea xx Queanbeyan District Hospital and xx Dungog and District Hospital Health Service xx East Maitland Community Health xx Yass District Hospital xx Kurri Kurri District Hospital xx Singleton Health Services

ACHS ANNUAL REPORT 2008–2009 51 Listing Our Members

Hunter New England Health – Lower Mid Navy Ward (St Vincent’s Hospital) Royal North Shore and Ryde Health Service North Coast Cluster NCAHS Coffs Clarence Network xx Royal North Shore Hospital and Community xx Buladelah Community Health Centre xx Bellinger River District Hospital Health Service xx Bulahdelah Community Hospital xx Coffs Harbour Health Campus xx Ryde Hospital and Community xx Forster Community Health Centre xx Dorrigo Multipurpose Service Health Services xx Gloucester Community Health Centre xx Grafton Base Hospital and Community Rural Health Directorate Southern xx Gloucester Soldiers Memorial Hospital Health Southern Hospital Network xx Hawks Nest Tea Gardens Community xx Macksville and District Hospital, The xx David Berry Hospital Health Centre xx Maclean Hospital and Community Health xx Milton Ulladulla Hospital xx Taree Community Health Centre Services xx Shoalhaven Memorial District Hospital xx Wingham Community Hospital NCAHS Hastings Macleay Network Royal Prince Alfred Hospital Hunter New England Health xx Camden Haven Community Health Centre Royal Rehabilitation Centre Sydney – Maitland Hospital xx Kempsey District Hospital SESIH Central Hospitals Network Hunter New England Health xx Port Macquarie Base Hospital xx St George Hospital and Community – McIntyre Cluster xx Port Macquarie Health Campus Health Service xx Ashford Community Health Centre xx South West Rocks Community Health Centre xx Sutherland Hospital and Community Health xx Bingara Community Hospital xx Wauchope District Memorial Hospital Service, The xx Bundarra Community Health Centre NCAHS Richmond Network (A) South Eastern Sydney/Illawarra Area H/S Mental Health Service xx Inverell District Health Service xx NCAHS Ballina District Hospital and xx Tingha District Hospital Community Health xx Illawarra Area Mental Health Service xx Warialda District Hospital xx NCAHS Campbell Hospital xx South East Health Mental Health Service Hunter New England Health – Peel Cluster xx NCAHS Casino District Memorial Hospital St Joseph’s Hospital – Auburn xx Barraba Community Health Centre and Casino Community Health St Vincent’s Hospital – Sydney (Public) xx Gunnedah District Health Service xx NCAHS Lismore Base Hospital SWAHS – Central Cluster xx Manilla District Health Service NCAHS Richmond Network (B) xx Blacktown – Mt Druitt Health xx Nundle Community Health Centre xx Bonalbo Hospital SWAHS – Eastern Cluster xx Walcha Community Health Centre xx Kyogle Memorial Hospital xx Auburn Hospital and Community Hunter New England Health xx Nimbin Health Health Services – Tablelands Cluster xx Urbenville District Hospital (g) xx Westmead Health xx Armidale Community Health Centre NCAHS Tweed Byron Network SWAHS – Integrated Cluster xx Glen Innes District Health Service xx Mullumbimby and District War xx Cumberland Hospital xx Guyra Multipurpose Service Memorial Hospital SWAHS – Western Cluster xx Tenterfield Community Hospital xx Murwillumbah Hospital and Murwillumbah xx Blue Mountains District Anzac xx Uralla Community Health Centre Community Health Northern Public Memorial Hospital xx Vegetable Creek – Emmaville Multi xx NCAHS Byron Shire Hospitals and xx Lithgow Integrated Health Service Purpose Centre Community Health Service xx Nepean Hospital Hunter New England Mental Health Service xx NCAHS Tweed Hospital and Sydney Children’s Hospital Community Health xx Armidale Hospital Clark Centre Sydney Hospital and Sydney Eye Hospital Network of Alcohol and Drug Agencies xx Hunter Mental Health Sydney South West Area Health Service (NADA) xx James Fletcher Hospital Campus – Community Health North Coast Area Health Service xx John Hunter Hospital Nexus Unit Sydney South West Area Mental – Mental Health Services xx Maitland Hospital Mental Health Unit Health Service xx Northern Rivers Area Health Service xx Manning Mental Health Unit and Community xx Central Sydney Area Mental Health Services – Mental Health Services Mental Health Unit Sydney South West Oral Health Services and Northern Beaches Health Service xx Morrisset Hospital Sydney Dental Hospital xx Manly Hospital xx NEAHS – Mental Health xx Sydney Dental Hospital xx Mona Vale Hospital and Community xx Tamworth Base Hospital – Banksia Mental Tresillian Family Care Centres Health Unit and Dean House Health Service War Memorial Hospital, Waverley Justice Health Northern Sydney/Central Coast Mental Health Service Wollongong Hospitals and Community Karitane xx Northern Sydney Health – Area Mental Health Services Liverpool Hospital Health Services xx Coledale District Hospital Lourdes Hospital, Health & Aged Care Service Orange Health Service xx Port Kembla Hospital – Rehabilitation, Manning Rural Referral Hospital Prince of Wales Hospital and Community Aged and Extended Care Services Mercy Care Centre, Young Health Services xx Wollongong Hospital Mercy Health Service Albury Limited Riverina Division of General Practice and Primary Health Ltd

52 ACHS ANNUAL REPORT 2008–2009 NT Private xx Eastside Community Care Services xx Mareeba Respite Centre xx Henderson Day Respite Centre xx Mossman Blue Nurses Darwin Private Hospital xx Mt Gravatt Day Respite Centre xx Mount Isa Blue Nurses NT Public xx Northside Community Service Centre xx Mount Isa Respite Centre xx Southside Community Service Centre xx Prosperine Blue Nurses Alice Springs Hospital xx Unicare "Fulcher House" xx Sarina Blue Nurses Gove District Hospital xx Volunteers Metropolitan xx Sarina Respite Centre Katherine Hospital xx West End Day Respite Centre xx Tablelands Blue Nurses Northern Territory Mental Health Services xx Wynnum Lifestyle Services xx Tablelands Respite Centre xx Central Australian Mental Health Service Blue Care Central Queensland/Wide xx Townsville Blue Nurses xx Top End Mental Health Service Bay Region xx Townsville Homecare Dementia Oral Health Services xx Biggenden Respite Services xx Townsville Respite Centre Royal Darwin Hospital xx Bundaberg Blue Nursing xx Tully Blue Nurses Tennant Creek Hospital xx Bundaberg Respite Services xx Tully Respite Centre xx Bundaberg Therapy Centre Blue Care South West Queensland Region QLD Private xx Callide Valley/Biloela Blue Nursing and xx Blue Care Allied Health Respite Services xx Blue Care Allora/Clifton Allamanda Private Hospital xx Capricorn Coast Community Services xx Blue Care Charleville xx Allamanda Surgicentre xx Capricorn Coast Day Respite Services xx Blue Care Chinchilla/Miles Belmont Private Hospital xx Central Queensland Allied Health xx Blue Care Crows Nest Blue Care – Logan/Ipswich and South Coast xx Eidsvold Respite Services xx Blue Care Cunnamulla Clusters xx Emerald Community Care xx Blue Care Dalby xx Beaudesert Community Care Service xx Fraser Coast Allied Health xx Blue Care Goondiwindi xx Beenleigh Community Care Services xx Gayndah Blue Nursing and Respite Services xx Blue Care Injune xx Blue Care – Logan/Ipswich and South xx Gladstone Blue Nursing and xx Blue Care Lockyer Coast Clusters Respite Services xx Blue Care Millmerran xx Burremah Place Respite Services xx Hervey Bay Blue Nursing xx Blue Care Mitchell xx Commonwealth Carelink and Carer Respite xx Hervey Bay Respite Services Centre – Ipswich (West Moreton) Private xx Blue Care Pittsworth xx Longreach Respite Services xx Commonwealth Carelink and Carer Respite xx Blue Care Regional Office xx Maryborough Blue Nursing Centre – Logan Outpost xx Blue Care Roma xx Maryborough Respite Services xx Commonwealth Carelink and Carer Respite xx Blue Care Stanthorpe xx Monto Blue Nursing and Respite Services Centre – Varsity Lakes (South Coast) xx Blue Care Toowoomba Centre Based Private Associate xx Moura Blue Nursing and Respite Services Day Care xx Coomera Community Care Services xx Munduberra Blue Nursing xx Blue Care Toowoomba Community xx Fassifern Community Care Services xx Rockhampton Blue Nursing xx Blue Care Warwick xx Gold Coast Allied Health Service xx Rockhampton Respite xx Commonwealth Respite and Carelink Centre xx Ipswich Allied Health xx Wide Bay Continence Advisory Centre – Toowoomba xx Ipswich Community Care Services Blue Care North Queensland Region xx Maranoa Health Enhancement Program xx Ipswich Multicultural Liaison Service xx Bowen Blue Nursing Blue Care Suncoast Hinterland Region xx Ipswich Respite Services xx Bowen Respite Centre xx Blue Care Brisbane Valley xx Lower South Coast/Tweed Community Care xx Burdekin Blue Nursing Centre xx Blue Care Caboolture xx Lower South Coast Community Nursing xx Burdekin Respite Centre xx Blue Care Caloundra and Care xx Cairns Respite Centre xx Blue Care Caloundra Respite xx Milpera Cottage xx Cairns Blue Nursing xx Blue Care Cooloolah District xx Redbank Respite Services xx Charters Towers Dom xx Blue Care Cooloolah District Respite Services xx Southport/Surfers Paradise Blue Nurses xx Charters Towers Respite xx Blue Care Coolum Respite xx Southport/Surfers Paradise Community xx Cloncurry Blue Nurses xx Blue Care Maroochy Care Services xx Collinsville Blue Nurses xx Blue Care Murgon xx Springwood Community Care xx Commonwealth Carer Respite and Carelink xx Blue Care Noosa xx Tweed Coast Community Care Services xx Ingham Blue Nurses xx Blue Care Redcliffe Blue Care Brisbane xx Ingham Respite Centres xx Blue Care Sandgate xx Acacia Ridge Day Respite Centre xx Innisfail Blue Nurses xx Blue Care South Burnett xx Allied Health Services – Carina Heights xx Mackay Blue Nurses xx Caloundra Respite and Wynnum xx Mackay Carer Respite xx Coolum Respite xx Ashgrove Day Respite Centre xx Mackay Galaxy Program Brisbane Endoscopy Services xx Carramar Cottages xx Mackay Homecare Dementia Brisbane Private Hospital xx Continence Advisory Service xx Mackay Respite Caboolture Private Hospital xx Coopers Plains Day Respite Centre xx Mareeba Blue Nurses

ACHS ANNUAL REPORT 2008–2009 53 Listing Our Members

Cairns Audiology Group Pty Ltd Pulse Health Pty Ltd xx Mossman Hospital Cairns Private Hospital xx Gympie Private Hospital xx Remote Area MH Team Caloundra Private Hospital xx Kingaroy Private Hospital xx Smithfield Community Health Clifton Co-op Hospital Ltd QFG Day Theatres Central Highlands Hub – Central Queensland Health Services District Currumbin Clinic Queensland Eye Hospital xx Blackwater Hospital Eastern Endoscopy Centre ROQ (Toowoomba) Pty Ltd xx Capella Clinic Eden Rehabilitation Centre Inc Salvation Army, The, Recovery Services – xx Emerald Hospital Eye Tech Day Surgeries and Eye Brisbane xx Gemfields Multi Purpose Clinic Tech Southside Salvation Army, The, Recovery Services – xx Springsure (MPHS) Friendly Society Private Hospital Gold Coast xx Tieri Outpatients Clinic Greenslopes Private Hospital Salvation Army, The, Recovery Services – Townsville Central West Health Service District Haematology and Oncology Clinics xx Aramac Hospital of Australasia Southside Endoscopy Centre xx Barcaldine Hospital xx Haematology and Oncology Clinics of Spendelove Private Hospital Australasia – Chermside Medical Centre St Andrew’s Ipswich Private Hospital xx Blackall Hospital xx Haematology and Oncology Clinics St Andrew’s Toowoomba Hospital xx Longreach Hospital Australasia Gold Coast Cancer Centre St Andrew’s War Memorial Hospital xx Winton Hospital Henry Dalziel VC Dialysis Centre – Brisbane Darling Downs – West Moreton Health Service District (Darling Downs Rural Division) Hillcrest Rockhampton Private Hospital St Stephen’s Hospitals Maryborough and xx Chinchilla Health Service Holy Spirit Northside Private Hospital Hervey Bay xx Dalby Health Service Home Therapeutics St Vincent’s Hospital Brisbane xx Goondiwindi Health Service Hopewell Hospice Services Inc St Vincent’s Hospital – Toowoomba xx Inglewood Health Service Ipswich Day Hospital Sunnybank Private Hospital xx Jandowae Health Service Ipswich Hospice Care Incorporated Sunshine Coast Private Hospital, The xx Miles Health Service Toowong Private Hospital Karuna Hospice Service xx Millmerran Health Service Toowoomba Hospice Association Inc Logan Endoscopy Services Pty Ltd xx Stanthorpe Health Service Townsville Day Surgery Mackay Day Surgery xx Tara Health Service Marie Stopes International, Queensland Wesley Hospital, The xx Texas Health Service Mater Health Services North Zoe’s Place Ltd xx Wanadoan Primary Health Care Centre Queensland Limited xx Warwick Health Service xx Women’s and Children’s Hospital, QLD Public xx Fraser Coast Health Service District Mater Hyde Park Area Health Service – SQ (ADF Joint xx Hervey Bay Hospital Mater Hospitals – Rockhampton, Yeppoon Health Command) xx Maryborough Hospital and Gladstone Banana Health Service District Gladstone Health Service District xx Mater Hospital Gladstone xx Baralaba Hospital Gold Coast Health Service District xx Mater Hospital Rockhampton xx Biloela Hospital xx Gold Coast Hospital – Robina Campus xx Mater Hospital Yeppoon xx Moura Health Service xx Gold Coast Hospital – Southport Campus Mater Misericordiae Hospital – Bundaberg xx Taroom Hospital Mackay Health Service District Mater Misericordiae Hospital – Mackay xx Theodore Council on the Ageing xx Clermont Multipurpose Service Moreton Eye Group xx Theodore Hospital xx Dysart Hospital NephroCare Queensland Cairns Base Hospital and Mental Health and xx Glenden Community Health Centre xx Allamanda Dialysis Clinic ATOD Services xx Mackay Base Hospital xx Chermside Dialysis Unit xx Atherton and Mareeba Hospitals xx Middlemount Community Health Centre New Farm Clinic xx ATODS Community Centre xx Moranbah Health Campus Noosa Hospital, The xx ATODS, Qld Alcohol Diversion Program and xx Proserpine Hospital and Whitsunday Peninsula Private Hospital Day Detox Program Community Health Centre Pindara Gold Coast Private Hospital and xx Community Mental Health Centre xx Sarina Hospital & Primary Health Care Centre Short Street Day Surgery Unit xx Edmonton Community Health Mater Misericordiae Health Services xx Pindara – Gold Coast Private Hospital xx Forensic Mental Health and Evolve Team Brisbane Limited xx Short Street Day Surgery xx Homeless Health Outreach Team xx Child Youth Mental Health Service (CYMHS) Pine Rivers Private Hospital xx Innisfail Hospital – Dutton Park Clinic Pittsworth and District Hospital Friendly xx Mental Health Child and Youth Team xx Child Youth Mental Health Service (CYMHS) Society Ltd xx Mental Health Executive Team – Greenslopes Clinic Premion xx Mental Health Unit; Consultation Liaison team; xx Child Youth Mental Health Service (CYMHS) Older Persons MH team; Lakeside Clinic – – Inala Clinic Cairns Base Hospital xx Mater Adult’s Public Hospital – Brisbane

54 ACHS ANNUAL REPORT 2008–2009 xx Mater Children’s Private Hospital Rockhampton and Yeppoon Hospitals and xx Nanango Hospital and Nanango Community xx Mater Misericordiae Private Hospital Integrated Mental Health Service Health Centre – Redland xx Rockhampton Hospital xx Park – Centre for Mental Health, The xx Mater Mother’s Private Hospital xx Yeppoon Hospital xx Proston Primary Care Centre xx Mater Mother’s Public Hospital – Brisbane Royal Children’s Hospital and Health Service xx West Moreton Health Service District xx Mater Private Hospital Brisbane District Brisbane, The xx Wondai Hospital and Wondai Primary xx Mater Public Children’s Hospital – Brisbane Sunshine Coast Wide Bay Health Service Health Centre Metro North Health Service District Redcliffe, District – Southern Cluster Wide Bay Health Service District Caboolture and Kilcoy Hospitals, Oral Health xx Caloundra Hospital xx Biggenden Hospital and Primary and Community Health Services xx Gympie Health Service District xx Bundaberg Hospital xx Caboolture Hospital xx Maleny Soldiers Memorial Hospital xx Childers Hospital xx Kilcoy Hospital xx Nambour General Hospital xx Eidsvold Hospital xx Redcliffe Caboolture Health Service District Torres Strait and Northern Peninsula Area xx Gayndah Hospital xx Redcliffe Hospital Health Service District xx Gin Gin Hospital xx Redcliffe – Caboolture Mental Health and xx Central Islands – Poruma Primary Health xx Monto Hospital Disability Services Care Centre xx Mt Perry Health Centre xx Redcliffe – Caboolture Oral Health Service xx Eastern Island – Murray – Primary Health xx Mundubbera Hospital Metro North Health Service District Royal Care Centre Brisbane and Women’s Hospital xx Northern Peninsula Area – Cape York and SA Private xx Community Forensic Mental Health Service Bamaga – Primary Health Care Centres ACHA Health Metro North Health Service District, The xx Thursday Island Hospital – Prince Charles Hospital xx Thursday Island Primary Health Care Centre xx Ashford Community Hospital Inc Mental Health Services, and Jacana ABI xx Top Western Island – Boigu – Primary Health xx Flinders Private Hospital xx Memorial Hospital, The xx Jacana Centre, The Care Centre Adelaide Day Surgery xx Prince Charles Hospital Health Service xx Western Islands – Mabuiag – Primary Health District, The Care Centre Adelaide Surgicentre Pty Ltd Metro South Health Service District Townsville Health Service District Brighton Day Surgery xx Beaudesert Hospital xx Ayr District Hospital and CHS Burnside War Memorial Hospital Inc xx Logan Hospital xx Charters Towers Health Centre Calvary Central Districts Hospital Metro South Health Service District – QEll xx Charters Towers Rehabilitation Unit Calvary College Grove Rehabilitation Hospital Jubilee Hospital xx Cleveland Youth Detention Health Centre Calvary North Adelaide Hospital xx Eventide Aged Care Complex Metro South Health Service District – Redland Calvary Wakefield Hospital and Wynnum Hospitals xx Home Hill Hospital xx Wakefield Surgicentre xx Hughenden Health Centre xx Dunwich Health Service Centre Marie Clinical Care Professionals Rose Centre xx Ingham Health Service Epiclinic Pty Ltd xx Redland Hospital xx Joyce Palmer Health Service Glenelg Community Hospital Inc xx Wynnum Hospital xx Kirwan Health Service Glenelg Day Surgery Pty Ltd Metro South Health Service District xx Kirwan Rehabilitation Unit (Southside Community and Primary xx Magnetic Island Health Griffith Rehabilitation Hospital Services) Public xx North Ward Health Campus Hamilton House Day Surgery xx Moreton Bay Nursing Care xx Parklands Residential Aged Care Facility Home Support Services Metro South Health Service District xx Richmond Health Centre Keith and District Hospital Inc (Southside Mental Health) xx Townsville General Hospital Kerry Day Surgery Mount Isa Health Service District West Moreton South Burnett Health Moonta Health and Aged Care Service Inc xx Burketown Primary Health Care Centre Service District Nephrocare South Australia xx Camooweal Primary Health Care Centre xx Boonah Health Service Oxford Day Surgery Centre xx Cloncurry Hospital xx Cherbourg Community Health Centre Parkside Cosmetic Surgery xx Djarra Health Centre xx Cherbourg Hospital Parkwynd Private Hospital xx Doomadgee Hospital xx Downtown Community Health Ramsay Health Care (SA), Mental xx Julia Creek Hospital xx Esk Hospital Health Services xx Karumba Health Centre xx Goomeri Primary Care Clinic xx Adelaide Clinic, The xx Mornington Island Primary Health xx Ipswich Hospital xx Fullarton Private Hospital Care Centre xx Kilkivan Primary Care Clinic xx Kahlyn Private Hospital xx Normanton Health Services xx Kingaroy Hospital and Kingaroy Community Renal Therapy Services – Payneham Princess Alexandra Hospital Health Health Centre South Coast District Hospital Inc and Victor Service District xx Laidley Health Service Harbor Private Hospital Inc Queensland Tuberculosis Control Centre xx Murgon Community Health Centre xx Murgon Hospital

ACHS ANNUAL REPORT 2008–2009 55 Listing Our Members

St Andrew’s Hospital Inc Millicent District Hospital and Health Eye Hospital, The Waverley House Plastic Surgery Centre Service Inc Hobart Clinic, The Western Hospital Modbury Hospital Hobart Day Surgery Pty Ltd xx Modbury Public Hospital Hobart Private Hospital and St Helen’s SA Public Mount Barker District Soldiers Memorial Private Hospital Hospital Barossa Health North West Private Hospital Mount Gambier and Districts Health Service xx Angaston District Hospital Steele Street Clinic Murray Bridge Soldiers Memorial Hospital Inc xx Tanunda War Memorial Hospital Naracoorte Health Service Bordertown Memorial Hospital TAS Public Noarlunga Health Services Ceduna District Health Service Inc Correctional Primary Health Services Northern Adelaide Hills Health Service Inc Central Northern Adelaide Health Service, Forensic Mental Health Services xx Gumeracha DSM Hospital Mental Health Directorate Launceston General Hospital xx Mount Pleasant District Hospital Inc xx Glenside Campus Mental Health Service Mersey Community Hospital Northern Yorke Peninsula Health Services Central Northern Adelaide Health Service, North West Region Hospital Regional Office Penola War Memorial Hospital Inc Royal Hobart Hospital xx Central Northern Adelaide Health Service, Port Augusta Hospital and Regional Health Services Mental Health Directorate VIC Private xx CNAHS – Ambulatory and Primary Health xx Flinders Terrace Community Health Centre Care Directorate xx Port Augusta Hospital Albert Road Clinic xx CNAHS – Statewide Service – Port Broughton District Hospital and Health Ambicare Patient Transfer Service SA Dental Services Service Inc Anam Cara House Geelong xx CNAHS, Statewide Services Directorate, Queen Elizabeth Hospital and Health Avenue Day Surgery BreastScreen SA Service, The Avenue Hospital, The xx Lyell McEwin Hospital Repatriation General Hospital – Southern Ballan and District Soldiers Memorial Bush xx Modbury Hospital Adelaide Health Service Nursing Hospital xx Queen Elizabeth Hospital and Health Riverland Regional Health Service Inc and Ballarat District Nursing and Healthcare Service, The Riverland Private Hospital (BDNH) xx Royal Adelaide Hospital Roxby Downs Health Services and Woomera Beleura Private Hospital xx St Margaret’s Rehabilitation Hospital Community Hospital Bellbird Private Hospital Children, Youth and Women’s Health Service xx Woomera Community Hospital Berwick Surgicentre xx Child and Adolescent Mental Health Services Royal Adelaide Hospital Cabrini Health xx Child and Family Health xx Hampstead Rehabilitation Centre xx Cabrini Brighton xx Women’s and Children’s Hospital Royal District Nursing Service of SA Inc xx Cabrini Malvern xx Women’s Health Statewide Southern Adelaide Health Service xx Cabrini Prahran xx Yarrow Place xx Flinders Medical Centre xx Cabrini Health Hawthorn Campus CNAHS – Ambulatory and Primary Health xx Noarlunga Health Services Care Directorate Chesterville Day Hospital xx Repatriation General Hospital – Southern Cobden District Health Services Inc xx CNAHS Prison Health Service Adelaide Health Service Coburg Endoscopy Centre CNAHS – Statewide Service – Southern Flinders Health SA Dental Services Community Connections (Victoria) Ltd xx Crystal Brook District Hospital Inc CNAHS – Statewide Services Directorate xx Laura Hospital and Gladstone Health Centre Como Private Hospital – BreastScreen SA St Margaret’s Rehabilitation Hospital Cotham Private Hospital Coober Pedy Hospital and Health Service Strathalbyn and District Health Service Croydon Day Surgery, The Flinders Medical Centre Waikerie Health Services Inc Delmont Private Hospital Gawler Health Service Whyalla Hospital and Health Services Digestive Health Centre, The Kangaroo Island Health Service Donvale Rehabilitation Hospital Leigh Creek Health Services TAS Private Dorset Rehabilitation Centre Lyell McEwin Hospital Eastern Palliative Care Association Inc Calvary Health Care Tasmania Mannum District Hospital Inc, The Epworth HealthCare xx Calvary Hospital Hobart Inc Mid North Health xx St John’s Hospital Hobart xx Epworth Eastern xx Booleroo Centre District Hospital and Health Calvary Health Care Tasmania xx Epworth Freemasons Services Inc – Launceston Campuses xx Epworth Rehabilitation – Brighton xx Jamestown Hospital and Health Service Inc xx Calvary Health Care Tasmania xx Epworth Rehabilitation – Camberwell xx Orroroo Health Service – St Luke’s Campus xx Epworth Rehabilitation – Richmond xx Peterborough Soldiers’ Memorial Hospital xx Calvary Healthcare Tasmania xx Epworth Richmond and Health Services Inc – St Vincent’s Campus Euroa Health Inc Mid-West Health Inc

56 ACHS ANNUAL REPORT 2008–2009 Frances Perry House St John of God Health Care – Berwick Cohuna District Hospital Fulham Correctional Centre – Medical Centre St John of God Healthcare – Ballarat Dental Health Services Victoria Geelong Clinic, The St John of God Hospital – Warrnambool Djerriwarrh Health Services Geelong Private Hospital, The St Vincents and Mercy Private Dunmunkle Health Services Glen Endoscopy Centre, The Hospital Limited East Grampians Health Service Glenferrie Private Hospital xx Mercy Private Hospital Inc East Wimmera Health Service Goulburn Valley Hospice Care Service Inc xx St Vincent’s Private Hospital xx EWHS – Birchip Campus Health Frontiers Pty Ltd xx Vimy Private Hospital xx EWHS – Charlton Campus Supported Housing Development Healthe Care xx EWHS – Donald Campus Group Pty Ltd xx La Trobe Private Hospital xx EWHS – St Arnaud Campus Unified Healthcare Group xx South Eastern Private Hospital xx EWHS – Wycheproof Campus Vaucluse Hospital xx Valley Hospital, The Eastern Health Very Special Kids Healthe Work xx Angliss Health Service, The Victoria Clinic, The Healthscope Community Programs xx Box Hill Hospital Victorian Rehabilitation Centre, The Healthscope Ltd xx Maroondah Hospital Warringal Private Hospital Heidelberg Endoscopy and Day xx Peter James Centre Surgery Centre Waverley Private Hospital xx Yarra Ranges Health Service Hyperbaric Health Pty Ltd Yackandandah Bush Nursing Hospital Echuca Regional Health John Fawkner Private Hospital Edenhope and District Memorial Hospital Kew Private Dialysis Centre VIC Public Gippsland Southern Health Service Knox Private Hospital Albury Wodonga Health – Wodonga Campus Goulburn Valley Health Linacre Private Hospital Alexandra District Hospital Hepburn Health Service Marie Stopes International, East St Kilda Alfred Health Hesse Rural Health Service Maryvale Private Hospital xx Caulfield Hospital Heywood Rural Health Masada Private Hospital xx Alfred, The Inglewood and Districts Health Service Melbourne Clinic, The xx Sandringham Hospital Isis Primary Care Inc Melbourne Endoscopy Group Pty Ltd Austin Health Kerang District Health Melbourne Private Hospital xx Austin Hospital Kilmore and District Hospital, The Mercy Health and Aged Care xx Heidelberg Repatriation Hospital Kooweerup Regional Health Service xx Royal Talbot Rehabilitation Centre Mercy Health O’Connell Family Centre Kyabram and District Health Services Bairnsdale Regional Health Service Mildura Base Hospital Kyneton District Health Service Ballarat Health Services Mitcham Private Hospital Latrobe Regional Hospital Banksia Palliative Care Service Inc Monash Surgical Private Hospital Lorne Community Hospital Barwon Health Neerim District Health Service Maldon Hospital xx Barwon Health – Aged and Continuing Care Nephrocare VIC Maryborough District Health Service xx Barwon Health – Surf Coast Community North Eastern Rehabilitation Centre McIvor Health and Community Services Health Service Melbourne Citymission Palliative Care Northpark Private Hospital xx Barwon Health – The Geelong Hospital Melbourne Health Pacific Shores Healthcare Bass Coast Regional Health xx Royal Melbourne Hospital, The – Peninsula Endoscopy Centre Pty Ltd xx Wonthaggi and District Hospital City Campus Peninsula Private Hospital Beaufort and Skipton Health Service xx Royal Melbourne Hospital, The – Royal Reservoir Private Hospital Day Beechworth Health Service Park Campus Procedure Centre Benalla and District Memorial Hospital Mercy Hospital for Women Ringwood Private Hospital Bendigo Health Care Group Mercy Palliative Care Royal District Nursing Service xx Anne Caudle Centre Campus Moyne Health Services Sea Lake and District Health Service Inc xx Bendigo Hospital Campus Mt Alexander Hospital Shepparton Private Hospital xx Stewart Cowan Community Nathalia District Hospital Sir John Monash Private Hospital Rehabilitation Centre Northeast Health Wangaratta South East Palliative Care Ltd Boort District Health Northern Health – Stream 1 St John of God Health Care – Bendigo Calvary Health Care Bethlehem xx Broadmeadows Health Service, The St John of God Health Care – Geelong Casterton Memorial Hospital xx Bundoora Extended Care Centre St John of God Health Care Central Gippsland Health Service Northern Health – Stream 2 – Nepean Rehabilitation xx Heyfield Hospital Inc xx Craigieburn Health Service St John of God Health Care xx Maffra District Hospital xx Northern Hospital, The – Pinelodge Clinic Cobram District Hospital xx Panch Health Service

ACHS ANNUAL REPORT 2008–2009 57 Listing Our Members

Numurkah District Health Service Werribee Mercy Hospital WA Public Omeo District Health xx Mercy Mental Health – Community Armadale Health Service Orbost Regional Health Rehabilitation Centre Bentley Health Service xx Orbost and District Hospital xx Mercy Mental Health Saltwater Clinic Child and Adolescent Health Service Peninsula Health xx Mercy Mental Health Wyndham Community Treatment Program and Consultations Department of Corrective Services xx Frankston Hospital Partnerships Team – Health Services xx Rosebud Hospital xx Mercy Mental Health Community Care Units Fremantle Hospital and Health Service Peninsula Hospice Service West Gippsland Healthcare Group Health Corporate Network Peter MacCallum Cancer Centre West Wimmera Health Service North Metropolitan Area Health Service Portland and District Health Western District Health Service Mental Health Rochester and Elmore District Health Service xx Coleraine District Health Services xx Graylands Hospital Royal Children’s Hospital xx Western District Health Service Oral Health Centre of WA Royal Victoria Eye and Ear Hospital Western Health Service Osborne Park Hospital Program Royal Women’s Hospital, The xx Sunshine Hospital Rockingham Peel Group Rural Northwest Health xx Western Hospital Royal Perth Hospital xx Rural Northwest Health Beulah Campus xx Williamstown Hospital, The Sir Charles Gairdner Hospital xx Rural Northwest Health Hopetoun Campus Wimmera Health Care Group Swan Kalamunda Health Service xx Rural Northwest Health Warracknabeal Yarram and District Health Service xx Kalamunda Health Service Campus Yarrawonga District Health Service xx Swan Health Service Seymour District Memorial Hospital Yea and District Memorial Hospital WA Country Health Service – South West South West Healthcare xx Augusta Multi Purpose Health Service xx South West Healthcare Camperdown WA Private xx Boyup Brook and Districts Soldiers Campus Memorial Hospital Albany Community Hospice xx South West Healthcare Hamilton xx Bridgetown District Hospital Attadale Private Hospital xx South West Healthcare Lismore Campus xx Busselton District Hospital Bethesda Hospital Inc xx South West Healthcare Macarthur Campus xx Collie District Hospital xx South West Healthcare Portland Diaverum Pty Ltd, WA xx Donnybrook Balingup Health Service xx South West Healthcare GI Clinic xx Harvey District Hospital Warrnambool Campus Glengarry Private Hospital xx Margaret River District Hospital Southern Health – Clinical Stream – Acute Hollywood Private Hospital xx Nannup Health Service MPS Southern Health – Clinical Stream – Joondalup Health Campus xx Pemberton District Hospital Continuing Care and Mental Health Kimberley Satellite Dialysis Centre xx Warren District Hospital Southern Health – Corporate Services Kings Park Day Hospital xx Yarloop Hospital xx Casey Hospital Marian Centre, The WACHS, Eastern Wheatbelt Health Service xx Cranbourne Integrated Care Centre Marie Stopes International, WA xx Bruce Rock Memorial Hospital xx Dandenong Hospital Mercy Hospital Mount Lawley xx Corrigin Hospital xx Jessie McPherson Private Hospital xx Kellerberrin Memorial Hospital xx Kingston Centre Midland Dialysis Centre xx Kununoppin Health Service xx Monash Medical Centre – Clayton Mount Hospital xx Merredin Health Service xx Monash Medical Centre – Moorabbin Mount Lawley Private Hospital xx Narembeen District Memorial Hospital St Vincent’s Health Niola Private Hospital xx Quairading Hospital xx Caritas Christi Hospice Peel Health Campus xx Southern Cross Hospital xx St George’s Health Service Perth Clinic WACHS, Goldfields xx St Vincent’s Correctional Health Service Perth Day Surgery Centre xx Coolgardie Health Centre xx St Vincent’s Hospital Melbourne Sentiens Pty Ltd xx Coonana Health Centre Stawell Regional Health Silver Chain Nursing Association xx Esperance Community Health and Mental Swan Hill District Hospital xx Silver Chain Hospice Care Services including Health Unit Take Two Program Hospital at the Home Post Acute Services xx Esperance Hospital Tallangatta Health Service South Perth Hospital Incorporated xx Kalgoorlie Hospital Terang and Mortlake Health Service Southbank Day Surgery xx Kalgoorlie–Boulder Community Timboon and District Healthcare Service St John of God Health Care – Murdoch Mental Health Tweddle Child and Family Health Service St John of God Hospital – Bunbury xx Kalgoorlie–Boulder Population Health Unit Victorian Institute of Forensic Mental St John of God Hospital – Geraldton xx Kambalda Health Centre Health (VIFMH) St John of God Hospital – Subiaco xx Laverton District Hospital St John of God Murdoch Community Hospice xx Leonora Hospital Waikiki Private Hospital xx Menzies Health Centre Westminster Day Surgery

58 ACHS ANNUAL REPORT 2008–2009 xx Norseman Hospital EQuIP Corporate Member WA xx Ravensthorpe Health Centre Services Diaverum Pty Ltd, WA WACHS, Great Southern Kimberley Satellite Dialysis Centre xx WACHS, Central Great Southern NSW Sentiens Pty Ltd Multi-Purpose Health Service College of Nursing, The xx WACHS, Lower Great Southern Mental Health Coordinating Council Health Service Quality for Divisions Network WACHS, Kimberley Network of Alcohol and Drug Agencies (QDN) (NADA) xx Broome Health Services xx Derby Health Services NSW EQuIP Corporate Health xx Fitzroy Crossing District Hospital Barwon Division of General Practice xx Halls Creek District Hospital Services Blue Mountains Division of General Practice xx Kununurra District Hospital Dubbo/Plains Division of General Practice xx Northwest Mental Health Service and ACT GP Access Kimberley Community Drug Service Team National Health Call Centre Network Ltd Hastings Macleay General Practice xx Wyndham District Hospital Network Ltd NSW WACHS, Midwest – Gascoyne District Hawkesbury–Hills Division of General Practice Alliance Health Services Group Pty Ltd xx Exmouth Hospital Hunter Rural Division of General Practice ahm Total Health WACHS, Midwest Murchison – Central West Illawarra Division of General Practice GEO Group Australia Pty Ltd, The Mental Health Macarthur Division of General Practice Greater Southern Area Health Service WACHS, Midwest Murchison – Geraldton Mid North Coast (NSW) Division of General Health Campus Hunter New England Area Health Service Practice Ltd WACHS, Midwest Murchison North Coast Area Health Service Nepean Division of General Practice Inc – Midwest District Northern Sydney/Central Coast Area New England Division of General Practice WACHS, Midwest Murchison Health Service North West Slopes (NSW) Division of – Murchison District Salvation Army, The Recovery Services General Practice WACHS, Pilbara – Department Head Office NSW Central West Division of xx Newman Health Services Sydney West Area Health Service General Practice xx Nickol Bay Hospital Incorporating Barrier Division xx Onslow District Hospital SA xx Barrier Division of General Practice Ltd xx Paraburdoo District Hospital Central Northern Adelaide Health Service xx Riverina Division of General Practice and xx Port Hedland Regional Hospital Smith Sterilising Primary Health Ltd xx Roebourne District Hospital Southern Adelaide Health Service Shoalhaven Division of General Practice xx Tom Price District Hospital Southern General Practice Network xx Wickham District Hospital VIC Southern Highlands Division of Coach Program Pty Ltd, The WACHS – Southern Wheatbelt Health Region General Practice Moira Healthcare Alliance INC. xx Boddington Hospital St George Division of General Practice Inc xx Dumbleyung/Kukerin Health Service Northern Health Sutherland Division of General Practice Inc xx Kondinin/Kulin MPS South Health – Corporate Services xx Lake Grace Hospital Spotless Services Australia NT xx Narrogin Hospital General Practice Network NT Ltd xx Pingelly Hospital WA xx Wagin Hospital North Metropolitan Health Service – Area QLD WACHS – Western Wheatbelt Health Service Corporate Services Moreton Bay General Practice Network xx Beverley Health Service SA xx Cunderdin Meckering and Tammin Multi EQuIP Certification Purpose Service Adelaide North East Division of xx Dalwallinu District Hospital MPS NSW General Practice xx Goomalling Health Service Crows Nest Day Surgery WA xx Moora District Hospital Great Southern GP Network Ltd xx Northam Regional Hospital QLD Osborne GP Network Ltd xx Wongan Hills MPS Health Service Cairns Audiology Group Pty Ltd xx York Health Services MPS ROQ (Toowoomba) Pty Ltd Pilbara Division of General Practice Women and Newborn Health Service VIC Anam Cara House Geelong Medical Connect Pty Ltd

ACHS ANNUAL REPORT 2008–2009 59 Listing Our Surveyors As at 30 June 2009

Our surveyor workforce totals over 400 dedicated healthcare The surveyors participate in regular training sessions and are professionals and health consumers from throughout Australia able to gather relevant information to verify the healthcare and overseas. organisation’s achievement in the standards being assessed. The surveyors, who conduct peer reviews, all have recent Our surveyor training program has been recognised experience within health services, many still in fulltime roles internationally and is accredited by the International Society such as health service managers, physicians, allied health for Quality in Health Care. professionals and nurses. Thank you to the surveyors listed below for their contribution.

ACT Mr Robert Cusack Ms Deborah Latta Mr Anthony Schembri Mr Matthew Daly Ms Deborah Lewis Adjunct Professor Stuart Dr Peggy Brown Ms Therese Daubaras Ms Bernadette Loughnane Schneider (Resigned) Mr Grant Carey-Ide Ms Darryl (Lynn) Davis Ms Judy Lovenfosse Dr Kevin Sesnan Dr Robert Griffin Ms Helen Dowling Mr Stuart MacKinnon Ms Sue Shilbury Ms Kaye Hogan AM Ms Jenny Duncan Ms Belle Mangan Ms Mary Simpson Ms Irene Lake Ms Helen Eastwood Ms Kerry Marden Mr Ben Skerman Ms Mary Martin Ms Karen Edwards Ms Carol Martin Dr Alicja Smiech Ms Yvonne McCann Mr Michael Edwards Ms Louise McFadden Ms Valerie Smith Mr Russell McGowan Prof Joan Englert AM Mrs Jo McGoldrick Ms Rosemary Snodgrass Ms Jenelle Reading Ms Caroline Farmer Mr Kevin McLaughlin Mrs Jean Spurge Ms Christine Waller Dr Terence Finnegan Mr Bernard McNair Ms Gowri Sriraman NSW Mr Frank Flannery Mr Keith Merchant Mr John Stuart Ms Lynnette Ford Ms Helen Milne Dr Christopher Swan Dr Teresa Anderson Mr John Geoghegan (Resigned) Dr Sharon Miskell Dr George Szonyi Dr Dinesh Arya Prof Adrian Gillin Dr Katherine Moore Mr Arnold Tammekand Mr Peter Avery Ms Robyn Goffe Dr John Murray Ms Andrea Taylor Mr Mark Ayling Dr Deane Golding Associate Professor Ganapathi Mrs Anne Temblett Mr Peter Barber Associate Professor Jane Gordon Murugesan Mrs Solly Toefy Mrs Shirley Batho Ms June Graham Mr Danny O’Connor Ms Helen Vaz Mrs Karen Becker Ms Pamela Gulbis Ms Anne O’Donoghue Mr Michael Wallace Dr Alexander Bennie Mr Ken Hampson Ms Marilyn Orrock Mr Tony Wallace Dr Sameer Bhole Ms Paula Hanlon Mrs Rosalind O’Sullivan Mr Robert Walsh Dr Claire Blizard Mr Garth Healey Dr Charles Pain Conjoint Professor Jennie West Dr Susan Buchanan Dr Ralph Higgins OAM Dr Richard Parkinson Adjunct Professor Richard West Mrs Christine Bulters Dr Kim Hill Mr Ian Paterson Ms Jan Whalan Ms Margo Carberry Mr John Hodge Ms Carmel Peek Mr Harry Williams Ms Sandie Carpenter Mrs Sally Holmes Mrs Nancye Piercy Ms Desley Casey Dr Roger Hooper Mrs Sandra Platt NT Ms Vivian Challita-Ajaka Dr Ian Hoult Mr David Poon Mr Peter Frendin Ms Connie Chan Dr Philip Hoyle Dr Robert Porter Ms Judith Hoskins Mr Sam Choucair Mr Peter Hurst Ms Toni Powell Ms Frances Pagdin Dr Matthew Chu Dr Helen Jagger Dr John Powers Ms Penny Parker Mr John Clark Mrs Kate Jerome Ms Robyn Quinn Ms Elizabeth Clarke Mr Peter Johnson Mr Geoff Rayner QLD Mrs Marie Clarke Ms Ann Kelly Ms Cindi Rees Mr Rick Austin Ms Glenda Cleaver Dr Peter Kennedy (Resigned) Ms Yve Repin Mr Mark Avery Mr Peter Clout Ms Dianna Kenrick Associate Professor Ian Rewell Dr Stephen Ayre Mrs Sue Colley Ms Didi Killen Mr Raad Richards Dr Winton Barnes Dr Jean Collie Mr Kim Knoblauch Dr Grahame Robards Associate Professor Brian Bell Dr Jeanette Conley Dr Friedbert Kohler Dr Pauline Rumma Ms Marian Bills Mr Chris Crawford Dr Peter Kramer Ms Kerry Russell Ms Mary Bonner Dr Paul Curtis Dr Harvey Lander Dr Margaret Sanger Dr Nick Buckmaster

60 ACHS ANNUAL REPORT 2008–2009 Ms Cheryl Burns Ms Glynda Summers TAS Ms Lyn Hayes Dr Wilbur Chan Mrs Penny Thompson Ms Marguerite Hoiby Mr Ken Campbell Ms Gillian Clark Ms Theresa Thompson Mr Graeme Houghton Associate Professor Des Graham Dr Michael Cleary Ms Val Tuckett Ms Mary Hyland Mr Bernard Griffiths (Resigned) Ms Anne Copeland Mrs Kym Volp Dr M R Jones PSM AM Mrs Marlene Johnston Ms Val Coughlin-West Dr John Waller AM Dr Sajeev Koshy Ms Karen Linegar Associate Professor David Mr Brendon Weavers Dr Ian Kronborg Dr Peter Renshaw Crompton OAM Dr Noela Whitby AM Dr Tony Landgren Mr Kannan Srinivasan Mr Kenneth Denny Ms Raewyn Wolcke Ms Marie Larkin Mrs Eve Thorp Ms Vicki Eckart Dr John Youngman Ms Andrea Leonard Ms Brigid Tracey AM Associate Professor Brett Mr Alan Lilly Emmerson Ms Jenny Tuffin SA Dr Martin Lum Ms Lisa Fawcett Dr Dianne Barrington Mrs Ionela Manescu Ms Joan Fellowes VIC Ms Toni Bickley Mrs Josephine Maprock Dr Frank Fiumura (Resigned) Mr Peter Abraham Mrs Lorraine Bruun Dr Chris Maxwell Mr Kevin Freele Dr Cathy Balding Ms Dianne Campbell (Resigned) Ms Christine Minogue Mrs Deborah Grant Ms Christine Best Ms Tina De-Zen Dr John Monagle Ms Diana Grice Mr Allan Boston (Resigned) Dr Maria Fedoruk Dr David Newman Mr Charlie Grugan Dr Peter Bradford Mr Paul Gardner Mr George Osman Mr Philip Hawkins Mrs Lorraine Broad Mrs Sharon Godleman Dr Karen Owen Dr G. Adair Heath Ms Therese Caine Mrs Marion Holden Mrs Glenna Parker Ms Garda Hemming Dr Tom Callaly Mr Geoff Illman Mr Ric Pawsey Dr David Henderson Mr Alex Campbell Ms Sharon Kendall Mr Ormond Pearson Mrs Cheryl Herbert Ms Jillian Carson Mr Alan Lehman Ms Sally Percy Adjunct Associate Professor Mr Wesley Carter Ms Janne McMahon Ms Susan Perrott Leonie Hobbs Ms Julie Cartwright Dr Susan Merrett Mr David Plunkett Dr John Hooper Mrs Ann Cassidy Ms Jill Michelson Ms Merrin Prictor Mr Terry Hughes Dr Wayne Chamley Mrs Cathy Miller Mrs Patricia Quinn Ms Catherine James Dr Alex Cockram Mr David Miller Ms Jenny Rance Mr Paul Kachel Dr Brian Cole Dr Ea Mulligan Ms Catherine Roper (Resigned) Mr David Kelly Ms Julie Collette Ms Kathy Nagle Mrs Nelly Ross Ms Dianne Knight Ms Annette Coy Mrs Dianne Norris Mr Trevor Sanders Ms Debra Le Bhers Dr Catherine Crock Ms Karen Parish Dr Susan Sdrinis Ms Moina Lettice Ms Lydia Dennett Dr Patrick Phillips (Resigned) Ms Sue Sinni Dr David Lindsay (Resigned) Dr Harry Derham Mr Neville Phillips Mr Darrell Smith Dr William Lindsay Dr Sherene Devanesen Ms Jane Pickering (Resigned) Ms Joyce Smith Mrs Cherryl Lowe Ms Clare Douglas Mrs Mara Richards Ms Mavis Smith Dr Donald Martin Mr Sid Duckett Ms Pam Schubert Mrs Marilyn Sneddon Mrs Patricia Matthews Mr Tim Elrington Ms Lesley Siegloff Ms Catherine Steele Dr Chris May Dr Peter Fahy Mr Wayne Singh Mrs Maria Stickland Mr Ian Mill Ms Lee Fairley Ms Judy Smith (Resigned) Dr Lakshmi Sumithran Dr Clare Morgan Ms Anna Fletcher Mrs Margaret Smith Mr Raymond Sweeney Ms Virginia Morris Dr Simon Frasier (Resigned) Ms Michele Smith Mr Denis Swift Dr Donna O’Sullivan Mr Vince Gaglioti Dr Rima Staugas Ms Jennifer Taylor Ms Ros Pearson Ms Michele Gardner Dr Tony Swain Mr Peter Turner Dr Scott Phipps Dr Mark Garwood Ms Rosemary Taylor Mrs Lee Vause Dr John Reilly Mr David Gerrard Dr Ruth Vine Mrs Cheryle Royle Mrs Leigh Giffard Dr Arlene Wake Mrs Monica Seth Mrs Sue Gilham Mr Dan Weeks Ms Tracey Silvester Ms Diane Gill Miss Ruth White (Resigned) Associate Professor Patricia Mr Phillip Goulding (Resigned) Mr John Wigan Snowden Dr Lee Gruner Mrs Wendy Wood Ms Rosemary Steinhardt Ms Bronwyn Harris (Resigned) Ms Lorraine Stevenson Dr Richard Harrod

ACHS ANNUAL REPORT 2008–2009 61 Listing Our Surveyors

WA Ms Diane Barr Surveyors from outside Australia Dr William Beresford ACHS has had a surveyor exchange program with Ireland and New Zealand for several Ms Patricia Canning years. The relationships developed through the work of ACHS International have provided Mr Trevor Canning additional opportunities to train surveyors from Hong Kong, India, the Kingdom of Ms Geraldine Carlton Bahrain, the Kingdom of Saudi Arabia, Malaysia and the United Arab Emirates. Dr Wing Cheong Chiu The surveyors are able to participate on teams reviewing our Australian member Adj Assoc Professor Robyn Collins organisations. These surveyors will also participate on survey teams with Australian Ms Nola Cruickshank surveyors in their home countries. We welcome the diversity of experience and Mr Kim Darby perspectives they bring to the surveyor workforce. Ms Kate Dyson Hong Kong India Malaysia Mrs Marcia Everett Ms Gloria Aboo Dr Bidhan Das Mr Stuart Rowley Ms Helen Hoey Dr Derrick Au Mr Somnath Das Dr Jenni Ibrahim (Resigned) New Zealand Mr Eric Chan Ms Jessy Jacob Ms Diane Jones Mr Fred Wai Cheung Chan Dr Srinivas Murali Ms Jacqueline Flynn Dr Peter Kendall Ms Mabel Chan Ms Rose Laloli Ms Lena Lejmanoski Kingdom of Bahrain Ms Grace Cheng Mrs Julie Nitschke Adj Assoc Professor Patricia Letts Ms Iris Lam Shuk Ching Mrs Ruth Aiyer Mrs Grace Ley United Arab Emirates Ms Kate Choi Dr Bahaa Fateha Dr David Lord Dr Deena Alani Ms Connie Chu Mr Timothy Gardner Mr Shane Matthews Dr Oussama Kayali Ms Grace Chung Mr G. Arun Govind Ms Moira Munro Ms Kim Primmer Dr Kin Lai Chung Dr Hari Sivadas Ms Patricia O’Farrell Dr Alan Sandford Dr Jack Hung Dr Riyaz Ahmad Syed Dr Clive Purcell Dr Samy Sidky Dr Anne Kwan Mr Jacob Thomas Ms Anne Rutherford Dr Chor-chiu Lau Dr Mark Salmon Kingdom of Saudi Ms Fion Wai-man Lee Ms Sally Skevington Arabia Ms Chan Wai Leng Mr Warwick Smith Dr Armand Agababian Ms Julie Li Mr Keith Symes (Resigned) Ms Wing On Lou Professor Marc Tennant Mr Antony Lui Mrs Sandy Thomson Dr Joseph Lui Ms Debbie Waddingham Mr Raymond Mak Dr Deborah Wilmoth Dr Windsor Mak Ms Fay Winter Ms Manbo Man Mr Siew Man Pang Dr Stephen Pang Mr Wai-Kwong Poon Dr Yuk Wah Shum Ms Tammy So Dr Chung-Ngai Tang Mrs Mary Wan Ms Bonnie P M Wong Ms Ellen Wong Dr Loretta Yam Ms Rosa Yao Ms Betty Yeung Mrs Sim-heung Yeung Dr Victoria Tan

62 ACHS ANNUAL REPORT 2008–2009 Listing Publications and Presentations

Comments Johnston, B. Management of the Surveyor Role – panel discussion. ISQua Accreditation Seminar. International Society Australian Commission on Safety and Quality in for Quality in Health Care (ISQua); Copenhagen, October 2008. Health Care Johnston, B. Accreditation Evaluation – Recent results analysed Development of a consumer engagement strategy for the from large accreditation studies with new research results on Commission, October 2008. accreditation and surveying – contributing discussant. ISQua 25th International Conference. International Society for Quality National Patient Charter of Rights, March 2008. in Health Care (ISQua); Copenhagen, October 2008. Australian Institute of Health and Welfare Johnston, B. ‘Bringing Accreditation and Measures together to Towards National Indicators of Safety and Quality in Health complement each other’. ISQua 25th International Conference. Care, December 2008. International Society for Quality in Health Care (ISQua); Copenhagen, October 2008. University of Technology, Sydney Johnston, B. Health and Globalisation: Challenges and Interprofessional Health Education in Australia, a proposal for Opportunities – an optimist’s view. Challenges in Rights future research and development, January 2009. for Health. Global Forum for Health Leaders; Taipei, November 2008. Electronic Media Johnston, B. Healthcare Accreditation: Global and Regional Trends. Bangkok, November 2008. ACHS Clinical Indicators and PIRT 2009, December 2008. Johnston, B. International Trends in Accreditation and the ISQua Monographs Experience, Jubilee Conference, Netherlands Institute for the Accreditation of Health Care Organisations; Holland, April 2009. Quality Initiatives 2008 – Entries in the 11th Annual ACHS Sneddon, MJ. Introduction to Healthcare Quality Systems. Quality Improvement Awards 2008. Aboriginal Hospital Liaison Officers Training Program. Performance and Outcomes Service, ACHS. Australasian Victorian Aboriginal Controlled Health Organisation; Melbourne, Clinical Indicator Report 1998–2007: Determining the Potential June 2009. to Improve Quality of Care, 9th edition. ACHS; 2008. Stark, H. Measuring Standards of Patient Services in Australian ACHS. Summary Clinical Indicator Guide. ACHS; 2008. Hospitals using Clinical Indicators. Qingdao Hospital Quality Performance and Outcomes Service, ACHS. Clinical Indicator Control and Performance Evaluation Education Program Information Package. ACHS; 2009. University of Sydney; Sydney, March 2009.

Presentations Publications Hennessy, D. Introduction to the EQuIP Quality Improvement Greenfield, D, Braithwaite, J, Pawsey, MP, Johnston, B and Program. Paper presented to the Patient Safety – Future Robinson, M. Distributed leadership to mobilise capacity for Directions Conference. Association of Private Hospitals of accreditation research, J Health Organ Manag 2009; 23(2): Malaysia; Kuala Lumpur, July 2008. 255–267. Hennessy, D. Overview of Standards Development and Greenfield, D and Braithwaite, J. Developing the evidence Implementation., National Bowel Cancer Screening Program; base for accreditation of healthcare organisations: a call for Brisbane, May 2009. transparency and innovation. Qual Saf Health Care 2009; 18(3): 162–163. Hennessy, D. Relationship with National BreastScreen Standards and EQuIP 4 Standards. BreastScreen Australia; Sydney, Greenfield, D, Pawsey, M, Naylor, J and Braithwaite, J. June 2009. Are healthcare accreditation surveys reliable? Int J Health Care Qual Assur 2009; 22(2): 105–116. Hennessy, D. Overview of ACHS Accreditation for the Private Sector. Australian Health Services Alliance; Sydney, June 2009. Hogan, K. Introduction to EQuIP 4. Departmental Staff, Office of Aboriginal and Torres Straits Islander Health; Canberra, June 2009.

ACHS ANNUAL REPORT 2008–2009 63 Listing Overview of Products and Services

Our core program is the Evaluation and Quality Improvement Program (EQuIP) which requires members to participate in a four-year cycle of quality improvement activities including self-assessment and on-site peer review.

Other products and services that are offered by ACHS include: ººDiagnostic Imaging Accreditation Scheme – accreditation ººEQuIP Certification – for newly established healthcare for diagnostic imaging services providing ultrasound, organisations and other organisations that have not yet general x-ray, mammography, angiography, fluoroscopy, developed formal quality improvement programs. orthopantomography, MRI and CT. ººEQuIP Corporate Health Services – designed for corporate ººClinical Indictor Program – a data repository, analysis offices with or without direct care responsibility. and reporting service provided by the ACHS to healthcare organisations. It provides comparative information on the ººEQuIP Corporate Member Services – developed for processes and outcomes of healthcare. With over 400 colleges, professional associations, health insurers, and indictors and over 800 participating member organisations, others involved in supply, human resources, learning and the ACHS Clinical Indicator Program is the most development, to identify how well they meet member and comprehensive program of its kind in Australia. customer needs. Customised reporting of data allows single healthcare ººEQuIP In-Depth Reviews – conducted by the ACHS to organisations or groups to compare their own performance determine how well specialist services (for example mental to National, State and Territory aggregates. health services, palliative care, pharmacotherapy services) ººCustomised education – workshops and consultancies have addressed the ACHS standards and the relevant as well as access to online publications and resources ACHS Guidelines. are offered to help organisations in their quality ººQuality for Divisions Network (QDN) – developed for improvement journey. divisions and State Based Organisations (SBO) aiming ººCustomised quality improvement programs – to deliver a service that is member focused; the ACHS For example, ACHS has designed tailored programs for QDN accreditation standards have been approved by the South Australia and mental health services in Tasmania. Commonwealth Department of Health & Ageing and are the only standards specifically developed for divisions of For more detail on any of our products and services, please visit general practice. our website: www.achs.org.au

ACHS International...... 28 Education...... 19 Performance and...... 22 Outcomes Service Board...... 29 EQuIP...... 22 Index President’s and Chief...... 9 Board Members...... 31-33 Executive Team...... 14 Executive’s Report Business Development...... 11 Financial Performance...... 36 Products and Services...... 64 Business Services...... 27 Financial Statements...... 38 Publications,...... 63 Clinical Indicators...... 7, 8 & 23 Glossary...... Inside back cover Presentations Corporate and...... 6 Highlights...... 12 Research...... 23 Strategic Plan Human Resources...... 26 Surveyors...... 60 Corporate governance...... 29 Information Technology...... 26 Values...... 3 Corporate Services...... 25 ISQua...... 10 Vision...... 3 Council...... 34 Members...... 50 Council Members...... 34 Mission...... 3 Customer Services...... 18 Organisation Chart...... 13 Development...... 22 Occupational Health...... 25 Directors’ Report...... 36 and Safety

64 ACHS ANNUAL REPORT 2008–2009 Glossary of terms

Definitions in this glossary are for use in the context of this Report

Accreditation Public recognition of achievement by a healthcare organisation, of requirements of national healthcare standards1 ACHS The Australian Council on Healthcare Standards, Australia’s leading independent, not-for-profit organisation dedicated to improving the quality and safety of healthcare through continual review of performance, assessment and accreditation Certification ACHS’ quality management program for newly established and other healthcare organisations that have not yet implemented a formal quality program Clinical indicator A measure of the clinical management and outcome of care; a method of monitoring consumer/ patient care and services which attempts to ‘flag’ problem areas, evaluate trends and so direct attention to issues requiring further review Consumer/patient People who directly or indirectly make use of health services2 Corporate governance Understood to be the system by which organisations are directed, controlled and held to account3 Credentialling The process of accessing and conferring approval on a person’s suitability to provide a defined type of healthcare4 Criteria The measurable key components of a standard; that are necessary for meeting the standard EQuIP Evaluation and Quality Improvement Program, ACHS’ framework to improve the quality and safety of healthcare Evaluation Judging the value of something by gathering valid information about it in a systematic way and by making a comparison. The purpose of evaluation is to help the user of the evaluation to decide what to do, or to contribute to scientific knowledge5 Inter-rater reliability Ensuring consistency between and within survey teams on ratings of the criteria within each standard ISQua The International Society for Quality in Health Care, a non-profit, independent organisation with members in over 70 countries that works to provide services to guide health professionals, providers, researchers, agencies, policy makers and consumers, to achieve excellence in healthcare delivery, and to continuously improve the quality and safety of care Member An organisation participating in an ACHS accreditation program Performance improvement Continuous study and adaptation of processes in order to achieve desired outcomes and meet the needs and expectations of customers Policy A documented statement that formalises the approach to tasks and concepts which is consistent with organisational objectives Procedure A set of documented instructions conveying the approved and recommended steps for a particular act or sequence of acts Process A series of actions, changes / functions that bring about an end or a result Quality The extent to which the properties of a service or product produces a desired outcome4 Risk management The culture, processes and structures that are directed towards realising potential opportunities whilst managing adverse effects6 Safety Freedom from hazard1 Standard Describes the overall goal; for example, high quality care for patients with desirable outcomes Surveyor A health professional trained by ACHS to assess the performance of healthcare organisations against EQuIP standards 1 Australian Council for Safety and Quality in Health Care (ACSQHC), 2006, Shared Meanings. 2 Department of Public Health and Flinders University/SA Community Health Research Unit. Improving health services through consumer participation – a resource guide for organisations. Canberra: Department of Health and Ageing, 2000. 3 Financial Reporting Council London Stock Exchange. Cadbury Report: The Financial Aspects of Corporate Governance. 1992. 4 ACSQHC, List of Terms and Definitions for Safety and Quality. 5 Øvretveit J. Action Evaluation of Health Programmes and Changes. Radcliff Medical Press, 2002: 12. 6 Standards Australia. AS/NZS 4360 -2004 (2004) Risk management. Contact us

The Australian Council on Healthcare Standards (ACHS) 5 Macarthur Street Ultimo NSW 2007 Australia Phone 61 2 9281 9955 Fax 61 2 9211 9633 Email [email protected] Website www.achs.org.au Additional copies of this Annual Report may be obtained by emailing the Communications Manager at [email protected] or visiting the ACHS website (under the Publications and Resources menu option) at www.achs.org.au Thank you to all ACHS staff who assisted with this report. Design and layout by Impress Design.