The Australian Council on Healthcare Standards annual Report 2006-07
Safety Quality Performance valediction
Dr Edward ‘Ted’ Booth AM It is with great sadness that the ACHS recognises the recent passing of Dr Edward ‘Ted’ Booth AM. Dr Booth was a respected radiologist from Sydney, past President (1966–1967) of the NSW branch of the Australian Medical Association and the first Chairman of the Joint Steering Committee on Hospital Accreditation (which evolved to become the ACHS). Working with some very dedicated individuals, he was a dynamic force in establishing research into developing an accreditation program for public hospitals throughout Australia. It was the first time two such powerful and influential groups (NSW AMA and Victorian AHA) had met and worked together in a formal Pictured: Employees and consumers from the Royal Brisbane and Royal Women’s Hospitals and the structure outside the framework of their professional bodies. 63 Balmain Hospital and Eastern Sector Aged Community Services, Sydney Dr Booth was also a former President of the Royal Australian and New Zealand College of Radiologists (1964–1965). The ACHS is indebted to Dr Booth for his contribution to the development of internationally recognised accreditation for Australian health services.
The Australian Council on Healthcare Standards safety, quality, performance ACHS ANNUAL REPORT 2006-07
The Australian Council on Healthcare Standards (ACHS) would like to thank our own employees as well as the management, employees, consumers and visitors at the following member organisations, for participating in the photography for this Annual Report: • Balmain Hospital and Eastern Sector Aged Community Services, Sydney • Royal Brisbane and Royal Women’s Hospitals, Brisbane • Royal Prince Alfred Hospital, Sydney • Skin & Cancer Foundation Westmead Day Clinic, Sydney • St Luke’s Hospital Complex, Sydney • The Ophthalmic Surgery Centre (Chatswood), Sydney • The Sydney Eye Specialist Centre (Kingsford), Sydney
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 ISBN: 1 92126527 2 (paperback) Aboriginal people who have recently deceased. ISBN: 1 921265 28 0 (website) Readers are warned that this publication may inadvertently contain such photographs. This Report is available in pdf format via the ACHS website (under the Publications and Resources menu option) from the homepage: www.achs.org.au 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 order a printed copy, please contact to publish and distribute our report to ACHS member organisations, ACHS surveyors, the ACHS: health industry bodies, governments, consumers and the community. 5 Macarthur Street October 2007 Ultimo NSW Australia 2007 © The Australian Council on Healthcare Standards Telephone 61 2 9281 9955 Facsimile 61 2 9211 9633 Apart from any use as permitted under the Copyright Act 1968, no part may be E-mail [email protected] reproduced by any process without prior written permission from the Australian Council on Healthcare Standards. Website http://www.achs.org.au CONTENTS
Highlights 4 Our identity 6 Our performance 8 Our performance 8 President and Chief Executive Report 12 ABOUT ACHS 14 Our Executive team 14 Our organisation 15 Recognising achievement 16 ACHS ANNUAL REPORT 2006-07 ABOUT ACHS international 18 ACHS International 18 Division Reports 20 Division Report: Customer Services 20 Division Report: Development 23 Division Report: Corporate Services 25 Corporate Governance 27 Corporate Governance overview 27 ACHS Board of Directors 30 ACHS Council members 32 FINANCIALS 34 Financial statements – Directors’ report 34 LISTINGS 47 ACHS Member list 47 ACHS Surveyor list 57 Publications and Presentations 61 Valediction Dr Edward ‘Ted’ Booth AM 63 highlights 2006/2007
LAUNCH OF UPDATED The vast majority of colleges, health The EQuIP 4 standards increase the ACCREDITATION STANDARDS departments, and peak industry bodies, emphasis on issues such as the safe including consumer representation, management of blood, falls prevention EQuIP 4, the updated standards for provided detailed comments. This infection control and continuity of care the ACHS Evaluation and Quality feedback significantly impacted the between health care providers. Improvement Program – EQuIP – were outcome of the final version. launched at the 4th Australasian Encouragingly there is also international Conference on Safety and Quality in Over 850 stakeholders voted on the interest in these standards, with Health Care, Brisbane during August accreditation criteria to be selected hospitals in India and the Asia Pacific 2006. The Conference, which was as mandatory. This is a significant and Middle East regions choosing to co-hosted by the ACHS, included a increase when compared with the seek accreditation under the EQuIP 4 workshop on the updated accreditation 100 stakeholders who voted on the standards. standards. mandatory criteria for the 3rd edition of the EQuIP standards. Improving transparency of EQuIP 4 information kits were distributed accreditation results to ACHS Members and Surveyors. The Australian health care kits include guidelines and resources for For the purpose of increasing implementing the updated organisation- organisations chose transparency around the accreditation wide accreditation framework. new standards process, from 1 July 2004 ACHS Between January and July 2007 health provided a voluntary service (and The rollout of EQuIP 4 also included encouraged members) to publish national education workshops to train care organisations that participated in ACHS accreditation had the option to be either a Jointly Agreed Statement or ACHS Surveyors to review health care their full accreditation report on our organisations against the new standards. assessed against either the 3rd edition or 4th edition of EQuIP. From 1 July 2007 (or their own) website. The review of standards is a major all health care organisations seeking Disappointingly there was limited take undertaking and appropriately requires a accreditation through the ACHS will up of this voluntary initiative. significant allocation of resources by the use EQuIP 4. ACHS. The process takes approximately In response to the increasing Over 60% of organisations chose to ACHS ANNUAL REPORT 2006-07 two years to complete including provision industry and community demand for time for the educational program. be surveyed or complete their self for more information about health The key stages in the review were: assessment against the new standards, service accreditation performance, prior to being required. All our remaining the ACHS Board foreshadowed the • literature review member organisations have commenced need to promote more transparency • comparison with other implementing these updated standards, of the accreditation process. During countries’ standards which are used by the majority of 2006/2007 the ACHS determined Australian health care organisations • collaboration with working groups for to introduce more detailed Agreed to guide their safety and quality Performance Statements. specific topic areas improvement efforts. • establishment of reference groups to We introduced new contracts with provide additional input our member organisations to enable this initiative (to coincide with the • collaboration with expert introduction of the 4th edition of our advisory groups EQuIP accreditation standards). The • conduct of focus groups to examine new contracts are being introduced specific aspects of the development on a rolling basis from 1 July 2007 program (as member contracts expire). • wide-ranging consultation with key stakeholders in both the public and private sectors • field review of draft standards across the industry • continual revision of the text • pilot testing in a number of sites reflecting the diversity of the industry, including an onsite assessment by a survey team • final drafting by the Standards Committee • the ACHS Board’s final consideration and adoption. Pictured: Employees from Skin & Cancer Foundation Westmead Day Clinic, Sydney 60% Over 60% of organisations chose to use new accreditation standards, prior to being required.
First Australian hospital NATIONAL REPORT ON International developments requests consumer review ACCREDITATION PERFORMANCE The growth of ACHS International of their service While the ACHS released the 2nd during 2006/2007 exceeded During 2006/2007 we congratulated ACHS National Report on Health expectations. A growing number of Launceston General Hospital; the first in Services Accreditation Performance international health care organisations Australia to achieve accreditation after the reporting period (in August chose ACHSI certification with a consumer as part of the review 2007), the analyses was completed and accreditation. team for the entire onsite survey. during the first half of 2007. Some of the first hospitals accredited While consumer and carer surveyors The Report contains aggregate by ACHS International were the Saad have participated in ACHS onsite information from 1233 accreditation Specialist Hospital, Kingdom of Saudi surveys of mental health services for surveys of Australian health care Arabia, Kerala Institute of Medical many years, this was the first time a organisations between 2003 and 2006. Sciences, India and the American Mission Hospital, Kingdom of Bahrain. Consumer Surveyor had been part The data demonstrates significant of the team for the organisation-wide improvement in organisations (over the We also hosted an increasing number survey of a hospital. period of the Report) with regard to of international delegations which ACHS Consumer Surveyors undergo formal frameworks to manage risks as aimed to share the Australian the same rigorous training in the ACHS well as an improvement in preparedness experience of performance standards and accreditation processes for an emergency. measurement and accreditation. as the surveyors with health industry Areas which were identified as needing 2006/2007 also saw a significant experience. They bring to the survey further improvement included: increase in the number of surveyors their expertise as carers or patients ACHS trained from countries such as as well as members of the wider • Involving consumers in the activity Hong Kong, India and Malaysia. community. of the health service, and As reported in the 2005/2006 • Improving systems for evaluating Establishing an evidence base Annual Report ACHSI entered into a the performance of staff. Memorandum of Understanding, in Despite its increasing use globally ACHS ANNUAL REPORT 2006-07 The purpose of the Report is to July 2006, with the Quality Council there had existed a dearth of establish comprehensive national of India (QCI) to provide support information on the role of accreditation benchmarks for accreditation and assistance through its National in improving the performance of health performance; which will assist health Accreditation Board for Hospitals and care organisations. For this reason care organisations to evaluate their own Healthcare Providers (NABH) in the in 2001 ACHS made a commitment performance against the aggregate. development of a national program of to establish a research function and accreditation in India. Early outcomes improve the evidence base for decisions The Report includes information on the of the agreement have included around accreditation of health care majority of health care organisations in surveyor training, education organisations. This type of research is Australia and is organised in themes services and collaboration on quality fundamental to providing knowledge such as: infection control, issues for improvement initiatives. for the expanded use of health care mental health services, consumer accreditation both in Australia and involvement and risk management. worldwide. A secure financial future The outcomes of this significant undertaking are beginning to be realised. The financial performance for the year ended 30 June 2007 shows a small The most notable of these research surplus of $10K. When compared to the initiatives was commenced in 2005 with original projected budget loss of $76K, four Australian Research Council funded the turnaround has been substantial. studies (along with The University of Income from renewal memberships, NSW and industry partners) to explore education workshops and savings from the relationship between accreditation operating expenses were the main and organisational performance. contributors to the result. The early results of this research are being published and indicate that there is a strong relationship between accreditation and the performance of a health care organisation.
Pictured: ACHS International survey at the Saad Specialist Hospital, Kingdom of Saudi Arabia our identity The Australian Council on Healthcare Standards (ACHS) is an independent, not-for-profit organisation, dedicated to improving the quality of health care in Australia through continual review of performance, assessment and accreditation.
Established in 1974, after many years Who sets the standards? What is accreditation? of pioneering work from a range of The ACHS develops standards The Winter 2002 edition of Consumers’ health care professionals including with industry, governments and Health Forum of Australia Inc’s journal members of the Australian Medical consumers. We lead the collaboration The Australian Health Consumer Association, the Australian Healthcare and consultation required to set published a number of articles on and Hospitals Association and relevant, achievable and evidence- accreditation. In the Editorial, medical colleges, the ACHS has based standards. Mr Lou McCallum, the then chair of maintained its position as the the Consumers’ Health Forum principal independent authority on the Who uses ACHS accreditation summarised consumer expectations measurement and implementation 1 in the following way: of quality improvement systems for programs? Australian health care organisations. • All major teaching and referral For consumers, accreditation is hospitals in Australia participate in our basically an issue of trust. People Standards for evaluation, assessment who use health services want to have and accreditation are determined Evaluation and Quality Improvement confidence that those services are by a council drawn from peak bodies Program – EQuIP safe and will provide consistent high in health, representatives of the • The majority of ACHS members are quality care. People understand that governments and consumers. in the public sector (58% compared there are risks associated with using to 42% private sector) The ACHS is governed by a Board the health system, but they want those of Directors elected by Council • The State/Territory distribution of risks minimised.3 members and supported by a our members roughly reflects the The International Society for Quality corporate management structure population base in Health Care (ISQua) lists a number which oversees the process of • More than half of ACHS member of descriptors of accreditation. evaluation and assessment by organisations with inpatients have Accreditation: professionally qualified surveyors. fewer than 100 beds. • is public recognition of achievement The ACHS Evaluation and Quality Who does the ACHS Improvement Program (EQuIP) by a healthcare organisation, of
ACHS ANNUAL REPORT 2006-07 2 was launched in 1996 providing accreditation surveys? requirements of national healthcare health care organisations with a • Over 350 ACHS surveyors are either standards framework to deliver a consumer- supported by the organisation that • is generally available to public and centred service focusing on the employs them to volunteer their time private sectors continuum of care, by incorporating for surveying or they are paid an • covers a range of healthcare systematic external peer review. honorarium environments from local community- The ACHS is regularly consulted by • Two full-time surveyors participated based care through to tertiary level other countries in relation to standards in a large number of surveys on a trial providers and healthcare systems development, accreditation systems basis in 2005 and 2006. • may have specialised healthcare and clinical indicators and hosts services as a particular focus international delegations. • is awarded based on achievement of quality standards and the independent external survey by peers of an organisation’s level of performance in relation to the standards.4
Our mission: to improve the quality and safety of health care Our 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 health care Our values: Excellence, Leadership, Commitment, Integrity, Transparency, Teamwork, Consumer focus, Cultural responsiveness Our Council: represents health care professionals, consumers, government and industry stakeholders to develop and continually review standards for the health industry.
1, 2 The Australian Council on Healthcare Standards (2007) The ACHS National Report on Health Services Accreditation Performance, 2003–2006 3 The Australian Health Consumer Winter Number Two p4 Australian Capital Territory 2002 4 International Society for Quality in Health Care http://www.isqua.org/isquaPages/Accreditation.html (15/4/07) 1,000 Over 800 member health care organisations, representing more than 1,000 individual organisations, are members of ACHS quality improvement programs.
Our products and services ACHS EQuIP Members by Sector as at 31 December 2006 (Full & Associates) To achieve and maintain accreditation our members participate in a four-year cycle of quality improvement activities, culminating annually in either a Self- (n435) Private Assessment or an onsite survey to meet industry-developed standards. 42% Our core accreditation program is the (n613) Public Evaluation and Quality Improvement 58% Program (EQuIP). Other programs include:
• EQuIP Certification • EQuIP Corporate (Heath Services) • EQuIP Corporate Member Services • EQuIP In-depth Reviews ACHS EQuIP Members (Full and Associates) by Bed Size as at 31 December 2006 • Quality for Divisions Network • Clinical Indicator program 45 41% With over 400 indicators in total, our 40 Clinical Indicator Program is the most 35 comprehensive in Australia. 30 We also provide customised reporting 25 from our rich data sources, enabling 20 17% 15% single health care organisations or 15 13% 10% ACHS ANNUAL REPORT 2006-07 groups of organisations to compare 10 4% their own performance to State/Territory 5 and national aggregates. 0 0 1-49 50-99 100-199 200-499 =>500 We also offer customised education, Beds workshops, consultancies and access to publications, supporting ongoing quality improvement initiatives. Is accreditation compulsory? Our funding There is a range of governance models As an independent, not-for-profit among the Australian States and organisation, the vast majority of our Territories as well as across public and funding is from our membership fees. private health care. Therefore We also sometimes receive funding this varies. from government organisations and There is an expectation in the industry other industry bodies, linked to the that hospitals will be accredited. delivery of individual projects. Accreditation is one aspect of We receive a specific contribution performance measurement/ from Baxter Healthcare for the requirements set by several state health publication of this Annual Report departments and also a consideration and our Quality Improvement for health insurers when negotiating Awards program. contracts for the payment of benefits on behalf of their members. The emphasis of ACHS accreditation is whole organisation continuous improvement versus achieving minimum requirements. Our performance Our progress and plans for achieving our Strategic Goals
Strategic Goal Provision of products and services Be the leading organisation in 06/07 Aims & Objectives: the health care industry providing products and services which include • Exploration of more diversity in standards development, performance product range, including clinical assessment, accreditation and in-depth review programs such education as cancer and chronic disease management Maintain, and where possible, grow • Relevant products and services to be Over the membership base evaluated and revised including 100% of specialty resources 06/07 Aims & Objectives: Member satisfaction levels to be • 50% medical clinician surveyors on survey teams by 2008. 850 surveyed and maintain/improve on 2004/05 (satisfaction) survey results. … stakeholders voted on criteria to be 06/07 Activities & Outcomes: selected as mandatory (for our EQuIP 4 06/07 Activities & Outcomes: • Development of programs and standards) compared with the 100 Membership changes due publication of the EQuIP Corporate stakeholders who voted on the 3rd edition to restructure: Health Services Guide, 3rd edition • 06/07 New: 26, Cancelled: 42 • Development of EQuIP 4 web-based (Many of the cancelled memberships have Resource Tools for Oral Health, re-joined as combined memberships due Hospitals, Day Procedures, Mental to restructure.) Health, Community, Primary Care Other membership changes: and Multi-Purpose Services • 06/07 New members: 28 • Development of EQuIP 3/EQuIP 4 • 06/07 Cancellations: 17 Linkage for Standards ACHS ANNUAL REPORT 2006-07 • 40% of organisation-wide surveys All organisation evaluations on now have a medical clinician as part ACHS and surveyors from 2003 to 50% of the team Target: to achieve 50% medical clinician 2006 analysed and reported on in 07/08 Aims & Objectives: surveyors on survey teams by 2008 National Report on Health Services Accreditation Performance 2003–2006 • Publish an EQuIP 4 Risk Management (National Report). and Quality Improvement Handbook 07/08 Aims & Objectives: • Develop and publish an EQuIP 4 • Identify potential growth markets Clinicians Guide through comparison of Australian • Develop Methadone Resource Tool, Institute of Health and Welfare Area Health Cluster Resource Tool, database of health care organisations Consumer Framework Guide against ACHS member database • Achieve 50% medical clinician • Review follow-up process and option surveyors on survey teams by 2008 of using online survey tool • Expand the surveyor workforce to for evaluations. include more allied health clinicians.
Pictured: Balmain Hospital and Eastern Sector Aged Community Services, Sydney Increased consumer participation Strategic Goal 07/08 Aims & Objectives: in survey program Develop and sustain collaborative • Continue to provide program support 06/07 Aims & Objectives: links with key stakeholders and quality management assistance Attract support for consumer surveyors’ to international member organisations involvement in surveys. Maintain liaison with significant industry leaders through a measurable • Continue to assist in worldwide 06/07 Activities & Outcomes: stakeholder plan with number of quality health initiatives and to provide individual education programs to Two consumer surveyors have been contact visits and outcomes trained to participate on surveys and the visiting international heath care first health care organisation in Australia 06/07 Aims & Objectives: organisations and delegations/ requested a consumer on the general Increase collaboration with governance groups key stakeholders. survey team. • Increase targeted marketing in India, 07/08 Aims & Objectives: 06/07 Activities & Outcomes: Middle East and Hong Kong. 10% of organisation-wide surveys to • Nationwide Consultations undertaken include a consumer surveyor on Participation on significant with health care jurisdictions and the team. committees, in key events owners to evaluate the review of and conferences Maintain international recognition EQuIP 3rd edition and introduction 06/07 Aims & Objectives: of standards of EQuIP 4 06/07 Aims & Objectives: • Individual consultations conducted • Involvement in the update of National Achieve accreditation for a range of with member organisations Standards for Mental Health Services ACHS standards including EQUIP 4. to communicate the findings • Collaboration with key stakeholders in of the National Report on the planning for the 5th Australasian 06/07 Activities & Outcomes: Health Services Accreditation Conference on Safety and Quality in International accreditation achieved Performance 2003–2006. (from the International Society for Health Care (Brisbane, August 2007) Quality in Health Care – ISQua) 07/08 Aims & Objectives: • Participation/presentation at national/ for EQuIP 4 and EQuIP Corporate Maintain effective engagement and international conferences. ACHS ANNUAL REPORT 2006-07 Health Services 3rd edition. dissemination of information for 06/07 Activities & Outcomes: jurisdictions and member organisations 07/08 Aims & Objectives: with the established bi-annual State • Support for the Australian No new ACHS standards will require Advisory Committee meetings and accreditation during this period. Government, Department of Health provide continued support through and Ageing Review of the National other communications channels. Standards for Mental Health Increasing interaction with Services with the preparation of a key stakeholders including report summarising stakeholder consultations on current national international peers standards and recommendations for 06/07 Aims & Objectives: Continue standards review and implementation to collaborate with international peer • Successfully co-hosted (achieving organisations and maintain number of attendance targets) the 5th international delegations. Australasian Conference on Safety 06/07 Activities & Outcomes: and Quality in Health Care (Brisbane, August 2007) with key stakeholders • The ACHS welcomed 14 visiting and peer organisations international delegations during 2006/2007 and provided quality • Participation/presentation at management and information support national/international conferences – to World Health Organisation groups see page 61. from Malaysia and China 07/08 Aims & Objectives: • Increased ACHS International • Continued involvement in the update membership base beyond targets. of National Standards for Mental Health Services • Collaboration with key stakeholders in the planning for the National Forum on Safety and Quality Health Care (Adelaide, October 2008)
Pictured: Ann Kelly ACHS Surveyor and General • Participation/presentation at national/ Manager, Balmain Hospital and Eastern Sector international conferences. Aged Community Services, Sydney Strategic Goal Undertake research into quality improvement within the health care industry Consolidation of research program 06/07 Aims & Objectives: Australian Research Council funded project exploring the value of accreditation – results available and published in peer reviewed journals. 06/07 Activities & Outcomes: 10 Data collection for 3 of 4 studies complete; 2 conference presentations with 3 pending, 1 published paper, 1 paper in press, 1 paper submitted; 2 papers in draft. Pictured from left to right: Members of the ‘researching accreditation team’ 07/08 Aims & Objectives: Professor Jeffrey Braithwaite (University of New South Wales–UNSW), Dr David Greenfield (UNSW) Completion of all data collection; and Dr Marjorie Pawsey (ACHS) publication of the results of the four studies in peer reviewed journals; 07/08 Aims & Objectives: • New contracts introduced on a rolling results communicated through In-depth analyses of ACHS data basis from 1 July 2007 (as member conference presentations. to understand strengths and contracts expire). opportunities for improving quality Pursue further research and safety nationally. Effective usage of clinical 06/07 Aims & Objectives: indicator information ACHS ANNUAL REPORT 2006-07 Research Advisory panel to establish Strategic Goal 06/07 Aims & Objectives: partnership based research. Continue to review and refine the To promote and publish information way clinical indicator data are 06/07 Activities & Outcomes: in relation to quality of health care Meeting in November 2006; Department collected and reported. of Health and Ageing (Australian Increase public disclosure of 06/07 Activities & Outcomes: Government) requested and agreed performance information Working groups convened for the to fund a project proposal from ACHS 06/07 Aims & Objectives: Review of Rehabilitation and Pathology to identify future research priorities Examine and publish information ACHS Indicators during 06/07. identified by an Australian Accreditation on the trends in the publication of Research Network workshop based on 07/08 Aims & Objectives: survey performance information the ACHS Research Advisory Panel and Liaise with medical colleges and on the ACHS website. the Collaborative Group of Accreditation stakeholders in the development of Agencies convened by the ACHS. 06/07 Activities & Outcomes: clinical indicator sets and establish From 1 July 2004 the ACHS has working groups to review relevant 07/08 Aims & Objectives: provided a voluntary service (and ACHS clinical indicator data sets Submission of an Australian Research encouraged members) to publish during 07/08. Council linkage application with either a Jointly Agreed Statement or the Centre for Clinical Governance their full accreditation report on our (or Research, University of NSW on their own) website. There was limited researching models of accreditation. take up of this initiative. As at 30 June Publication of data 2007 17 members published Jointly Agreed Statements on accreditation 06/07 Aims & Objectives: performance on the ACHS website. Increase use of ACHS data sources through the National Accreditation 07/08 Aims & Objectives: Report 2003–2005. • Introduce more detailed Agreed 06/07 Activities & Outcomes: Performance Statements to Completion of the 2nd ACHS promote more transparency of the National Accreditation Report on accreditation process EQuIP 3rd edition data 2003–2006. • Introduce new contracts with our member organisations to enable this initiative (to coincide with the introduction of the 4th edition of our Pictured: Rehabilitation at Royal Brisbane and EQuIP accreditation standards) Royal Women’s Hospitals 105 One hundred and five organisationsnominated for the QI Awards 2007, representing a 4% increase on the previous year.
Provision of an effective website to • 105 organisations nominated for 06/07 Activities & Outcomes: QI Awards 2007, representing a 4% facilitate access of information by • Met budget targets all stakeholders increase on the previous year • Unqualified audit reports. 06/07 Aims & Objectives: • The first submission for QI Awards from an ACHS International member 07/08 Aims & Objectives: • Launch new website to meet user- organisation was received. • Meet budget targets needs as per website evaluation 07/08 Aims & Objectives: • Unqualified audit reports. • Website utilisation rates monitored Review communications and and evaluated submission strategies for the Business systems externally • Stakeholder endorsement of QI Awards 2008 to continue to accredited revised website. grow the QI Awards program. 06/07 Aims & Objectives & Activities: 06/07 Activities & Outcomes: Promotion of ACHS through • Continue to implement ISQua 11 • New website launched October 2006 conference presentations recommendations • New website is linked to the ACHS 06/07 Aims & Objectives: 07/08 Aims & Objectives: Customer Relationship Management • Continue to increase the number Ongoing evaluation of progress to new database and type of conference and performance indicators. workshop presentations with positive • 1,918 successful registrations for Member satisfaction with services Member, Surveyor or Board access evaluations, consistent with the and products; including effective to restricted and tailored information communications strategy communication with members • Web hits regularly monitored • Successful evaluation from and evaluated participation in the 4th Australasian 06/07 Aims & Objectives: • Steady increase in web hits since Conference on Safety and Quality • Deliver the web-based EAT and October 2006, with a drop over the in Health Care (Melbourne, Performance Indicator Reporting Tool August 2006). (PIRT) to members
December/January holiday period ACHS ANNUAL REPORT 2006-07 • Excluding the homepage and login 06/07 Activities & Outcomes: • Evaluate member involvement in the screens, Electronic Assessment Tool Working Groups for the web-based • Successfully co-hosted (EAT) pages are the most commonly EAT development (achieving attendance targets) the accessed, followed by EQuIP 4 5th Australasian Conference on • Evaluate member satisfaction with content pages then Clinical Indicator Safety and Quality in Health Care new web-based tools (EAT and the Program pages. (Brisbane, August 2007) with key new website). 07/08 Aims & Objectives: stakeholders and peer organisations 06/07 Activities & Outcomes: • Participation/presentation at national/ • Continue to evaluate user needs and • PIRT questions and answers posted international conferences – evolve the website on to the ACHS website to assist see page 61. • Explore additional online service, for members of the ACHS Clinical example online tool for submission of 07/08 Aims & Objectives: Indicator Program clinical indicators. • Continue to increase the number • June 2007: Upgrade on EAT 4 Program of external recognition of and type of conference and functions as a result of feedback from users excellence in performance workshop presentations with positive evaluations, consistent with the • Analysis of EAT 4 feedback from 06/07 Aims & Objectives: communications strategy organisations Jan 07 – Jun 07 (n38): • Online application to be explored • Collaboration with key stakeholders • 29 very satisfied/satisfied for ACHS Quality Improvement in the planning for the National Forum • 9 dissatisfied/very dissatisfied. (QI) Awards for 06/07 on Safety and Quality Health Care • Continue to encourage participation (Adelaide, October 2008). 07/08 Aims & Objectives: in awards and recognition programs • Expand communication via the ACHS including at least a 20% increase Strategic Goal website to members of the ACHS in participation in the QI Awards. Clinical Indicator Program to assist To maintain an effective internal meeting data submission timelines 06/07 Activities & Outcomes: system that enables goals to be efficiently achieved • Utilise online survey tools to improve • Submission for ACHS QI Awards feedback processes. revised during 2006/2007 Effective financial performance • Website-based submission 06/07 Aims & Objectives: information expanded • Meet budget targets • Unqualified audit reports. PRESIDENT AND CHIEF EXECUTIVE REPORT 2006/2007
Change and challenge are recurring Financial management Despite several changes within our themes in today’s environment and this team, services have been maintained Membership numbers have remained has been the ACHS’s experience over at a high standard. Whilst the workload high and it is pleasing to note the the year in review. The following report has been substantial the commitment increasing range of services and summarises the major issues and events. of employees, the surveyor workforce programs being included in the program and other key contributors has enabled accessed by existing members such as Corporate Governance performance targets to be met; this community health services, mental health result is greatly appreciated and never In response to broad consultation, services and corporate offices. Again a taken for granted. it was decided at the November 2006 small financial surplus was achieved with Annual General Meeting to amend the price increases being contained within New Standards Constitution to provide for an additional acceptable limits. position on the Board. The new position The 4th edition of the Evaluation is open to all members of Council. The National Safety and and Quality Improvement Program, 12 Mr Stephen Walker was subsequently Quality Agenda EQuIP 4, was successfully launched, elected and the Board was delighted effective from 1 January 2007. to welcome him as a member to his The work of the Australian Commission It incorporates a much stronger first meeting in December 2006. on Safety and Quality in Health Care emphasis on clinical care delivery Mr Walker represents the Australian in conducting a review of accreditation and health consumer expectations. Private Hospitals Association on the systems has gathered momentum Mandatory criteria were revised with ACHS Council. There have been no during the course of the year. The the number being reduced to provide other changes to Board membership first round of major submissions was a sharper focus on key requirements over this period. This stability has lodged in March and provided a rich affecting safety. A comprehensive contributed very positively to the and diverse range of views. Further guide has been published to support consideration of policy and strategic consultations and opportunities for participating organisations in their issues important to the organisation’s formal input are to be provided. pursuit of the highest standards in continued well being and in its planning The ACHS remains very supportive the provision of health services. Initial for the future. of the process and has taken a feedback from member organisations,
ACHS ANNUAL REPORT 2006-07 number of opportunities to contribute surveyors and key stakeholders, Ms Helen Dowling, Director of constructively to the debate. A final has been extremely positive. Pharmacy, John Hunter Hospital, who report is not due to be submitted represents Allied Health Professions to the Australian Health Ministers’ The EQuIP Corporate Health Services Australia on the Council, was appointed Conference until early in 2008. standards have also been revised. We by the Board as Chair of the Standards are delighted to record that both sets Committee of which she has been a The intention of increasing the use of standards have been accredited member for several years. Helen has of accreditation across a broader by ISQua. already demonstrated her enthusiasm range of health services and settings and commitment to this important role will provide many opportunities for Partnerships with Health very effectively. the ACHS. The emerging position of Care Organisations building on the existing programs, The addition of representatives from rather than creating a new system is ACHS was delighted to have been State Advisory Committees to Council strongly supported. selected by the Commonwealth meetings has continued to make a Department of Health and Ageing as very worthwhile contribution to the Our team the successful tenderer to review the discussions at Council meetings. national standards for mental health It is with great pleasure that we services. These standards have not acknowledge the appointment of The involvement of Councillors been revised since 1996. In conducting Ms Darlene Hennessy to the position has again been very important and this review ACHS has been able to of Executive Manager, Development. significant contributions have been draw effectively on its experience In this capacity, she has responsibility made to the Board’s deliberations in undertaking assessments and for the key functions of standards through the discussion of key strategic onsite surveys against the existing review and development, the clinical issues. Key subjects considered standards, together with feedback from indicator program and oversight of the by the Council include the potential member organisations and other key organisation’s research activities. She introduction of unscheduled surveys stakeholders, to undertake this complex has already demonstrated a high sense (bringing unpredictability in survey visits), and significant task. Completion is of purpose and strong management clinical indicators and their utilisation scheduled for May 2008. under EQuIP 4, and the development skills in this key role. of ACHS position statements covering The Chief Executive was elected as the organisation’s approach to chairman of the International Society contemporary issues. for Quality in Health Care’s (ISQua)’s Accreditation Council for the period of two years. An important initiative by the Board has The Importance of research Our thanks been to extend the requirements for Several years ago we joined a 2007 marks 20 years of support by the public provision of information on collaboration with the Centre for Baxter Healthcare of ACHS, through accreditation performance. Clinical Governance Research, its sponsorship of both our annual Commencing from July 2007 member University of New South Wales, and quality improvement awards and the organisations will be required to allow other industry partners to undertake publication of this Annual Report. publication of an agreed statement of a research project funded by the Baxter Healthcare has a long and performance, which will be able to be Australian Research Council. The proud history of support for the accessed by the public. results of this study are expected to health industry and the ACHS places be known over the course of the next enormous value on the strength of our In a significant move Quality Health year and will have very substantial enduring relationship. New Zealand (QHNZ) determined to national and international importance. implement the EQuIP standards into Looking forward that country. The standards are being International Growth 13 modified to suit the requirements The year ahead will see many positive of New Zealand. The ownership This year has marked the first opportunities involving the provision of QHNZ has been transferred to substantial year of international of accreditation programs, publication another New Zealand company, business activities. The first hospitals and promotion of the results from the Telarc SAI Ltd. ACHS is in the process accredited by ACHS International were research studies, the results of the of finalising a formal agreement the Saad Specialist Hospital, Kingdom national review of accreditation systems between the two organisations. This of Saudi Arabia, and Kerala Institute and a range of international business development will have significant of Medical Sciences, India. These opportunities. We look forward to benefits for both countries in the organisations clearly demonstrated continuing to work with all stakeholders years ahead, particularly given the high levels of performance in relation in advancing the quality provision of similarity of our healthcare systems. to safety and quality. Each will prove to health services. The ACHS wishes to acknowledge be leaders in their own countries in the the positive contribution of Mr Peter provision of high-quality services.
Rose, Chief Executive, Telarc SAI Ltd. In a very important development, a ACHS ANNUAL REPORT 2006-07 and his team to the negotiations. Memorandum of Understanding was The ACHS was again delighted to entered into in July 2006 with the join with the Australasian Association Quality Council of India (QCI) to for Quality in Health Care (AAQHC) to provide support and assistance host the 5th Australasian Conference through its National Accreditation on Safety and Quality in Health Care. Board for Hospitals and Healthcare At the time of writing, this conference Providers (NABH) in the development has been held in Brisbane, 5–8 August of a national program of accreditation 2007. This successful event attracted in that country. The importance of this more than 900 delegates. ACHS development cannot be understated wishes to place on record its and reflects positively on the appreciation for the opportunity international standing of ACHS. Dr Michael Hodgson AM, President provided by AAQHC, under the Early outcomes of the agreement chairmanship of Ms Kathleen Ryan, have included surveyor training, to join this undertaking. education services and collaboration on quality improvement initiatives. The Board acknowledges the positive and constructive role played by Mr Girdhar Gyani, Secretary General, QCI, and his staff in developing this ongoing relationship.
Mr Brian Johnston, Chief Executive about achs Our executive team
Dr Desmond Yen 3 B.Com, MBA, DBA, FAICD ACHS Executive Manager, Corporate Services • Member of the ACHS Executive team since 1995 • Over 30 years local and international 1 2 4 3 management, finance and information technology experience • Contributor, Australian Research Council Linkage accreditation 14 research project, Centre for Clinical Mr Brian Johnston 1 Ms Heather McDonald 2 Governance Research in Health, Dip Pub Admin (NSWIT) BHA, FCHSE, MQIHC, BIT, RM, RN PhD candidate University of New South Wales FAICD, FAIM USyd, MAICD • Member, Australian Institute ACHS Chief Executive ACHS Executive Manager, of Management Customer Services • Fellow Member, Australian Institute • Formerly ACHS surveyor of Company Directors • Member ACHS Standards Committee As Executive Manager, Customer Services for the ACHS Heather’s Desmond’s portfolio covers local and • Fellow, Australian College of Health key responsibility is the delivery of international new business development, Service Executives accreditation services to members of finance, information technology, human • Fellow, Australian Institute of the Evaluation and Quality Improvement resources management, business Company Directors Program, and education and support support services and strategic planning. services for both member organisations
ACHS ANNUAL REPORT 2006-07 • Fellow, Australian Institute and ACHS surveyors. The accreditation of Management program has been adopted by over Ms Darlene Hennessy 4 • Visiting Fellow, Centre for Clinical 1,000 health care organisations across ACHS Executive Manager – Governance Research in Health, Australia. This includes all types of Development University of New South Wales hospitals, community health care Darlene Hennessy joined the • Member, Management Committee, settings as well as day surgeries. ACHS in August 2006 as Executive Royal Australasian College of This position is also responsible for the Manager – Development. Her key Surgeons’ Australian Safety management, development and support responsibilities include developing and Efficacy Register of New of the ACHS surveyors, a workforce of and maintaining industry standards, Interventional Procedures – over 350 professionals. The support and leading the organisation’s programs Surgical (ASERNIP-S) management of the surveyor workforce in performance and outcomes • National Councillor, Australian includes induction training and regular measurement and research. Healthcare and Hospitals Association education days for both the surveyors and the trained coordinators who are Prior to joining the ACHS, Darlene • Former Treasurer, Australian the team leaders on surveys. most recently held a position in a Healthcare and Hospitals Association private health insurance organisation • Current Chair, International Heather’s previous roles include Quality as manager of a contracting team. In Management, Academic work as well Accreditation Program Council, of this role her responsibilities included as nursing roles in a variety of settings. the International Society for Quality the negotiation and management of in Health Care, ISQua contracts with Australian private hospitals and day surgeries. During his time with the ACHS, Brian has focused on shifting the standards Darlene has worked with the towards a greater clinical focus New South Wales Department and continues to make the ACHS of Health in the Performance accreditation program more rigorous Management Division and has and reliable. Brian has also driven the previously been a member of the establishment of a research program Education Service of the ACHS. and worked towards developing an With undergraduate studies in organisational structure which provides Nursing, Darlene has postgraduate more support for members and evolving qualifications in Advanced Nursing, the surveying system to improve the Health Administration and Marketing. quality of reporting. our organisation
Council
Board of Directors
COMMUNICATIONS Chief Executive Manager
Communications & Events Officer
Executive Assistant 15
CORPORATE SERVICES CUSTOMER SERVICES DEVELOPMENT Executive Manager Executive Manager Executive Manager
BUSINESS DEVELOPMENT & Administrative Assistant Administrative Assistant SERVICES Business Manager
CUSTOMER SERVICES STANDARDS &
Team Leader PROGRAM DEVELOPMENT ACHS ANNUAL REPORT 2006-07 EVALUATION SERVICES Customer Services Managers Senior Project Officer Project Officers Project Officers/Assistant
BUSINESS SERVICES EDUCATION & Team Leader SUPPORT SERVICE PERFORMANCE & OUTCOMES SERVICE Admin Assistants Education Manager Word Processing Officers Education Consultants Clinical Director Receptionist Coordinator Trainees Data and Admin Assistant
SURVEYOR WORKFORCE EDUCATION SERVICES Resource Coordinator RESEARCH Supervisor Surveyor Bookings Principal Consultant Admin Assistant Administrator Clerical Assistant Survey Bookings Assistant
FINANCIAL SERVICES Accountant Accounts Officers
IT SERVICES IT Manager Programmers Support Officer recognising Achievement
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ACHS Gold Medallist for 2006 Professor Ross Holland (left) with ACHS President Dr Michael Hodgson AM at the ACHS Annual Dinner, 23 November 2006.
ACHS Gold Medallist 2006: Professor Ross Holland The ACHS awarded its highest honour, “This groundbreaking project has the ACHS Gold Medal, for 2006 to directly improved the mortality Professor Ross Holland for his devotion figures for anaesthesia in Australia,” to anaesthesia safety. commented Dr Hodgson. ACHS ANNUAL REPORT 2006-07 The Medal, inaugurated in 1984, “Professor Holland’s long and recognises an outstanding contribution distinguished career reflects an to improving quality and safety in exceptional individual who has Australian health services and was dedicated his professional life awarded at the ACHS Annual Dinner to developing the specialty of in Sydney, 23 November 2006. anaesthesia through both education and the reduction of mortality rates. When presenting the unexpected He is well respected… by his peers honour Dr Michael Hodgson AM, and past students. His contribution President of the ACHS, commented to the community is well above that that Professor Holland is truly a of his colleagues and his support legend in Australian, and international, for the profession… is outstanding.” health care. Nomination from the Australian In the early 1960s Professor Holland, Society of Anaesthetists. and his colleague Professor Douglas Joseph, established the NSW Deaths under Anaesthesia Committee; a world- first approach to quality assurance in anaesthesia. Professor Holland was the inaugural Secretary of the Committee and later appointed as its Chair. He remains an active member. ACHS Quality Improvement SUPPORT CATEGORY CORPORATE QUALITY CATEGORY Awards 2006 Winner: Winner: Royal Perth Hospital, Sir George Hollywood Private Hospital, Launched in 1996 and supported by Bedbrook Spinal Unit, Shenton Park, Environmental/Waste Management Baxter Healthcare since 1998, the ACHS WA with their submission The Challenge Committee, Nedlands, WA with their Quality Improvement (QI) Awards, which of Change: Implementation of a Safe submission The Greening of Hollywood are open to all members of ACHS quality Handling Policy on the Sir George The project incorporated a range of improvement programs, recognise Bedbrook Spinal Unit initiatives to develop and implement outstanding achievement in activities, a comprehensive sustainable programs, projects and strategies in The project identifies alternative manual environmental strategy, including health care organisations. handling procedures for care of the (among others): Tree Planting, Worm acute spinal cord injured patient – The winners for 2006, selected from Farms, Carbon Neutral vehicles and aimed at reducing the severity of injuries over 100 entries, were announced at water reduction strategies. to staff whilst performing patient manual the ACHS Annual Dinner in Sydney, 17 handling episodes and at the same time The Greening of Hollywood project 23 November 2006. maintaining patient safety. demonstrated measurable outcomes, Judging takes place annually during for example the TravelSmart Programme July and August. The panel consists of resulted in a 14% reduction in staff an ACHS Councillor, an ACHS Surveyor driving to work alone and an increase and a representative of an EQuIP from 5% to 8% of staff walking/cycling member organisation. or using public transport. All of the QI Awards participants not only help raise the standard of health care but through sharing their work they encourage quality improvement initiatives beyond their own organisations. ACHS ANNUAL REPORT 2006-07 CLINICAL QUALITY CATEGORY Winner: Peninsula Health, Pharmacy Department, Frankston, VIC with their Representing Royal Perth Hospital from submission Implementing an Integrated left to right: Jane Sanders, Clinical Nurse, Electronic Prescribing and Discharge Rehabilitation Engineering and Anne Watts, Clinical Nurse Manager, Representing Hollywood Private Hospital from Summary System to Optimise the Spinal Unit, Rehabilitation Engineering left to right: Kevin Cass-Ryall, Executive Director Medication Management Pathway. Hollywood Private Hospital and State Manager Western Australia and South Australia; The outcomes of the initiative Nola Cruickshank, Director of Clinical Services; included increased use of Wayne Williams Manager Project Development e-prescribing, medication error & Property Services; Jackie Bullock, Quality reduction and a reduction in the Improvement Manager; Pat Grier, Managing potential or actual patient harm Director Ramsay Health Care. due to inaccurate e-prescribing.
View the winning and highly commended QI Award entries in full in the Quality Initiatives 2006 Representing Peninsula Health from left to right: publication, available via the Dr Peter Bradford, Executive Director Medical ACHS website: www.achs.org.au, Services; Ben Leung, Pharmacy Manager; by selecting ‘Honours and Bob Ribbons, Manager, Clinical Informatics; awards’(under ABOUT US from Skip Lam, Director of Pharmacy; Gary Braun, Director of Clinical Practice Improvement the homepage). ACHS international
“Preparing for accreditation drew the best from our leadership and staff. We developed an improved team approach to problem solving.” Paul L Armerding, MD FACS Chief Medical Officer/CEO American Mission Hospital, Bahrain Accredited by ACHS International
About ACHS International In the Middle East and India, ACHSI Surveyors has partnered with Quality Healthcare While ACHS has had a surveyor Australia to deliver successful exchange program with Ireland and 18 organisational development programs New Zealand for several years, the to improve performance and achieve relationships developed through the accreditation. work of ACHSI have provided additional opportunities to train surveyors from countries such as Hong Kong, India and Malaysia. In June 2005, after increasing global The surveyors have participated interest, we established a wholly owned on teams reviewing our Australian subsidiary, ACHS International (ACHSI), member organisations as well as to deliver our programs and services contributing to survey teams with internationally. Australian surveyors in their home ACHSI delivers accreditation and quality The year in review countries. We welcome the diversity improvement programs for health care of experience and perspectives they
ACHS ANNUAL REPORT 2006-07 The growth of ACHS International organisations, offers a clinical indicator during 2006/2007 has exceeded bring to our surveyor workforce. program, provides consultancies for expectations and projections. the development of local accreditation Key achievements: A growing number of international programs and undertakes tailored • Significant and growing presence and reporting and analyses. health care organisations have chosen ACHSI certification and membership base in India, the Middle ACHSI also offers complete education accreditation over offerings from East and Hong Kong solutions with an experienced in-house Canada, the US and elsewhere. • Memorandum of Understanding with team of education program designers the key national quality body and the The first hospitals accredited by and facilitators. national accreditation body in India ACHS International were the Saad Both the reputation of Australian Specialist Hospital, Kingdom of • One of the main providers of health health care and the ACHS led to Saudi Arabia, and Kerala Institute care quality improvement services demand from countries (that do not of Medical Sciences, India. in Hong Kong. have established health accreditation) Perhaps most notably these outcomes to either seek ACHS International As reported in the 2005/2006 Annual have largely been achieved through our accreditation or seek support in Report ACHSI entered into an MOU reputation and testimonials rather than establishing local programs. in July 2006 with the Quality Council of India (QCI) to provide support any significant marketing spend. In the Middle East – and assistance through its National Our own accreditation from, and We accredit hospitals. Accreditation Board for Hospitals involvement with, the International and Healthcare Providers (NABH) In India – We accredit hospitals and Society for Quality in Health Care in the development of a national have a Memorandum of Understanding (ISQua) and the international program of accreditation in India. (MOU) with both the Quality reputation of Australian health care Early outcomes of the agreement Council of India and the National have contributed to our ability to have included surveyor training, Accreditation Board for Hospitals ‘export’ Australian accreditation and education services and collaboration and Healthcare Providers to provide quality improvement programs. on quality improvement initiatives. consultation in the development of We would like to acknowledge the a local accreditation program. support of Austrade representatives We accredit hospitals in Hong and Australian embassy Kong, train local surveyors and work representatives in developing the with health authorities on quality reputation of ACHS International. improvement in China and the Asia Pacific Region. Our philosophy and focus
• Relationship development: we host Kerala Institute of Medical Sciences (KIMS) Trivandrum, India, international visitors to provide the www.kimskerala.com opportunity to learn and see ACHSI ‘up-close’ ACHSI Chief Executive, Brian Johnston attended the KIMS accreditation ceremony in India in February 2007, the first ACHSI accreditation in • We approach countries Partnership: that country. with a philosophy of partnership rather than aiming to sell an off-the- shelf accreditation program. We are willing to share our knowledge in order to help local bodies improve • Our flexible approach: the accreditation standards are able to be 19 modified and supporting guidelines produced; ensuring the product is culturally appropriate, whilst comparable with standards used in Australian health care organisations • Supporting local expertise: We train local surveyors to be able to survey against our standards • Our surveyors: have developed a reputation for professionalism, cultural sensitivity and local knowledge
• The Electronic Assessment Tool: ACHS ANNUAL REPORT 2006-07 which is used as part of the Pictured: ACHS and ACHS International Chief Executive, Brian Johnston at the accreditation process is the first KIMS accreditation ceremony web-based accreditation assessment software globally. CASE STUDY Dr Sahadullah MD. FRCP(Ire), FRCP(London), MBA Chairman and Managing Director Kerala Institute of Medical Sciences (KIMS), Trivandrum, India Why did you select to undertake accreditation with ACHSI? ACHSI is a renowned agency under ISQua (the International Society for Quality in Health Care) and has accredited many hospitals. Moreover I found them genuine and more approachable.
What has been the most worthwhile aspect of participating in ACHSI accreditation? KIMS has become more acceptable for foreign patients. Our credibility as a health care provider emphasising quality health care has increased Pictured: ACHS International survey at the Saad Specialist Hospital, Kingdom of Saudi Arabia several fold. Our staff too are more confident as accreditation increased their prospects and opportunities. Our patients are also now more confident to choose KIMS as we have a proven and established clinical standard based on quality. What has been the biggest impact on your organisation? Staff empowerment and awareness on various aspects of quality with special relevance on safety, Risk Management and TQM (Total Quality Management). We were also successful in developing a culture of data driven decision making. Why do you believe accreditation is important? Benchmarking of service and recognition by an independent organisation instils more confidence and acceptance. division report: CUSTOMER SERVICES Supporting our members to improve the safety and quality of their services
The ACHS accreditation programs 2006/2007 Activities provide an organisation-wide framework This year has seen the introduction for members to improve the safety and of the updated ACHS accreditation quality of care. standards, EQuIP 4. These standards 91% In order to achieve and maintain have an increased emphasis on …in 2006, 91% of our members were accreditation most of our members the clinical aspects of a health ‘satisfied’ or ‘very satisfied’ with the participate in a four-year cycle of quality service. The Customer Services Customer Support Service. improvement activities, culminating team has supported the application annually in either self assessment or an of these standards within member onsite survey. Those members who are organisations. This has included: participating in the Quality for Divisions a) assisting organisations to In addition to our existing consumer Network accreditation program surveyors who participate in surveys of participate in a three-year cycle. understand and implement the EQuIP 4 standards mental health services we also trained 20 two consumers to participate in general Customer Services consists of three b) assisting organisations with the main areas: surveys. We are hoping members will new “Requirements for Private embrace this initiative and request a 1. Customer Services Managers and Health Care organisations not consumer surveyor on future survey Surveyor Bookings required to be licensed” in onsite teams. Launceston General Hospital surveys where applicable 2. Surveyor Workforce, and has already included a consumer c) reviewing and implementing surveyor at their onsite survey which is 3. Education and Support Service. new policies and processes to an excellent result. implement the new EQuIP 4 Customer Services Managers As at 30 June 2007 our surveying standards and processes. and Surveyor Bookings: workforce totals around 350 OUTCOME: dedicated health care professionals. Overview and Outcomes Of these over half devote their time Customer Services Managers are As at 1 July 2007, over 60% of on a voluntary basis, 149 are paid an
ACHS ANNUAL REPORT 2006-07 responsible for promoting and ACHS members participating in a self honorarium and are available more managing services for members assessment or onsite survey in the first often than ten days per year, and 71 of ACHS accreditation and quality half of 2007 elected to use these new are paid Trained Coordinators. We improvement programs, such as EQuIP standards. The remaining organisations also have two full-time surveyors and Quality for Divisions Network have commenced the process of employed directly by ACHS. (QDN). They support our members in implementing the new standards. In recent years there has been a the implementation of the accreditation reduction in the number of volunteer process. Each Customer Services Surveyor workforce surveyors on surveys. This is largely due Manager is responsible for a designated In 2006, 97% of customers were to the increased difficulty for volunteer EQuIP and QDN membership base. ‘satisfied’ or ‘very satisfied’ with the surveyors to commit to survey dates The Customer Services Managers cohesiveness of the survey team at in advance as most are in full-time support member organisations by the onsite survey. positions within the health care industry. providing telephone, email and onsite The surveyor workforce consists of guidance and education throughout The two full-time surveyors, a new experienced, senior health care workers the accreditation cycle. This includes initiative reported on in our 2004/2005 with recent and broad experience in assistance prior to onsite surveys, Annual Report, have participated in a health care. While there is a range during and after the survey to finalise large number of survey teams. Their of backgrounds within the surveying survey reports and accreditation inclusion on teams has been evaluated workforce, the ACHS is actively outcomes. Evaluation data show that well by member organisations from the recruiting clinical surveyors. This in 2006, 91% of our members were perspective of their in-depth knowledge includes nursing, medical and allied ‘satisfied’ or ‘very satisfied’ with the of the survey process as well as the health clinicians. We anticipate the Customer Support Service. EQuIP standards. The surveyors who increased clinical focus of EQuIP 4 will have participated on teams with the The Customer Services team is also mean we attract more clinical surveyors, full-time surveyors have evaluated the responsible for the coordination and specifically medical clinician surveyors. process as extremely valuable, as they management of the survey process. Retention strategies are currently have learnt a different dimension to the This includes supporting surveyors being explored to ensure that we are surveying process. and matching the most appropriate also able to continue to maintain our surveyors to the organisations to ensure surveyor workforce. the best outcome. Feedback suggests we are improving in this area. Education for Surveyors State Advisory Committees Outlook Each year the Customer Services team Each year the Customer Services In the coming year our Customer coordinates education and training for Team coordinates the State Advisory Services team will continue to focus on all of our surveyors across Australia. In Committees in each state. The State ensuring a successful implementation 2006/2007 325 surveyors were trained Advisory Committees provide support of our updated accreditation standards, in EQuIP 4. Each existing surveyor and assist the ACHS by participating EQuIP 4. We will need to ensure a more attends at least one full-day session in consultations with members and clinical focus providing more clinical of training per year. Topics include key stakeholder groups in their state, surveyors in the accreditation process. EQuIP 4 standards, accreditation providing advice on addressing issues This will involve not only recruitment but processes, team building, performance and on ACHS products, services also retention strategies to maintain the indicators, survey report writing and and activities. These meetings are a clinical surveyor workforce. surveying differing types of health valuable avenue to review these issues. We are also focused on ensuring, care facilities. These training days are Membership includes surveyors, EQuIP as far as practicable, that the costs planned to meet surveyor learning and members and other jurisdictional 21 of providing our member services development needs and programs stakeholders. This year we have are contained and the program is change each year depending on successfully run twelve meetings sustainable for both the ACHS and surveyor and ACHS requirements. (September 2006 and February 2007) our members. for QLD/NT, NSW/ACT, VIC, TAS, SA Customer Services trains all new and WA. Refining the Advanced Completion surveyors through a three-day induction Survey process is also a priority to program. In 2006/2007 41 new Trained Coordinators ensure our members are able to surveyors were trained which included We have achieved a 100% rate of focus on the immediate corrective 23 clinicians, 16 administrators and 2 Trained Coordinators participating on action sometimes required after an consumers. The aim of the induction all surveys during the past 12 months onsite survey. program is to ensure surveyors for the purpose of increasing inter-rater understand the role of the surveyor, reliability. This means that on each the ACHS, the EQuIP 4 standards, survey there is a surveyor who has how to be part of a survey team and ACHS ANNUAL REPORT 2006-07 attended extra training days each year to be able to verify evidence. New as well as being specifically trained surveyors take part in training surveys to be a team leader. It is important and are evaluated prior to being able that there are skilled team leaders to to survey for the ACHS. All surveyors ensure a greater understanding of are evaluated on an ongoing basis by the standards and how to verify the organisations and by each other to evidence. ensure that we provide a service that meets internal and external customer On each team there is also a surveyor expectations. who has the latest industry knowledge; this surveyor is likely to be a volunteer surveyor who is still employed in the health industry. The combination of the leader and the industry representative ensures the best team available. International experience We continue to participate in the international exchange of surveyors. During the past year, in addition to Pictured: ACHS Executive Manager, contributing Australian surveyors to New Customer Services, Heather McDonald Zealand reviews, five of our surveyors participated in a survey process in Ireland. Also, in partnership with the Irish Health Services Accreditation Board, two surveyors from Ireland contributed to survey teams in Australia. We have also prepared surveyors to review progress against our standards for the ACHS International memberships.
Pictured: ACHS Surveyor Associate Professor Brett Emmerson 5,000 Over 5,000 health industry employees accessed education on the updated ACHS accreditation standards, EQuIP 4.
Education & Support Service The mode of delivery for education ACHS Surveyor workforce by services has been broadened to An annual program of education experience/background include teleconferences on targeted calendar workshops is offered for our topics. Topics include Policy and Policy members, covering topics such as: Management, Surveyor Education and • Applying the EQuIP 4 Standards Orientation to EQuIP 4. • Effective Policies and Open Disclosure As part of our collaboration with • Governance Matters industry the ACHS and the Australian Red Cross Blood Service delivered • Influencing Quality Improvement and education regarding the use of Practice Improving Methodologies blood and blood products. • Interpreting and Using Clinical There has been an increased focus Indicator Data on website marketing to ensure all 22 Nursing 135 • Risk Management members are aware of the programs Allied Health 9 • Self Assessment Reporting and the that are available. Marketing via email Consumers 16 Electronic Assessment Tool. has enabled a focused, targeted, state-based campaign to be Medical and Dental 78 We continued to offer customised implemented approximately every Administration 90 onsite programs which are proving two weeks. popular for many of our members with demand increasing. Executive Masterclass Significant activities and outcomes The Executive Masterclass series was during 2006/2007 held again in February 2007, tailored to executive managers, CEOs and leader • Education provided support for the clinicians. The topic, Leadership: the rollout of EQuIP 4 critical success factors – leading change
ACHS ANNUAL REPORT 2006-07 • Over 5,000 health industry employees strategically, leading improvement, accessed education on the updated attracted a senior and motivated group ACHS accreditation standards, of health industry leaders. This series EQuIP 4 will be become a feature of the annual education program. • Increased the availability of web-based education information Outlook 2007/2008 and self-learning tools suitable for • More self-learning materials and in-house use resources provided via the ACHS • Increased the focus of programs website to specific target audiences (mental • Detailed program information available health, day surgeries, clinicians, on the website to help decision private health services, divisions of making and improve responsiveness general practice) to in-house customised programs • Tailored programs delivered as • Program design and content regularly customised onsite education reviewed and modified based on supporting the implementation customer demand and evaluation of EQuIP 4 • Teleconferences to be used • Broadened the number of specialist increasingly as a targeted and low- facilitators to include surveyors in cost education channel the provision of education. This has ensured the ACHS is able to reach a • Increasing the number of programs wider audience from a larger pool of designed for more experienced facilitators. quality coordinators • Identifying strategic partners for specific programs. division report: development
The ACHS Development unit researches Review of Indicator sets 2. Standards and Program and generates new program initiatives The Performance and Outcomes Development and publications as well as reviewing Service will be reviewing several sets of existing ACHS programs for the As reported in the 2005/2006 Annual its clinical indicators during 2007/2008, purpose of improving safety and Report the major undertaking for the including oral health, obstetrics and quality of health care in Australia. Standards and Program Development pathology. team during that year was coordinating Development is structured into three The procedure for reviewing clinical the review and updating of the ACHS main areas: indicators is an intensive process accreditation standards (progressing from EQuIP 3rd edition to EQuIP 4). 1. Performance and coordinated by the Performance and Outcomes Service Outcomes Service but led by the To assist in the implementation of the Australian and New Zealand medical 2. Standards and EQuIP 4 standards, during 2006/2007 colleges, associations and societies. Program Development the team has developed specific resource tools and linkage documents 3. Research Indicator sets are regularly reviewed to 23 ensure their relevancy to clinicians and supporting the implementation of the Work undertaken within the unit is contemporary health care practices to standards for mental health services, guided by an extensive consultative and ensure they remain a valuable tool for day surgeries, oral health, hospital and collaborative process with consumers, quality improvement. community organisations, primary care governments and the health care and multipurpose services. industry. Benchmarking In addition to developing the specific 1. Performance and Outcomes The Performance and Outcomes EQuIP 4 resources, the major Service encourages EQuIP undertaking during this reporting Service (POS) organisations to externally measure period for the Standards and Program POS key project areas and Outlook outcomes with peer group leaders Development team has been the review 2007/2008 through an online benchmarking of the National Standards for Mental program easily accessible by members Health Services (NSMHS). The Clinical Indicator Program now of the Clinical Indicator Program. The has over 400 individual indicators use of this service has more than 3. Research ACHS ANNUAL REPORT 2006-07 to assist member organisations doubled during the reporting period. measure performance. Researching quality improvement The Performance and Outcomes and accreditation processes is a There are 23 sets of indicators Service will continue to encourage and key activity for the ACHS being covering wide-ranging clinical promote benchmarking participation one of our strategic goals and an disciplines including gastrointestinal throughout 2007/2008. ACHS Board Key Performance endoscopy which has been Indicator. The achievements of this introduced during 2006/2007 and year demonstrate that research the separation of indicator sets for and evaluation studies continue to obstetrics and gynaecology. contribute to the evidence base for quality, safety and accreditation.
THE REVIEW OF THE NATIONAL STANDARDS FOR MENTAL HEALTH SERVICES The Australian Council on Healthcare Standards (ACHS) include a service level assessment framework to enable commenced the review of The National Standards for providers to assess their capability to deliver services that Mental Health Services (NSMHS) in November 2006 and it is meet the standards. scheduled to conclude in May 2008. This project is funded The revised NSMHS will reflect: by the Commonwealth Department of Health and Ageing. Although many aspects of the existing NSMHS (which were • the rights of consumers and carers to participate released in1996) remain relevant it is considered necessary at all levels in the planning, development, delivery to revise them for language, to reflect current practice and and evaluation of services to optimise outcomes for to broaden their application. consumers • the right of consumers and carers to expect that mental The principles guiding the revision of the NSMHS are health service staff with whom they come into contact will aligned with those underpinning the National Mental Health Strategy. uphold their rights and deliver fair and proper standards of care and service provision The revised NSMHS are being developed to assist mental • the need for the mental health services to promote health service providers to deliver quality, evidence based, positive outcomes and facilitate sustained recovery. recovery-focused integrated care to people with a mental illness (consumers). The standards acknowledge and respect the consumer’s rights and needs, as well as the rights and needs of their carers and are structured to Evaluation studies The Australian Research Council A Consumer Panel with representatives of the Consumers’ Health Forum The evaluation of the development project researching accreditation has provided a valuable sounding of the EQuIP 4 (the 4th edition of This project is a partnership between board for the research. This process the ACHS Evaluation and Quality industry (ACHS and Ramsay HealthCare of consumer participation in Improvement Program) reviewed the providing seeding funding) and the research is itself being evaluated. process of the development of the University of New South Wales’ Centre EQuIP 4 standards using a best practice for Clinical Governance Research. It ACHS Research Advisory Panel framework for standards development is a world first in its comprehensive This panel provides the ACHS Board derived from principles from the approach to researching health care with strategic advice on research. The Australian Productivity Commission, accreditation. EQuIP is used as second meeting in November 2006 the International Society for Quality in the exemplar of accreditation. The reaffirmed the need for a continuing Health Care and the ACHS Board. The achievements of this year are many: major conclusion was that targeted research agenda into accreditation. 24 and customised communication would • Completion of ethnographic A range of topics was suggested ensure that all stakeholders had an studies of organisational culture, for researching ACHS accreditation equal opportunity to participate in climate, leadership and consumer processes, for using ACHS data for the review. participation in 22 health services research and for more general topics for including three that have never research into safety and quality. The ACHS National Report on Health participated in accreditation Services Accreditation Performance Doctorate students 2003–2006 provided the ACHS the • Initial analysis of data examining the The ACHS commitment to research is opportunity for valuable reflection on relationships between organisational further demonstrated by the fact that the impact of the previous edition of the performance (ethnographic studies), there are three ACHS employees who standards (EQuIP 3rd edition). Trends accreditation performance (EQuIP are part-time PhD students, including were reviewed in the aggregated, de- Organisation-Wide Surveys) and two Executive Managers. The study identified data from more than 1200 clinical performance (ACHS clinical topics are closely related to the research onsite surveys. Overall, there was indicator results) into accreditation.
ACHS ANNUAL REPORT 2006-07 noticeable improvement in performance • Completion of focus groups, Department of Health and over the four year period in the key interviews, questionnaire surveys and areas of safety and quality as illustrated scenario testing to explore survey Ageing (Australian Government) by the mandatory criteria. The report team inter-rater reliability funded project also provides information useful to In June 2007, the ACHS, working with consumers, policy makers and funders • A case study with two simultaneous the Centre for Clinical Governance on national performance against a survey teams at an onsite survey to Research, University of New South range of quality and safety standards understand inter-rater reliability of Wales commenced a three-month assessed in EQuIP. survey teams project to expand and consolidate a • Two doctorate students research network of academics and commencing data collection accreditation agencies that the ACHS by survey questionnaire and had already established to set an interviews to explore the impact of agenda for collaborative research into surveyors in their own organisations accreditation. The Department sought using network theory to assist in building research capacity • A number of papers and and asked the ACHS to develop a presentations including a paper on proposal which they may subsequently the methodology: approve for funding. A meeting of the network that was expanded to A prospective, multi-method, include policy makers and funders multi-disciplinary, multi-level, (the Australian Accreditation Research collaborative, social-organisational Network) was to meet to set priorities design for researching health sector for researching accreditation. Funding accreditation [LP0560737] Jeffrey was also provided to develop the first Braithwaite, Johanna I Westbrook, stage of a research proposal. Marjorie Pawsey, David Greenfield, Justine Naylor, Rick A Iedema, Bill Research activities are updated on Runciman, Sally Redman, Christine the ACHS website as they occur Jorm, Maureen Robinson, Sally (www.achs.org.au/research). Nathan and Robert Gibberd BMC Health Services Research, 6:113 (12 Sep 2006) http://www.biomedcentral.com/ Pictured: Rehabilitation at Royal Brisbane and 1472-6963/6/113 Royal Women’s Hospitals division report: CORPORATE SERVICES
The foundation to achieve Customer Relationship Management Electronic Assessment Tool (EAT) our goals database (CRM) The Electronic Assessment Tool is Our Corporate Services division delivers The CRM is a web-based integrated ACHS-developed software used by the foundation for our goals to be corporate database. All users self member organisations to capture efficiently and effectively achieved, manage their own user identification their quality improvement initiatives including: and passwords to access the respective and progress against the ACHS secure sites. This in turn is linked to, accreditation standards. • Financial services and allows user access to, the new web EAT 4 has been officially in use since • Information technology services based Electronic Assessment Tool (used November 2006 with more than 1,800 • Human resources management by both member organisations and registered users. The web-based EAT surveyors in the accreditation process). • Business services, including strategic is also used by international member New features and reports have been planning, and organisations and surveyors. Training incorporated into the CRM to improve and support is provided face-to- • Business development, local and 25 management of the various stages in face at workshops as well as via international. the accreditation process. teleconferences. There are also detailed A secure financial future Our website www.achs.org.au training manuals for all levels within The financial performance for the year the tool. Supplementary products The new website is linked to the ACHS ended 30 June 2007 shows a small on the EAT 4 platform are also being CRM database and has been fully surplus of $10K. When compared to the developed and implemented, such operational since October 2006 with original projected budget loss of $76K, as EAT for EQuIP Corporate Health 1,918 successful registrations for either the turnaround has been substantial. Services and Conditional Surveys. Member, Surveyor or Board access to Income from renewal memberships, Enhancements to the EAT are in restricted and tailored information (as education workshops and savings from progress based on user feedback at 31 May 2007). New registrations are operating expenses were the main such as the ability to work offline and still occurring at the rate of between 15 contributors to the result. enhancing reporting options. to 25 per day. The ACHS Board section IT has also extended its maintenance
The business plan and budget for of the site has also been updated with ACHS ANNUAL REPORT 2006-07 2008 indicate a continuance of tight links to previous minutes of meetings schedule to cover the website and EAT financial constraints under which the and policies dating from 1995. The 4 application twenty-four hours per day. ACHS is expected to operate during same has been done for the ACHS Performance Indicator Reporting the next financial year. This has largely Council and Annual General Meeting Tool (PIRT) been driven by the increasing costs minutes from 2000/2001. There is of providing services to members; also a new section to promote ACHS PIRT is the ACHS-developed inflationary pressures and a reduction in International. application provided to organisations the number of volunteer surveyors able that participate in our Clinical The new website has resulted in a to be included on teams. Indicator Program. The tool is used to revival of interest in the ACHS website capture and submit clinical indicator Information technology as a communications tool especially data. Planning for a web-based for members and surveyors. The application has commenced with The year ended 30 June 2007 has website content is updated more seen many significant changes to IT ACHS user specification meetings. frequently as more staff know how to Plans for the formation of a working infrastructure at the ACHS. The main use the ‘Content Management System’ changes relate to the ACHS website, party and identification of pilot test (which requires no knowledge of organisations are in progress. The Customer Relationship Management HTML) and updates can also be made database (CRM) and the Electronic functionality and access will be remotely (not just from ACHS offices). similar to the web-based EAT. Assessment Tool (EAT). Many of This means updated information is our internal and external tools and readily available with downloadable applications have been successfully Adobe PDF format publications transitioned to a web-based format and resource tools made freely resulting in a more user friendly and available for members and surveyors. flexible system that enables “real- The ACHS also has information time” availability of data. Evaluation on website hits for evaluation of of the new website in June 2007 content and marketing strategies. supports the ACHS decision to design and develop programs which utilise these systems with 96.2% of our customers using Internet Explorer version 6 browsers and 91.97% using Windows operating systems.
Pictured: Royal Brisbane and Royal Women’s Hospitals Business Services Outlook 2007/2008 Employee development and training During 2006/2007 our Business • Strategies to formalise cross training Both in-house and external training Services team undertook a range of of staff to ensure succession planning was provided to our employees. quality improvement activities which and resourcing This included quality improvement involved evaluations and implementation conferences, courses on qualitative • Staff satisfaction survey of improvements as required. analysis tools, IT, public relations, These included: • Operationalise the web-based PIRT. seminars on evaluation systems and Our team company directorship. There was also • Review and alignment of policies, significant in-house training provided procedures and flowcharts for ACHS employees demonstrate an to employees and surveyors on IT the EQuIP program administrative ongoing commitment to improving applications such as the CRM, EAT and services from our previous health care in Australia. We are fortunate maintenance of the website. accreditation standards to our to have such dedicated staff, many of 26 updated accreditation standards whom have been with the ACHS for Group Trainee Program several years and are able to contribute (EQuIP 3 to EQuIP 4) The ACHS participates in a Group to our organisational continuity. • Review of policies, procedures Trainee Program and as at 30 June and flowcharts for education Of note in the 2006/2007 period are the 2007 hosted five trainees, from Health administrative services to support following celebrations of service: Industry Group Training Company (HIGTC) and MEGT (Australia) Ltd. improved use of the website for 1 staff member 22 years workshop registrations and increased The aim is to provide the trainees with use of teleconferences for education 2 staff members 19 years on-the-job training and off-the-job training at TAFE (or other approved • Audit of member organisation 1 staff member 15 years training provider). The program is for a correspondence and report files 3 staff members 10 years 12-month period and at the completion • Audit and review of archive policy in of the program the trainees receive relation to member organisation files Our workplace environment a nationally recognised certificate and could also be offered full-time
ACHS ANNUAL REPORT 2006-07 • Pilot testing of the web-based EAT for During the year a number of initiatives employment with the ACHS. During the EQuIP and EQuIP Corporate Health were implemented to ensure a safe period 2006/2007, two of the trainees Services programs and pleasant working environment. An extensive renovation of level 2 of completed their traineeships and were • Processing of all user-applications our offices in Ultimo, Sydney occurred offered and accepted positions as full- requesting access to the website and in April 2007. The renovation was the time employees with the ACHS. the EAT. result of an office ergonomics audit Business Development which raised the sloping floor on level During 2006/2007 Business 2 as a significant occupational, health Development: and safety issue. The renovation started in the middle of April 2007 and was • Provided data and analyses for the completed at the end of May 2007. ACHS National Report on Health The renovation included levelling of the Services Accreditation Performance uneven floor, installing a new suspended 2003–2006 sound absorptive ceiling and carpets. The renovation was approved by the • Completed qualitative and quantitative Board at a cost of $150K. evaluations on feedback data from organisations and surveyors on The Occupational Health and Safety accreditation surveys from 2003 to Committee continued its important 2006 work throughout the year meeting eight times. These meetings dealt with regular • Formalised system for data entry and and special issues, fire wardens and analyses of education onsites and renovation plans for level 2. calendar workshops • Provided data and analyses for The key accomplishments of this conference presentations and papers committee over 2006/2007 were: • Provided monthly key performance • Implementation of policy and indicator reports and feature reports procedure on emergency evacuation to the ACHS Board and Council. • Emergency evacuation and fire training course conducted • Successful relocation of staff during level 2 renovations • Tagging of electrical appliances Pictured: Skin & Cancer Foundation Westmead throughout the building. Day Clinic, Sydney CORPORATE GOVERNANCE: OVERVIEW
Introduction The functions and responsibilities of Stakeholders The ACHS, a company limited by the Board include: The State Advisory Committees guarantee, is governed by a board • The strategic direction of the ACHS, (SACs) include representatives from of 12 directors elected, by council including approval of the corporate the health industry, governments members and supported by a strategic plan and guiding policies and consumers. The SACs are a corporate management system. collaborative forum providing advice to • Establishing policies to safeguard the ACHS staff and Council on issues of The Board is responsible to the Council, ACHS and to monitor performance in strategic interest. During 2006/2007 for the direction and oversight of achieving its goals through requiring the SACs were expanded to include ACHS activities, and provides a report regular and timely reporting on a more representation from member on performance at the ACHS Annual comprehensive set of performance groups both private and public and General Meeting. issues stakeholders including jurisdiction Both bodies are guided by the • Approval of the annual financial report (health department) representation. Corporations Law and the Constitution and budget SAC members join the councillors at 27 of the Australian Council on Healthcare twice yearly meetings to ensure that • Satisfying itself that a robust and Standards, adopted in 1974 and there is a dynamic mix of ideas and sound system of issue and risk regularly reviewed. representation. management exists, with the Functions and responsibilities executive responsible for identifying Structure of the Board of the Board and managing issues and risk The experience and areas of expertise The Board has adopted statements of • Accountability, and of each member of the Board is set out vision and mission which are designed • Representation of the ACHS. on page 30. to determine the organisation’s The Board undertakes regular evaluation The ACHS Board consists of 12 strategic direction, and has endorsed of its own performance and this process representatives voted on at the Annual organisational values and behaviours will be assisted by an external facilitator General Meeting in November by the to ensure its operations are conducted to examine the structure and skills ACHS Council. The ACHS Council to meet high standards of service and required for an effective board in the includes 34 representatives from ACHS ANNUAL REPORT 2006-07 professionalism. latter part of 2007. consumers, peak health industry bodies and governments throughout Australia. Whilst the Board reviews and approves The Board maintains currency of its the organisation’s strategic plan and understanding of ACHS operations Given the Board’s representational guiding policy, day-to-day management through monthly meetings. In make-up, at the commencement of of the ACHS and implementation of preparation the Board receives: each Board meeting, members are the strategic plan are delegated to the asked to declare any conflict of interest Chief Executive with the assistance of • Monthly reports from the Chief arising from agenda items and to executive managers. Executive and executive team withdraw from the relevant discussion. on financial, human resources, The goals of the organisation’s strategic quality, risk management and directions and priorities have remained industry performance the same and performance indicators were refined to reflect the current • Feature reports from ACHS staff environment. regarding initiatives of strategic interest • Monthly and quarterly reporting of key performance indicators related to the strategic goals of the organisation. The President and Chief Executive communicate regularly on issues and performance. The Board has procedures in place so that its members may seek independent professional advice on any ACHS matter at the organisation’s expense, subject to the prior approval of the President. The Board is assisted in its deliberations on issues relating to the ACHS standards by the Standards Committee. Annual General Meeting: Remuneration November 2006 Our staff remuneration policies and Dr Michael Hodgson AM, was re-elected conditions are struggling to remain as the President. Dr Hodgson who is comparative to market and industry based in Tasmania, is a representative benchmarks. of the Australian Medical Association on Our Board’s travel and accommodation the ACHS Council and has been a Board expenses are covered, however no Member since 1999. honorarium is paid. In his previously held role as Chair of the Standards Committee Dr Hodgson Standards Committee led the development of the revised The Standards Committee is a standing accreditation standards (EQuIP 4) to be committee of the ACHS Board and 28 applied from the beginning of 2007. takes its direction from, and reports to, the Board. Dr Noela Whitby AM, Chair of Australian General Practice Accreditation The prime function of the Standards Limited (AGPAL), who represents the Committee is to oversee and guide the Royal Australian College of General ongoing review of ACHS standards Practitioners on the Council, was and related resources. The Committee re-elected as Vice President and determines and recommends to Associate Professor Peter Woodruff, the Board whether new or revised who represents the Royal Australasian standards are appropriate for use within Pictured: Ms Helen Dowling, Chair, ACHS Standards Committee College of Surgeons, and is the Director ACHS accreditation programs. of Vascular Surgery at the Princess The Standards Committee membership Alexandra Hospital in Queensland was represents consumers, governments re-elected as the Treasurer. Mr Stephen and peak health industry professional Walker, a councillor representing the ACHS ANNUAL REPORT 2006-07 bodies; including clinicians, Australian Private Hospitals Association, administrators and quality coordinators. was welcomed to the Board. Committee membership also includes Internal committees and representatives of the ACHS Executive, guiding policies (including the Executive Manager – Development, Executive Manager– Our internal Occupational Health Customer Services as well as the ACHS and Safety Committee continued its Chief Executive). important work throughout the year meeting four times and ensuring The Committee Chair is ACHS compliance with relevant regulations Councillor Ms Helen Dowling. and legislation. No significant workplace The major determinations for the injuries were reported during the year. year 2006/2007 were the piloting, Human resources consultation and evaluation of new standards (EQuIP 4) and The conditions offered to staff from our recommendations to the ACHS Board human resources principles and policies on the selection of EQuIP 4 mandatory exceed the minimum requirements of criteria. Throughout 2006/2007 there legal and regulatory requirements. was extensive consultation within Our executive appointments are the Standards Committee and it met approved by the Board. formally on four occasions. No workplace agreements are as yet in place. The membership of the Standards Committee 2006/2007 and attendance at meetings were as follows:
STATE A B Dr Michael Hodgson AM, (Chair 2001–2006), FAMA, MBBS , FANZCA, FRCA, AFCHSE ACHS President, ACHSI President, TAS 2 2 ACHSI Standards Committee Chair Ms Helen Dowling (Chair 2006–Current), NSW 4 3 BPharm, Dip Hosp Pharm (Admin), Grad Cert QI Hlth C, CHP, ACHS Councillor Mrs Jackie Bullock WA 4 3 RN, BA (Govt Studies) Ecowan Ms Margo Carberry NSW 4 4 RN, C&FHN, AFAAQHC, ACHS Surveyor Associate Professor Brett Emmerson QLD 4 4 29 MB BS (Qld), MHA (NSW), FRANZCP, FRACMA, ACHS Surveyor Mr Phillip Goulding VIC 4 4 SRN, BBA, Grad Dip BA, MBL, AFCHSE, ACHS Surveyor Dr Philip Hoyle NSW 4 2 MB BS, MHA, FRACMA, ACHS Surveyor Ms Leith MacMillan QLD 4 1 RN, ACHS Councillor Ms Sue McKean QLD 4 3 MHSc (Risk Management), Grad Dip (OHS), Dip OHS Ms Alison McMillan* VIC 2 1 RN, BEd, MBA
Ms Jenni Smith ACHS ANNUAL REPORT 2006-07 VIC 4 3 BApp Sc (Pthy), Grad Dip Physiotherapy (Research) Ms Ann Thomson ACT 4 2 BA Hons, Dip Ed, MA Mr Stephen Walker SA 4 3 BBus, Grad Dip (Acc), Dip Eng, ACHS Councillor
* Appointed to Standards Committee, December 2006
A Meetings held during the period of office of the member
B Meetings attended by the member ACHS BOARD OF DIRECTORS As at 30 June 2007 Representing consumers, governments and the Australian health care industry.
It was decided at the November 2006 Dr Noela Whitby AM (Vice President) 2 Ms Karen Jane Linegar 4 ACHS Annual General Meeting to MBBS (Qld), Grad Dip HumNut, DPD, RN, RM, Ba AppSc. (Nursing), MHA, amend the Constitution; providing FRACGP, FAICD Post Grad. Comm. Law, FRCNA for an additional position on the Board. The new position is open to • ACHS Board Member since 2000 • ACHS Board Member since 2004 all members of Council. Mr Stephen • ACHS Vice President since 2005 • Director of Nursing , North West Walker was subsequently elected and • Chair, National Expert Committee on Regional Hospital, Burnie the Board was delighted to welcome Standards of RACGP, 2002–2005 1994–present him as a member to his first meeting in • President Royal College of Nursing, December 2006. There have been no • Member, National Expert Australia 2002–2004 other changes to Board membership Committee on Standards of RACGP over this period. 1994–present • Board member Royal College of • Chair, Australian General Practice Nursing 2002–2007 30 Accreditation Limited, 2003–2006 • Chair Nursing Board of Tasmania Dr Michael Hodgson AM (President) 1 • Director Australian General Practice 2000–2003 FAMA, MBBS, FANZCA, FRCA, AFCHSE Accreditation Limited, 2000–2006 • ACHS Surveyor 2005–present • ACHS Board Member since 1999 • Director, Quality in Practice Pty Ltd, • Chair ACHS Tasmanian Advisory 2003–2006 Committee 2005–present. • President since 2005 • Director National Asthma Council • Chair ACHS Standards Committee 2005–present 2001–2006 Ms Kae Martin 5 • General Practice Principal, • Member of Working Group Clinicians RN, RM, BHSc(Nursing), MHA, LLB, ACHSE Carindale Medical Clinic, Brisbane, Guide to EQuIP, Working Group, 2004 1979–present • ACHS Board Member since 2003 • President, Medical Council of • Associate Professor of General • Executive Director, Service Tasmania, 1999–present Practice, Bond University Development, Central Northern • Chair, Postgraduate Medical Institute Adelaide Health Service, ACHS ANNUAL REPORT 2006-07 2006–present of Tasmania, 1997–present 2004–present Associate Professor Peter Woodruff • Director, Acute Care & Clinical • Member, Australian Medical Council (Treasurer) 3 (AMC), 1999–present Services, SA Department of Health, MBBS, ChM, FRCS, FRACS, FACS • Chair, Joint Medical Boards Advisory 2000–2004. Committee (AMC), 2003–present • ACHS Board Member since 2002 • Past President, Tasmanian Branch, • ACHS National Advisory Committee Mr Russell McGowan 6 Australian Medical Association Chair, 2002–2003 BA (Adelaide) • Director of Vascular Surgery, Princess • Past member of Executive • ACHS Board Member and consumer Alexandra Hospital, Qld, 2003–2005 Committee, Australian Medical surveyor since 2001 Association • Vice President, Royal Australasian • National Advisory Committee Chair, College of Surgeons, 2003–2005 • Past President, Australian and 2003–2005 New Zealand College of Anaesthetists • Honorary Treasurer, Royal • Director, Australian Divisions of Australasian College of Surgeons, • Past President, Australian Society General Practice, 2003–present of Anaesthetists 2000–2002 • Member, ACT Health Council, • President, Australian and New • Past Member, Royal Hobart Hospital 2003–present Board of Management and Southern Zealand Society for Vascular Surgery, • Community Member, National Blood Regional Health Board. 2006–2007. Authority Board, 2003–2007 • Vice Chair, Consumers’ Health Forum of Australia, 2002–2006 Attendance at ACHS Board Meetings july 2006–June 2007 • Consumer representative on A B A B numerous local and national Dr Michael Hodgson AM 9 8 Mr Michael Roff 9 7 healthcare committees. Ms Karen Linegar 9 6 Mr John Smith 9 9 Ms Kae Martin 9 8 Dr Dana Wainwright 9 4 Mr Russell McGowan 9 7 Mr Stephen Walker 5 5 Dr Len Notaras AM 9 8 Dr Noela Whitby AM 9 9 Dr Robert Porter 9 7 A/Prof Peter Woodruff 9 6
A Meetings held during the period of office of the Board Member
B Meetings attended by the Board member 1 2 3 4 5
Dr Len Notaras AM 7 Mr Michael Roff 9 Mr Stephen Walker L AFCHSE, LLB, BA (Hons), DipComm, Grad. Cert. Mgt. As.Dip.Eng., B.Bus., Grad.Dip.Acc., AICD, BMed, MHA, MA. AFACHSE ACHS • ACHS Board Member since 2003 • ACHS Board Member since 2002 • ACHS Board Member since 2006 • Executive Director, Australian Private • Clinicians Involvement Working Group Hospitals Association, 2000–present • Chief Executive Officer, St Andrew’s Chair, 2003–2004 Hospital, Adelaide, 2001–Present • Member, National Health Performance • Medical Superintendent Royal Darwin Committee, 2000–present • Board member, Australian Private Hospital, 1994–present Hospitals Association (APHA) • Member, Private Health Industry 2005–Present • Senior Superintendent NT Acute Care Quality & Safety Committee, Network, 2003–present 2000–2004 • Chairman, SA Branch APHA 2004–Present • Member NT Medical Board, • Member, National Centre for 1996–present Classification in Health, Management • Member, SA Safety and Quality 31 • Chair NT Radiographers Board Advisory Committee, 2000–present Council 2007–Present 1997–present • Director, Australian Centre for Health • Member, Private Hospital Sector • Senior Lecturer NT Clinical School Research, 2006–present. Committee, Australian Commission 1995–present on Safety and Quality in Healthcare 2007–Present • Council Member National Council Mr John Smith PSM J for Safety and Quality in Healthcare, • Past Vice President, SA branch MHA, Grad Dip HSM, AFACHSE, CHE, ACHSE 1999–2006 FAHSFMA, AFAHRI, AFAIM, FHFM, FAICD • Past ACHS and QHNZ Surveyor. • NT President ACHSE 2003–present • ACHS Board Member since 2005 • Chair NT Acute Care Quality • Chief Executive Officer, West Committee, 2003–present Wimmera Health Service • Medical Director of the NT Medical • National Councillor–Australian
6 7 ACHS ANNUAL REPORT 2006-07 Administration Network, Healthcare Association 2000–current 2005–present • Director Victorian Healthcare • Region #1 Top End Medical Disaster Association 1997–2004 Coordinator. • Board Member, The Victorian Hospitals Industrial Association Dr Robert Porter 8 Limited 1994–current. MBBS, FRACGP, FRACMA, AFACHSE
• ACHS Board Member since 2003 Dr Dana Wainwright K 8 9 • ACHS Surveyor since 1992 MBBS, FRACP • Councillor, Royal Australasian College • ACHS Board Member since 2003 of Medical Administrators, 1997–May 2006 • V.M.O. Royal Brisbane Hospital • Area Director of Clinical Services, • Chair, AMA Federal Council Mid North Coast Area Health Service, 2003–present 2001–2005 • President of A.M.A.Q. 1998–1999 • Project Manager Medical Workforce • Chairman of Medical Staff Association J K and Director of Medical Services Royal Brisbane Hospital Maitland Hospital, Hunter New 2006–present. England Area Health Service, 2005–2007 • Medical Advisor, Internal Audit Hunter New England Health Service 2007 • Area Director of Medical Services Greater Western Area Health L Service 2007 • Consultant in Medical Administration. ACHS COUNCIL MEMBERS As at 30 June 2007 Our Council represents consumers, governments and peak health industry bodies from throughout Australia
The ACHS Council’s powers and 2006/2007 ACHS Council Members, their qualifications and duties include: bodies represented were: • Election of the Board, President, Vice President and Mr Richard Bartlett BA (Hons) Treasurer at the Annual General Meeting Commonwealth Department of Veterans’ Affairs
• Appointment of council committees Dr Caroline Brand MBBS, BS MPH, FRACP • Consideration and recommendation to the Board regarding Royal Australasian College of Physicians the acceptance of other organisations as members of (Resigned 10/2006) the Council Mr Ken Campbell • Contribution and support of the ACHS and assistance in Department of Health and Human Services, Tasmania determining the strategic direction of the ACHS Mr Trevor Canning BHA, CPA, FACHSE • Participation in the determination of accreditation status, Australian College of Health Service Executives 32 where appropriate • Consideration and monitoring of Board performance. Dr Margaret Cowling MA, BM, BCh, DObst, RCOG, FRCA, FANZCA Australian and New Zealand College of Anaesthetists (Appointed 06/2007)
Professor David Davies BSc(Hons), MB, ChB, MD, FRCPA The Royal College of Pathologists of Australasia
Dr Paul Devenish-Meares, MBBS (QLD), FRANZCOG, FRCOG Royal Australian and New Zealand College of Obstetricians and Gynaecologists (Appointed 11/2006)
Ms Helen Dowling BPharm, DipHospPharm(Admin), GradCert QI HlthC, CHP
ACHS ANNUAL REPORT 2006-07 Health Professions Council of Australia
Ms Jenny Duncan RN, RM, Post Grad OT Cert, B Admin (Nursing), FCN, FRCN Catholic Health Australia (Appointed 02/2007)
Ms Tanya Gawthorne BSc, GradDipEd, PostGradDipPubHlth, Masters App.Epi Department of Health, Western Australia Ms Christine Gee Australian Private Hospitals Association (Resigned 10/2006)
Professor Warwick Giles MBBS, FRACOG, DDU, PhD, CMFM Royal Australian and New Zealand College of Obstetricians & Gynaecologists (Resigned 08/2006) Associate Professor Deborah Green BSocStud Dr Eva Raik AM, MBBS, FRCPA, FRACP Australian Healthcare and Hospitals Association Council Life Member
Dr Michael Hodgson AM (President), MBBS, FAMA, FANZCA, FRCA, Mr Michael Roff Grad.Cert.Mgt. AFCHSE Australian Private Hospitals Association Australian Medical Association Ms Kathleen Ryan FAAQHC Mrs Alice Jones RN RM CHCNS BAS (Nursing) The Australasian Association for Quality in Health Care ACT Health Dr Paul Scown MBBS(QLD), BHA(NSW) FRACMA, AFCHSE, CHE Mr Mark Kearin RN, ADCNS-Gerontology, BHS-Management, Australian Healthcare and Hospitals Association MHS-Management (Appointed 09/2006) Australian Nursing Federation Mr John Smith MHA, Grad Dip HSM, AFACHSE, CHE, FAHSFMA, Dr Diana Khursandi MA BM BCh DObst RCOG FRCA FANZCA AFAHRI, AFAIM, FHFM, FAICD Australian and New Zealand College of Anaesthetists Australian Healthcare and Hospitals Association 33 (Resigned 05/2007) Dr Michael Smith Ms Karen Linegar RN, RM, Ba AppSc (Nursing), MHA, Post Grad. NSW Health Comm. Law, FRCNA (Appointed 08/2006) The Royal College of Nursing (Resigned 02/2007)
Professor Katherine McGrath MB BS FRCPA MACMA Dr Dana Wainwright MBBS, FRACP NSW Health Australian Medical Association (Appointed 02/2007) Mr Stephen Walker AsDipEng, BBus, GradDip.Acc, AICD, AFCHSE Dr Sally McCarthy MBBS, FACEM, MBA Australian Private Hospital Association Australasian College for Emergency Medicine (Appointed 10/2006) (Appointed 10/2006) Dr Noela Whitby AM MBBS (Qld), Grad Dip HumNut, DPD,
Dr Peter McGeorge QSO, MBChB, FRANZCP FRACGP, FAICD ACHS ANNUAL REPORT 2006-07 Royal Australian and New Zealand College of Psychiatrists Royal Australian College of General Practitioners
Mr Russell McGowan BA (Adelaide) Professor Andrew J Wilson BMedSci, MBBS, PhD., Consumers’ Health Forum of Australia FRACP, FAFPHM Queensland Health Ms Alison McMillan RN, BEd, MBA Department of Human Services, Victoria Associate Professor Woodruff MBBS, ChM, FRCS, FRACS, FACS Royal Australasian College of Surgeons Ms Leith MacMillan RN Australian Day Surgery Council Dr Choong-Siew Yong MBBS, FRANZCP, CertCAPsy Australian Medical Association Ms Kae Martin RN, RM, BHSc(Nursing), MHA, LLB, ACHSE Department of Human Services, South Australia 5 Resigned Dr Len Notaras AM, AFCHSE, LLB, BA(Hons), DipComm, BMed, MHA, MA. 8 Appointed (following 3 Nominations pending Northern Territory Department of Health and as at 30 June 2006) Community Services 0 Nominations pending as at 30 June 2007 Dr Robert Porter MBBS, FRACGP, FRACMA, AFCHSE The Royal Australian College of Medical Administrators financial statements: directors’ report
The names of the members of the Board in office during Share capital the reporting year are: The company was incorporated on 4th December 1979 Dr Michael Hodgson AM as a company limited by guarantee.
Ms Karen Linegar Review of operations Ms Kae Martin Total trading revenue for the year ending 30 June 2007 was Mr Russell McGowan $8,228,140 compared to $7,428,263 in the previous year. The favourable variance compared to last year is attributed to: Dr Leonard Notaras • Membership fees Dr Robert Porter • Projects Mr Michael Roff • Education workshops. 34 Mr John Smith During the year a wholly-owned subsidiary, ACHS International Dr Dana Wainwright Pty Ltd, continued its focus on strategic markets: the Middle East, India and Hong Kong. ACHS International Pty Ltd extends Mr Stephen Walker (Appointed 23 November 2006) the mission of the Australian Council on Healthcare Standards Dr Noela Whitby (ACHS) internationally, through consultation, accreditation, publications and education. ACHS International delivers Associate Professor Peter Woodruff accreditation and quality improvement programs to health care Directors have been in office since the start of the financial year organisations throughout the world. The accreditation program to the date of this report unless otherwise stated. is based on the Evaluation and Quality Improvement Program 4th edition standards. Consultants are also available to assist Company Secretary countries in the development of their own accreditation and quality improvement programs. The following person held the position of company secretary at the end of financial year: Financial assistance by way of grants was received from
ACHS ANNUAL REPORT 2006-07 New South Wales Department of Health and Australian Mr Brian Johnston – Fellow of the Australian College of Health Trade Commission. Service Executives, the Australian Institute of Company Directors and the Australian Institute of Management. He has State of affairs over 30 years of Australian health industry experience. In the opinion of the Directors, there were no significant Principal activities changes in the state of affairs of the Company that occurred during the financial year under review or any significant changes The principal activities of the Company during the financial year likely to affect the state of affairs of the Company in future remained unchanged and were to be recognised nationally financial years. and internationally as the leading Australian organisation that independently assesses performance in order to promote and Future developments improve quality and safety of health care. Likely developments in the operations of the Company and There was no significant change in the nature of the Council’s the expected results of those operations in future financial activities during the 2006/2007 period. years have not been included in this report as the inclusion of such information is likely to result in unreasonable prejudice Operating results to the Company. The consolidated net profit for the financial year ended 30 June 2007 before extraordinary items was $9,789.27. The company Environmental issues is exempt from the payment of income tax. The directors believe that the operations of the company are not subject to any specific or significant environmental The parent entity is exempt from the payment of income tax. regulation under either Commonwealth or State Legislation. The subsidiary, ACHS International Pty Ltd, which was formed Accordingly, the directors do not anticipate any effect on the to extend the mission of Australian Council on Healthcare operations of the Company, or on its operating results, as a Standards (ACHS) internationally, is subject to Australian result of environmental regulations. income tax.
Dividends paid or recommended The Australian Council on Healthcare Standards Limited is a not-for-profit organisation, and accordingly no dividends were paid or recommended. 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 2007.
Events subsequent to balance date Non-audit services There are no matters or circumstances that have arisen The board of directors report that there was no non-audit since the end of the period which significantly affected or services provided during the year. may significantly affect the operations of the economic entity, On behalf of the Directors the results of those operations or the state of affairs of the economic entity in subsequent years.
Proceeding on behalf of company No person has applied under Section 237 of the Corporations Act 2001 to bring proceedings on behalf of the company Dr Michael Hodgson AM or intervene in any proceedings to which the company is a President party for the purpose of taking responsibility on behalf of the company for all or any part of those proceedings. The company was not a party to any such proceedings during the year. 35
Indemnification and insurance of officers and auditors Associate Professor Peter Woodruff The Company has not, during or since the financial year, in Treasurer respect of any person who is or has been an officer or auditor Sydney – 27th day of September 2007 of the company or a related body corporate: • indemnified or made any relevant agreement for indemnifying Auditor’s independence declaration against a liability incurred as an officer, including costs and Auditor’s independence declaration under section 307C expenses in successfully defending legal proceedings; or of the Corporations Act 2001 to the Directors of Australian • paid or agreed to pay premium in respect of a contract Council on Healthcare Standards Limited and controlled entities. insuring against a liability incurred as an officer for the costs The directors received the following declaration from the auditor ACHS ANNUAL REPORT 2006-07 or expenses to defend legal proceedings; with the exception of Australian Council on Healthcare Standards Limited. of the following matters: I declare that, to the best of my knowledge and belief, during – During the period the Council paid an insurance premium the year ended 30 June 2007 there have been: indemnifying each of the Directors and Officers of the economic entity against all liabilities to another person • no contraventions of the auditor independence requirements that may arise from the position as Directors or Officers set out in the Corporations Act 2001 in relation to the audit; of the Council, except where the liability arises out of and criminal or dishonest conduct or behaviour involving a • no contraventions of any applicable code of professional lack of good faith. conduct in relation to the audit. – The Company maintained its Professional Indemnity and Directors and Officers insurance policy through OAMPS Insurance Brokers Limited to which the directors are not obliged to contribute.
Board members’ benefits TALBOTS Chartered Accountants During or since the financial year no director of the Company has received or become entitled to receive a benefit, other than a benefit included in the aggregate amount of emoluments received or due and receivable by the Directors shown in the financial statements by reason of a contract entered into by the Company that was related to the Company when the contract S A HOLLIER was made or when the director received or became entitled to Partner receive, the benefit with: Level 9 • a director, or 91 York Street • a firm of which a director is a member, or SYDNEY NSW 2001 • an entity in which a director has a substantial Sydney – 28th day of September 2007 financial interest. financial statements (ContINUED)
INCOME STATEMENTS BALANCE SHEETS Economic Entity Parent Entity Economic Entity Parent Entity Note 2007 2006 2007 2006 Note 2007 2006 2007 2006 Sales revenue 3 8,228,140 7,428,263 7,960,457 7,331,511 Current assets Cost of sales (3,063,334) (2,335,001) (2,873,530) (2,313,263) Cash 5 1,740,922 1,399,402 1,740,003 1,394,402 Gross profit 5,164,806 5,093,262 5,086,927 5,018,248 Trade receivables 6 1,472,421 1,424,303 1,408,281 1,406,743 Other revenues from ordinary Total current activities 381,813 211,018 334,413 211,018 assets 3,213,343 2,823,705 3,148,284 2,801,145 Marketing, Non-current promotional assets 36 & publication Plant & expenses (173,575) (182,323) (64,288) (149,603) equipment 7 553,190 443,543 553,190 443,543 Occupancy Land & building 8 2,713,424 2,658,520 2,713,424 2,658,520 expenses (118,577) (92,342) (118,577) (92,342) Intangible assets 9 1,844 2,458 – – Administration expenses (950,564) (667,779) (910,168) (656,363) Investments 10 2,609 2,400 2,609 2,400 Human Total non- resources current assets 3,271,067 3,106,921 3,269,222 3,104,463 expenses (3,845,877) (3,901,309) (3,845,877) (3,901,309) Total assets 6,484,410 5,930,626 6,417,506 5,905,608 Depreciation (271,036) (248,288) (271,036) (248,288) Current Other expenses (177,201) (203,631) (177,201) (192,421) liabilities
ACHS ANNUAL REPORT 2006-07 Profit from Trade payables 11 994,669 832,726 979,669 827,376 operation 4 9,789 8,608 34,193 (11,060) Provisions 12 660,963 758,419 660,963 758,419 Retained Unearned profit/(loss) at income 13 4,099,010 3,619,502 4,042,370 3,619,502 the beginning of the year 719,979 711,371 700,311 711,371 Total current liabilities 5,754,642 5,210,647 5,683,002 5,205,297 Retained profit at the end of the Total liabilities 5,754,642 5,210,647 5,683,002 5,205,297 financial year 729,768 719,979 734,504 700,311 Net assets 729,768 719,979 734,504 700,311 Accumulated members funds 729,768 719,979 734,504 700,311 STATEMENT OF CHANGES IN EQUITY STATEMENT OF CASHFLOWS Note Retained Profit Economic Entity Parent Entity Balance as at 30 June 2005 711,371 Note 2007 2006 2007 2006 Profit attributable to members parent entity 8,608 Cash flows from operating Balance as at 30 June 2006 16 719,979 activities Receipts from Balance as at 30 June 2006 719,979 customers net of payments Profit attributable to members parent entity 9,789 to suppliers Balance as at 30 June 2007 16 729,768 and employees 180,517 20,176 276,898 9,561
Interest received 81,672 82,652 81,672 82,652 37 Net cash provided in operating activities 14 262,189 102,828 358,570 92,213 Cash flow from investing activities Prepayment of expenses 15,900 (16,778) 15,900 (14,235) Acquisition of property, plant and equipment (402,237) (283,781) (402,237) (280,709) ACHS ANNUAL REPORT 2006-07 Acquisition of investment and short term deposits (209) – (209) – Net cash provided from investing activities (386,546) 16,597 (386,546) (294,944) Cash flow from financing activities Proceeds from borrowing 15 465,877 (260,279) 373,576 (260,279) Net cash provided by financing activities 465,877 (260,279) 373,576 (260,279) Net increase/ (decrease) in cash held 341,520 (140,854) 345,601 (463,010) Cash at the beginning of financial year 1,399,402 1,857,412 1,394,402 1,857,412 Cash at the end of financial year 17 1,740,922 1,399,402 1,740,003 1,394,402 notes to and forming part of the financial statements
FOR THE YEAR ENDED 30 JUNE 2007
Note 1: Statement of significant Plant and equipment accounting policies Plant and equipment are measured on the cost basis. The financial report covers the economic entity of The The carrying amount of property, plant and equipment is Australian Council on Healthcare Standards Limited and reviewed annually by the Board to ensure it is not in excess of controlled entities, and The Australian Council on Healthcare the recoverable amount of these assets. Standards Limited as an individual parent entity. The parent entity is a company limited by guarantee, incorporated and • The recoverable amount is assessed on the basis of the domiciled in Australia. expected net cash flows which will be received from the assets employment and subsequent disposals. a) Basis of preparation • The expected net cash flows have not been discounted to The financial report is a general purpose financial report that present values in determining recoverable amount. has been prepared in accordance with: Depreciation 38 • Corporations Act 2001 The depreciable amount of all fixed assets excluding freehold • Applicable Australian Accounting Standards, property are depreciated on a straight line basis over their • Urgent Issues Group (UIG) Consensus Views and estimated useful lives to the entity commencing from the time the asset is held ready for use. • Other authoritative pronouncements of the Australian Accounting Standard Board (AASB) The useful lives used for each class of depreciable assets are:
Australian Accounting Standards include Australian equivalents Class of fixed assets Depreciable rate to International Financial Reporting Standards (AIFRS). Compliance with AIFRS ensures that the consolidated financial Office Equipment 5 years statements and notes comply with International Financial Computer and IT Equipment 3 years Reporting Standards (IFRS). Furniture and Fittings 10 years Except as described below, the accounting policies have been Freehold Building 40 years applied to all periods presented in these financial statements ACHS ANNUAL REPORT 2006-07 and have been applied consistently. The assets’ residual values and useful lives are reviewed and b) Basis of consolidation adjusted if appropriate at each balance date. All inter-company balances and transactions between entities An asset’s carrying amount is written down immediately to its in the economic entity, including unrealised profits or losses, recoverable amount if the asset’s carrying amount is greater have been eliminated on consolidation. Accounting policies of than its estimated recoverable amount. subsidiaries have been changed where necessary to ensure consistencies with those policies applied by the parent entity. d) Impairment of assets At each reporting date, the group reviews the carrying values Where controlled entities have entered or left the economic of its tangible and intangible assets to determine whether there entity during the year, their operating results have been is any indication that those assets have been impaired. If such included/excluded from the date control was obtained or until an indication exists, the recoverable amount of the asset, being the date control ceased. the higher of the asset’s fair values less costs to sell and value A list of controlled entities is contained in Note 10 to the in use, is compared to the asset’s carrying value. Any excess financial statements. All controlled entities have a June financial of the asset’s carrying value over its recoverable amount is year-end. expensed to the income statement. The financial report has been prepared in Australian dollars on e) Financial Instrument an accrual basis and is based on historical costs and does not take into account changing money values or, except where Financial instruments are initially measured at cost on trade stated, current valuations of non current assets. Cost is based date, which includes transaction costs, when the related on the fair values of the consideration given in exchange for assets. contractual rights or obligations exist. Subsequent to initial recognition these instruments are measured as set out below. c) Property, plant and equipment Financial assets at fair value through profit and loss Property, plant and equipment are brought to account at A financial asset is classified in this category if acquired cost, less, where applicable, any accumulated depreciation, principally for the purpose of selling in the short term or if impairment losses plus costs incidental to acquisition. designated by management and within the requirements Property of AASB139: Recognition and Measurement of Financial Freehold land and buildings are shown at their original Instruments. Derivatives are also categorised as held for costs plus costs incidental to acquisition less subsequent trading unless they are designated as hedges. Realised and depreciation for buildings. unrealised gains and losses arising from changes in the fair value of these assets are included in the income statement in the period in which they arise. Held-to-maturity investments j) Leases These investments have fixed maturities; and it is the group’s Lease expenditure relating to leases deemed to be “operating intention to hold these investments to maturity. Any held-to- leases” is expensed as incurred. Operating lease commitments maturity investments held by the group are stated at amortised outstanding at balance date include guaranteed residual values. cost using the effective interest rate method. k) Unearned revenue Fair value The income held in advance at Note 13 of the accounts will be Fair value is determined based on current bid prices for all brought to account on a “time pro rated” basis over the period quoted investments. Valuation techniques are applied to of the contract concerned. Sales revenue is also recognised on determine the fair value for all unlisted securities, including this basis. recent arm’s length transactions, reference to similar instruments and option pricing models. l) Interests in joint venture f) Income tax The Company’s share of the assets, liabilities, revenue and 39 expenses of joint ventures are included in the appropriate items The Company has not adopted tax effect accounting. The of the balance sheet and income and expenditure account. Parent Company has received confirmation from the Australian Details of the joint venture are shown at Note 10, as shares in Taxation Office that its income is exempt from income tax associated companies. pursuant to Section 50-5 of the Income Tax Assessment Act 1997 and accordingly the Company does not have any liability m) Goods and services tax (GST) for income tax. Revenues, expenses and assets are recognised net of the Where a controlled entity is a taxable entity the charge for amount of GST, except where: current tax expense is based on the profit for the year adjusted • the amount of GST incurred by The Australian Council on for any non-assessable or disallowed items. It is calculated Healthcare Standards as a purchaser that is not recoverable using the tax rates that are applicable during the financial year. from the Australian Taxation Office is recognised as part g) Employee benefits of the cost of acquisition of the asset or as part of an item
of expense; ACHS ANNUAL REPORT 2006-07 Liabilities for wages and salaries, annual leave and related on- costs are recognised and measured as the amount unpaid at • receivables and payables are stated including the amount the reporting date at current pay rates in respect of employees’ of GST. services up to that date. n) Comparatives figures Long Service Leave provision is based on the remuneration Comparative figures have been reclassified where necessary for rates at year end for all employees with five or more years consistency with the current period’s financial statements and of service. It is considered that this measurement technique other disclosures. produces results not materially different from the estimate determined by using the present value basis of measurement. o) Revenue and income recognition The outstanding amounts of workers’ compensation insurance Sales revenue comprises revenue earned (net of returns, premiums and fringe benefits tax, which are consequential to discounts and allowances) from the business activities and is employment, are recognised as liabilities and expenses where recognised at point of sale or lodgement. the employee entitlements to which they relate have been recognised. • EQuIP membership fees are brought to account on a “time pro rated” basis over the period of the contract concerned Contributions are made by the Company to employee superannuation funds and are charged as expenses • Interest received is recognised as it accrues. when incurred. Revenue from the sale of goods is recognised upon the delivery of goods to customers. h) Provisions All revenue is stated net of the amount of goods and services Provisions are recognised when the group has a legal or tax (GST). constructive obligation, as a result of past events, for which it is possible that an outflow of economic benefits will result and p) Trade and other creditors that outflow can be reliably measured. Liabilities are recognised for goods or services received prior i) Cash and cash equivalents to the end of the reporting period and which are unpaid. The amounts are unsecured and are usually paid within 30 days Cash and cash equivalents include cash on hand, deposits held of recognition. at call with banks, other short-term highly liquid investments with original maturities of three months or less, and bank q) Interest revenue overdrafts. Bank overdrafts are shown within short-term borrowings in current liabilities on the balance sheet. Interest revenue is recognised on a proportional basis taking into account the interest rates applicable to the financial assets. The Company has no short-term borrowings. notes to and forming part of the financial statements (ContINUED)
FOR THE YEAR ENDED 30 JUNE 2007
r) Government grants Note 3: Operating revenue comprises revenue from Government grants are recognised at fair value where there the following operating activities is reasonable assurance that the grant will be received and all Economic Entity Parent Entity grant conditions will be met. Grants relating to expense items 2007 2006 2007 2006 are recognised as income over the periods necessary to match the grant to the costs they are compensating. Grants relating Membership fees 7,001,229 6,395,098 6,770,911 6,298,346 to assets are credited to deferred income at fair value and are Education workshops 651,338 564,303 614,933 564,303 credited to income over the expected useful life of the asset on a straight-line basis. Projects 417,556 349,958 417,556 349,958 Publications 107,055 80,124 106,095 80,124 s) Critical accounting estimates and judgements Other 50,962 38,780 50,962 38,780 The Directors evaluate estimates and judgements incorporated into the financial report based on historical knowledge and best Revenue from ordinary activities 8,228,140 7,428,263 7,960,457 7,331,511 40 available current information. Estimates assume a reasonable expectation of future events and are based on current trends Grants received 121,414 77,400 86,013 77,400 and economic data, obtained both externally and within the group. Interest revenue: Interest received from financial institutions 81,672 82,652 81,672 82,652 Other income 178,728 50,967 166,728 50,967 Total operating revenue 8,609,954 7,639,282 8,294,870 7,542,530
Note 4: Profit from ordinary activities Economic Entity Parent Entity ACHS ANNUAL REPORT 2006-07 2007 2006 2007 2006 Profit from ordinary activities has been determined after: Cost of sales 3,063,334 2,335,001 2,873,530 2,313,263 Depreciation – plant & equipment 183,357 158,061 183,357 158,061 – buildings 87,679 90,227 87,679 90,227 Remuneration of auditors 27,898 23,400 26,698 23,400 Total 3,362,268 2,606,689 3,171,264 2,584,951
Note 5: Cash Economic Entity Parent Entity 2007 2006 2007 2006 Cash on hand 1,000 1,000 1,000 1,000 Cash at bank 1,739,922 1,398,402 1,739,003 1,393,402 Total cash 1,740,922 1,399,402 1,740,003 1,394,402 Note 6: Receivables & other assets Note 8: Land and building Economic Entity Parent Entity Economic Entity Parent Entity 2007 2006 2007 2006 2007 2006 2007 2006 Trade debtors 1,441,269 1,377,251 1,377,129 1,372,251 Land – at cost 380,000 380,000 380,000 380,000 Less: Provision for (30,000) (30,000) (30,000) (30,000) Building – at cost 1,425,454 1,425,454 1,425,454 1,425,454 doubtful debts Less: Accumulated Other debtors and 61,152 77,052 61,152 64,492 depreciation (302,909) (267,273) (302,909) (267,273) prepayments Net book value 1,122,545 1,158,181 1,122,545 1,158,181 Total receivables 1,472,421 1,424,303 1,408,281 1,406,743 Building improvements – at cost 1,589,238 1,446,655 1,589,238 1,446,655 Note 7: Plant & equipment Less: Accumulated 41 depreciation (378,359) (326,316) (378,359) (326,316) Economic Entity Parent Entity Net book value 1,210,879 1,120,339 1,210,879 1,120,339 2007 2006 2007 2006 Net book value, land Furniture and fittings and building 2,713,424 2,658,520 2,713,424 2,658,520 – at cost 206,123 206,123 206,123 206,123
Less: Accumulated depreciation (158,733) (148,813) (158,733) (148,813) Note 9: Intangible assets Net book value 47,390 57,310 47,390 57,310 Economic Entity Parent Entity Office equipment 2007 2006 2007 2006 – at cost 175,727 174,944 175,727 174,944 Formation costs 3,072 3,072 – – Less: Accumulated
Less: Amortisation (1,228) (614) – – ACHS ANNUAL REPORT 2006-07 depreciation (126,626) (105,663) (126,626) (105,663) Total unearned income 1,844 2,458 – – Net book value 49,100 69,281 49,100 69,281 Information technology – at cost 979,893 748,644 979,893 748,644 Note 10: Investment non-current
Less: Accumulated Economic Entity Parent Entity depreciation (594,303) (457,223) (594,303) (457,223) 2007 2006 2007 2006 Net book value 385,590 291,421 385,590 291,421 Shares in associated Motor vehicle – at cost 74,851 47,231 74,851 47,231 non-listed companies Less: Accumulated Investment in depreciation (3,742) (21,700) (3,742) (21,700) Australian Clinical Net book value 71,109 25,531 71,109 25,531 Review Pty Limited (ACR) 6,500 6,500 6,500 6,500 Net book value, plant & equipment 553,190 443,543 553,190 443,543 Less: Provision for diminution of investment (6,500) (6,500) (6,500) (6,500) Total investment non-current – – – – Shares in listed companies Shares in SAI Global Ltd 2,609 2,400 2,609 2,400 Total investment non-current 2,609 2,400 2,609 2,400 notes to and forming part of the financial statements (ContINUED)
FOR THE YEAR ENDED 30 JUNE 2007
Note 11: Trade payables Note 14: Reconciliation of cash flow from operations with operating profit/(loss) after income tax Economic Entity Parent Entity Economic Entity Parent Entity 2007 2006 2007 2006 2007 2006 2007 2006 Accounts payable 689,686 529,824 689,686 529,824 Operating profit/(loss) Accrued expenses 247,554 231,841 232,554 226,491 after income tax 9,789 8,608 34,193 (11,060) Non cash flows in Work in progress 57,429 71,061 57,429 71,061 operating profit Total trade payables 994,669 832,726 979,669 827,376 Depreciation and loss on disposal of asset 238,299 248,902 237,685 248,289
Note 12: Provisions – current Charges to provision (97,456) 22,179 (97,456) 22,179 Changes in assets 42 Economic Entity Parent Entity and liabilities 2007 2006 2007 2006 Increase in trade and term debtors 175,575 (128,286) 184,027 (123,286) Employee entitlements 534,485 498,685 534,485 498,685 Increase/(decrease) Provision, overseas in trade creditors market development 50,000 53,256 50,000 53,256 and accruals (64,018) (48,575) 121 (43,909) Provision, future costs 20,000 40,000 20,000 40,000 Total cash flows from operating activities 262,189 102,828 358,570 92,213 Provision, research and development – 60,000 – 60,000 Note 15: Proceeds from borrowing Provision, strategic initiatives 56,478 56,478 56,478 56,478 2007 2006 Movement Provision, printing
ACHS ANNUAL REPORT 2006-07 Work in progress (57,430) (71,061) (13,631) EQuIP Guide 4th edition – 50,000 – 50,000 Future income 4,099,010 3,619,502 479,508 Total provisions 660,963 758,419 660,963 758,419 Net movement 4,041,580 3,548,441 465,877
Note 13: Unearned income Note 16: Retained profits Economic Entity Parent Entity Economic Entity Parent Entity 2007 2006 2007 2006 2007 2006 2007 2006 EQuIP membership fees and Education Retained profits at the service fees 4,099,010 3,619,502 4,042,370 3,619,502 beginning of the year 719,979 711,371 711,371 711,371 Total unearned Profit attributable to income 4,099,010 3,619,502 4,042,370 3,619,502 members for the year 9,789 8,608 34,193 (11,060) Retained profits at the end of the financial year 729,768 719,979 745,564 700,311
Note 17: Reconciliation of cash flow from operations Economic Entity Parent Entity 2007 2006 2007 2006 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 1,000 1,000 1,000 1,000 Cash at bank 1,739,922 1,398,402 1,739,003 1,393,402 Total cash flows from operations 1,740,922 1,399,402 1,740,003 1,394,402 Note 18: Members’ guarantee Note 22: Financial instruments The Council is incorporated as a company limited by guarantee. a) Financial risk management In accordance with the Constitution of the Company, every member of the Company undertakes to contribute an amount The Company’s financial instruments consist mainly of deposits limited to $50 per member in the event of the winding up of the with banks, accounts receivable and payable. Company during the time that he/she is a member or within The main purpose of non-derivative financial instruments is to one year thereafter. raise finance for Company operations. The Company group does not have any derivative or any financial instruments at Note 19: Remuneration of Board members and 30 June 2007. other Councillors Treasury risk management The Board of Directors and Councillors of The Australian Council on Healthcare Standards Limited during the financial Directors and the senior executive meet on a regular basis year are listed in the Annual Report of the Board. to consider the extent of interest rate exposure and where necessary evaluate treasury management strategies in the 43 Apart from amounts received by way of reimbursement for context of the most recent economic conditions and forecasts. expenses incurred in the attendance at various Executive and Committee Member’s meetings, and fees received (for Financial risks example, honoraria) by Councillors for services in connection The main risks the Company is exposed to through its financial with Surveys and the Educational programs, no amounts were instruments are interest rate risk, liquidity risk and credit risk. received by a Committee Member or Councillor in connection with the management of the affairs of the Company. Interest rate risk Interest rate risk is managed by minimising the extent of long- Note 20: Related party transactions term interest bearing debt. For further details on interest rate Apart from the transactions referred to in the Annual Report risk refer to Note 22(b). of the Board there have been no transactions between the Foreign currency risk Company and related parties of the Company which require The Company is not exposed to fluctuations in foreign currencies.
separate disclosure. ACHS ANNUAL REPORT 2006-07 Liquidity risk Note 21: Segment reporting The Company manages liquidity risk by monitoring cash flows The economic entity operates in one business segment being and ensuring that adequate unutilised borrowing facilities are the health care industry where it supports organisations in maintained. their implementation of quality improvement through EQuIP to develop and continually review quality standards and guidelines Credit risk in consultation with the industry. The maximum exposure to credit risk, excluding the value of any collateral or other security, at balance date to recognised financial assets, is the carrying amount, net of any provisions for impairment of those assets, as disclosed in the balance sheet and notes to the financial statements. The Company does not have any material credit risk exposure to any single receivables or group of receivables under financial instruments entered into by the Company. Price risk The Company is not exposed to any material commodity price risk. notes to and forming part of the financial statements (ContINUED)
FOR THE YEAR ENDED 30 JUNE 2007
b) Interest rate risk The Company’s exposure to interest rate risk, which is the risk that a financial instrument value will fluctuate as a result of changes in market interest rates and the effective weighted average interest rates on those financial assets and financial liabilities, is as follows:
Weighted Fixed interest maturing average Floating More than Non-interest effective On call interest rate interest Rate 1 year bearing 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 Financial assets % % $ $ $ $ $ $ $ $ 44 Cash at bank 6.0 5.5 329,674 216,556 1,411,248 1,399,402 – – – – Receivables 1,441,269 1,377,251 Total financial assets 329,674 216,556 1,411,248 1,399,402 – – 1,441,269 1,377,251 Financial liabilities Accounts payable 994,669 832,726 Provisions 660,963 758,419 Total financial liabilities 1,655,632 1,591,145 Net financial assets (214,363) (213,894)
ACHS ANNUAL REPORT 2006-07 Note 23: 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 DIRECTORS’ DECLARATION The directors of the Company declare that: 1) The financial statements and notes set out on pages 34 to 44 are in accordance with the Corporations 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 2007 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. 45 3) The Chief Executive and the Executive Manager – 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. ACHS ANNUAL REPORT 2006-07
On behalf of the Directors
Dr Michael Hodgson AM President
Associate Professor Peter Woodruff Treasurer Sydney – 27th day of September 2007 notes to and forming part of the financial statements (ContINUED)
FOR THE YEAR ENDED 30 JUNE 2007
INDEPENDENT AUDITORS REPORT TO THE MEMBERS OF Audit Opinion AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS LIMITED In our opinion the financial report of The Australian Council on Healthcare Standards Limited is in accordance Scope We have audited the financial report of the Australian Council 1) with the Corporations Act 2001, including; on Healthcare Standards Limited and controlled entities for the a) giving a true and fair view of the company’s and financial year ended 30 June 2007 as set out on pages 34 to 44. consolidated entity financial position as at 30 June 2007 The financial report includes the consolidated financial and of their performance for the year ended on statements of the consolidated entity comprising the company that date; and and the entities it controlled at the year’s end of from time to b) complying with Accounting Standards in Australia and time during the financial year. The company’s directors are the Corporations Regulations 2001; and responsible for the financial report. We have conducted an 2) other mandatory professional reporting requirements. independent audit of this financial report in order to express 46 an opinion on it to the members of the company. Inherent Uncertainty Regarding Accounting Estimates Our audit has been conducted in accordance with Australian Without qualification to the opinion expressed above, attention Auditing Standards to provide reasonable assurance as to is drawn to the following matter. As indicated in Note 13 to the whether the financial report is free of material misstatement. financial report, The Australian Council on Healthcare Standards Our procedures included examination, on a test basis, of has included as liabilities $4,099,010 as unearned income evidence supporting the amounts and other disclosures in the and Note 11 $57,429 as Work in Progress. These relate to the financial report, and the evaluation of accounting policies and Evaluation and Quality Improvement Program (EQuIP) and the significant accounting estimates. These procedures have been progressive recognition of income and expenses throughout the undertaken to form an opinion as to whether, in all material contract cycle based on estimation of each phase completed. respects, the financial report is presented fairly in accordance As the figures taken into account are estimates their accuracy with Accounting Standards and other mandatory professional cannot presently be determined with an acceptable degree reporting requirements in Australia and statutory requirements of reliability. so as to present a view which is consistent with our understanding
ACHS ANNUAL REPORT 2006-07 of the Company’s financial position and performance as represented by the results of its operations and cash flows. The audit opinion expressed in this report has been formed on the above basis. TALBOTS Independence Chartered Accountants Level 9 In conducting our audit we followed applicable independence 91 York Street requirements of Australian professional and ethical SYDNEY NSW 2001 pronouncements and the Corporations Act 2001. In accordance with ASIC Class Order 05/83, we declare to the best of our knowledge and belief that the auditors independence declaration set out on page 35 of the financial report has not changed as at the date of providing our audit opinion. S A HOLLIER Partner Sydney – 28th day of September 2007 achs member list As at 30 June 2007
ACHS accredits the majority of health care organisations Carswell Clinic Day Surgery Centre in Australia. The health care organisations participating in Castlecrag Private Hospital ACHS quality programs range from major teaching hospitals, Caswell Health Care corporate offices of private health companies, day surgeries such as endoscopy clinics, also nursing agencies, community City West Day Surgery health centres to divisions of general practice. Coolenberg Clinic Day Surgery Centre For a more current list of ACHS member organisations, please visit the ACHS website: www.achs.org.au and select Dee Why Endoscopy Unit the ‘Member organisation list’ option (under the ACHS Denison Street Clinic* MEMBERS tab on the homepage). Diagnostic Endoscopy Centre Key: Organisations listed with an asterisk (*) are new Dubbo Private Hospital members awaiting accreditation or existing members awaiting Dudley Private Hospital a survey or accreditation results. Dutiful Daughters 47 A new member may have a history of accreditation with the Eastern Heart Clinic ACHS, but due to recent changes, such as restructuring, may – Sutherland Heart Clinic be awaiting accreditation as a new entity. Epping Surgery Centre Excel Endoscopy Centre ACT Figtree Private Hospital Private Gambro Healthcare; Gambro Pty Ltd Calvary John James Hospital – Linfield Dialysis Centre Canberra Eye Hospital – Diamond Valley Dialysis Unit – St Andrews Toowoomba Renal Dialysis Unit Canberra Surgicentre, The Garden Court Clinic Marie Stopes International, ACT Griffith Nursing Service* Mugga Wara & Brindabella Endoscopy Centres
Griffiths Road Day Procedure Centre ACHS ANNUAL REPORT 2006-07 National Capital Private Hospital, The Hawkesbury District Health Service Ltd Public HCF Dental Centres ACT Health – Brookvale, Blacktown, Chatswood, Hurstville, Parramatta, – ACT Health – Community Health Bondi, Sydney – Canberra Hospital, The Healthwoods Specialist Centre – Mental Health ACT Hills Private Hospital, The Calvary Health Care ACT Hirondelle Private Hospital Department of Defence, ACT/SNSW Area Health Service, Hunter Valley Private Hospital Defence Health Services* Hunters Hill Private Hospital NSW Insight Clinic Pty Ltd Private Junee Correctional Centre – Health Centre* Kareena Private Hospital Adori Day Clinic Kinder Caring Home Nursing Services ahm Dental & Eyecare Practice Lady Davidson Hospital ahm Total Health Lawrence Hargrave Hospital Albury Wodonga Private Hospital Lingard Private Hospital Alia Clinic Lismore Private Day Surgery Allowah Presbyterian Children’s Hospital Lithgow Community Private Hospital Alwyn Rehabilitation Hospital Liverpool Day Surgery Armidale Private Hospital Macarthur Private Hospital Ashbrooke Cosmetic Surgery Maitland Private Hospital Baringa Private Hospital & Coffs Harbour Day Surgical Centre Marie Stopes International, NSW Berkeley Vale Private Hospital Marsden Eye Surgery Centre Bondi Junction Private Hospital Mater Hospital, North Sydney,The Bowral Day Surgery Matraville Medical Complex, Aesthetic Surgery Centre Byrne Surgery Mayo Healthcare Group Calvary Health Care Riverina Inc Metwest Surgical Calvary Health Care Sydney – Hurstville Community Miranda Eye Surgical Centre Cape Hawke Comm. Pvte Hosp & Community Private Home Care Mosman Private Hospital ACHS Member List (continued)
Mt Wilga Private Hospital Tamara Private Hospital National Day Surgery – Sydney Pty Ltd Toronto Private Hospital Nepean Private Hospital Vista Laser Eye Clinic of NSW Newcastle Plastic Surgery Day Case Centre Wales Day Centre, The Newcastle Private Hospital Warners Bay Private Hospital North Gosford Private Hospital Westmead Private Hospital North Shore Private Hospital Yeoval Community Hospital Coop Ltd Northside, Northside West and Northside Cremorne Clinics Public – Northside and Northside Cremorne Clinics – Northside West Clinic Ballina District Hospital and Community Health Nowra Private Hospital Balmain Hospital and Eastern Sector Aged Community Services Ophthalmic Surgery Centre (North Shore) Bankstown Health Service 48 Orange Eye Centre Bathurst Base Hospital Pennant Hills Day Endoscopy Centre Blayney Health Service Port Macquarie Private Hospital & Hastings Day Surgery* Bowral and District Hospital Preterm Foundation Broken Hill Health Service* Primary Health Care Day Surgeries* Bulli District Hospital – Bankstown Primary Health Care Day Surgery Calvary Health Care Sydney – Sydney Day Surgery Calvary Mater Newcastle – Warringah Mall Day Surgery – Western Plains Day Surgery Campbell Hospital and Coraki Prince of Wales Private Hospital Campbelltown and Camden Hospitals Quality Health Care Canowindra Hospital Regal Health Services Canterbury Hospital ACHS ANNUAL REPORT 2006-07 Regional Imaging Cardiovascular Centre Casino District Memorial Hospital and Casino Community Health Riverina Cancer Care Centre Central Coast Health Rosebery Day Surgery Central Sydney Area Mental Health Services* Rosemont Endoscopy Centre Cobar/Narromine Health Services – Cobar Health Service San Day Surgery Hornsby – Narromine Health Service Scott Street Clinic Coffs Clarence Network* Shellharbour Private Hospital – Grafton Base Hospital & Community Health Southern Skin & Cancer Foundation Westmead Day Clinic – Maclean Hospital and Community Health Services South Coast Home Health Care Pty Ltd – Mid North Coast Acute Services – Gloucester & Bulahdelah Hospitals South Pacific Private Hospital – Mid North Coast Community Based and Mental Health Services Southern Suburbs Day Procedure Centre Pty Ltd Concord Repatriation General Hospital St George Private Hospital Coonamble/Gilgandra/Baradine/Gulargambone Health Services St John of God Health Services – Baradine Multipurpose Health Service – St John of God Hospital – Burwood – Coonamble Health Services – St John of God Hospital – Richmond – Gilgandra Health Service St Luke’s Care – Gulargambone Multi Purpose Service St Vincent’s Health Services Cowra and Grenfell Health Service – GWAHS St Vincent’s Hospital – Lismore Dubbo Base Hospital St Vincent’s Private Hospital – Sydney Dubbo Community Health Centre Strathfield Private Hospital Fairfield Health Service Surry Hills Day Hospital Family Drug Support* Sussex Day Surgery Greater Newcastle Acute Hospital Network* – Belmont District Hospital Sydney Adventist Hospital – Royal Newcastle Hospital Sydney Clinic for Gastrointestinal Diseases, The Greater Newcastle Cluster* Sydney Clinic, The – Hunter Health Care Network Community Based Services Sydney Eastern Eye Centre Greater Western Area Health Service (Cluster 1) Sydney Eye Specialist Centre, The – Parkes District Hospital and Community Health Service Sydney Pharmacotherapy Clinic Greater Western Area Health Service (Cluster 2) Sydney Southwest Private Hospital – Condobolin Health Service – Forbes District Hospital – Lake Cargelligo Orange Health Service Greater Western Area Health Service (Cluster 4) Peel Cluster – Peak Hill District Hospital – Manilla/Barraba – Tottenham Hospital – Gunnedah – Trundle Hospital Port Macquarie Base Hospital & Port Macquarie and – Tullamore Hospital Camden Haven Community Based Services Greater Western Area Health Service – Oral Health Service* Prince of Wales Hospital and Community Health Services* Gulgong/Coolah/Dunedoo Health Services Royal Hospital for Women – Coolah Health Service Royal North Shore and Ryde Health Service – Dunedoo War Memorial Hospital & CHS – Royal North Shore Hospital & Community Health Service – Gulgong Health Service – Ryde Hospital and Community Health Services GWAHS – Mental Health, Drug and Alcohol Services – Central and Royal Prince Alfred Hospital Castlereagh Clusters* Royal Rehabilitation Centre Sydney Hope Healthcare 49 – Braeside Hospital Rural Hospitals and Health Services Program – Hope Healthcare North – Bonalbo Health Service – Kyogle Memorial Health Hornsby Ku-ring-gai Hospital & CHS – Nimbin Multipurpose Services Hunter/New England Area Health Service Rylstone District Hospital Hunter New England Health – Tablelands Cluster SESIH Central Hospitals Network* Hunter New England Mental Health Service* – St George Hospital and Community Health Service – Hunter Mental Health – Sutherland Hospital and Community Heath Service Justice Health Shellharbour & Kiama Hospitals Karitane Shoalhaven Hospital Group* Kempsey and Wauchope District Hospital and South Eastern Sydney/Illawarra Area Health Service Community Health Services* Mental Health Service*
– Kempsey District Hospital – Illawarra Area Mental Health Service ACHS ANNUAL REPORT 2006-07 – Wauchope District Memorial Hospital – South East Health Mental Health Service Lismore Base Hospital St Joseph’s Hospital – Auburn Liverpool Hospital St Vincent’s Hospital – Sydney (Public) Lottie Stewart Hospital SWAHS – Central Cluster* Lourdes Hospital, Health & Aged Care Service – Blacktown Hospital Lower Hunter Cluster – Mount Druitt Hospital – Cessnock/Kurri Kurri Health Service SWAHS – Eastern Cluster* – Dungog and District Hospital – Westmead Hospital – Singleton Health Services – Auburn Hospital Lower Mid North Coast Cluster* SWAHS – Integrated Cluster* Maitland Hospital, The SWAHS – Western Cluster* Manning Rural Referral Hospital* – Nepean Hospital – Blue Mountains Hosital McIntyre Cluster – Springwood Hospital – Inverell/Warialda/Bingara/Ashford/Tingha/Bundara – Lithgow Integrated Health Service Mehi Cluster – Portland Hospital – Moree/Bogabilla/Toomelah/Mungindi Sydney Children’s Hospital Mercy Care Centre, Young Sydney Hospital and Sydney Eye Hospital Molong District Hospital Sydney South West Area Health Service – Community Health* Mudgee Health Service Sydney South West Oral Health Services and Sydney Dental Hospital NCAHS Tweed Byron Network – Sydney Dental Hospital – Tweed Hospital and Community Health Services Sydney West Area Health Service – Murwillumbah Hospital and Community Health Services – Byron Shire Hospitals and Community Health Services Tamworth and Armidale Hospital Group Newcastle Mater Misericordiae Hospital Tresillian Family Care Centres North Coast Area Health Service Upper Hunter Cluster – Upper Hunter Health Sector North Coast Area Health Service, Mental Health Services* War Memorial Hospital, Waverley Northern Beaches Health Service Warren/Nyngan/Trangie Health Services Northern Sydney/Central Coast Mental Health Service* – Nyngan Health Service – Northern Sydney Health – Area Mental Health Services – Trangie Multi Purpose Health Service Oberon Multipurpose Service – Warren Multi Purpose Health Service ACHS Member List (continued)
Wellington/Coonabarabran Health Services Mackay Day Surgery Wollongong Hospitals and Community Health Services* Marie Stopes International, Queensland – Rehabilitation, Aged & Extended Care Services Mater Health Services – Private NT Mater Hospitals – Rockhampton, Yeppoon & Gladstone Mater Misericordiae Hospital – Bundaberg Private Mater Misericordiae Hospital – Mackay Darwin Private Hospital Mater Misericordiae Hospital Townsville Ltd Public Mater Misericordiae Private Hospital – Redland Alice Springs Hospital Montserrat Day Hospitals Central Australian Mental Health Service Moreton Eye Group Gove District Hospital Mt Olivet Hospital 50 Katherine Hospital NephroCare Queensland Oral Health Services New Farm Clinic Royal Darwin Hospital Noosa Hospital, The Tennant Creek Hospital North Queensland Day Surgical Centre Top End Mental Health Service North West Brisbane Private Hospital QLD Palm Beach-Currumbin Clinic, The Peninsula Private Hospital Private Pindara – Gold Coast Private Hospital Allamanda Private Hospital Pindara Day Procedure Centre – Allamanda Surgicentre Pine Rivers Private Hospital Belmont Private Hospital Pioneer Valley Private Hospital Blue Care Brisbane Region Pittsworth & District Hospital Friendly Society Ltd ACHS ANNUAL REPORT 2006-07 Blue Care Central Queensland/Wide Bay Region Precision Cosmetic Laser and Surgery Blue Care South West Queensland Region QFG Day Theatres Blue Care Southern Region Queensland Eye Hospital Blue Care Suncoast Hinterland Region Renew You* Blue Care North Queensland Region Short Street Day Surgery Brisbane Endoscopy Services South Burnett Community Private Hospital Brisbane Private Hospital Southside Endoscopy Centre Caboolture Private Hospital Spendlove Private Hospital Cairns Private Hospital Spiritus – Community Services Caloundra & Nambour Selangor Private Hospitals St Andrew’s Ipswich Private Hospital Chasely Day Surgery St Andrew’s Toowoomba Hospital Clifton Co-op Hospital Ltd St Andrew’s War Memorial Hospital – Brisbane Cooloola Community Private Hospital St Stephen’s Hospitals Maryborough and Hervey Bay Eastern Endoscopy Centre – St Stephen’s Hospital – Hervey Bay Eden Healthcare Centre Inc St Vincent’s Hospital – Toowoomba Eye Tech Day Surgeries and Eye Tech Southside Sunnybank Private Hospital Fraser Coast Palliative Care Service Sunshine Coast Day Surgery Friendly Society Private Hospital Sunshine Coast Private Hospital, The Greenslopes Private Hospital Toowong Private Hospital Haematology & Oncology Clinics of Australasia Toowoomba Hospice Association Inc Hillcrest Rockhampton Private Hospital Townsville Day Surgery Holy Spirit Northside Private Hospital Tri Rhosen Day Hospital Home Therapeutics Vision Centre Day Surgery Hopewell Hospice Services Inc Wesley Centre for Hyperbaric Medicine, The Ipswich Hospice Care Incorporated Wesley Hospital, The John Flynn Private Hospital Public Karuna Hospice Service Killarney & District Memorial Hospital Ltd Banana Health Service District – Baralaba Hospital Logan Endoscopy Services Pty Ltd – Biloela Hospital Rockhampton and Yeppoon Hospitals and Integrated Mental – Moura Health Service Health Service – Theodore Hospital Royal Brisbane and Women’s Hospital Health Service District Bayside Health Service District – Queensland Forensic Mental Health Service – Casuarina Lodge Royal Children’s Hospital and Health Service Brisbane, The – Redland Hospital Toowoomba Health Service District – Wynnum Hospital Torres Strait and Northern Peninsula Area Health Service District Bowen Health Service District – Ayr District and Homehill Hospitals & CHS Townsville Health Service District – Bowen Hospital – Ingham Health Service – Collinsville Hospital – Palm Island Hospital – Townsville General Hospital Bundaberg Health Service District – Bundaberg Base Hospital West Moreton Health Service District – Childers Hospital 51 – Gin Gin Hospital SA – Mt Perry Hospital Private Cairns Base Hospital and Integrated Mental Health Service ACHA Health Cairns District Community Services * – Ashford Community Hospital Inc – Cooktown District Hospital – Flinders Private Hospital – Douglas Shire Multipurpose Health Service – Gordonvale Hospital Adelaide Day Surgery – Yarrabah Health Service Adelaide DermSurgery Central West Health Service District Adelaide Eye & Laser Centre – Barcaldine Hospital Brighton Day Surgery – Blackall Hospital Burnside War Memorial Hospital Inc – Longreach Hospital – Winton Hospital Calvary Central Districts Hospital Charters Towers Health Service District Calvary College Grove Rehabilitation Hospital ACHS ANNUAL REPORT 2006-07 – Hughenden Hospital Calvary North Adelaide Hospital – Richmond Hospital Calvary Wakefield Hospital Fraser Coast Health Service District Clinical Care Professionals – Hervey Bay Hospital – Maryborough Hospital Glenelg Community Hospital Inc Gladstone Health Service District Glenelg Day Surgery Pty Ltd Gold Coast Health Service District Griffith Rehabilitation Hospital – Gold Coast Hospital – Robina Campus Hamilton House Day Surgery – Gold Coast Hospital – Southport Campus Home Support Services Gympie Health Service District Keith & District Hospital Inc Logan – Beaudesert Health Service District Kerry Day Surgery – Beaudesert Hospital Modbury Public Hospital – Logan Hospital – Community Health Service Moonta Health and Aged Care Service Inc Mackay Health Service District Nephrocare South Australia – Mackay Base Hospital North Eastern Community Hospital Inc – Proserpine Hospital and Whitsunday Community Health Centre Oxford Day Surgery Centre – Sarina Hospital and Primary Health Care Centre Parkside Cosmetic Surgery Mater Health Services – Public Parkwynd Private Hospital Mount Isa Health Service District Ramsay Health Care (SA), Mental Health Services Prince Charles Hospital Health Service District, The – Adelaide Clinic, The Princess Alexandra Hospital Health Service District – Fullarton Private Hospital QEII – Southside Health Service District – Kahlyn Private Hospital Queensland Tuberculosis Control Centre Renal Therapy Services – Payneham Redcliffe Caboolture Health Service District Sach Day Surgery – Caboolture Hospital South Coast District Hospital Inc & Victor Harbor Private – Kilcoy Hospital Hospital Inc – Redcliffe Hospital South Terrace Urology Day Surgery – Redcliffe-Caboolture Community Health and Aged Care Services – Redcliffe-Caboolture Mental Health and Disability Services Sportsmed. SA Hospital – Redcliffe-Caboolture Oral Health Service St Andrew’s Hospital Inc Stirling District Hospital Inc ACHS Member List (continued)
Waverley House Plastic Surgery Centre TAS Western Hospital Private Public Calvary Health Care Tasmania Barossa Area Health Services Inc – Calvary Hospital Hobart Inc – St John’s Hospital Hobart Bordertown Memorial Hospital Calvary Health Care Tasmania, St Luke’s Campus Ceduna District Health Service Inc Calvary Healthcare Tasmania, St Vincent’s Campus Central Northern Adelaide Health Service – Mental Health Directorate – Glenside Campus Mental Health Service Dr R.S. Jensen’s Day Surgery* Central Northern Adelaide Health Service – Primary Health Care Eye Hospital, The Services* Hobart Clinic, The Central Northern Adelaide Health Service, Prison Health Service* Hobart Day Surgery Pty Ltd 52 Children, Youth and Women’s Health Service* Hobart Private Hospital & St Helen’s Private Hospital Coober Pedy Hospital and Health Service North West Private Hospital Flinders Medical Centre Steele Street Clinic* Gawler Health Service Public Glenside Campus Mental Health Service Launceston General Hospital Leigh Creek Hospital Inc Mersey Community Hospital Lyell McEwin Hospital North West Region Hospital Mannum District Hospital Inc, The Royal Hobart Hospital Mid North Health* Mid-West Health Inc VIC Millicent District Hospital & Health Service Inc Private Mount Barker District Soldiers Memorial Hospital ACHS ANNUAL REPORT 2006-07 Albert Road Clinic Mount Gambier and Districts Health Service Inc Avenue Day Surgery Murray Bridge Soldiers Memorial Hospital Inc Avenue Hospital, The Naracoorte Health Service Inc Ballan & District Soldiers Memorial Bush Nursing Hospital Noarlunga Health Services Ballarat District Nursing & Healthcare Northern Adelaide Hills Health Service Inc Beleura Private Hospital Northern Yorke Peninsula Regional Health Service Bellbird Private Hospital Penola War Memorial Hospital Inc Berwick Surgicentre Port Augusta Hospital and Regional Health Services Inc Cabrini Health Port Broughton District Hospital & Health Service Inc Camberwell Eye Clinic Queen Elizabeth Hospital and Health Service, The Chesterville Day Hospital Repatriation General Hospital Cliveden Hill Private Hospital Riverland Regional Health Service Inc and Riverland Private Hospital Cobden District Health Services Inc. Roxby Downs Health Services & Woomera Community Hospital Coburg Endoscopy Centre Royal Adelaide Hospital Community Connections (Victoria) Ltd Royal District Nursing Service of SA Inc Como Private Hospital South Australian Dental Service (CNAHS) * Cotham Private Hospital Southern Flinders Health* Croydon Day Surgery, The St Margaret’s Rehabilitation Hospital Incorporated Delmont Private Hospital Strathalbyn and District Health Service Digestive Health Centre, The Waikerie Health Services Inc. Donvale Rehabilitation Hospital Whyalla Hospital & Health Services Inc Dorset Rehabilitation Centre Eastern Eye Surgery Centre Eastern Palliative Care Association Inc Elsternwick Private Hospital Epworth HealthCare – Epworth Hospital – Epworth Freemasons – Epworth Rehabilitation Camberwell Euroa Health Inc Eye Clinic Footscray St Vincents & Mercy Private Hospital Limited Frances Perry House – Mercy Private Hospital Inc – St Vincent’s Private Hospital Geelong Clinic, The Taburn Specialist Medical Centre Geelong Private Hospital, The Vaucluse Hospital Glen Endoscopy Centre, The Very Special Kids Glenferrie Private Hospital Victoria Clinic, The Healthscope Community Programs Victorian Rehabilitation Centre, The Healthscope Ltd Vimy House Private Hospital Ivanhoe Private Rehabilitation Hospital and Olympia Private Rehabilitation Hospital Wangaratta Private Hospital John Fawkner Private Hospital Warley Hospital Inc Warringal Private Hospital Kew Private Dialysis Centre 53 Knox Private Hospital Waverley Private Hospital La Trobe Private Hospital Western Oral Surgery St Albans Pty Ltd Linacre Private Hospital Western Private Hospital Maryvale Private Hospital Western Suburbs Endoscopy Service Masada Private Hospital Worklife Donnelly Ayres Melbourne Private Hospital Yackandandah Bush Nursing Hospital Melbourne Citymission Palliative Care Public Melbourne Clinic, The Alexandra District Hospital Melbourne Day Surgery Austin Health Melbourne Endoscopy Group Pty Ltd – Austin Hospital Mercy Health and Aged Care – Heidelberg Repatriation Hospital – Royal Talbot Rehabilitation Centre ACHS ANNUAL REPORT 2006-07 Mildura Base Hospital Bairnsdale Regional Health Service Mildura Private Hospital Ballarat Health Services Mitcham Private Hospital Banksia Palliative Care Service Inc Monash Surgical Private Hospital Barwon Health Murray Valley Private Hospital Bayside Health* Nagambie Hospital Inc – Alfred, The Neerim District Health Service – Caulfield General Medical Centre Northpark Private Hospital – Sandringham & District Memorial Hospital O’Connell Family Centre Beaufort & Skipton Health Service Pacific Shores Healthcare* Beechworth Health Service Peninsula Endoscopy Centre Pty Ltd Benalla & District Memorial Hospital Peninsula Private Hospital Bendigo Health Care Group Reservoir Private Hospital Day Procedure Centre Boort District Hospital Ringwood Private Hospital Casterton Memorial Hospital Rosebud SurgiCentre Central Gippsland Health Service Royal District Nursing Service – Heyfield Hospital Inc – Maffra District Hospital Sea Lake and District Health Service Inc Cobram District Hospital Shepparton Private Hospital Cohuna District Hospital Sir John Monash Private Hospital Colac Area Health South East Palliative Care Ltd Dental Health Services Victoria South Eastern Private Hospital* – Valley Hospital, The Djerriwarrh Health Services St John of God Health Care – Bendigo Dunmunkle Health Services St John of God Health Care – Geelong East Grampians Health Service St John of God Health Care – Nepean Rehabilitation East Wimmera Health Service St John of God Health Care – Pinelodge Clinic Eastern Health – Angliss Health Service, The St John of God Health Care Berwick – Box Hill Hospital St John of God Healthcare – Ballarat – Maroondah Hospital St John of God Hospital – Warrnambool – Yarra Ranges Health Service ACHS Member List (continued)
Echuca Regional Health – Kingston Centre Edenhope and District Memorial Hospital – Monash Medical Centre – Clayton – Monash Medical Centre – Moorabbin Gippsland Southern Health Service St Vincent’s Health Goulburn Valley Health – Caritas Christi Hospice Hepburn Health Service – St George’s Health Service Hesse Rural Health Service – St Vincent’s Correctional Health Service – St Vincent’s Hospital Melbourne Heywood Rural Health Stawell Regional Health Inglewood & Districts Health Service Swan Hill District Hospital ISIS Primary Care Inc Take Two Program* Kerang District Health Tallangatta Health Service Kilmore & District Hospital, The Terang & Mortlake Health Service 54 Kooweerup Regional Health Service Timboon & District Healthcare Service Kyabram & District Health Services Tweddle Child & Family Health Service Kyneton District Health Service Victorian Institute of Forensic Mental Health Latrobe Regional Hospital Werribee Mercy Hospital Lorne Community Hospital West Gippsland Healthcare Group Maldon Hospital West Wimmera Health Service Manangatang & District Hospital Western District Health Service* Maryborough District Health Service – Coleraine District Health McIvor Health and Community Services – Western District Health Service Melbourne Health Western Health Service – Royal Melbourne Hospital, The – Royal Park Campus – Sunshine Hospital Mercy Hospital for Women – Western Hospital ACHS ANNUAL REPORT 2006-07 Mercy Western Palliative Care – Williamstown Hospital, The Moyne Health Services Wimmera Health Care Group Mt Alexander Hospital Wodonga Regional Health Service Nathalia District Hospital Yarram and District Health Service Northeast Health Wangaratta Yarrawonga District Health Service Northern Health Yea & District Memorial Hospital Northern Health – Stream 1* WA – Broadmeadows Health Service, The – Bundoora Extended Care Centre Private Northern Health – Stream 2* Albany Community Hospice – Northern Hospital, The Attadale Private Hospital – Panch Health Service Bethesda Hospital Inc Numurkah District Health Service Colin Street Day Surgery Pty Ltd Omeo District Health GI Clinic Orbost Regional Health Glengarry Hospital Peninsula Health Hollywood Private Hospital Peninsula Hospice Service Joondalup Health Campus Peter MacCallum Cancer Centre Kimberley Satellite Dialysis Centre* Portland & District Health Kings Park Day Hospital Rochester and Elmore District Health Service Marian Centre, The Royal Children’s Hospital Marie Stopes International, WA* Royal Victorian Eye and Ear Hospital McCourt Street Day Surgery Royal Women’s Hospital, The Mercy Hospital Mount Lawley Rural Northwest Health Midland Dialysis Centre Seymour District Memorial Hospital Mount Hospital South West Healthcare Mount Lawley Private Hospital Southern Health – Cranbourne Integrated Care Centre Murdoch Surgicentre – Dandenong Hospital Niola Private Hospital – Jessie McPherson Private Hospital Peel Health Campus Perth Clinic WACHS, Kimberley Health Region* Perth Day Surgery Centre – Broome Health Services – Derby Health Services RAN Alcohol and Drug Program* – Fitzroy Crossing District Hospital Silver Chain Hospice Care Service – Halls Creek District Hospital South Perth Hospital Incorporated – Kununurra District Hospital – North West Mental Health Service and Kimberley Com Drug Southbank Day Surgery Service Team St John of God Health Care – Murdoch – Wyndham District Hospital St John of God Hospital – Bunbury WACHS, Lower Great Southern Health Service St John of God Hospital – Geraldton – Albury Regional Hospital St John of God Hospital – Subiaco – Denmark District HS – Plantagenet District Hospital St John of God Murdoch Community Hospice WACHS, Midwest Murchison, Central West Mental Health* Waikiki Private Hospital 55 WACHS, Midwest Murchison, Geraldton Health Campus Westminster Day Surgery WACHS, Midwest Murchison, Midwest District Public – Dongara Health Service – Northampton Kalbarri Health Service Armadale Health Service – Morawa Health Service Bentley Health Service – Mullewa Health Service Child and Adolescent Health Service* – North Midlands Health Service – Princess Margaret Hospital WACHS, Midwest, Murchison District Department of Corrective Services – Health Services – Meekatharra Hospital Fremantle Hospital and Health Service WACHS, Pilbara Gascoyne Region – East Pilbara District – Fremantle Kaleeya Hospital – Newman Health Services Indian Ocean Territories Health Service* – Port Hedland Regional Hospital North Metropolitan Area Health Service Mental Health WACHS, Pilbara Gascoyne Region – Gascoyne Region ACHS ANNUAL REPORT 2006-07 Oral Health Centre of WA WACHS, Pilbara Gascoyne Region – West Pilbara District* – Nickol Bay Hospital Osborne Park Hospital Program – Onslow District Hospital Peel and Rockingham Kwinana Health Services – Paraburdoo District Hospital Royal Perth Hospital – Roebourne District Hospital – Tom Price District Hospital Sir Charles Gairdner Hospital – Wickham District Hospital Swan and Kalamunda Health Service WACHS, Southern Wheatbelt Health Region – Kalamunda Health Service – Boddington District Hospital – Swan Health Service – Dumbleyung District Hospital WACHS, Central Great Southern Multi-Purpose Health Service – Kondinin District Hospital WACHS, Eastern Wheatbelt Health Service – Lake Grace District Hospital – Bruce Rock Memorial Hospital – Narrogin Regional Hospital – Kellerberrin Memorial Hospital – Pingelly District Hospital – Kununoppin Hospital – Wagin District Hospital – Merredin Hospital WACHS, Western Wheatbelt Health Service – Narembeen District Memorial Hospital – Beverly Health Service – Quairading District Hospital – Cunderdin Meckering and Tammin Multi Purpose Service – Southern Cross District Hospital – Dalwallinu District Hospital MPS WACHS, Goldfields South East Region* – Goomalling Health Service – Dundas HS – Moora District Hospital – Esperance District Hospital – Northam Regional Hospital – Goldfields Health Region, Comm MH Esperance – Wongan Hills MPS Health Service – York Health Services MPS Women’s and Newborn Health Service* – King Edward Hospital ACHS Member List (continued)
EQuIP Corporate Health Services VIC NSW Ambicare Patient Transfer Service ahm Total Health Mandometer Pty Ltd GEO Group Australia Pty Ltd, The WA Greater Southern Area Health Service Marian Centre* HealthQuest* Hunter/New England Area Health Service* Divisions of General Practice North Coast Area Health Service NSW SA Barrier Division of General Practice Ltd* Central Northern Adelaide HS, Regional Office* Barwon Division of General Practice 56 Blue Mountains Division of General Practice* Smith Sterilising* Dubbo/Plains Division of General Practice VIC Hastings Macleay Division of General Practice* Mercy Health and Aged Care Hawkesbury-Hills Division of General Practice* Northern Health* Hunter Rural Division of General Practice Spotless Services Australia* Hunter Urban Division of General Practice* Illawarra Division of General Practice* Macarthur Division of General Practice WA Mid North Coast (NSW) Division of General Practice Ltd Health Corporate Network* Nepean Division of General Practice Inc* North Metropolitan Health Service – Area Corporate Services New England Division of General Practice WA Country Health Service*
ACHS ANNUAL REPORT 2006-07 North West Slopes (NSW) Division of General Practice* – WACHS, Midwest Murchison, Corporate Office NSW Central West Division of General Practice WACHS, South West Area Health Service Riverina Division of General Practice and Primary Health Ltd EQuIP Corporate Member Services Shoalhaven Division of General Practice* Southern Highlands Division of General Practice NSW St George Division of General Practice Inc* Alliance Health Service Group Pty Ltd Sutherland Division of General Practice Inc College of Nursing, The QLD EQuIP Certification Redcliffe Bribie Caboolture Division of General Practice* NSW SA Bega Valley Cluster* Adelaide North East Division of General Practice* Eurobodalla Cluster* Golden Cluster* WA Greater Albury Cluster* Greater Southern GP Network Ltd Greater Southern Area Health Service – Mental Health * Osborne Division of General Practice* Lower Western Cluster Pilbara Division of General Practice* Monaro Cluster* Murrumbidgee Cluster* Southern Slopes Cluster* Southern Tablelands Cluster* Quality Health Care Wagga Wagga Cluster* QLD Banana Coast Home Nursing* Precision Cosmetic Laser and Surgery ACHS surveyor List As at 30 June 2007
Our Surveyor workforce totals around Ms Elizabeth Clarke Dr Peter Kennedy 350 dedicated health care professionals Mrs Marie Clarke Ms Dianna Kenrick and health consumers. Ms Glenda Cleaver Ms Didi Killen These ACHS Surveyors, who conduct peer reviews, have recent experience in Mr Peter Clout Ms Di Knight health services with many still in full-time Dr Jeanette Conley Mr Kim Knoblauch roles such as health service managers, physicians, allied health professionals Mr Chris Crawford Dr Friedbert Kohler and nurses. Associate Professor David Crompton OAM Ms Deborah Latta They are trained and skilled in surveying Dr Paul Curtis Ms Deborah Lewis techniques and are able to gather Mr Robert Cusack Ms Bernadette Loughnane relevant information to verify the health Mr Matthew Daly Ms Judy Lovenfosse care organisation’s achievement in the 57 standards being assessed. Ms Therese Daubaras Mr Stuart MacKinnon ACHS Consumer Surveyors undergo Ms Darryl (Lynn) Davis Ms Kerry Marden the same rigorous training in the ACHS standards and accreditation processes Mrs Marie Dickinson Mrs Jo McGoldrick as the surveyors with health industry Ms Jenny Duncan Mr Kevin McLaughlin experience. Ms Karen Edwards Mr Bernard McNair Australian Capital Territory Professor Joan Englert AM Mr Keith Merchant Dr Peggy Brown Dr Terence Finnegan Mr Eddy Mirck Mr Grant Carey-Ide Mr Frank Flannery Dr Katherine Moore Dr Robert Griffin Ms Jacky Flynn Associate Professor Ganapathi Murugesan
Ms Kaye Hogan AM Ms Lynnette Ford Mr Danny O’Connor ACHS ANNUAL REPORT 2006-07 Ms Irene Lake Mr Peter Frendin Ms Anne O’Donoghue Ms Mary Martin Mr John Geoghegan Ms Marilyn Orrock Mr Russell McGowan Ms Diane Gill Mr Colin Osborne Ms Jenelle Reading Professor Adrian Gillin Mrs Rosalind O’Sullivan Ms Christine Waller Ms Robyn Goffe Dr Charles Pain New South Wales Dr Deane Golding Dr Richard Parkinson Dr Teresa Anderson Associate Professor Jane Gordon Mr Ian Paterson Mr Peter Avery Ms June Graham Ms Carmel Peek Mrs Michelle Azizi Ms Pamela Gulbis Mrs Nancye Piercy Mr Peter Barber Mr Ken Hampson Dr Robert Porter Mrs Shirley Batho Ms Paula Hanlon Mr Geoff Rayner Dr George Bearham Dr Kim Hill Ms Cindi Rees Mrs Karen Becker Mr John Hodge Mr Ian Rewell Dr Alexander Bennie Mrs Sally Holmes Mr Raad Richards Mrs Christine Bulters Dr Roger Hooper Dr Grahame Robards Ms Margo Carberry Dr Ian Hoult Dr Pauline Rumma Ms Sandie Carpenter Dr Philip Hoyle Ms Kerry Russell Ms Desley Casey Mr Peter Hurst Dr Margaret Sanger Ms Vivian Challita-Ajaka Ms Zoe Hutchinson Adjunct Professor Stuart Schneider Ms Rosemary Chester Dr Helen Jagger Ms Mary Scott Mr Sam Choucair Mrs Kate Jerome Dr Kevin Sesnan Dr Matthew Chu Mr Peter Johnson Mr Michael Shaw Mr John Clark Ms Ann Kelly Mr Ben Skerman ACHS Surveyor List (continued)
Dr Alicja Smiech Dr G Adair Heath South Australia Ms Valerie Smith Ms Garda Hemming Ms Dianne Campbell OAM Ms Rosemary Snodgrass Dr David Henderson Dr Richard Cockington Mrs Jean Spurge Ms Roslyn Henney Dr Maria Fedoruk Ms Gowri Sriraman Mrs Cheryl Herbert Dr Brian Fotheringham AM Ms Janet Stretton Adjunct Associate Professor Leonie Mr Paul Gardner Hobbs Mr John Stuart Mrs Marion Holden Dr John Hooper Dr Christopher Swan Mr Geoff Illman Mr Terry Hughes Dr George Szonyi Mr Alan Lehman Ms Catherine James Mr Arnold Tammekand Ms Janne McMahon 58 Adjunct Associate Professor Paul Kachel Ms Andrea Taylor Ms Jill Michelson Mr David Kelly Mrs Anne Temblett Mrs Catherine Miller Ms Debra Le Bhers Mrs Solly Toefy Mr David Miller Ms Moina Lettice Ms Brigid Tracey AM Dr Ea Mulligan Dr William Lindsay Mr Michael Wallace Mrs Dianne Norris Mrs Cherryl Lowe Mr Tony Wallace Ms Karen Parish Dr Donald J G Martin Mr Robert Walsh Mr Len Payne Mrs Patricia Matthews Conjoint Professor Jennie West Mr Neville Phillips Dr Chris May Adjunct Professor Richard West Dr Patrick Phillips
ACHS ANNUAL REPORT 2006-07 Ms Sue McLellan Ms Jan Whalan Ms Jane Pickering Adjunct Professor David McMaugh Mr Harry Williams Dr Paul Rainsford Mr Ian Mill Dr Arthur Wooster Mrs Mara Richards Ms Virginia Morris Dr Helen Yoong Ms Pam Schubert Dr Donna O’Sullivan Ms Lesley Siegloff Northern Territory Dr Scott Phipps Mr Wayne Singh Dr Leonie Katekar Mr David Poon Ms Judy Smith Dr John Reilly Queensland Ms Michele Smith Mr Rick Austin Mrs Cheryle Royle Dr Tony Swain Dr Winton Barnes Mrs Monica Seth Ms Rosemary Taylor Associate Professor Brian Bell Ms Tracey Silvester Dr Susan Buchanan Associate Professor Patricia Snowden Tasmania Dr Stephen Ayre Mr Nick Buckmaster Ms Rosemary Steinhardt Associate Professor Des Graham Ms Anne Copeland Ms Lorraine Stevenson Mr Bernard Griffiths Ms Val Coughlin-West Ms Glynda Summers Mrs Marlene Johnston Mr Ken Denny Mrs Penny Thompson Ms Karen Linegar Ms Michelle Denton Ms Theresa Thompson Dr Peter Renshaw Associate Professor Brett Emmerson Ms Val Tuckett Ms Meg Skegg Ms Lisa Fawcett Mrs Kym Volp Mrs Eve Thorp Ms Joan Fellowes Dr John Waller AM Dr Frank Fiumara Associate Professor Jill Watts Ms Jenny Tuffin Mr Kevin Freele Mr Brendon Weavers Victoria Dr Kong Hai Goh Ms Raewyn Wolcke Mr Peter Abraham Mrs Deborah Grant Dr John Youngman Dr Cathy Balding Mr Charlie Grugan Mr Allan Boston Dr Peter Bradford Mr Michel Maalouf Ms Nola Cruickshank Mrs Lorraine Broad Mrs Mary Manescu Mr Kim Darby Ms Therese Caine Mrs Josephine Maprock Ms Kate Dyson Mr Alex Campbell Dr Chris Maxwell Mrs Marcia Everett Dr David Campbell Ms Christine Minogue Ms Helen Hoey Dr Jillian Carson Dr John Monagle Dr Jenni Ibrahim Mr Wesley Carter Mr George Osman Ms Diane Jones Ms Julie Cartwright Dr Karen Owen Dr Peter Kendall Mrs Ann Cassidy Mrs Glenna Parker Ms Lena Lejmanoski Dr Wayne Chamley Mr Ric Pawsey Adjunct Associate Professor Ruth Letts 59 Ms Gillian Clark Mr Ormond Pearson Mrs Grace Ley Dr Alex Cockram Ms Ros Pearson Mr Shane Matthews Dr Brian Cole Ms Merrin Prictor Ms Ellen Nightingale Ms Julie Collette Mrs Patricia Quinn Ms Patricia O’Farrell Ms Annette Coy Ms Jenny Rance Ms Anne Rutherford Mr Michael Delahunty Ms Catherine Roper Dr Mark Salmon Ms Lydia Dennett Dr Alan Sandford Ms Sally Skevington Dr Harry Derham Mr Michael Scarlett Mr Warwick Smith Dr Sherene Devanesen Ms Mavis Smith Mr Keith Symes
Ms Clare Douglas Mr Darrell Smith Associate Professor Marc Tennant ACHS ANNUAL REPORT 2006-07 Mr Sid Duckett Ms Kaye Smith Mrs Sandy Thomson Mr Tim Elrington Mrs Marilyn Sneddon Ms Debbie Waddingham Dr Peter Fahy Ms Catherine Steele Dr Deborah Wilmoth Dr Simon Fraser Mrs Maria Stickland Ms Fay Winter Mr Vince Gaglioti Dr Lakshmi Sumithran Dr Mark Garwood Mr Raymond Sweeney Mr David Gerrard Mr Denis Swift Mrs Leigh Giffard Ms Jennifer Taylor Mrs Sue Gilham Mr Peter Turner Mrs Sharon Godleman Mrs Lee Vause Mr Phillip Goulding Dr Arlene Wake Dr Ian Graham Associate Professor Jeff Wassertheil Dr Lee Gruner Mr Dan Weeks Ms Bronwyn Harris Miss Ruth White Dr Richard Harrod Mr John Wigan Ms Lyn Hayes Mrs Wendy Wood Ms Marguerite Hoiby Western Australia Mr Graeme Houghton Ms Diane Barr Dr M R Jones (Taffy) Ms Patricia Canning Dr Tony Landgren Mr Trevor Canning Ms Marie Larkin Ms Geraldine Carlton Mr Alan Lilly Dr Winston Chiu Dr Martin Lum Ms Robyn Collins ACHS Surveyor List (continued)
ACHS Surveyors from India outside Australia Dr Bidhan Das While ACHS has had a surveyor Dr Srinivas Murali exchange program with Ireland and New Zealand for several years, the Ireland relationships developed through the work of ACHS International have Ms Anne Carrigy provided additional opportunities to train Mr Ian Carter surveyors from countries such as Hong Mr Brian Conlan Kong, India and Malaysia. Ms Triona Fortune The surveyors are able to participate on teams reviewing our Australian Dr Roderick (Rory) O’Connor 60 member organisations. These surveyors will also participate on survey teams Malaysia with Australian surveyors in their home Mr Stuart Rowley countries. We welcome the diversity of experience and perspectives they bring New Zealand to our surveyor workforce. Dr Dinesh Arya Hong Kong Ms Rose Laloli Mr Fred Wai Cheung Chan Mrs Julie Nitschke Ms Iris Lam Shuk Ching Dr Chor-chiu Lau Dr David Lau
ACHS ANNUAL REPORT 2006-07 Ms Fion Wai-man Lee Ms Chan Wai Leng Ms Julie Li Ms Manbo Man Mr Siew Man Pang Dr Chung-Ngai Tang Mrs Mary Wan Dr Loretta Yam Ms Rosa Yao Mrs Sim-heung Yeung Publications and presentations
Monographs Presentations Hennessy, D. ‘EQuIP 4 Standards Development, World Health Quality Initiatives 2006 – Entries in 9th Braithwaite, J, Farraway, C & Mallock, Organisation (WHO) delegation annual ACHS Quality Improvement N. ‘A Tool to Construct and Assess (Malaysia), Sydney, December 2006 Awards – 2006 “Ideal” Clinical Pathways’, 4th Australasian Conference on Safety Hennessy, D. ‘An Introduction to ACHS Clinical Indicator Report for and Quality in Health Care, Melbourne, EQuIP 4’. Delegation Queen Mary Australia and New Zealand 1998–2005, August 2006 Hospital and University of Hong Kong, Determining the Potential to Improve Sydney December 2006. Quality of Care, 7th edition Burton, J. ‘Hospital Performance Assessment and Hospital Johnston, B & Hodgson, M. Certificate ACHS Clinical Indicator Users’ Manual Management,’ Qingdao Hospital presentation to the Southern Highlands 2007 Delegation, 26 October 2006 Division of General Practice, July/ ACHS Performance and Outcomes August 2006 Burton, J. ‘Overview of EQuIP’, 2nd Service Information Package 2007 Australia-China Hospital Management Johnston, B. ‘Introduction to ACHS 61 ACHS Clinical Indicator Summary Guide International Forum, 29 November 2006 and Australian Accreditation Programs’, 2006 Fudan University, Shanghai, July/August Burton, J. ‘Overview of EQuIP’, 2006 EQuIP 4 Resource Tool for Hospitals Queen Mary Hospital and the Hong Kong University Delegation, 21 December 2006 Johnston, B. World Health Organisation EQuIP 4 Resource Tool for Community, China Delegates, July/August 2006 Primary Care and Multipurpose Services Dickinson, M. ‘Accreditation and Evaluation of Hospital Business Johnston, B. Quality Council of India EQuIP 4 Resource Tool for Day Achievement and Hospital Productivity’, and National Accreditation Board for Procedure Centres Qingdao Hospital Management Hospitals and Healthcare Providers, EQuIP 4 Resource Tool for Mental Program, University of Sydney, July/August 2006 Health Services 20 March 2007 Johnston, B. Asia Pacific Society for EQuIP 4 Resource Tool for Oral Health Dickinson, M. ‘Managing Quality Risk Healthcare Quality–1st International
Services and Cost in Health Care’, Masters of Conference, August/September 2006: ACHS ANNUAL REPORT 2006-07 Health Services Management, University • ‘The Australian Accreditation System ACHS EQuIP Corporate Health Services of Technology, 7 August 2006 and Experience’ Guide, 3rd edition • ‘National Standards for Mental Health Farraway, C, Gibberd, R & Mallock, N. Services – lessons from the last ACHS National Report on Health ‘Clinical Indicators: Reporting Trends five years’ Services Accreditation Performance: for Organisational Governance’, 4th 2003–2006 Australasian Conference on Safety Johnston, B. ‘Accreditation in the ACHS Quality for Divisions network and Quality in Health Care, Melbourne, Australian Health Care System’ – 4th Guide, 1st edition August 2006 year medical students, Clinical School, Darwin, August/September 2006 Farraway, C. ‘EQuIP 4 Clinical Electronic Media Indicators’, National Blood Authority, Johnston, B. Mr Abel Gutterres, Consult Clinical Indicators and PIRT 2007, Canberra, September 2006 General for East Timor, August/ December 2006 September 2006 Farraway, C. ‘EQuIP 4 Clinical Indicators’, Justice Health, Sydney, Johnston, B. ‘Comparing Accreditation October 2006 Programs ACHS vs ISO’ APHA 26th National Congress, Gold Coast, Farraway, C. ‘EQuIP 4 Clinical September/October 2006 Indicators’, Oral Health Care Convention, Sydney, November 2006 Johnston, B. ‘Controversies in Performance Measures: Are we ready Farraway, C. ‘Using Clinical Indicators for international consensus – linking to Measure Quality Management’, performance data and accreditation: Delegation Qingdao Hospital are we there yet?’ ISQua Indicators/ Management Training Program, Measures Workshop, September/ University of Sydney, March 2007 October 2006 Farraway, C. ‘EQuIP 4 Clinical Indicators’, Hearing Services Consultative Committee, Canberra, March 2007 Hennessy, D. ‘An introduction to EQuIP 4 Standards’, National Bowel Cancer Conference, Melbourne, November 2006 Publications and Presentations (continued)
Johnston, B. ‘Accreditation for quality Pawsey, M. ‘The EQuIP 4 Program’, improvement: making it happen Prevention and Management of – how do you answer the question: Accommodation of Adults with does accreditation improve the Children in Hospital Forum, The Royal quality of care? – Addressing an Australasian College of Physicians, accreditation paradox: a design to Sydney, February 2007 examine accreditation’s contribution to improvement’, ISQua Accreditation Comments Symposium (presentation on behalf of Australian Commission on Safety and Braithwaite et al.), September/October Quality in Health Care 2006 National Safety and Quality Johnston, B. Kazakhstan Study Tour Accreditation Standards Delegation, September/October, Australian Government, Department of 62 Sydney 2006 Health and Ageing Johnston, B. Presentation of Submission Accreditation Scheme accreditation certificate, The Saad for Practices Providing Radiology Hospital, Saudi Arabia, 25 September Services under Medicare 2006 Australian Government, Productivity Johnston, B. ‘The EQuIP Standards Commission and Complaints Management’ 2006 Study into Standard Setting and Australasian Health Complaints Laboratory Accreditation Draft Conference, November/December 2006 Research Report Johnston, B. ‘The Australian Health NSW Health Care Industry and Accreditation’, Review of Inquiry into Complaints Malaysian Ministry of Health Delegation, Handling in NSW Health
ACHS ANNUAL REPORT 2006-07 organised by the WHO, November/ December 2006 Johnston, B. Queen Mary Hospital and Hong Kong University Delegation, November/December 2006 Johnston, B. ‘Governance and Quality’, West Wimmera Health Service – Board Development Day, March 2007 Johnston, B. ‘Medical Tourism and Hospital Accreditation’, Quality Health Care Conclave, Kerala Institute of Medical Sciences, India, March 2007 Kaiser, B. ‘EQuIP 4 and Carers’, Carers Support Service NSW, 8 September 2006 Lewis, B. Workshop for Australia New Zealand Clinical Waste Interest Group, Sydney, 15 March 2007 Pawsey, M. ‘An Introduction to EQuIP 4’, Delegation Quality Council of India, Sydney, July 2006 Pawsey, M. ‘An Introduction to the ACHS’, World Health Organisation (WHO) Fellows’ Accreditation Study Group (China), Sydney, July 2006 Pawsey, M. ‘Creating a Culture of Quality Improvement and Benchmarking’, Moyne Health Services, Port Fairy, December 2006 valediction
Dr Edward ‘Ted’ Booth AM It is with great sadness that the ACHS recognises the recent passing of Dr Edward ‘Ted’ Booth AM. Dr Booth was a respected radiologist from Sydney, past President (1966–1967) of the NSW branch of the Australian Medical Association and the first Chairman of the Joint Steering Committee on Hospital Accreditation (which evolved to become the ACHS). Working with some very dedicated individuals, he was a dynamic force in establishing research into developing an accreditation program for public hospitals throughout Australia. It was the first time two such powerful and influential groups (NSW AMA and Victorian AHA) had met and worked together in a formal Pictured: Employees and consumers from the Royal Brisbane and Royal Women’s Hospitals and the structure outside the framework of their professional bodies. 63 Balmain Hospital and Eastern Sector Aged Community Services, Sydney Dr Booth was also a former President of the Royal Australian and New Zealand College of Radiologists (1964–1965). The ACHS is indebted to Dr Booth for his contribution to the development of internationally recognised accreditation for Australian health services.
The Australian Council on Healthcare Standards safety, quality, performance ACHS ANNUAL REPORT 2006-07
The Australian Council on Healthcare Standards (ACHS) would like to thank our own employees as well as the management, employees, consumers and visitors at the following member organisations, for participating in the photography for this Annual Report: • Balmain Hospital and Eastern Sector Aged Community Services, Sydney • Royal Brisbane and Royal Women’s Hospitals, Brisbane • Royal Prince Alfred Hospital, Sydney • Skin & Cancer Foundation Westmead Day Clinic, Sydney • St Luke’s Hospital Complex, Sydney • The Ophthalmic Surgery Centre (Chatswood), Sydney • The Sydney Eye Specialist Centre (Kingsford), Sydney
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 ISBN: 1 92126527 2 (paperback) Aboriginal people who have recently deceased. ISBN: 1 921265 28 0 (website) Readers are warned that this publication may inadvertently contain such photographs. This Report is available in pdf format via the ACHS website (under the Publications and Resources menu option) from the homepage: www.achs.org.au 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 order a printed copy, please contact to publish and distribute our report to ACHS member organisations, ACHS surveyors, the ACHS: health industry bodies, governments, consumers and the community. 5 Macarthur Street October 2007 Ultimo NSW Australia 2007 © The Australian Council on Healthcare Standards Telephone 61 2 9281 9955 Facsimile 61 2 9211 9633 Apart from any use as permitted under the Copyright Act 1968, no part may be E-mail [email protected] reproduced by any process without prior written permission from the Australian Council on Healthcare Standards. Website http://www.achs.org.au The Australian Council on Healthcare Standards annual Report 2006-07
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