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