22/10/2013. The Australian Commission on Safety and Quality in Health Care. When Governments get Interested in Quality

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1 When Governments get Interested in Quality ISQua 30 th International Conference, Edinburgh 2013 Adjunct Associate Professor Karen J Linegar FACN JP President ACHS Dr Lena Low Acting Chief Executive ACHS When Governments Get Interested in Quality 1. Observations on progression and consequences of Government State/Territory Governments agreeing to national set of core standards focused on improving performance of health services 2. Introduction of the National Safety and Quality Health Service (NSQHS) Standards endorsed by Health Ministers, published Sep 2012 mandatory for Australian hospitals, day procedure services 1 Jan 2013 accreditation strategy in Australia moved significantly from continuous quality improvement to compliance The Australian Commission on Safety and Quality in Health Care present 3. ACHS evolution from a business model of accrediting to its own standards since 1974 to accrediting to the NSQHS Standards challenges and innovative methodologies Creation and Evolution of the ACSQHC The Australian Commission on Safety and Quality in Health Care (the Commission) was created by Health Ministers in 2006, and funded by all governments on a cost sharing basis, to lead and coordinate health care safety and quality improvements in Australia As a result of its work, the Commission has an ongoing program of significant national activity aimed at demonstrating direct patient benefit as well as creating essential underpinnings for ongoing improvement In 2011, the Federal Parliament passed the National Health Reform Act 2011 (the NHR Act) which established the ACSQHC as an independent statutory authority under the Commonwealth Authorities and Companies Act 1997 (the CAC Act). The governance structure is determined by these Acts. ACSQHC (Commission) Structure The Commission reports to the Standing Council on Health (SCoH) The Board is the governing body of ACSQHC (Commission) Board the Commission and works with the Inter-Jurisdictional Committee The Commission has three Committees The Primary Care Committee which provides primary care advice and liaison with the primary care sector The Inter-Jurisdictional Committee is made up of federal and state representatives The Information Strategy Committee which provides input and advice in relation to the Information Strategy Senior Safety and Quality Managers from the Commonwealth Department of Health and Ageing Standing Council on Health (SCoH) Inter-Jurisdictional Committee The Private Hospital Sector Committee, comprising nominees from key private health care bodies in Australia Each State and Territory Department of Health 1

2 ACSQHC Partnership and Consultation The Commission also works in close partnership with Advisory Committees that directly relate to key aspects of individual work programs. These involve key stakeholder groups, including consumers and health professionals. The National Safety and Quality Health Service (NSQHS) Standards present The National Safety and Quality Health Service (NSQHS) Standards 10 NSQHS Standards The National Safety and Quality Health Service (NSQHS) Standards were endorsed by the Australian Health Ministers in September 2011 The NSQHS Standards became mandatory for hospitals and day procedure services nationally, with implementation 1 January 2013 NSQHS Standards Framework 10 Standards (Statement of Intent / Context) 41 Criteria 113 Items 256 Actions 223 Core (changed to 209 Core) 33 Developmental (47) Comparison: NS actions = ACHS elements Rating Scale Not Met (NM) - the requirements of the item have not been achieved Satisfactorily Met (SM) - all elements of the item have been achieved at the base level Met with Merit (MM) in addition to meeting all the requirements to achieve a Satisfactorily Met rating, measures of good quality and a higher level of achievement are evident. Evidence of Satisfactorily Met could be present, although rare and/or Met with Excellence may occasionally be evident, but Met with Merit best describes the organisation s typical practice. 2

3 ACHS NSQHS Standards Program Progress report Onsite survey Progress report ACHS NSQHS Standards program Onsite survey More of an auditing focus Evidence for all core items Compliance model Progress reports Action plan for any National Standards not mets Progress on recommendations Minimal documentation and resources required ACHS Developments NSQHSS Survey Tool ACHS Methodologies to Adapt to Introduction of NSQHS Standards 1. Comparison Between EQuIP5 and NSQHS Standards EQuIP5 and NSQHS Comparison 1. 30% of NS actions are direct matches with EQuIP5 elements 2. 40% of NS actions broadly covered/ similar areas to EQuIP5 70% of National Standards content is covered in EQuIP % of NS actions are not covered in EQuIP5 4. All NS actions fall within the LA, SA, MA ratings of EQuIP5 5. Overall (including EA, OA rating) 80% of EQuIP5 elements not covered in NS Examples of 30% direct matches in NSQHS Standards Additional Actions Standard 3: Infection Control Compliance rates from hand hygiene audits are regularly reported to the highest level of governance in the organisation The clinical workforce is trained in aseptic non-touch technique Compliance with aseptic non-touch technique is regularly audited Action is taken to increase compliance with the aseptic non-touch technique protocols ACHS Elements e.g. infection control policy / guidelines referenced to Australian Standards, jurisdictional legislation, codes of practice, industry guidelines. 3

4 Examples of 40% Content broadly covered in EQuIP5 Elements Management of external service providers / contractors (e.g. sterilisation, linen, cleaning and food supplies) Occupational health and safety management systems (e.g hazardous substances including radiation control, manual handling) Emergency and disaster management systems Security management (e.g security of staff and buildings) Workforce / staff planning Employee support systems and workplace relations Corporate record management systems Data and information collection, use and storage Planning, use and management of information and communication technology Examples of 40% Content broadly covered in EQuIP5 Elements Health promotion to support community health and well being Management of organisational risk associated with research Defining the needs of the community Access and admission to system of care being prioritised according to healthcare needs Nutritional needs for patients 16 ADDITIONAL CRITERIA UNIQUE TO EQuIP5 Additional areas in EQuIP5 have been included as a result of consultation with healthcare providers practicing in the Australian healthcare system ACHS Developments Survey to NSQHS Standards During Transition Phase 1 July 2011, ACHS offered to survey the NSQHS Standards in addition to scheduled EQuIP5 surveys at no additional cost to members An additional survey day was allocated to support the NSQHS Standards survey Survey manpower was increased to support the NSQHS Standards survey ACHS Methodologies to Adapt to Introduction of NSQHS Standards 2. Development of EQuIPNational 2012 EQuIPNational Rationale for Development In response to implementation of the NSQHS Standards, ACHS developed EQuIPNational EQuIPNational - a comprehensive organisation-wide assessment 10 NSQHS Standards (clinical processes) 5 EQuIP Standards (service delivery processes, provision of care, non-clinical systems) Removes duplication between EQuIP5 and NSQHS Standards - designed to provide a seamless, integrated organisation-wide evaluation and quality improvement program Milestone Dates for Development Jun 2011 Draft National Safety & Quality Health Service Standards released Sep 2011 NSQHS Standards endorsed by Health Ministers Sep 2011 Standards Committee (consideration of formatting options) Nov 2011 Board Endorsement to proceed with development of EN Feb/Mar 2012 EQuIPNational desktop reviews Apr 2012 Standards Committee (review of desktop review feedback) May 2012 EQuIPNational Pilot Surveys Jun 2012 Standards Committee (recommendation to Board to endorse EN) 4

5 Milestone Dates for Development Jul 2012 ACHS Board approval EQuIPNational (26 July) EQuIPNational Desktop Review Feb/Mar 2012 Aug 2012 Guideline development, ART development, product design & print Sep 2012 LAUNCH EQuIPNational - ACHS Conference (24-27 September) Oct-Dec 2012 Surveyor / HCO education, training, roadshow Note: 20 respondents (7.7%) identified as a Day Procedure Centre Note: 20 respondents (7.7%) identified as a Day Procedure Centre Jan 2013 EQuIPNational Go Live 1 January 2013 Desktop Review Results / Feedback Desktop Review Results / Feedback Pilot Survey Feedback Overall impression the product is surveyable not onerous or burdensome Identified opportunities to further remove duplication and streamline content, which has been addressed in latest version standards Support for the development of related guidelines to assist the survey process Opportunities identified to further streamline process integrated approach to scheduling meetings with staff to assess multiple standards (e.g. workforce management, corporate systems and safety, with parts of governance) Support for further education and training for surveyors Linking EN to Evidence from ACHS Surveys 126 AC60s and 88 HPRs received from 509 surveys Examples of Areas Requiring Further Improvement not addressed by National Standards 1. Emergency and disaster management to support safe practice and a safe environment* (n=28 AC60) (n=25 HPR) non-clinical 2. Processes for credentialling and defining the scope of clinical practice to support safe, quality health care* (n=11 AC60) (n=6 HPR) non-clinical 3. Safety management systems to ensure safety and wellbeing for consumers/patients, staff, visitors and contractors* (n=6 AC60) (n=4 HPR) non-clinical REFERENCE: ACHS National Report on Health Services Accreditation Performance

6 10 National Safety and Quality Health Service Standards NSQHS Standards Content Standards 10 Criteria 42 Items 113 Actions 256 EQuIPNational Content Standards 5 Criteria 27 Items 70 Actions 111 Mandatory Actions = 24 (22%) EQuIPNational comprehensive and integrated EQuIPNational EQuIP National OWS NSQHS Standards SASS SASS PR Conclusions 1. EQuIPNational ensures organisations meet requirements to participate in a program including the NSQHS Standards, 1 January The product is simple and easy to implement, as it is formatted in alignment with the NSQHS Standards a seamless and integrated program Launch of EQuIPNational Thursday 27 September 2012 Sofitel Sydney Wentworth 3. EQuIPNational allows a comprehensive organisation wide assessment monitoring and reporting of clinical and non-clinical systems and processes 4. An evidenced based program survey results demonstrate that patient safety and quality of care can be at risk without a mechanism to monitor and evaluate the performance of non-clinical systems 5. Member feedback to date has demonstrated strong support for the value and relevance of EQuIPNational to their organisation 6

7 ACHS Flexibility in Transition Period ACHS Methodologies to Adapt to Introduction of NSQHS Standards 3. Program Implementation Contracts Renegotiate by agreement 1, 2, 3 or 4 year renewal periods Programs EQuIP Joint surveys NSQHS Standards Events Date changes (within cycle requirements) Options for ACHS Members - transition EQuIP5 EQuIP5 aligned to the NSQHS Standards by 1 Jan 2013 Comprehensive quality program Completed Resources Joint Program Members offered a complimentary NSQHS Standards review with the EQuIP survey from 1 July 2011 until 1 Jan NSQHS Standards only NSQHS Minimum required for safety Standards EQuIPNational EQuIPNational Day Procedure Centres Implemented January 2013 Aligned with NSQHS standards format 7

8 EQuIPNational Resource for Private Hospitals Accreditation Workbook Completed May 2013 Companion resource to EQuIPNational The feedback from all of our divisions has been very positive St John of God Completed May 2013 Developed in response to member requests for a resource in alignment with NSQHS Standards resources, for the additional 5 ACHS EN standards Risk Management & Quality Improvement Handbook Completed June 2013 ACSQHC endorsed with NSQHS Standards logo Results Developed for NSQHS Standards and EN members as a resource: Quality Improvement Plans Risk Register Quality Improvement Tools Accreditation requirements A requirement of the ACSQHC program is that all 209 Core actions within the NSQHS Standards have to be rated as Met to achieve accreditation. Developmental actions within the NSQHS Standards do not need to be rated Met to achieve accreditation. 161 organisations accepted the offer of NSQHS Standards gaps assessment between Jul 2011 to Dec Top 3 Core Action Not Met Comparison During the period of the gaps assessments, the top 3 core actions with Not Met ratings were from NSQHS Standard 3. ACHS provided support with: Road shows across Australia Development of resources E-learning tools Education for organisations and surveyors Information on the ACHS website The NSQHS Standards were implemented on 1 Jan

9 Collaboration The collaboration with the ACSQHC and sharing of the data for the first twelve months resulted in the ACSQHC changing some Core actions to Developmental actions. The concept of flexible arrangements and 8 prescribed actions were also introduced by the ACSQHC to ease organisations into the NSQHS Standards program for Graph 1 Graph 1 compares the ratings over the period before the changes and after which indicate that based on these results, a significantly high number of organisations would not have achieved accreditation if the Core actions had not been changed to Developmental. Results of ACHS initiatives The ACHS initiative of providing its members with the option of gaps assessments one and a half years prior to implementation of the NSQHS Standards enabled ACHS to support its members in the transition process. The assessment data provided evidence based data to share with the ACSQHC and the collaboration efforts together with the introduction of more flexible arrangements assisted with transition to the new NSQHS Standards. Results of ACHS Initiatives The analysis of the data also enabled ACHS to focus on areas of concern for content of its programs in road shows to members, newsletters, resources and education programs to ensure timely and relevant support for its members and surveyors. As a consequence, ACHS member organisations are better positioned to meet the requirements of the NS program. Summary Focus on collaborative approach with government Partnership and consultation with all stakeholders Evolution and innovation Adaptation of methodologies mapping, program revisions, flexibility, product and resource development Initiatives gaps assessments Thank you Members better positioned to meet government requirements 9

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