The Australian Council on

Healthcare Standards
International
The Future of International Hospital Accreditation Bodies
Joint Program to Improve Quality & Patient Safety in Indonesian Hospitals

KARS Pitselnas
Jakarta, Indonesia | Monday 5 August 2019

Mr Michael Giuliano, Executive Director – ACHS International

© Copyright 2019, ACHS International Pty Ltd (ABN 17 109 446 237)
A wholly-owned subsidiary of The Australian Council on Healthcare Standards (ACHS)
ACHS is an ISQua (International Society for Quality in Healthcare) accredited organisation
All rights reserved. No part of this document may be reproduced, stored in a retrieval system or transmitted in any form or by any means
electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the copyright owner.
 Objectives

Today’s discussion will address these questions:

• How can KARS and ACHS pioneer a joint

international accreditation program?

• What are the benefits to Indonesian hospitals?

• What are the benefits to assessors?

• How will the joint program work?

• What are the timeframes?

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 ACHS Overview
 Established in 1974 by the Australian Medical Association (AMA) and Australian Hospital
Association (AHA)

 Independent, private, not-for-profit, non-government funded organisation

 Australia’s largest and oldest healthcare quality improvement agency (1,500+ members)

 Governed by a Board and Council representing peak healthcare organisations

Vision
Inspire excellence in healthcare

Mission
To strengthen safe, quality health care by
continuously advancing standards and education
nationally and internationally

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 ACHS International

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 Licencing vs Accreditation
Departments of Health at the state / territory level approve the commissioning and monitor ongoing
prevention for all public and private hospitals

Commissioning Prevention & Improvement

Commencing a new service or facility Ongoing monitoring of operations

• Hospital licence – Western Australia LARU • Hospital accreditation -

(https://ww2.health.wa.gov.au/Articles/A_E/About-
licensing-of-private-healthcare-facilities) and Victorian
Department of Health
(https://www2.health.vic.gov.au/hospitals-and-health-
services/private-hospitals)
https://www.safetyandquality.gov.au/
• NSW Work Health & Safety Audits -
https://www1.health.nsw.gov.au/pds/ActivePDSDocum
ents/PD2016_017.pdf

• Hospital declaration - • NSW Clinical Excellence Commission -

http://www.health.gov.au/internet/main/publishing.nsf/ http://www.cec.health.nsw.gov.au/
Content/hospitals2.htm
• Safer Care Victoria -
• Hospital infrastructure standards - https://bettersafercare.vic.gov.au/about-us/about-
https://www.standards.org.au/ safer-care-victoria

• Hospital accreditation -
https://www.safetyandquality.gov.au/

• NSW Process of Facility Planning (POFP) -

https://www1.health.nsw.gov.au/pds/ActivePDSDocum
ents/PD2010_035.pdf

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 Regulating Patient Safety

National Safety & Quality

Health Service Standards
(NSQHSS)

Accrediting Agencies
(8 approved)

State / Territory
Regulator

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 Our Standards – EQuIP
Introduced in 1996, ACHS’ Evaluation and Quality Improvement Program (EQuIP) is a quality assessment and
improvement program for healthcare organisations that supports excellence in consumer / patient care and services.

It is designed to provide a framework which will assist and support you to ensure the provision of safe, high quality
care and services, and to achieve continuous quality improvement.

EQuIP Key Components

• the standards that organisations work to achieve
• a yearly self-assessment to evaluate performance against the standards
• ACHS assistance and guidance around the organisation’s self-assessment
• biennial onsite assessments by an external, experienced team of accreditation assessors to provide an
independent assessment of the organisation’s performance against the standards
• improvement process undertaken to address the recommendations from the onsite assessments.

EQuIP Principles
• Consumer Focus
• Effective Leadership Evaluation
• Continuous Improvement
• Evidence of Outcomes
and
• Striving for Best Practice Quality
Improvement
Program

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 EQuIP Rating System
 The EQuIP criteria have been developed around a five-level rating scale designed to measure and support
continuous improvement in key areas of a healthcare organisation’s operation.

 Each of the criteria has five possible levels of achievement: Little Achievement (LA), Some Achievement (SA),
Marked Achievement (MA), Extensive Achievement (EA) and Outstanding Achievement (OA).

 Organisations and assessors will use the elements in each of the criteria to rate the level of the organisation’s
achievement. The elements are not meant to be an audit checklist; they describe the practices that contribute to the
achievement of each level. While the manner in which the elements are implemented and the evidence presented
may differ between healthcare organisations, each organisation should be able to demonstrate that their practices
address the intent of the elements, and that their evidence responds to their aims or purposes.

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 EQuIP Editions
The ACHS EQuIP is offered in seven (7) editions based on the type of healthcare organisation wishing to
implement one of our quality programs

EQuIP Edition Relevant To Program Length Criteria

• Hospitals
• Mental Health
4 years Total = 47
Core • Community Care
SASS > OWS > SASS > PR Mandatory = 16
• Telemedicine / Telehealth
• Medical Transport / Emergency Care

• Healthcare Corporate Offices

Healthcare Support 4 years Total = 26
• Ministries of Health
Services SASS > OWS > SASS > PR Mandatory = 7
• Public Hospital / Health Authorities

• Standalone dialysis clinics

3 years Total = 25
Haemodialysis • Dialysis departments within acute or other
SASS > OWS > SASS Mandatory = 15
healthcare facilities

• General Dentistry
3 years Total = 25
Oral Health • Dental Specialities such as orthodontics,
SASS > OWS > SASS Mandatory = 15
periodontics, maxillofacial

• Nursing Homes
3 years Total = 42
Aged Care Services • Aged Care Day Services
SASS > OWS > SASS Mandatory = 17
• Other Residential Aged Care

• Day Surgical Centres

3 years Total = 26
Day Procedure Centres • Day Endoscopy Centres
SASS > OWS > SASS Mandatory = 15
• Ambulatory Care

• Primary Care Centres 3 years

Primary Care Coming Soon
• General Practice SASS > OWS > SASS

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 EQuIP National
ACHS has demonstrated previous experience in developing joint programs

• Created EQuIP National as an ‘add on’ program to the Australian National Safety and Quality
Health Service (NSQHS) Standards (version 1 – 2013 to 2018)
• Included 5 additional standards covered in EQuIP, but not addressed in NSQHS v1
• Aligned structure of EQuIP National to structure of NSQHS v1 for consistency
• One onsite assessment covered by programs to avoid duplication for the organisation

Program National Standards (NSQHS) v1 EQuIP National

1. Governance 1. Service delivery

2. Partnering with consumers 2. Provision of care
3. Hospital acquired infections 3. Workforce planning and management
4. Medication safety 4. Information management
5. Patient identification & procedure matching 5. Corporate systems and safety
Standards
6. Clinical handover
7. Blood and blood products
8. Pressure injuries
9. Clinical deterioration
10. Preventing Falls and Harm from Falls

Criteria 41 criteria 27 criteria

Actions 256 total – 209 core 111 total – 24 mandatory

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 SNARS EQuIP Joint Program
KARS and ACHS will be the first two ISQua accredited organisations to pioneer a joint
international accreditation program

KARS SNARS ACHS EQuIP

Would add on likely

The standards would be integrated 3 – 5 standards
back into the SNARS program to
ensure ease of understanding for
assessors and organisations
(not tacked on as separate)

To ensure alignment, the ACHS Product Development team will:

• Integrate any ACHS EQuIP add on material into the main SNARS program
• Use the same rating system as indicated in SNARS
• Use the same program length and annual requirements as SNARS
• Develop the joint program in same framework and layout as SNARS

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 Development Timeline
End August 2019 – finalise draft of ACHS EQuIP add on program, ensure no duplication
between programs and streamline integration of standards

September 2019 – review and comment from ACHS Standards Committee and KARS

October 2019 – comment review and program update, ACHS Standard Committee sign off

17 October 2019 – ACHS Board endorsement

November 2019 – ISQua endorsement

End 2019 – SNARS EQuIP joint program ready for launch

January 2020 – launch media event, marketing commences, and joint program begins

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 Benefits for Indonesian Hospitals
What are the benefits to Indonesian hospitals?

• Receive two accreditations at the same time and:

o Avoid duplication and repetition from two separate programs
o Receive two certificates from ISQua accredited organisations
o Spend less time preparing for two accreditation programs
o Save cost by merging two programs into one
o Ensure support by KARS and government of the new joint program

• Complimentary full access to ACHS Clinical Indicator Program

• Access to ACHS support programs such as Expert Connect, Member Connect, and Coach

• Insights and perspectives from an international team of assessors

• Maintain culturally sensitive and localised approach to international accreditation

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 Benefits for Our Assessors
What are the benefits for KARS and ACHS assessors?

• Develop a global network of learning

• Create a cross exchange of ideas and perspectives on patient safety and quality

• Learn different approaches to healthcare standards

• Improve assessment skills from interacting with international assessors

• Understand different approaches to assessment methodology

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 Operations
How do we operationalise the joint program?

• Pricing – ACHS to develop indicative pricing for the joint program in conjunction with KARS
by aligning scoping approaches

• Training – ACHS and KARS to train assessors on the new program so they are ready to
undertake onsite assessments in the future

• Contracting – hospitals to sign one contract with KARS and ACHS

• Invoicing – hospitals to pay fees directly to KARS and then KARS to transfer ACHS portion
back to ACHS Australian bank account

• Marketing – ACHS and KARS to market the joint program on their websites and in
conversations with Indonesian healthcare organisations

• Approval – KARS to assist in receiving Indonesia MOH approval and recognition of the joint
program to support marketing efforts and acceptance by Indonesian community

• Exclusivity – KARS should not develop another joint program with another international
healthcare accrediting organisation

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 Questions & Discussion

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The Australian Council on
Healthcare Standards
International

+61 2 9281 9955

+61 2 9211 9633

achsi@achs.org.au

www.achs.org.au/international

© Copyright 2019, ACHS International Pty Ltd (ABN 17 109 446 237)
A wholly-owned subsidiary of The Australian Council on Healthcare Standards (ACHS)
ACHS is an ISQua (International Society for Quality in Healthcare) accredited organisation
All rights reserved. No part of this document may be reproduced, stored in a retrieval system or transmitted in any form or by any means
electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the copyright owner.