The Australian Council on Healthcare Standards

ANNUAL
REPORT
SAFETY, QUALITY
PERFORMANCE

The Australian Council on Healthcare Standards Common acronyms included in this Report:
(ACHS) would like to thank management, employees,
ACHS The Australian Council on Healthcare Standards
consumers and visitors at the Royal North Shore
Hospital, Sydney who kindly participated in the ACHSI ACHS International
photography for this Annual Report. A special
thanks to Melissa Chain for her organisation skills AAQHC Australasian Association for Quality in Health Care
and efforts for the photographic shoot.
AC60 Advanced Completion in 60 days
The ACHS seeks to treat indigenous cultures and ACSQHC Australian Commission on Safety and Quality
beliefs with respect. In many areas of indigenous in Health Care
Australia, it is considered offensive to publish
photographs or names of indigenous people who AIHW Australian Institute of Health and Welfare
are recently deceased. Readers are advised that
this publication may inadvertently contain such APS Agreed (accreditation) Performance Statement
photographs. ISQua International Society for Quality in Health Care

IAP International Accreditation Programme

The ACHS strongly acknowledges the generous EAT
support provided by Baxter Healthcare for the EQuIP
purposes of publishing this Annual Report. This
support enables us to publish and distribute our EQuIP 4
report to ACHS member organisations, ACHS
surveyors, health industry bodies, governments
and the community and maintain our profile in the EQuIP5
health community.
Electronic Assessment Tool
Evaluation and Quality Improvement Program
The 4th edition of the ACHS Evaluation and
Quality Improvement Program
the 5th edition of the ACHS Evaluation and
Quality Improvement Program

October 2010 HKHA Hong Kong Health Authority

© The Australian Council on Healthcare Standards QI Awards Quality Imrpovment Awards

Apart from any use as permitted under the Copyright PIRT Performance Indicator Reporting Tool
Act 1968, no part may be reproduced by any process
without prior written permission from the Australian
Council on Healthcare Standards.

The Australian Council on Healthcare Standards

Annual Report 2009-2010
ISBN-13: 978 1 921806 04 9 (paperback)
ISBN-10: 1 921806 04 4 (paperback)
ISBN-13: 978 1 921806 05 6 (web)
ISBN-10: 1 921806 05 2 (web)

Editor: Ian McManus

Editorial Assistant: Stefani Jelic
Photographers: Rebecca Rosconi and Derek Lau
Designer: Garry McArthur - McDesign

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

To order a printed copy, please contact the ACHS at:

5 Macarthur Street Ultimo NSW Australia 2007
T: 61 2 9281 9955 I F: 61 2 9211 9633
E: communications@achs.org.au I www.achs.org.au
 CONTENTS

About ACHS
Vision, Mission and Values I 03
Our Identity I 04

Our Performance
Corporate and Strategic Plan I 06
President’s and Chief Executive’s Report I 11
Highlights of the year I 15

Our Organisation
Organisation Chart I 16
Executive Team I 18

Recognising Achievement
ACHS Medal and ACHS Quality
Improvement Awards I 20

Division Reports
Customer Service I 22
Development I 28
Corporate Services I 31
ACHS International I 34

Corporate Governance
Overview I 35
ACHS Board of Directors I 38
ACHS Council Members I 41

Financial Performance
Director’s Report I 44
Independent Auditor’s Report I 47
Financial Statements I 47
Notes to the Financial Statements I 50
Director’s Declaration I 59

Listing
Our Members I 60
Our Surveyors I 72
Publications and Presentations I 75
Overview of Products and Services I 76

Glossary of Terms
Inside back cover
Tender times for patient Joyce Lloyd
and nurse EEN Sarah Cox.
 ABOUT ACHS

To be recognised nationally and internationally as the leading Australian

Vision organisation that independently assesses performance and promotes
and improves the quality and safety of health care.

Mission To improve the quality and safety of health care.

Values The following words encapsulate how the organisation seeks to behave:

Excellence Transparency
To strive for excellent performance To be clear and visible in all matters
in all that we do

Leadership Team work

To demonstrate leadership and To work co-operatively with each
support the leadership role of other and all stakeholders
stakeholders

Commitment Cultural responsiveness

To consistently demonstrate our To respond to the various beliefs,
commitment to the achievement of traditions and customs that are reflected
safety and quality in the provision of in Australian society
all health services

Integrity Consumer focus

To be professional, truthful and reliable To look at health system issues through
in all our actions the eyes of consumers

ACHS ANNUAL REPORT 2009 - 2010 I 3

ABOUT ACHS
OUr IdENTITy

The Australian Council on Healthcare Standards (ACHS) is an independent, not-for-profit

organisation; collaborating with consumers, health care professionals, industry bodies and
the broader community to develop the accreditation standards and quality improvement
programs used by the majority of Australian hospitals and health care organisations.

ACHS is governed by a Board of Directors elected by a NumberofEQuIP(Full&AssocMembers)

Council drawn from peak bodies in the health industry, as from2006to2009bysectorasat31/12/2009
well as representatives from governments and consumers.
Sector 2006 2007 2008 2009
We are recognised by the International Society for Quality Private 435 417 431 567
in Health Care (ISQua) for our organisational framework, Public 613 675 780 817
our accreditation programs and our surveyor training. 1048 1092 1211 1384
Total
ACHS has been a member of ISQua’s International
Accreditation Programme (IAP) since its launch in 1999.
The ACHS was also part of ISQua’s pilot testing of its
ACHSMembers
International Accreditation Program.
More than 1,300 individual healthcare organisations are
Productsandservices members of ACHS quality improvement programs.

External and independent peer review is considered

Some of the types of organisations that participate in
international best-practice for many industries, including
ACHS accreditation and quality improvement programs are:
health care. ACHS surveyors are health-industry
hospitals, community health organisations, divisions of
professionals and consumers trained to conduct reviews
general practice, corporate offices of health services and
of health care organisations against the standards of the
day surgeries.
ACHS Evaluation and Quality Improvement Program
(EQuIP). (For a complete list of ACHS Member organisations see page 60)

The current edition of this program’s standards, EQuIP 4, ACHSSurveyors

was introduced in January 2007 and has significantly
More than 400 surveyors are trained by the ACHS in
increased the focus on consumer participation in health
evaluation techniques to assess organisations against a
care and the need to provide evidence of clinical and
range of standards. Many of these surveyors still work full
organisational outcomes.
time in the health industry and contribute on a volunteer
basis.
The purpose of accreditation has not changed over the
years. It remains a credible alternative to reviewing against
In addition to the growing number of consumer surveyors,
a checklist as it provides a thorough and realistic roadmap
the majority of ACHS surveyors are professionals with
for improvement and helps organisations establish a culture
relevant healthcare experience such as doctors, nurses,
that strives for excellence.
medical administrators and allied health professionals.

The ACHS is regularly consulted by other countries for its
knowledge and expertise. We have successfully built
relationships throughout the world in relation to standards
development, accreditation systems and clinical indicator
programs.
(For more information on ACHS products and services see page 76)
(For a full list of ACHS Surveyors see page 72)
Funding
As an independent, not-for-profit organisation, the majority
of our funding is derived from membership fees. Funding
is also received from tenders and projects undertaken on
behalf of government organisations and other industry
bodies. We also receive a specific annual contribution from
Baxter Healthcare for our Quality Improvement (QI) Awards
program and the publication of this Annual Report.

4 I ACHS ANNUAL REPORT 2009 - 2010

 OUr IdENTITy

ACHSMemberships(Full&Associate)
byBedSizeasat31/12/2009
The growth of our ageing population as well as the
63%
(n867) increasing cost of funding of healthcare has meant that
there has been a growing emphasis on population and
preventative health. The release of the National
Preventative Health Strategy by the Commonwealth
Preventative Health Taskforce in September 2009 has
foreshadowed a new national health reform Agenda.

A significant part of our efforts this financial year has gone

towards the ongoing review of EQuIP 4 culminating in the
development of the new EQuIP5, scheduled for release on
1 July, 2011. This has entailed work and consultation with
13%
a wide range of experts in the preventative health field to
12%
(n174) (n160) 9%
ensure we deliver the new standards - to the highest
(n126) standard.
4%
(n57)
Our Corporate and Strategic plan page 6 details our future
direction for the new challenges presenting themselves in
0-49 50-99 100-199 200-499 >500
beds beds beds beds beds our environment.

Ourenvironmentandthefuture
The quality agenda for the Australian health care industry
for more than a decade has been focused on ensuring
patient safety and high quality performance. The Australian
Health Ministers in 2001 adopted a National Health
Performance Framework which includes nine dimensions
of “health system performance”. EQuIP reflects this
framework.
Membership to the ACHS accreditation program has seen
steady growth from 1,048 member organisations in 2006 to
current membership of 1,457 organisations in 2009. This
represents a 39% increase in membership to the ACHS
accreditation program over the last four years.
The improvement of patient safety continues to remain a
significant touchstone of the health system for operators,
clinicians, the public and politicians.
There is an increased usage of standards-based
performance assessment (accreditation) programs across
the health industry. This is illustrated by the inclusion of
accreditation requirements in government policy/legislative
initiatives and from within the industry. The Australian
Commission on Safety and Quality in Health Care
(ACSQHC) has completed a review of accreditation.
Australian Health Ministers are in the process of reviewing
the proposed new model.
Partnerships
With a range of governance models amongst the Australian
States and Territories, as well as across the public and
private healthcare sectors, one of the overriding challenges
of the ACHS is to present a cohesive relevant model of
appropriate accreditation that meets the complex needs
of the member organisations.
As can be expected, there are many views on the methods
and approaches to undertake improving quality and safety
in healthcare and the ACHS works hard to ensure we hear
and understand them all.
With our key activities of surveying, standards development
and clinical indicator working groups, our partnerships
remain the key to our success. Without the collaborative
contributions of our many member organisations and
stakeholders we could not deliver the continual upgrade
to the standards that have an impact on Australian and
international health standards.

ACHS ANNUAL REPORT 2009 - 2010 I 5

OUr PErFOrMANCE
COrPOrATE ANd
STrATEGIC PLAN

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

1
Tobetheleadingorganisationinthehealthcareindustryprovidingproductsandservices
Strategic thatpromoteandimprovequalityandsafetyintheprovisionofhealthservices,including
Goal standardsdevelopment,performanceassessment,accreditationandeducation.

Objective 2008-2011 Aims 2009-2010 Outcomes 2010-2011 Outlook

Betheproviderofchoice; Pursue potential growth Additional memberships Additional memberships and
maintainingandwhere markets through comparison achieved in Injury Management programs in NGO and Medicare
possiblegrowingthe of AIHW data against our and Workplace Health fields. Local areas to be developed.
membershipbase. member database.

Implement a recruitment
strategy to increase the
number of allied health
clinician surveyors.
EQuIP for Day Hospitals product
developed and launched. Initial
satisfaction survey very positive.
Successful recruitment drives
for medical and mental health
surveyors.
EQuIP program tailored for the
needs of small or rural health
services to be developed.
Additional surveyors sought
from medical, mental health,
aged care, rural and
community sectors.

I3 part-time contracted Use of e-learning to reach

survey co-ordinator positions more remote memberships to
recruited, in order to improve educate members regarding
inter-rater reliability. the EQuIP5 rollout.

2009 member satisfaction Continue to collect

survey action plan developed accreditation related data to
and implemented. assist in business decisions.

ACHS and AIHW comparative Rebuild of EAT5 to ensure

data used to pursue potential
EQuIP for Day Hospital members.
Simplified Electronic
Assessment Tool (EAT) for
EQuIP for Day Hospitals
product.
compatibility with member
organisation and surveyor
operating systems.
Review and evaluate EAT5.
Integrate training for EAT5
into e-learning tools.

Providerelevantevidence- Commence an effective Continued development of the Introduction of the EQuIP5

basedproductsand consultative framework for EQuIP 4 program review. program.
services. the review of EQuIP 4.
Introduction of the EQuIP for Review of the EQuIP for Day
Day Hospitals program. Hospitals program.

Review of EAT v4 by steering Submission to ISQua for the

committee consisting of all accreditation of the EQuIP5
ACHS stakeholders. and EQuIP Corporate programs.

Improved EAT5 for ACHS

member organisations and
surveyor workforce.

Maintaininternational Maintain ISQua IAP Progress report on Surveyor Complete further progress
recognitionofthe accreditation. Training accreditation report to maintain ISQua
organisation,standards submitted on time to ISQua. accreditation for surveyor
andthesurveyortraining training program.
program.

6 I ACHS ANNUAL REPORT 2009 - 2010


Strategic Goal 1 Indicator continued
Increaseconsumer
participationinsurveyor
program.
PromoteACHSthrough
publicationsand
conferencepresentations.
2 Strategic
Goal
Objective
Maintainliaisonwith
industry-leading
organisationsandbe
responsivetotheirneeds.
Interactwithkey
stakeholders,including
participationonsignificant
committees,inkeyevents
andatconferences.
STrATEGIC PLAN
Assess methodologies for
including consumer input.
Achieve 10% of Organisation-
wide Surveys with a consumer
surveyor on the team.
Promote ACHS through
National Forum on Safety
and Quality in Health Care
(Adelaide, October 2008).
Todevelopandsustaincollaborativelinkswithkeystakeholders.
2008-2011 Aims
Further implement
consultation processes for
the review of EQuIP 4
program.
Strengthen collaborative links
with member organisations.
Continue partnerships in the
development of the premier
annual health industry
conference in Australasia.
Maintain effective relationship
with ACSQHC and other key
bodies.
COrPOrATE ANd
Resource tool to support
consumer surveyors
commenced.
ACHS promoted through the
planning of the 2010 National
Forum on Safety and Quality
in Health Care.
History of EAT published in the
Private Hospital Magazine.
ACHS member organisation
and surveyor workforce
feedback results analysed and
published in the 2009 NAR.
2009-2010 Outcomes
Comprehensive stakeholder
consultation during the EQuIP 4
review with expanded Field
Review and pilot processes
and development of guidelines.
Recommendations from the
ACHS Member Survey
implemented and progress
on the action plan available
on ACHS website.
Consultation with members and
surveyors for review of EAT4.
Consultation with Australian
and International ACHS
member organisations in
providing integrated business
and technology solutions.
Custom Strategic Performance
Analysis reports prepared for
State departments.
Collaboration with key
stakeholders, ACSQHC,
ACT Health and CEC in the
planning for 2010 National
Forum on Safety and Quality
in Health Care.
ACHS ANNUAL REPORT 2009 - 2010 I 7
Promote consumer surveyors
on teams for general
memberships with new EQuIP.
Meet target of 600 attendees
to the 2010 National Forum
on Safety and Quality in Health
Care.
Planned webcast to promote
2010 National Forum on Safety
and Quality in Health Care
plenary sessions through the
ACHS website.
Member Satisfaction with
services and products.
2010-2011 Outlook
Participation in the Remote
Health Standards and
Accreditation Project, led by
the NT Department of Health
and Families, in conjunction
with the RACGP and AGPAL.
Continued stakeholder
consultations for the review
of the EQuIP for Day Hospitals
program.
Consultation to take place
with stakeholders and member
organisations regarding the In-
Depth Mental Health Reviews.
Consultation with member
organisations on data
integration from external data
base to EAT5.
Pursue opportunities to partner
with AAQHC, RACMA and
AHHA for a 2011conference.
 COrPOrATE ANd
STrATEGIC PLAN
3 Strategic
Goal
Todevelopandsustaincollaborativelinkswithkeystakeholders.
Objective 2008-2011 Aims
Advancethecollaborative Consolidate the activities of
researchprogram. the ACHS Research Advisory
Panel.
Develop collaborative
partnerships for research
into accreditation and quality
management in healthcare
services.
Publishresearch. Publish annual ACHS
Australasian Clinical Indicator
Report and papers on
research into quality
improvement.
8 I ACHS ANNUAL REPORT 2009 - 2010
2009-2010 Outcomes
Working groups established
to review the ACHS Clinical
Indicators for Anaesthesia,
Hospital-wide and Mental
Health Inpatient and Internal
Medicine.
Annual ACHS Australasian
Clinical Indicator Report 2001-
2008 published Nov 2009.
National Report on Health
Services Accreditation
Performance, 3rd edition
2007-2008.
Braithwaite J, Greenfield D,
Westbrook J, Pawsey M,
Westbrook M, Gibberd R,
Naylor J, Nathan S, Robinson
M, Runciman B, et al. Health
service accreditation as a
predictor of clinical and
organisational performance:
a blinded, random, stratified
study 2010; Quality and Safety
in Health Care 19: 14-21.
2010-2011 Outlook
Establishment of working
groups to review Adverse
Drug Reaction (to be renamed
Medication Safety), Emergency
Medicine, Hospital in the
Home, Intensive Care, Mental
Health Community Based,
Obstetrics and Ophthalmology
Clinical Indicator sets.
Continued development of
the web-based data reporting
system PIRT Online.
Collaboration with University
of New South Wales and
Griffith University on research
projects.
Annual ACHS Australasian
Clinical Indicator Report 2001
-2009 to be finalised for Nov
2010 publication.
Papers on research into quality
improvement to be developed
around case study
methodology.
Data analysis National Report
on Health Services
Accreditation, 4th edition.

4 Strategic
Goal
Objective
Promotepublicdisclosure
ofperformanceinformation.
Implementeffectiveusage
ofclinicalindicator
information.
STrATEGIC PLAN
Topromoteandpublishinformationinrelationtothequalityandsafetyofhealthcare.
2008-2011 Aims
Agreed Performance
Statement (APS) percentage
of compliance in line with
contractual obligation.
Prepare biennial National
Accreditation Report (NAR)
on EQuIP 4 performance
information.
Assist the effective collection
and analysis of ACHS Clinical
Indicator data with the
introduction of a web-based
PIRT program, 2009.
Continued review of current
ACHS Clinical Indicator sets
and introduction of new
ACHS indicator sets on
behalf of medical colleges
and health associations.
Publish national clinical
indicator report.
Increase utilisation of clinical
indicator data by surveyors.
COrPOrATE ANd
2009-2010 Outcomes
100% compliance with APS
for surveys completed in and
up to June 2010.
Published National Report on
Health Services Accreditation
Performance.
Member list with APS and
accreditation list published
on ACHS website.
EQuIP accreditation related
data collected and analysed
for NAR.
Customer Support Form for
PIRT Online established.
Enhancements for PIRT
on-line completed.
Anaesthesia and Internal
Medicine sets reviewed and
updated.
7 Clinical Indicator Working
Parties completing their
reviews.
Annual ACHS Australasian
Clinical Indicator Report 2001-
2008 published Nov 2009.
Formal process established
between Accreditation
Services and Performance
and Outcomes Service to
ensure surveyors receive the
most recent clinical indicator
comparative reports for
healthcare organisations that
contribute to the Clinical
Indicator Program.
ACHS ANNUAL REPORT 2009 - 2010 I 9
2010-2011 Outlook
Ensure 100% compliance of
APS published is maintained.
Continue to collect data
and analyse to evaluate
accreditation performance.
Planned development of PIRT
Online enhancements (Bulletin
Board, embedded terminology,
graphical representation).
Finalise 11 indicator set
reviews - Day Surgery,
Emergency Medicine,
Gastrointestinal Endoscopy,
Hospital in the Home, Intensive
Care, Medication Safety,
Mental Health Community
Based, Obstetric,
Ophthalmology, Radiation
Oncology, and Radiology.
Promote the Clinical Indicator
Program at relevant
conferences, symposiums,
and scientific meetings.
Annual ACHS Australasian
Clinical Indicator Report 2001-
2009 currently being finalised
for Nov 2010 publication.
Review layout and content
of Annual ACHS Australasian
Clinical Indicator Report
2001-2010 prior to content
preparation.
Evaluate the process of report
provision to surveyors in
relation to surveyor
satisfaction.
 COrPOrATE ANd
STrATEGIC PLAN
Strategic Goal 4 Indicator continued
Ensurewebsitefacilitates
accessofinformationbyall
stakeholders.
EnsureAwardprogram
recognisesexcellencein
performance.
5 Strategic
Goal
Objective
Delivereffectivefinancial
performance.
Ensurebusinesssystems
areexternallyaccredited.
Ensureeffective
communicationsandmedia
strategiesinplace.
10 I ACHS ANNUAL REPORT 2009 - 2010
Implement second web
server to improve access and
minimise disruption for users.
Increase participation rates.
Review collection systems for
submissions and expand the
information provided in the
accompanying publication
(Quality Initiatives).
Tomaintainaneffectiveinternalsystemthatenables
businessgoalstobeefficientlyachieved.
2008-2011 Aims
Meet budget targets.
Ensure audit report is
unqualified.
Implement new accounting
software and integration with
the existing corporate
database.
Maintain ISQua IAP
accreditation.
Strategy targets measured
through media references
and stakeholder feedback.
IT infrastructure upgraded,
significant improvements to
the ACHS web services
delivery and reliability.
Revision of submission
guidelines and applicability
of the submission processes
for the QI Awards.
2009-2010 Outcomes
Implementation of strategies
and realisation of financial
targets set for the period.
Engagement of external
auditors in the preparation of
year end financial statements.
New accounting software
implemented.
External audit of IT network
and infrastructure completed
with no high risk issues
identified.
Satisfactory progress achieved
in implementing media strategy
and results, to improve ACHS
reputation and identity.
Planned review of ACHS
website platform, style and
design and content.
Assessment of promotional
strategies for the QI Awards.
2010-2011 Outlook
Meet budget targets.
Review of ACHS Business
Plan and monitoring its
implementation.
Planned external audit of
ACHS Risk Management Plan
against the requirements of
AS/NZS ISO 31000.2009.
Organisation risk identification,
evaluation and resolution.
Employee engagement,
training and satisfaction to
be addressed.
Plan targeted strategy to
improve marketing of ACHS
services and products, identity
in the marketplace, enhance
partnerships and define and
meet future business goals.
 OUr PErFOrMANCE
P r ES Id EN T’S AN d
C H IEF Ex EC U TIvE’S rEP O r T

The year in review resulted in a number of very pleasing achievements for the organisation.
Activities and membership have expanded and the overall financial performance resulted in
a small surplus in keeping with our ‘not-for-profit’ status, whilst ensuring value-for-money
for member organisations.

ACHS enthusiastically acknowledges the substantial progress made by the Australian

Commission on Safety and Quality in Health Care with the national agenda for safety and
quality in health care and very much appreciates the breadth and depth of its engagement
with our organisation and others across the industry.

Governance Ms Darlene Hennessy, Executive Director Development,

Dr Noela Whitby AM, previously Vice President, completed
the maximum allowable term as a Director and was
succeeded by Dr David Lord, who represents the Royal
Australian and New Zealand College of Psychiatrists on the
Council. Dr Whitby’s contribution has been one of great
value, including being a Director of ACHS International and
an active surveyor. Dr Len Notaras AM was elected to the
Board of ACHS International, replacing Dr Whitby.
Regrettably, Dr Rob Porter retired as a Director after six
years. He has been replaced by Ms Jennie Baker, who
represents the Australasian College of Health Service
Managers on the Council. Dr Porter made a very thoughtful
and valuable contribution. He continues to be an active
surveyor.
It is important to acknowledge the appointment of Board
member Mr Russell McGowan as a Commissioner
(representing consumers) on the Australian Commission
on Safety and Quality in Health Care. He has made a very
significant contribution to ACHS over many years and it
is pleasing to see his knowledge and expertise further
recognised by this prestigious appointment.
resigned in April to pursue a career overseas. ACHS is
appreciative of her contribution, especially with a major
part of the EQuIP review and best wishes are extended
to her for the future.
We were delighted to see Dr Marjorie Pawsey, a
distinguished former member of staff well known to many
in the quality arena, made a Member of the Order of
Australia early this year. The award recognises her
tremendous contribution both nationally and internationally
over many years.
Financialperformance
The parent company and its wholly owned subsidiary,
ACHS International, both recorded small surpluses. Details
of the trading results are contained elsewhere in the report.
These results were achieved after making provisions for
several important projects in the next financial year,
including the launch of the new standards and major
upgrades to our computer systems. This is a very pleasing
outcome. Good growth in local membership and small but
significant gains with international business have both been
contributing factors.

The previous ACHS President, Dr Mike Hodgson AM, Maintainingperformance

was awarded life membership in 2009 in recognition of his
many years of exemplary service to ACHS.
Mindful of its obligations both legal and ethical to ensure
it maintains appropriate, high levels of governance, the
Board undertook a development program led by nationally
recognised consultant Ms Julie Garland-McLellan. The
program was structured to address the specific
requirements of the company over a series of meetings.
It was very valuable and will no doubt be used again in
the future.
The health industry is a dynamic environment in which there
are many drivers for change and continuous improvement.
For ACHS it is often the evolving expectations of the
industry it serves that are important in this regard. In late
2009 a survey of member organisations was commissioned
from independent consultants. It has been some years
since such a wide-ranging review was undertaken. The
report and the initial responses are published on the ACHS
website. Positive comments were made about the service
provided by our staff and the professionalism of surveyors.

ACHS ANNUAL REPORT 2009 - 2010 I 11

 P r ES Id ENT’ S AN d
C HI EF Ex EC UTIv E’ S r EP Or T
Teamwork has a special place in
health care workers lives.

Similarly, suggestions were put forward for improvements

in some program requirements, electronic support systems
and access to education programs. All of these topics are
being acted on and the results of the survey will be of
continuing value.

The review of the EQuIP standards and the program

requirements is almost complete. The new standards will
apply to all surveys from 1 July, 2011. The review process
has taken care to reflect the impending introduction of
national standards that will be common to all accreditation
programs where relevant. Also, steps have been taken
to reflect the nature and language emerging from the
development of the national electronic health record
program that will be of great significance in the future.

In November, ACHS published its third biennial National

Accreditation Performance Report. It reflects areas of
stronger performance, such as infection control and risk
management, but also points to areas where further
improvement could be possible. Interestingly, it includes
various aspects of infection control as well as comments
on performance. A further important review was the staff satisfaction survey.
Initiatives prompted by this process are being implemented
During January 2010 the new program for use by the day with the participation of staff representatives. Staff are our
hospital sector was launched. It has been very well major asset and the optimisation of human resource
received with some recent gains in membership after a management practices is most important.
period of decline. Several of the processes are to be used
in the new version of EQuIP. TheNationalSafetyandQualityAgenda
The advancement of the national agenda has progressed
In March, ACHS was advised that it had maintained its
substantially during the year. The issues and relationships
accreditation status under the International Society for
involved are very complex. However, progress towards an
Quality in Health Care’s programme. The process was
authoritative and nationally consistent quality framework,
again of great value and involved both the Board, staff
referred to in last year’s annual report, is increasingly within
members, as well as a number of member organisations
reach.
and surveyors. The outcomes were mostly complementary
and important suggestions were made with regard to risk
ACHS wishes to place on record its appreciation of the
management and internal quality improvement activities
vision and energy that Professor Chris Baggoley has
which have been acted upon.
shown, ably supported by his staff. We continue to
be involved at numerous levels in the activities of the
Substantial investment is being made to upgrade the
Australian Commission on Safety and Quality in Health
information technology systems, including data recovery
Care, including the Accreditation Implementation
and ensuring business continuity in the event of a disaster.
Reference Group, National Indicators Working Party
The underlying data processing platform will support more
and various other consultations.
efficient developments into the future, such as that
achieved with the on-line access to the performance
indicator reporting tool (PIRT) also introduced this year.

12 I ACHS ANNUAL REPORT 2009 - 2010

 P rES I dEN T’ S ANd
C H IEF ExEC U TIvE’S r EP O r T
Research
On a particularly pleasing note, the continuing growth in
importance of research in relation to quality in general and
to accreditation specifically, is noted. The major paper from
the various studies on the effects of accreditation on health
care systems undertaken by the Centre for Clinical
Governance, Faculty of Medicine, University of New South
Wales, with funding from an Australian Research Council
(ARC) Linkage Grant 2005 to 2007, was published this year.
ACHS was very pleased to have been a leading collaborator
in this study. The study program was led very ably and
enthusiastically by Professor Jeffrey Braithwaite.
Further success was achieved recently with Professor
Braithwaite being awarded a five year grant by the ARC
to substantially extend his studies in the subject of
accreditation. ACHS is again a leading collaborator in this
study and for the first time will be joined by other major
accreditation and quality focused organisations. This
research program places ACHS in a leading position
internationally where in the past there has been a lack
of published evidence.
The research collaboration with Dr Keith Townsend and
colleagues in the School of Business at Griffith University,
Queensland, has also progressed with an important paper
awaiting publication. ACHS is committed to extending its
support for this work in the future.
Partnerships
A formal conference was not convened this year. Instead
a successful series of advanced joint workshops were
conducted that focused on the important topics of
medication safety, working with consumers and multi-
disciplinary teamwork for safety. The very talented
presenters were Professor Guy Maddern, Ms Stephanie
Newell and Mr Daniel Lalor. The financial support of the
Australian Commission on Safety and Quality in Health
Care in conducting these workshops was most
appreciated.
Towards the end of the period in review the Northern
Territory Department of Health and Families initiated with
ACHS a project focused on ‘Quality for Remote Health
Services’. The Australian General Practice Accreditation
Limited (AGPAL) is also a partner. This is a very exciting
opportunity to develop a program designed specifically for
remote communities that may have national relevance and
has our enthusiastic commitment.
The President of ACHS was elected to the Executive Board
of the International Society for Quality in Health Care in
October. This is the first time an ACHS representative has
been on the Board. The position provides a further
opportunity to contribute at an international level.
Internationalbusinessactivities
The project to pilot an accreditation scheme for hospitals
in Hong Kong has progressed extremely well with high
levels of satisfaction recorded by all parties. The Board
established a Program Support Committee in Hong Kong
which is under the very capable and committed
chairmanship of Dr Lawrence Lai. The Hospital Authority
has also nominated a representative to our Standards
Committee for the duration of the project which has
increased our links. It has been especially pleasing to note
the growing involvement of the private hospitals in Hong
Kong in our program with many either having achieved
accreditation status or are well advanced in the program.
The Hong Kong Hospital and Sanatorium was the first to
achieve the award and did so with great distinction.
Phase 1 of our project will be completed later this year
well ahead of schedule, due to the high levels of
enthusiasm being experienced. ACHS hopes to be
selected as the partner for the next phase. It has been
particularly pleasing that many ACHS staff and surveyors
have had the opportunity to contribute to the project.
ACHS has not only provided its skills and knowledge but
has also benefited from the special opportunity that the
project has offered. The project in Hong Kong has now
attracted the interest of the Macau Special Administrative
Region and there is every prospect that it will enter into a
relationship with us.
Elsewhere, in India and the Middle East further growth has
been experienced, most recently in the Kingdom of Saudi
Arabia. ACHS is increasingly being recognised as a
significant provider of accreditation programs to the
international community. This success though remains
firmly based on the quality of the programs and services
we provide in Australia.
ACHS ANNUAL REPORT 2009 - 2010 I 13
 Pr ES Id EN T’S ANd
C H IEF Ex ECU TIvE’S rEP O r T
Withgratitude
We gratefully acknowledge the continued support of Baxter
Healthcare. This is a valued relationship by a company that
has a strong reputation for its corporate support across the
health industry.
Again, this year the commitment and enthusiasm of the
Council members, and particularly fellow Board Directors,
has been of a high standard.
Our staff and surveyors are the people who, through their
collective and individual contributions, deliver our various
programs and activities. Each of them is acknowledged
for their efforts. During the year the number of surveys
conducted has increased and the revision of the EQuIP
standards and program structure has brought added
dimensions to the normal pattern of activities. It was
particularly pleasing to note the positive expressions
from member organisations in relation to both staff and
the survey teams.
14 I ACHS ANNUAL REPORT 2009 - 2010
AssociateProfessor MrBrianJohnston
PeterWoodruff Chief Executive
President
Futureprospects
The national health reform agenda offers many
opportunities for the organisation, but will also bring
change to what we do and how we provide our services.
There will be new governance structures in place, the
effects of which will vary across the nation. There will be
the challenge of implementing the National Standards,
wider use of accreditation as a strategy to both guide and
assess quality and greater reliance placed on data for the
assessment of performance. ACHS is well placed to
address these requirements and to support its member
organisations.
Data, as mentioned, will be of increasing importance
and ACHS has an excellent platform to support future
requirements in this area. The use of better data, extracted
efficiently from electronic information systems, will serve
many purposes including supporting internal review process
particularly by clinicians, governance oversight, policy
formulation and review. ACHS has had increased interest
in its existing capacity to meet the information needs from
both the public and private sectors.
Future international business prospects are assessed as
very positive and will need further consideration of
expanding our commitment in that area.
We commend this report to you.
 OUr PErFOrMANCE
H IG H L IG HTS O F TH E yEAr

Celebrations took place in Hong Kong to mark the first Lena Low signs her name on the
appointment of ACHS (Hong Kong) Surveyors. ceremonial welcome board.

Inthepastyearwe:

Conducted a successful member satisfaction survey
with a good response. Overall results were extremely
positive and provided invaluable feedback on a range
of processes and services.
Released our new program EQuIP for Day Hospitals
on 1 January, 2010. Specifically designed to meet
the needs of stand alone, privately owned days
hospitals, it has been received very positively.
Worked on the Pilot Scheme on Hospital
Accreditation, initiated by The Hong Kong Hospital
Authority (HKHA), continued to demonstrate
progress, with an expected completion date by
the end of 2010 - 18 months ahead of schedule.
Conducted an ACHS ‘Staff Satisfaction Survey’,
used to gauge staff responses and views on a
number of issues.

Progressed the exhaustive review of our Evaluation
and Quality Improvement Program, (EQuIP)
culminating in the development of the new EQuIP5.
This work ensures our standards remain current,
valid and reflect the expectations from both industry
and the community and are evidence-based.
As a result of our strong ACHS team we achieved a
financial surplus of $80,627, improving on last year’s
$43,811 in challenging market conditions.
Increased the ACHS Clinical Indicator program
from 21 data sets collecting 245 Clinical Indicators,
to 23 data sets collecting over 360 clinical
indicators in 2009.
Maintained our accreditation status until 2014
through the International Society for Quality in
Health Care (ISQua) International Accreditation
Programme.

Increased our surveyor workforce including several

allied health clinicians, see page 60. Peter Woodruff
addresses the
surveyors.
Achieved incremental growth to our membership
base, see page 5.

Received international recognition of the Australian

model of accreditation with strong interest
generated from overseas countries. Potential
prospects include Bahrain, Korea and Ireland.

ACHS ANNUAL REPORT 2009 - 2010 I 15

OUr OrGANISATION
O r GAN IS ATI ON C H Ar T

ACHS
Council
Board of Directors

ACHS International
Board of Directors

Chief Executive
Communications
Manager
Executive
Assistant Communications
& Events Officer

International Business Corporate Services Customer Services Development

Executive Director Executive Director Executive Director Executive Director

International Business Executive Executive

Business Support
• Co-ordinator
Services Assistant Assistant
• Administrative Assistant
• Senior Project Officer
• Project Officers
Standards & Program
Customer Services
Development
Accreditation Administration • Team Manager
• Senior Project Officer
Services • Customer Services
• Project Officers
• Team Leader Managers
• Admin. Assistant
• Senior Admin Assistant
• Admin. Assistants
• Word Processing Officers
Performance &
• Clerical Assistant Education & Support
Outcomes Services
• Receptionist Services
• Clinical Director
• Trainees • Education Manager
• Co-ordinator
• Education Consultants
Education Administration • Data & Admin. Assistant
Services
• Supervisor
• Admin. Assistants Surveyor Workforce Research
• Resource Co-ordinator • Principal Consultant
• Surveyor Booking
Financial Services/ Administrator
Human Resource • Survey Booking Assistant
Management
• Accountant
• Assistant Accountants
• Accounts Officer

IT Services
• IT Manager
• Senior Analyst
Programmer
• Analyst Programmer
• Network Administrator
• IT Support Officer

16 I ACHS ANNUAL REPORT 2009 - 2010

Welcoming a new life at Royal North Shore
Hospital for 12 hour old Levi Wallis.

ACHS ANNUAL REPORT 2009 - 2010 I 17

OUr OrGANISATION
OUr ExECUTIvE TEAM
Mr Brian Johnston Ms Darlene Hennessy
MrBrianJohnston
Dip Pub Admin (NSWIT), BHA, FCHSE, FAICD, FAIM
ACHS Chief Executive
Brian Johnston has been Chief Executive of the ACHS
since November 2000. He has been professionally involved
with the ACHS since being appointed as a surveyor in
1985 and was also previously a member of the Standards
Committee for six years. He has qualifications in health
administration from the University of New South Wales
and in public administration from the NSW Institute of
Technology (now the University of Technology, Sydney).
Mr Johnston is a Fellow of the Australasian College of
Health Services Management, a Fellow of the Australian
Institute of Company Directors and a Fellow of the
Australian Institute of Management. He holds an
appointment as Visiting Fellow, Centre for Clinical
Governance Research, at the Faculty of Medicine,
University of New South Wales, and is a member of the
Management Committee of the Royal Australasian College
of Surgeons’ Australian Safety and Efficacy Register of
New Interventional Procedures - Surgical. He is the
current Vice Chair of the Council for the International
Accreditation Programme provided by the International
Society for Quality in Health Care (ISQua) and was the
Chair from 2006 to 2009.
Mr Johnston’s professional career has been wholly in
the health industry and includes experience at both
departmental and senior health service management
levels. He has been involved mainly in the operational
management of public health services and facilities,
particularly teaching and referral centres since 1977.
18 I ACHS ANNUAL REPORT 2009 - 2010
Ms Laurie Leigh Ms Lena Low Dr Desmond Yen
MsDarleneHennessy
B Nursing, Grad Dip Adv Nursing, MHA, Grad Cert marketing
Executive Director – Development Unit
Darlene Hennessy joined the ACHS in August 2006 as
Executive Director - Development. Her key responsibilities
included developing and maintaining industry standards,
leading the organisation’s programs in performance and
outcomes measurement and research.
In her role as Executive Director Development, Darlene
conducted presentations for major international
conferences and provided consultancy on standards
development to the Kuwait Ministry of Health. As an ISQua
surveyor she participated in the evaluation of healthcare
organisations internationally.
Darlene left the ACHS in April to take up an overseas
position.
MsLaurieLeigh
BA (Hons), MA, Dip (Nursing Studies), RMN (UK), RN (Aus),
AFCHSM, GAICD
Executive Director - Customer Services
Laurie Leigh commenced with the Australian Council on
Healthcare Standards in March 2009 in the role of Executive
Director - Customer Services. Her key responsibilities
include the management of EQuIP membership and
accreditation services, the surveyor workforce and the
ACHS education program.
Laurie has previously held a number of senior health
management positions; most recently as a nurse manager
for mental health services within a large area health service.

Having moved to Australia from the UK in 2003, Laurie’s
professional experience is as a mental health nurse and
senior manager for mental health services within hospital
and community settings. Her breadth of experience in
the two health systems is an area of expertise as is change
management and quality improvement. Both as a clinician
and as a health service manager, she has broad experience
in implementing the safety and quality agenda within large
complex health service organisations.
She has qualifications in social psychology, mathematics,
person-centred counselling and mental health nursing.
Laurie is currently completing an MA in Health Services
Management with the University of Technology, Sydney.
She is a graduate of the AICD Company Directors Course.
MsLenaLow
MBA, Grad Dip Mgmt, FAICD
Executive Director - Corporate Services
Lena Low has been with the ACHS since November
1995 and has been involved in developing health care
accreditation systems for over ten years. Her portfolio
covers finance, information technology, human resources
management, accreditation administration services and
business support services.
Her postgraduate qualifications in business management
combined with work experience has enhanced her skills
in business finance, statistical analysis and reporting,
organisational management, behaviour change
management and product development. Her qualifications
and experience in health care accreditation and the industry
facilitates the development, management and evaluation
of systems to enable accreditation. She is also a surveyor for
the International Accreditation Programme provided by the
International Society for Quality in Health Care (ISQua) and
a Fellow of the Australian Institute of Company Directors.
Lena is completing her PhD on medical clinicians and their
role as accreditation surveyors. This study contributes to
the groundbreaking research into the correlation between
accreditation processes and quality of care undertaken by
the Centre for Clinical Governance Research in Health,
University of New South Wales in conjunction with the
ACHS and other industry partners.
OUr ExECUTIvE TEAM
DrDesmondYen
B Com, MBA, DBA, FAICD
Executive Director - International Business
Desmond Yen joined the ACHS in July 1995 and is a key
member of the ACHS Executive team. His current portfolio
primarily covers all aspects of international business.
Prior to his current role, he was responsible for ACHS
Corporate Services. His multiple responsibilities have
included strategy, policies and systems development,
finance, risk management, information technology and
support services. He has been exposed to all aspects
of health care accreditation requiring interaction with the
ACHS Board, Councillors, member organisations and the
surveyor workforce.
His broad range of experience, mainly within large
multi-national organisations, covers a mix of local and
international strategic management, finance, and
information technology roles.
Desmond is a surveyor for the International Society for
Quality in Health Care (ISQua) and has surveyed the South
African and Malaysian accreditation agencies. Desmond
has recently been appointed as the Deputy Chairman
Research Committee for the Asian Society for Quality in
Health Care (ASQua).
Desmond holds graduate qualifications in commerce, a
Masters degree in Business Administration, a Doctorate in
Business Administration and is a Fellow of the Australian
Institute of Company Directors. He is also a contributor
to an Australian Research Council Linkage project titled
‘Examinations of the relationship between accreditation,
clinical and organisational performance’, being undertaken
by the Centre for Clinical Governance Research in Health,
University of New South Wales in conjunction with industry
partners.
He is currently completing a PhD doctorate on a
prospective and retrospective study of the organisational
influence of peer accreditation surveyors. His hypothesis
is that the presence and influence of surveyors in an
organisation has a positive association with health service
performance in accreditation programs and organisational
culture.
ACHS ANNUAL REPORT 2009 - 2010 I 19
rECOGNISING ACHIEvEMENT
AC H S MEd AL AN d Q UAL ITy
IMP r O vEMEN T AwArd S
Dr Michael Hodgson is congratulated
by the President on receiving his
Lifetime Membership.
Dr Taffy listens to the citation
given for his ACHS Medal.
2009ACHSMedallist
Dr Michael (Taffy) Jones AM
Awarded to an individual for outstanding achievement in
the promotion of quality and safety in healthcare services,
the Australian Council on Healthcare Standards was
pleased to honour Dr Taffy Jones AM with their most
prestigious award: the ACHS Medal.
Presented by ACHS President, Associate Professor Peter
Woodruff at the 2009 ACHS Annual Dinner, Dr Taffy Jones’
nomination was very well deserved.
Mr Graeme Houghton, Board Director from Western Health
and an ACHS surveyor nominated Taffy for the Medal.
“He described Taffy as a constantly strong promoter of
peer review quality processes” said Professor Woodruff.
“He was a strong advocate of adequately resourced quality
management programs for all professional streams and
he provided very practical guidance to particular quality
improvement projects such as better planning of discharge
processes”.
Dr Taffy Jones served as Director of Medical Services in
turn at Geelong Hospital, Austin Hospital and The Alfred
Hospital, after some years as a general medical practitioner.
Since retiring from full-time employment, Taffy remained
very active as an ACHS surveyor from 1983 until 2009,
completing 172 surveys.
He contributed to the devolvement of health services in
AusAID projects in the Asia Pacific region, in particular in
Vietnam, for several extended periods, through the Doctors’
Health Program of the Medical Practitioners Board of
Victoria, of which he was the founding Chair of the Board,
a role which he held for five years.
Past ACHS President, Dr Brian Collopy, said of Taffy, as
one of the referees for his nomination, “with Taffy as a
surveyor, the ACHS could rest assured that health care
organisations would obtain a view of ACHS as a
professional, knowledgeable and fair organisation.
20 I ACHS ANNUAL REPORT 2009 - 2010
ACHSMedalrecipients
Dr Lionel Wilson
Ms Doreen Moore
Dr Myles Kehoe
Mr Murray Clarke
Mr Brian Collopy
Dr Lindsay Thompson
Mr Kevin Dodd
Mr Trevor Pickering
Mr Brian Lewis
Mrs Phyllis Newnham
Dr John Greenwell
Dr Ian O’Rourke
Mr Michael Dooley
Dr Lisa Harvey
Professor Ross Holland
Professor William Rawlinson
Associate Professor Christine Kilpatrick
Dr Michael (Taffy) Jones AM
It was of great benefit to the ACHS that it was able to retain
his experience over so many years”.
Among his many achievements, Taffy was a also made a
Member of the Order of Australia in 2009.
LifetimeMemberofACHSCouncil
The Board of the Australian Council on Healthcare
Standards awarded former ACHS President, Dr Michael
Hodgson AM, Life Membership of the ACHS Council.
“The Board takes great pleasure in awarding Dr Michael
Hodgson, Life Membership of the ACHS Council,” said
ACHS President, Associate Professor Peter Woodruff at
the 2009 Annual Dinner.
“Dr Hodgson is a passionate supporter of quality and
safety in healthcare. He has had a distinguished career
as a consultant anaesthetist and has been involved across
a broad range of professional activities for many years”.
As Chair of the ACHS Standards Committee from 2001
to 2008, Dr Hodgson led the development of the revised
standards, EQuIP 4, which increased the focus on clinical
outcomes and consumer participation.
Dr Hodgson was a representative for the Australian Medical
Association (AMA) on the ACHS Council and was a Board
member between 1999 and 2008. He is a past President
of the Medical Council of Tasmania and past Chair of the
Postgraduate Medical Institute of Tasmania.
 ACH S M Ed AL AN d Q UAL ITy
IM P rO vEMEN T AwAr d S
He has been a member of the Australian Medical Council
(AMC) and Chair of the Joint Medical Boards Advisory
Committee.
Dr Hodgson is also a past President of the Tasmanian
Branch of the AMA and a past member of the AMA
Executive Committee, a past President of the Australian
and New Zealand College of Anaesthetists and the
Australian Society of Anaesthetists, as well as a member
of the Board of Management of the Royal Hobart Hospital.
ACHSQualityImprovement
Awards2009
The annual ACHS Quality Improvement
(QI) Awards recognise innovative quality
improvement in health services around
Australia and internationally.
Open to all EQuIP members, the QI
Awards were launched in 1996 and have
been supported by Baxter Healthcare since 1998.
In 2009 there were three categories EQuIP members could
submit quality initiatives in: Health Care Performance
Indicators; Non-Clinical Service Delivery; and Clinical
Excellence and Patient Safety.
The winners are selected by a panel of judges comprising
ACHS Councillors, ACHS surveyors and EQuIP member
representatives. Judging for the 2009 QI Awards took place
in August and September and winners were announced at
the ACHS Annual Dinner held in Sydney in November, 2009.
TheWinners
Singleton Health Service in Singleton, New South Wales,
was the winner in the Health Care Performance Indicators
category for the ‘No Boundaries Multi-Disciplinary
Discharge Project’.
At Singleton Health Service, issues were identified
concerning aged care discharge processes which had
resulted in increased patient length of stay. A multi-
disciplinary discharge planning team was implemented
to better co-ordinate discharge planning.
The outcomes included:
decreased length of stay
decreased re-admission rate
45% reduction in 14 day re-admission rate achieved
40% reduction in 28 day re-admission rate achieved.
The ‘Southern Health Technology and Clinical Practice
Program’ from Southern Health, Centre for Clinical
Effectiveness in Clayton, Victoria was the winner in the
Non-Clinical Service Delivery category. Recognising the
universal challenges faced by health care organisations
with limited resources, to the rapid technological advances
in health, Southern Health set about establishing a rigorous
and systematic process for the safe introduction of new
technologies and methodologies in to clinical practice.
A committee was established, tasked with developing a
transparent, accountable and evidence-based framework
for the adoption of new practices and technology and with
a focus on best practice. Six monthly reporting
mechanisms and comprehensive staff communication
strategies have been introduced with consumer
representation forming an integral element of the
Technology and Clinical Practice Program.
Liverpool Hospital’s Renal Unit in Liverpool, New South
Wales were winners two years in a row in the Clinical
Excellence and Patient Safety category. Their 2009 entry
‘Dialysis Access Flow Measurement - Early Intervention
Through Early Detection’ aimed to determine the
effectiveness of using online access flow measurement
so that early intervention could be instituted.
All haemodialysis patients with permanent dialysis access
were included in this quality project, conducted over two
years. A total of 20% of 165 patients studied were found
to have poor dialysis access flow.
A new procedure was introduced to regularly monitor
patients’ access flow measurement that improved patient
outcomes in a number of ways including:
Early detection of poor flow indicating
imminent dialysis access failure
Avoidable insertion and utilisation of temporary
dialysis catheter by 145%.
Regular and routine access flow measurement is now an
integral part of the renal service’s access monitoring,
surveillance and early intervention program.
ACHS ANNUAL REPORT 2009 - 2010 I 21
dIvISION rEPOrTS
C US TO MEr S Er vIC ES
The Customer Services department provides support and
services to ACHS members to improve the safety and
quality of their services. The role of the department is to
maintain, support and educate the ACHS membership as
well as co-ordinate and manage the accreditation process.
Customer Services is responsible for managing the surveyor
workforce to enable effective and efficient surveys and
survey reports to be delivered. The recruitment and ongoing
education of the surveyor workforce are key parts of the
business of Customer Services. The department works
closely with the Accreditation Administration Services team
to ensure the success of the accreditation program.
ACHS accreditation programs provide a framework for
members to improve the safety and quality of care and
services. In order to achieve and maintain accreditation,
our EQuIP members participate in a four-year cycle of
quality improvement activities, culminating annually in
either a self-assessment or an on-site survey. Those
members who are participating in the EQuIP for Day
Hospitals or Quality for Divisions Network accreditation
programs participate in a three-year cycle.
Customer Services, managed by the Executive Director
and Team Manager, consists of four main areas:
1 Customer Services Team
2 Surveyor Bookings Team
3 Surveyor Workforce
4 Education and Support Service
1
CustomerServicesTeam
The Customer Services Team is responsible for
implementing and operationalising accreditation processes
in conjunction with other ACHS departments such as
Accreditation Administration Services.
The Customer Services Managers are a valuable link
between ACHS members, surveyors and various
stakeholders. They are responsible for the promotion and
management of ACHS quality improvement programs,
such as EQuIP, EQuIP Corporate, EQuIP for Day Hospitals,
Quality for Divisions Network (QDN) and Home and
Community Care (HACC) reviews for existing and new
members.
Continual support is provided to member organisations and
surveyors throughout the accreditation cycle primarily by
telephone/teleconference and email. Arrangements can
22 I ACHS ANNUAL REPORT 2009 - 2010
also be made to conduct on-site advice, presentations
and education for member organisations when requested.
The Customer Services Managers co-ordinate and support
the entire survey process, which includes the review and
finalisation of survey reports and accreditation outcomes.
Each survey is evaluated by member organisations and
surveyors. The feedback is used for education and
improvement activities within the department for members
and surveyors.
The self-assessment support service is also managed
by the customer services team, through the provision of
guidance regarding the completion of self-assessments
and formal feedback reports.
The management of member contracts is another key
responsibility of the customer services team to ensure
that member organisations are matched with the most
appropriate accreditation program; that the survey meets
their needs with respect to size; and surveyor expertise.
In addition, the customer services team makes a vital
contribution to the development, review and updating of
relevant ACHS processes and documents to ensure the
ongoing success of the accreditation programmes.
Customer Services Managers are in touch with the health
industry on a daily basis and are able to monitor market
trends and provide feedback from the industry. This
includes the regular review of various policies and
procedures, resource tools, guidelines and EQuIP Updates
for members and surveyors. They also have a role in the
promotion and input into the development of new products
and services.
Customer Services Managers participate with stakeholders
in activities that promote ACHS products and services as a
quality improvement and accreditation strategy through
publications, conferences, education and projects.
2 SurveyorBookingsTeam
The Surveyor Bookings Team works to ensure surveyors
are allocated to survey teams according to the survey
scoping for the relevant organisation, so that they have a
team with the experience, expertise and numbers to meet
their needs. Surveyors have the option to nominate for
surveys and the most appropriate surveyors, based on
their experience and specialties, are invited to join the
survey teams.

DistributionofACHSSurveyorsinAustralia
ACT 7
NSW 130
NT 7 Allied Health
QLD 75
State/Territory
SA 28
TAS 7 Practitioner
VIC 97
WA 30
3 SurveyorWorkforce
Surveyors are ambassadors for the ACHS. They are highly
skilled and credible representatives for the ACHS. As at
30 June, 2010, the ACHS surveyor workforce consisted of
more than 400 dedicated, senior healthcare practitioners
with recent and broad experience in healthcare service
provision and management from both within Australia and
internationally.
Two thirds of the surveyor workforce provide their time on
a voluntary basis while still employed in the healthcare
industry. The ACHS has one full-time employed surveyor,
and three newly appointed contracted co-ordinators. The
increase in contracted surveyors is a strategy to improve
consistency and inter-rater reliability. An honorarium
payment is granted to surveyors and survey co-ordinators
who are not remunerated by an organisation for their time
during the survey.
Over the last year a performance appraisal and
re-appointment process has been implemented to ensure
that the surveyors are reviewed on a regular basis. The
appointment process and initial training have also been
strengthened to make sure the selection process for new
surveyors is more rigorous. During the reporting period
ten surveyors retired, 16 surveyors resigned due to current
work demands/work scheduling and 13 surveyors were
not re-appointed.
The ACHS has a group of surveyors that work with the
Education and Support Service, Executive Director -
Customer Services and other members of the Executive
to provide a three day training program for newly recruited
surveyors. These are currently offered three times per
year, and use a mixture of didactic and interactive learning.
The interactive sessions are structured to give a simulated
C U S TOM Er S Er vIC ES
ACHSSurveyorWorkforceby
ExperienceandBackground
Administration 145
14
Consumer 10
Medical or Dental
101
Nursing 115
experience of the survey environment, and are presented
by experienced senior survey co-ordinators.
Development days are offered to surveyors annually and
bi-annually to survey co-ordinators. These provide updates
on new developments within ACHS and issues impacting
on surveying. The development days are structured to
provide an opportunity for skills development and for
dialogue and peer support between surveyors.
There has been a successful recruitment drive for additional
medical and psychiatry clinicians, although this remains an
area of need. Increasing memberships in rural and remote,
community health and aged care sectors have led to a need
for more surveyors in these areas.
The survey bookings team lead the nomination process
and allocation of surveyors to match member organisations’
specialities. Survey teams are booked at least eight weeks
prior to the survey.
During the year, 95% of customers were satisfied or very
satisfied that ACHS surveyors had listened to and
understood what their staff were saying.
Below are some examples of satisfied organisation
comments regarding surveyors from the feedback forms:
Very helpful and interacted with staff in a constructive
manner
Every staff member who participated in the survey spoke
of a positive and enjoyable experience despite their
initial "fears and anxiety"
Both surveyors were excellent and made our team feel
comfortable to discuss our outcomes freely. The day
was a pleasure for all of us.
ACHS ANNUAL REPORT 2009 - 2010 I 23
 CU S TO MEr S Er vIC ES

NumberofWorkshopsbyState
July2009toJune2010
4 EducationandSupportService
State No.of
calendar
No.of
attendeesat
No.of
on-site
The role of the Education and Support Service is to provide workshops workshops workshops
members with education on health care safety and quality
topics. The service also offers workshops about specific NSW 12 161 11
ACHS products such as EQuIP 4. The ACHS Education QLD 7 101 8
and Support Service provides educational events to SA 5 49 *15
organisations on a pay per use basis. The services (*includes Country
currently offered are: Health SA contract)

VIC 11 184 7
Calendarworkshops WA 5 64 1

These are programs offered in different venues across ACT 1 15 2

Australia on set dates. Topics are selected based on NT 2 34 1
feedback from members via both an education needs TAS 5
survey and suggestions provided in workshop evaluations. NZ *13
Current topics include: (*provided for
Quality Health NZ)

Preparing for Survey

Total 43 608 63
Clinical Governance: A Licence for Safety
Implementing and Sustaining a Quality
Management System
Designing and Managing Clinical and Corporate EducationalActivities
Policy Frameworks July2009toJune2010
Leadership and Communication for Quality
Calendarworkshops No.ofevents Totalno.of
Partnering with Consumers to Achieve Quality attendees
Outcomes in Healthcare. Achieving Excellence (EA) 1 25
Achieving Excellence for QDNs 1 17
Customisedprograms Basic EQuIP for Beginners 6 77
Beyond MA 3 27
An organisation or a cluster of organisations are able to Changing Organisational Culture 1 17
choose a calendar workshop and modify it to suit prevailing Clinical Audit 4 52
needs. Alternatively, a program can be developed to meet Clinical Governance: A Licence
an organisation’s specific needs in relation to education on for Safety 1 18
quality and safety issues. These programs are proving EAT and Self Assessment 5 44
popular for many of our members with an ever increasing EQuIP for Drug and Alcohol
demand. Services 2 23
EQuIP for Mental Health Services 2 23
Executive Masterclass 2 43
On-lineeducation
From Quality Manager to
EQuIP for Day Hospitals was introduced using an online Quality Consultant 1 12
e-learning module. Two modules are available - one for Making the Most of Patient 2 20
Record Audits
potential and new members, and one for existing members.
Leadership and Communication
for Quality 1 11
SupportforContracts 1 19
Patient Safety
Preparing for Survey 7 144
ACHS Education and Support Service has co-ordinated
Standards, Audit and Measures
and facilitated a series of one day workshops to support
to Improve Performance 3 36
the introduction of EQuIP across all of the clusters in
Country Health South Australia. Total 43 608

24 I ACHS ANNUAL REPORT 2009 - 2010


In addition to the above activities, the Customer Services
Department is responsible for, and has been involved in the
following projects:
MentalHealthConsumerSurveyors
An evening session was held in September 2009 with the
mental health consumer surveyors to discuss issues with
surveying as a mental health consumer. Additional
resources for consumer surveyors have been developed.
A review of the Mental Health In-depth Review program is
planned for 2010 to coincide with the release of the new
National Mental Health Standards.
StateAdvisoryCommittees
State Advisory Committee meetings are conducted twice
a year across all States and Territories and are co-ordinated
by Customer Services. The committee meetings enable
ACHS to consult with members and stakeholders and
obtain feedback regarding State and Territory issues
relating to quality, safety, accreditation and ACHS products,
services and activities. The State Advisory Committees
provide support to members and key stakeholder groups.
State Advisory Committee membership includes surveyors,
EQuIP members and other jurisdictional stakeholders.
HomeandCommunityCare Department:
In 2010 the ACHS completed its contract to assess
compliance with Home and Community Care (HACC)
Standards and Criteria, for organisations in Victoria with
HACC services that were also undergoing an Organisation-
Wide Survey or Periodic Review under EQuIP 4.
Conducting the HACC review at the same time as the
EQuIP survey reduced the burden of participating in two
separate surveys and enabled the organisation to be
surveyed as a whole.
DiagnosticImagingAccreditationScheme
In 2008, ACHS was one of four organisations that
successfully tendered to accredit Diagnostic Imaging
Practices across Australia, as part of Stage One of the
Commonwealth Department of Health and Ageing
Diagnostic Imaging Accreditation Scheme. The ACHS
completed its work under Phase 1 in June 2010 but chose
not to submit a tender for Phase 2.
C U STO M Er SEr vI CES
NetworkofAlcoholandDrug
AgenciesMembership
In 2008 ACHS was endorsed by the Network of Alcohol
and Drug Agencies (NADA) as the preferred provider of
accreditation services for its members. NADA members
include NSW Health funded Non-Government Alcohol
and Other Drug Treatment Services. This membership
group has continued to grow through 2010. The majority
of members are undertaking their Organisation-Wide
Surveys in the coming year. A resource tool specifically
for this group was developed by NADA and is available
on the ACHS website.
AccreditationProgramfor
CountryHealthSouthAustralia
In 2010, ACHS won a major tender to provide an
accreditation framework and services to Country Health
South Australia. The memberships in this contract have
been provided with a number of on-site education
programs to help embed quality and safety knowledge
within the staff to support the roll-out of the accreditation
program.
Significantactivitiesandoutcomesduring
2009-2010fortheCustomerServices
A new accreditation program was developed to meet the
specific needs of Day Hospitals and was launched on 1
January, 2010. As of 30 June there are 59 members, 54
members of the full Day Hospital Accreditation program
and five new members who are undertaking Certification.
An initial satisfaction survey of the members who have
participated in a survey under EQuIP for Day Hospitals
found that 100% felt that it was more relevant than the
standard EQuIP program for them.
ACHS ANNUAL REPORT 2009 - 2010 I 25
 C US TO MEr S Er vIC ES

DoyouthinkthatEQuIPforDayHospitals
isanimprovementtoEQuIPforyourday
will be repeated regularly to inform future planning of
hospital? education events.
Answer options Response %
All education consultants are now appointed to their roles
Yes 100% subject to them meeting specified criteria, and are engaged
0% in a regular performance review.
No
Comments Outlookfor2010-2011
Significant improvement on the previous system
New Initiatives in 2010-2011 for Customer Services EQuIP5
More relevant
will be rolled-out in 2011. This includes many changes and
Better than the previous model that was trying to fit
improvements to the processes and policies that support
a square peg into a round hole
the accreditation program. There will be a reduced level of
There certainly has been a removal of some of the
documentation required for the self-assessments, quicker
unnecessary information required
voting processes for Certification and changes to the
requirements for Conditional Accreditation.
A recruitment exercise was undertaken to identify and
The Mental Health In-depth Review program will be
recruit suitably qualified surveyors to act as education
reviewed and updated with the future launch of the new
consultants. To date, 18 new surveyor-educators have
National Standards for Mental Health Services.
been appointed. This has resulted in a significantly
enhanced depth of experience in our education
The biennial Surveyor Satisfaction survey will take place
consultants. It also enables easier access to educators
at the end of 2010. There will be an action plan and work
for members across a wide geographic spread.
to be completed following this. This will help to maintain
and grow an effective surveyor workforce.
Increasing involvement of surveyors in ACHS education
continues to be well received by members. New workshops
There will be a major project looking at business process
which have been developed and presented by surveyors
redesign to decrease the turnaround times for the survey
include ‘Preparing for Survey’, by John Hodge and ‘Clinical
reports following survey. This is to enable ACHS members
Governance: A Licence for Safety’ by Dr Rob Griffin.
to promptly build on the motivation and enthusiasm of their
staff following a survey
A series of half day workshops was developed and run
jointly with the Australian Commission on Safety and
In response to the on-line Education Needs Analysis survey,
Quality in Health Care in October and November, 2009.
three new workshops have been developed to commence
The workshops covered three key themes: ‘Medication
from July 2010: Partnering with Consumers to Achieve
Safety’, ‘Working with Consumers’ and ‘Multi-disciplinary
Quality Outcomes in Healthcare; Designing and Managing
Teamwork for Safety’. These workshops were presented
Clinical and Corporate Policy Frameworks; and
by Professor Guy Maddern, Professor of Surgery at the
Implementing and Sustaining a Quality Management
University of Adelaide and Director of Division of Surgery
System.
at Queen Elizabeth Hospital; Daniel Lalor, Project Manager,
Medication Safety with the Clinical Excellence Commission
It is intended to use e-learning as part of the communication
in NSW and Ms Stephanie Newell, Consumer Advocate
strategy for EQuIP5, due to be implemented in July 2011.
and member of state, national and international peak health
On-line learning will be supplemented with a ‘take home’ CD
consumer organisations and a consumer representative
version for those who do not have ease of internet access.
of a number of state, federal and international committees.

An on-line Education Needs Analysis survey was conducted

in February 2010. More than 500 responses were received
and the information gathered was used in the planning of
education events for July to December 2010. The survey

26 I ACHS ANNUAL REPORT 2009 - 2010

Young patient Muzhdai Shamla learns the
fun never stops with Dr Have-A-Chat.

ACHS ANNUAL REPORT 2009 - 2010 I 27

dIvISION rEPOrTS
d EvELO P MEN T
The Development Unit is governed by the Executive
Director - Development and the unit’s key role is the
generation and maintenance of the ACHS quality
improvement programs; EQuIP, EQuIP Corporate programs,
EQuIP for Day Hospitals and Quality for Divisions Network,
along with the associated resources and specialist
publications that support them.
The other major responsibility for the Development Unit
is the management of the Performance and Outcomes
Service; the ACHS’s Clinical Indicator data collection and
analysis section.
The Development Unit assists the ACHS with any special
projects, working collaboratively with federal, state and
territory administrators and industry stakeholders to
investigate or consult on quality improvement or
accreditation-related tools or activities.
The annual ACHS Quality Improvement (QI) Awards are
managed by the Development Unit, which also provides
administration support to the ACHS Standards Committee,
a sub-committee of the ACHS Board.
1 StandardsandProgramDevelopment
The review of EQuIP 4
The focus of the Standards and Program Development
Department throughout 2009-2010 was the review of the
EQuIP 4 standards.
The review of EQuIP is undertaken every four years in
collaboration with industry stakeholders to ensure the
EQuIP quality improvement program continues to reflect
current health priorities and contemporary best practice.
Working groups with a membership that reflected the
diversity of ACHS member organisations were established
to evaluate the appropriateness and effectiveness of EQuIP
criteria and elements. Changes recommended by the
working groups were then referred to the ACHS Standards
Committee for consideration. Its role is to steer the review
process and evaluate recommended changes to the
program. The Standards Committee reports its
recommendations to the ACHS Board for ratification.
EQuIP5 marks a refinement of EQuIP 4. The EQuIP 4
structure of three functions has been retained. A major
initiative within the Clinical Function is the introduction
28 I ACHS ANNUAL REPORT 2009 - 2010
of a Nutrition Management criterion, under the Safety
standard 1.5.
The EQuIP5 Guide will include an expanded introduction
and comprehensive and detailed program support. In line
with national health initiatives, EQuIP5 will have elements
that highlight indigenous health issues, clinical handover,
patient identification and the need for health promotion
within clinical practice.
To better assist members in implementing EQuIP5
standards, the guidelines have been expanded, with
navigation aided by sub-headings, prompt points, evidence
and suggested performance measures for each criterion.
Significantly, the review of the EQuIP 4 standards identified
issues surrounding the Outstanding Achievement (OA)
rating levels of accreditation achievement. EQuIP5 has
addressed this with the introduction of surveyor only
assessment and recommendation for OA levels of
achievement.
The EQuIP5 standards were ratified by the ACHS Board
at its April 2010 meeting and EQuIP5 is scheduled for
implementation by organisations from July 2011.
EQuIP for Day Hospitals
In response to requests from members, the Standards and
Program Development team has developed a continuous
quality improvement program specifically tailored for day
hospitals.
EQuIP for Day Hospitals is based on the EQuIP 4 standards
program, but has some important differences that make it
eminently applicable to the day hospital setting. EQuIP for
Day Hospitals retains the three function EQuIP structure.
Accreditation is for a three year period; during the three
year cycle only one on-site survey is required.
EQuIP for Day Hospitals has standards specific to the day
healthcare sector and a specially developed online interface
designed to streamline the self-assessment reporting.

2 Performance and Outcomes Service
The Performance and Outcomes Service develops the
ACHS Clinical Indicators and analyses and reports on the
collected data. The Performance and Outcomes Service
was established in 1989 to facilitate the measurement by
organisations of important aspects of their health service
delivery. The ACHS Clinical Indicator program is available
to member organisations through their EQuIP membership
and to non-member organisations on a fee for service basis.
The Performance and Outcomes Service currently collects
more than 370 clinical indicators across 23 different clinical
areas. Data are collected nationwide allowing participants
to benchmark their performance against similar
organisations.
In partnership with Australasian medical colleges and key
health bodies, the ACHS develops its clinical indicators to
reflect and measure variations in care delivery processes
and outcomes. Working parties drawn from relevant
medical and health professional colleges, associations,
and societies, regularly review and monitor the applicability
of its clinical indicator sets. Working party membership
includes clinicians, consumers, and representation from
the National Centre for Classification in Health. Data
analysis is undertaken in collaboration with the Health
Services Research Group (HSRG), University of
Newcastle, NSW.
Clinical indicator data analysis is reported by the
Performance and Outcomes Service to individual
healthcare organisations in several ways:
ComparisonReports
Comparison reports are generated six-monthly following
submission of data by healthcare organisations. Individual
reports are provided for each submitting healthcare
organisation and compare the organisation’s results with
national aggregated and national peer results. Comparison
reports are accessible on demand from the ACHS website
by each organisation.
IndividualHospitalTrendReports
These reports provide individual organisations with their
trended comparative data commencing 2001 to current.
d EvELO P MEN T
CustomReports
Multi organisation comparative data reports are available
at the request of corporate members and area health
services. The Performance and Outcomes Service reports
annually on analyses of the nationally collected data in the
publication Australasian Clinical Indicator Report -
Determining the Potential to Improve Quality of Care.
Review of indicator sets 2009-2010
The ACHS Clinical Indicator database, based across all
sectors and levels of the Australasian health system, is
one of the largest of its kind and offers a benchmarking
service to participating healthcare organisations (HCO’s),
that facilitates the evaluation of and improvement in the
delivery of the clinical care they provide.
The Performance and Outcomes Service co-ordinated
the review and release of four revised indicator sets;
Anaesthesia, Hospital-wide and Mental Health Inpatient,
which were introduced in January, 2009 and Internal
Medicine, which became available in July, 2010.
Additional working parties that commenced the review
of their indicator set during the 2009-2010 period include
Adverse Drug Reaction (to be renamed Medication Safety),
Emergency Medicine, Hospital in the Home, Intensive
Care, Mental Health Community Based, Obstetrics, and
Ophthalmology. It is expected that all these revised
indicator sets will become available in January, 2011.
Membership
Membership of the ACHS Clinical Indicator program has
remained constant with more than 730 participating
healthcare organisations across Australia, New Zealand
and Indonesia.
Clinical Director - Performance
and Outcomes Service
Dr Chris Maxwell MBBS,
FRCOG, FRACOG, MPPM
Dr Chris Maxwell is the Clinical
Director of the ACHS Performance
and Outcomes Service (POS), a role
he has held since 2003.
As Clinical Director, Dr Maxwell liaises with the POS team
and co-ordinates the development and review of the clinical
indicators through the clinical indicator working parties and
ACHS ANNUAL REPORT 2009 - 2010 I 29
 d EvEL OP M EN T
provides a practical link between the Clinical Indicator
program and its application in EQuIP.
Since Dr Maxwell’s appointment in 2003 the ACHS Clinical
Indicator program has grown from 21 data sets collecting
245 Clinical Indicators to 23 data sets collecting more than
360 clinical indicators in 2009.
Dr Maxwell is one of the Senior Obstetricians and
Gynaecologists at The Northern Hospital, a busy general
hospital situated in the northern region of Melbourne. Dr
Maxwell was previously The Northern Hospital’s Director of
Clinical Services Obstetrics, Gynaecology and Paediatrics,
a position he held for 10 years. He was in private specialist
Obstetrics and Gynaecology practice until recently, and is a
ACHS surveyor.
30 I ACHS ANNUAL REPORT 2009 - 2010
Franca Galati has her chemotherapy
dosage checked by nurse Jan.
PIRTOnlineDevelopment
Clinical indicator data is now reported by member
organisations to the ACHS Performance and Outcomes
Service using a web based reporting tool - Performance
Indicator Reporting Tool (PIRT).
PIRT provides greater flexibility for contributors to the
ACHS Clinical Indicator program as data entry and the
immediate generation of reports can be undertaken by
multiple users and from different locations. The need to
install updates and new versions of the application has
been eliminated as this is all now managed centrally.
The ACHS is currently developing new features which
can be added to PIRT Online such as a bulletin board,
an electronic customer support form, trended data and
graphic displays of indicator data.
 dIvISION rEPOrTS
C O rP O r ATE S Er vIC ES

Corporate Services is responsible, in co-operation with other ACHS service units, for the
implementation of the ACHS accreditation processes, the promotion of ACHS products and
services, the preparation of standard and custom reports to ACHS management/governance
team and external stakeholders, the provision and maintenance of ACHS infrastructure, and
to ensure the health and safety of staff. It encompasses business support, information
technology (IT), financial/human resources management and accreditation
administration/education administration service units.

Keyresponsibilitiesandachievements New technology and functions to be deployed

inthepastyearwere:
Adequate financial controls and management
Financial record audit
Engagement of external auditors to conduct an annual
audit
Appropriate internal controls, debtor management policy
Management level reviews (i.e Financial Advisory
Committee, delegations)
Monitor ACHS Board and its corporate policy
adherence
Ensure ACHS is managed within its budget
Ensure the existing governance system is sound.
for EAT5.
EAT for Day Hospitals tool was released in early 2010,
and has been used by all ACHS EQuIP for Day Hospital
members
Various collaborative IT Projects involving the Hong
Kong Hospital Authority, Ramsay Health Care,
Malaysian Society for Quality in Health and other
external stakeholders are underway
Technological review and upgrade of the ACHS website
commenced
Organisation-wide telecommunication upgrade to digital
system started.

Review and update of organisation-wide Strategic management of organisation information

risk management policies
Conduct a review and update of ACHS risk
management policy and register
Create a register of major risks reported monthly to the
Board
Review ACHS information technology infrastructure, and
continue the implementation of business continuity and
disaster recovery plan to improve reliability and security
External audit of ACHS IT services, with no major risks
identified
Review of corporate insurance coverage
Conduct a review of external service provider contracts.
Formulation and implementation of information
technology solutions that align with the organisation’s
objectives
Organise system and application software upgraded
Major server hardware upgrade completed
Virtualisation of all ACHS servers completed
Electronic Assessment Tool (EAT) v4 review conducted
in anticipation of EQuIP5 release. Steering committee
set up for organisation and surveyor users. Received
valuable feedback during the first round of meetings.
to ensure IT sustains and promotes ACHS business
processes and strategic goals
Information Management Committee set up to provide
feedback and direction for IT business decisions
Document Management Committee set up to scope a
centralised solution system
Business intelligence project plan commenced
ACHS website content review started
Audit of ACHS contact database undertaken.
Maintain a safe and healthy work environment
Occupational Health & Safety audit, risks identified
and addressed
Compliant to legislative requirements
Building works included improvements to level 1 and
level 3 of our Ultimo premises. An environmentally
friendly air conditioning system was also installed.
Further building work is planned for the next year
Monthly building and maintenance incident report given
to management and staff
Desk/seating ergonomics review conducted by external
consultant for all employees, addressed all issues
raised.

ACHS ANNUAL REPORT 2009 - 2010 I 31

 CO r P O rATE S ErvI C ES

ACHSQualityMonitoringTool
(QMT)bycategory2009-2010
Management of human resources

Human resources incident report developed

Formal review of ACHS employment contracts
conducted by external company
Performance management review training by external
consultant provided to all staff
Regular training and education provided to staff, to
support the delivery of their work and promote a sound
working environment. (e.g. fire and IT training)
Review of ACHS Corporate Policies and appropriate
communication to staff
Legal review confirmed that ACHS terms of
employment comply with the standards set down by
the National Employment Standards and applicable
modern awards of the Fair Work Act 2009
As at 30 June, 2010 five trainees completed on-the-job
training with the ACHS and attained Certificate III in
Business from MEGT (Australia) Ltd. Currently there
are three trainees in the process of completing the
12 month program
Within the 2009-2010 year four staff completed or were
in the process of completing academic awards from an
Australian university, TAFE or other professional bodies
Flu vaccinations available to staff sponsored by ACHS
The average length of service of staff at ACHS as at 30
June, 2010 is now more than six years, which is higher
than last year’s average of five years.
ACHSemployeeanalysis and the Malaysian Society for Quality in Health.
asat30June,2010(Fulltimeequivalent)
60
50
IT 88%
Building Maintenance 8%
OH&S 5%
Provide education and support
to ACHS stakeholders
Currently more than 3,000 EAT users are being
supported by the ACHS technical support team. The
ACHS 2009 member satisfaction report by ARTD
consultants indicates more than 80% of respondents
believe the technical support provided is of high quality
and available when needed
A total of more than 1,000 Building and Maintenance,
IT and OH&S Quality Management Tool (QMT) requests
were submitted, reviewed and actioned by relevant staff
EAT education calendar and on-site sessions were
provided Australia-wide
A total of eight presentations were made to
international organisations and delegations which
included: the World Health Organization, the Hong
Kong Hospital Authority, Korean Health Industry
Development Institute, Fred Hollows Foundation
Bangladesh, Qingdao Municipal Public Health Bureau
Quantitative analysis for National Accreditation Report
2007-2008
Data and custom reports (seven external and 19 internal
excluding National Accreditation Report) provided to
state health services and departments.

40
No. of Staff

30

20

10

0
2001 02 03 04 05 06 07 08 09 10
Year

32 I ACHS ANNUAL REPORT 2009 - 2010


Surveytypesasapercentageoftotal
accreditationsurveys2009-2010
SASS 48%
OWS 26%
PR 12%
other 15%
To maintain effective internal processes that enable
business goals to be efficiently achieved
A thorough electronic archiving of 28 years worth of
filing, ACHS Survey reports and files from 1974-2001
was carried out
New accreditation administrative policies implemented
Education calendar now available on the ACHS website
Revised education marketing strategy attracted more
attendees than for previous periods.
During the 2009-2010 year approximately 700 ACHS
accreditation reports were supported and processed
through EAT and Accreditation Administration Services.
Surgical sterilisation procedures
are strictly evaluated as part of
Accreditation.
C Or P O r ATE S Er vIC ES
FinancialServices/Human
ResourcesManagement
Financial services provide services and support in all
aspects of financial management, including accounting
systems, financial planning, monitoring and reporting.
The service also maintains human resources related
records, payroll, and employment support systems
(including occupational health and safety systems).
InformationTechnology(IT)Services
Information technology services manage all electronic
business support systems internally and externally,
including corporate data-base, performance reporting
services, websites, ACHS applications development and
support. These services are also used by user support
services, including construction of data schema interfaces
with ACHS electronic tools for members.
BusinessSupportServices
Business support services provide services and support to
all ACHS service units, business processes, internal and
external analytical reporting. Furthermore, this support is
directed to various information technology and finance
project planning, implementation and monitoring initiatives,
international business, and the maintenance of the ACHS
office building.
AccreditationAdministrationServices
andEducationAdministrationServices
These two units provide support to all administrative and
operational services at the ACHS, including survey report
preparation, maintenance of membership/accreditation
processes, monitoring of services delivered and education
events support.
ACHS ANNUAL REPORT 2009 - 2010 I 33
dIvISION rEPOrTS
I IN TErN ATI ON AL

ACHS International enjoyed favourable growth in the past year (2009-2010) despite the global
financial crisis that led to slow business worldwide. ACHSI continued to advance ACHS’
vision to be recognised nationally and internationally as the leading Australian organisation
that independently assesses performance in order to promote and improve quality and
safety of health care.

Active involvement and participation in the International
Society for Quality in Health Care (ISQua) and the Asian
Society for Quality in Health Care (ASQua) have contributed
to re-affirming our position as a credible international
accreditation body.
In the past year, ACHSI saw continued overseas interest
in the EQuIP 4 accreditation program reflected by the
international delegation visits to Australia from China,
Korea, Macau and Vietnam, and expressions of interest
from countries including Sri Lanka, Ireland, Kazakhstan
and Greece. An overview of the key activities throughout
the past year are:
HongKong Regular visits to the region have resulted in steady growth
Work on the Pilot Scheme on Hospital Accreditation project,
initiated by The Hong Kong Hospital Authority (HKHA),
continued at a rapid pace. The project is expected to be
completed by the end of 2010, approximately 18 months
ahead of schedule.
The preparation of five public and three private hospitals
for accreditation has been completed. As at 30 June, 2010,
one public and two private hospitals had undergone an
Organisation-wide Surveys (OWS). A positive outcome is
expected. The remaining hospitals will have all undergone
their OWS by October, 2010.
Under the terms of the contract, 21 local healthcare
professionals were trained and appointed as ACHS
surveyors. A further 20 are currently in training phase.
In addition to the Pilot Scheme project, a number of the
other private hospitals and clinics have been accredited
and others are in the preparatory stage.
A second tender to implement a local accreditation program
will be led towards the latter part of 2010. An ACHSI wholly
owned subsidiary company, ACHS (Asia Pacific) Private
Limited, was registered in Hong Kong and an office will be
set up to manage the next phase of the project.
A Memorandum of Understanding (MoU) was also signed
with the Hong Kong College of Health Services Executives
(HKCHSE) to collaborate in providing education workshops
and other quality related activities for the region.
Macau
Following a visit by a delegation from the Government of
Macau Special Administrative Region in June, 2010 a
feasibility study, at their request, of the public and private
sector hospitals was conducted to determine the likelihood
of the hospitals ability to meet the EQuIP 4 standards.
MiddleEast
of the EQuIP 4 accreditation program membership with the
first Riyadh hospital in Saudi Arabia scheduled to undergo
an OWS in late 2010.
India
Several Indian based organisations have expressed their
interest in joining our accreditation program. However, due
to the global financial crisis, several projects are on hold,
others are in progress.
SriLanka
In March 2010, interest from the Hemas group, resulted in
a consultancy gap analysis of their two hospitals, followed
by an education workshop conducted to prepare the two
hospitals for accreditation surveys. The hospitals are
currently working towards undergoing an OWS in early
2011. Additional projects in the region are also in progress.
Outlookfor2010-2011
Despite the global recession and strong competition,
the outlook for 2010-2011 appears positive. International
recognition of the Australian model of accreditation has
generated strong interest from many countries. Potential
prospects are anticipated from Bahrain, Korea and Ireland.

34 I ACHS ANNUAL REPORT 2009 - 2010

 COrPOrATE GOvErNANCE
The ACHS, a company limited by guarantee, is governed by a Board of 12 directors,
elected by council members and supported by a corporate management system.
Introduction
The Board is responsible to the Council, for the direction
and oversight of ACHS activities, and provides a report
on performance at the ACHS Annual General Meeting.
Both bodies are guided by the Corporations Law and the
Constitution of the Australian Council on Healthcare
Standards, adopted in 1974 and regularly reviewed.
FunctionsandresponsibilitiesoftheBoard
The Board has adopted statements of vision and mission
which are designed to determine the organisation’s strategic
direction, and has endorsed organisational values and
behaviours to ensure its operations are conducted to meet
high standards of service and professionalism.
Whilst the Board reviews and approves the organisation’s
strategic plan and guiding policy, day-to-day management
of the ACHS and implementation of the strategic plan are
delegated to the Chief Executive with the assistance of
Executive Directors. The goals of the organisation’s
strategic directions and priorities have remained the same
and performance indicators have been refined to reflect the
current financial environment.
The functions and responsibilities of the Board include:
The strategic direction of the ACHS, including approval
of the corporate strategic plan and guiding policies
Establishing policies to safeguard the ACHS and to
monitor performance in achieving its goals through
requiring regular and timely reporting on a
comprehensive set of performance issues
Approval of the annual financial report and budget
Satisfying itself that a robust and sound system of issue
and risk management exists with the Executive
responsible for identifying and managing issues and risk
Accountability, and,
Representation of the ACHS.
The Board undertakes regular evaluation of its own
performance every two years.
The Board maintains currency of its understanding of ACHS
operations through monthly meetings. In preparation of the
monthly meetings, the Board receives:
Monthly reports from the Chief Executive and executive
team on financial, human resources, quality, risk
management and industry performance
OvEr vIEw
Feature reports from ACHS staff 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.
Stakeholders
A key component of the ACHS’s stakeholders are the State
Advisory Committees (SACs) which are collaborative forums
providing advice to ACHS staff and Council on issues of
strategic interest. The SACs include representatives from
the health industry, governments and consumers. During
2009-2010 the SAC meetings were very successful. SAC
members join the councillors at twice yearly meetings to
ensure that there is a strong mix of ideas and representation
for the combined meeting.
StructureoftheBoardandCouncil
The experience and areas of expertise of individual Board
members is set out on pages 38-40. The ACHS Board
consists of 12 representatives, voted in at the Annual
General Meeting in November by the ACHS Council.
Given the Board’s representational make-up, at the
commencement of each Board meeting, members are
asked to declare any conflict of interest arising from agenda
items and to withdraw from the relevant discussion.
The ACHS Council includes 37 representatives of
consumers, peak health industry bodies and governments
from throughout Australia. Full details on Councillors are
on page 41.
ACHS ANNUAL REPORT 2009 - 2010 I 35
 O vEr vIEw
AnnualGeneralMeeting:November2009
Dr Noela Whitby AM completed her term on the Board and
Dr Robert Porter resigned from his Board position.
Associate Professor Peter Woodruff, who represents the
Royal Australasian College of Surgeons on the ACHS
Council and is the Director of Vascular Surgery at the
Princess Alexandra Hospital in Queensland, was re-elected
as the President.
Ms Karen Linegar, representing the Royal College of
Nursing, Australia on the ACHS Council, was re-elected as
the Vice-President.
Mr John Smith, PSM, one of three Councillors representing
the Australian Healthcare and Hospital Association (AHHA),
was re-elected Treasurer.
Ms Jennie Baker, representing the Australasian College of
Health Service Management on the ACHS Council was
elected to the Board, as was Dr David Lord, representing
the Royal Australian and New Zealand College of
Psychiatrists on the ACHS Council.
Internalcommitteesandguidingpolicies
Our internal Occupational Health and Safety Committee
continued its important work throughout the year, meeting
four times and ensuring compliance with relevant
regulations and legislation. No significant workplace
injuries were reported during the year.
The ACHS Quality Improvement Committee met several
times throughout the year. Key achievements were:
DevelopmentandimplementationoftheACHS A key development in 2009-2010 was the ACHS’s second
ComplaintsPolicyandFramework ever ‘Staff Satisfaction Survey” used to gauge staff’s
This included a review of the Complaints Policy and creation
of a complaints management structure and process with
defined performance indicators. A central electronic log
to record and track external complaints as well as internal
compliments and suggestions for improvement is now in
place with analysis and trending of complaints being
undertaken on a three monthly basis.
Co-ordinationoftheactionplanresponse
totheStaffSatisfactionsurvey
The Committee formulated questions to encompass the
ACHS values and also coordinated the survey response
process.
36 I ACHS ANNUAL REPORT 2009 - 2010
This included collecting suggested actions from staff and
utilising these to develop a detailed action plan.
ReviewandupdatingoftheACHSQuality
ImprovementFramework
The Policies and Procedures Committee met six times
throughout the year and covered a number of issues. The
largest project undertaken is a progressive review (and
re-writing) of the Policies and Procedures manual, resulting
in Policies that more accurately reflect the current
workplace.
The Information Management Steering Committee met
on a bi-monthly basis and continued to review all items
impacting on Information Technology (IT) resources for staff,
members and stakeholders. The Committee specifically
looks at all data-bases, programs, updates, the website and
a range of issues that require a whole-of-business input,
with representation across he different ACHS services.
The Financial Advisory Committee was set up and held its
first meeting on 16 December, 2009. Chaired by Board
Treasurer Mr John Smith, and with representation from
other Board Members, the purview of the Committee is to
analyse current financial trends and advise on required
actions to be taken by the Board, when necessary.
Humanresources
The conditions offered to staff from our human resources
principles and policies exceed the minimum requirements
of legal and regulatory requirements. Our executive
appointments are approved by the Board.
responses and views on a wide-ranging number of views.
The results of the survey were released to staff in April and
a number of actions have been taken to addresses key
issues, under the auspices of the Quality Improvement
Committee. Implementation of all remaining activities will
continue throughout 2010.
Implementation of these actions has commenced and will
continue throughout 2010-2011.
 OvEr vIEw

Remuneration The Standards Committee also assists the ACHS Board in

its evaluation of speciality standards developed by other
It remains an ongoing challenge for ACHS to ensure staff
external health care organisations.
remuneration policies and conditions remain comparative
to market and industry benchmarks.
Membership of the Standards Committee during 2009-2010
and attendance at meetings are as follows:
While our Board’s travel and accommodation expenses
are covered, no honorarium is paid for their time.
A B
StandardsCommittee Ms Helen Dowling (Chair since 2008)
BPharm, Dip Hosp Pharm (Admin),
The Standards Committee has significant responsibility
Grad Dip QI HCare, CHP, FSHP, AICD NSW 6 4
within the governing structure of the ACHS. It provides
independent and expert guidance in the development of
Ms Jackie Bullock
new program standards and to revisions of existing
RN, BA (Govt Studies) WA 6 4
standards and programs. The Committee also guides
the development of the resources that support ACHS
Ms Margo Carberry
programs.
RN, C&FHN, AFAAQHC NSW 6 4

The Standards Committee is a standing sub-committee

Assoc Prof Brett Emmerson
of the ACHS Board and its determinations are reported
MBBS, MHA, FRANZCP, FRACMA QLD 6 4
directly to the Board through the Chair.

Dr Philip Hoyle
Membership of the Standards Committee is drawn from
MBBS, MHA, FRACMA NSW 6 6
across the health care sector and includes clinicians,
quality co-ordinators, consumers, senior administrators
Mr John Kenny
and allied health professionals. The committee
BSc, Grad Dip QA NZ 6 5
membership is drawn from both the public and private
sectors and includes representation from Quality Health
Ms Maralyn Masters
New Zealand. External stakeholder membership of the
RN, Grad Dip Hlth Serv Man SA 4 2
committee includes the ACHS President, ACHS Chief
Executive, and Executive Directors of Development and
Ms Sue McKean
Customer Services. Administration of the Standards
MHSc (Risk Man), Grad Dip OHS,
Committee is undertaken by the Development Unit.
Dip OHS QLD 6 6

The Standards Committee Chair is ACHS Board member

Ms Alison McMillan
Ms Helen Dowling, who has been a member of the
RN, BEd, MBA VIC 6 3
Committee since 2004 and Chair since 2008. The Chair
of the editorial sub-committee is Dr Philip Hoyle, who is
Ms Sandra Miller
also a ACHS surveyor.
BHSc (MRA), Grad Dip HSc
(Epi & Bio) WA 6 4
Key responsibilities for the Standards Committee during
2009-2010 were overseeing the review of the EQuIP 4
Mr Stephen Walker
standards and determining the direction of a revised
BBus, Grad Dip Acc, Dip Eng SA 6 2
EQuIP Corporate program.

Ms Patricia Warn
BA NSW 6 5

A I Meetings held during the period of office of the member

B I Meetings attended by the member

ACHS ANNUAL REPORT 2009 - 2010 I 37

COrPOrATE GOvErNANCE
B OAr d O F dI r EC TO r S
Representing consumers, governments
and the Australian health care industry
As at 30 June, 2010
AssociateProfessorPeterWoodruff
(President)
MBBS, ChM, FRCS, FRACS, FACS
w ACHS Board member since 2002
w ACHSI Board member since 2008
w ACHS National Advisory Committee
Chair, 2002-2003
w Honorary Treasurer, Royal Australasian
College of Surgeons, 2000-2002
w Chairman and Director of Vascular
Surgery, Princess Alexandra Hospital,
Qld, 2003-2009
w Vice President, Royal Australasian
College of Surgeons, 2003-2005
w Member Medical Board, Qld, since 2005
w President, Australian and New Zealand
Society for Vascular Surgery, 2006-2008
w Court of Honour, Royal Australasian
College of Surgeons
MsKarenLinegar(VicePresident)
RN, RM, Ba AppSc (Nursing), BaBus, MHA, Dip.
Comm. Law, JP, FRCNA
w ACHS Board member since 2004
w ACHS Vice-President since 2008
w ACHS Councillor since 2004,
representing Royal College of Nursing
Australia (RCNA)
w ACHS Surveyor since 2005
w Chair ACHS Tasmanian Advisory
Committee since 2005
w Executive Director of Nursing,
Midwifery and Care Redesign - North
West Area Health Service since 2009
w Director of Nursing - North West
Regional Hospital, Burnie 1994-2009
w President, Royal College of Nursing,
Australia 2002-2004
w Board member, Royal College of
Nursing, 2002-2007
w Chair, Nursing Board of Tasmania,
2000-2003
MrJohnSmithPSM(Treasurer)
MHA, Grad Dip HSM, AFACHSE, CHE,
FAHSFMA, AFAHRI, AFAIM, FHFM, FAICD
w ACHS Board Member since 2005
w ACHS Board Member since 2005
w ACHS Treasurer since 2007
w ACHSI Board Member since 2008
w ACHS Councillor representing the
Australian Healthcare and Hospital
Association (AHHHA), since 2000
w Chief Executive Officer West
Wimmera Health Service
38 I ACHS ANNUAL REPORT 2009 - 2010
w National Councillor, AHHA since 2000
w Director, Victorian Healthcare Association,
1974-2004
w National Councillor of AHHA and Board
member since 1994
w Board Member, The Victorian Hospitals
Industrial Association Limited since 1994
MsJennifer(Jennie)Baker
BHSc(Mgt), BBus(IR), MLegSt, MIR, FCHSM, CHE
w ACHS Board member since 2009
representing the Australasian College
of Health Service management (ACHSM)
w ACHSM Board member since 2005
w Director Business Support, ACT Health
since 2006
w Chair, ACT - South Eastern NSW
Breastscreen Quality Committee
w Member, Australian Institute of Radiography
MsHelenDowling
BPharm, DipHospPharm (Admin), GradDipQI
in HCare, CHP, FSHP, AICD
w ACHS Board member since 2008
w Chair, ACHS Standards Committee
since 2007
w ACHS Councillor representing The
Society of Hospital Pharmacists of
Australia (SHPA), since 2001
w Area Director of Pharmacy, Hunter New
England Health since 2008
w Director of Pharmacy, Greater
Newcastle Sector, Hunter New England
Health, 2001-2008
w Member and current President,
Pharmacy Council of NSW, 2010
w Member NSW Health Caring Together
Independent Panel since 2009
w Member NSW Health Medication Safety
Strategy Steering Committee since 2009
w Vice President, Pharmacy Board of NSW,
2008-2010
w Federal President (SHPA), 1999-2002
w SHPA GlaxoSmithKline Medal of Merit
recipient 2005
DrDavidLord
MBBS, DPM, FRANZCP
w ACHS Board member since 2009
w ACHS Councillor representing Royal
Australian and New Zealand College
of Psychiatrists
w ACHS Surveyor since 2007
w Retired (2008) psychiatrist
 B O Ard O F d Ir EC TOr S
MrRussellMcGowan DrDanaWainwright
BA
w ACHS Councillor representing the
Australian Consumers Health Forum,
since 2002
w ACHS Board member since 2001
w National Advisory Committee Chair,
2003-2005
w Consumer Commissioner, Australian
Commission on Safety and Quality in
Health Care, since 2008
w Director, Australian Divisions of General
Practice since 2003
w Member, ACT Health Council, since 2003
w Governing Committee Member,
Consumers Health Forum, since 2002
w Consumer Surveyor since 2001
MsKaeMartin
RN, RM, BHSc(Nurs), MHA, LLB, ACHSE
w ACHS Board member since 2003
w ACHS Councillor representing the
Department of Health South Australia
w Executive Director, Business
Development, Planning and
Performance, Central Northern Adelaide
Health Service since 2004
w Director, Acute Care and Clinical
Services, SA Department of Health,
2000-2004
MrMichaelRoff
Grad Cert Mgt.
w ACHS Board member since 2003
w ACHS Councillor representative of the
Australian Private Hospitals
Association, since 2004
w Chief Executive Officer, Australian
Private Hospitals Association since 2000
w Member, National Health Performance
Committee since 2000
w Member, Private Health Industry Quality
& Safety Committee, 2000-2004
w Member, National Centre for
Classification in Health,
Management Advisory Committee
since 2000
w Director, Australian Centre for Health
Research since 2006

MBBS, FRACP
w ACHS Board member since 2003
w ACHS Councillor representing the
Australian Medical Association since 2003
w VMO Royal Brisbane Hospital
w Past Chair, AMA Federal Council,
2003-2008
w President of AMAQ 1998-1999
w Chairman of Medical Staff Association
Royal Brisbane Hospital since 2006
w Adverse Drug Reactions Advisory
Committee of the TGA, 2000-2009
w Member, Australian Medical Council,
2004-2009
w Deputy Chairman, Medical Assessment
Tribunal, Workers Compensation
Regulatory Authority since 2004
DrLeonard(Len)NotarasAM
LLB, BA (Hons), DipComm, BMed, MHA, MA,
AFCHSE
w ACHS Board member since 2002
w ACHS Councillor representing the
Department of Health and Community
Services, NT since July 2002
w Chair, Clinicians Involvement Working
Group, 2003-2004
w Executive Director, National Critical Care
and Trauma Response Centre since 2009
w General Manager, Royal Darwin
Hospital, 1994-2009
w Senior Superintendent, NT Acute Care
Network since 2003
w Member, NT Medical Board since 1996
w Chair, NT Radiographers Board since 1997
w Senior Lecturer, NT Clinical School
since 1995
w Council Member National Council for
Safety and Quality in Healthcare,
1999-2006
w NT President, Australian College of
Health Service Executives (ACHSE),
since 2003
w Chair NT Acute Care Quality Committee
since 2003
w Medical Director, NT Medical
Administration Network since 2005
w Region #1 Top End Medical Disaster
Co-ordinator
ACHS ANNUAL REPORT 2009 - 2010 I 39
 B O Ar d OF d Ir EC TOr S

AttendanceatACHSBoardMeetings
July2009-June2010
MrStephenWalker A B
Ass. Dip.Eng., B.Bus, Grad.Dip.Acc.,
AFACHSE, AICD A/Prof Peter Woodruff 9 9
w ACHS Board member since 2006 Ms Karen Linegar 9 8
w ACHS Councillor representing the
Australian Private Hospitals Association Mr John Smith PSM 9 8
since 2006 Ms Jennie Baker 5 5
w Chief Executive Officer, St Andrew’s
Ms Helen Dowling 9 6
Hospital, Adelaide, since 2001
w Board member, Australian Private Dr David Lord 5 4
Hospitals Association (APHA) since 2005 Ms Kae Martin 9 7
w President, SA Branch APHA since 2004
Mr Russell McGowan 9 8
w Chairman, APHA National Safety and
Quality Committee since 2007 Dr Len Notaras AM 9 8
w Member, Private Hospital Sector 9 9
Mr Michael Roff
Committee, Australian Commission on
Safety and Quality in Health Care Dr Dana Wainwright 9 7
(ACSQH) since 2007 Mr Stephen Walker 9 7
w Past Vice President, SA branch
Australian College of Health Service A I Meetings held during the period of office of the Board Member
Executives (ACHSE) B I Meetings attended by the Board Member
w Past ACHS and QHNZ Surveyor

40 I ACHS ANNUAL REPORT 2009 - 2010

 COrPOrATE GOvErNANCE
C O UN C IL MEM B Er S As at 30 June, 2010

Our Council represents consumers, government and peak Professor David Davies
health industry bodies from throughout Australia. BSc, MBChB, MD, FRCPA
The Royal College of Pathologists of Australasia
The ACHS Council’s powers and duties include:
Election of the Board, President, Vice-President and Dr Paul Devenish-Meares
Treasurer at the Annual General Meeting MBBS, FRANZCOG, FRCOG
Appointment of Council committees Royal Australian and New Zealand College of Obstetricians
Consideration and recommendation to the Board and Gynaecologists
regarding the acceptance of other organisations as
members of the Council Dr Stuart Dorney
Contribution and support of the ACHS and assistance in MBBS, FRACP
determining the strategic direction of the ACHS NSW Health
Participation in the determination of accreditation
status, where appropriate Ms Helen Dowling
Consideration and monitoring of Board performance. BPharm, DipHospPharm (Admin), GradDipQI HCare,
CHP, FSHP, AICD
Health Professions Council of Australia
ACHSCouncilmembers,theirqualifications
andprofessionalbodiesrepresentedin Associate Professor Brett Emmerson
2009-2010were: MBBS, MHA, FRANZCP, FRACMA
Ms Jennie Baker Royal Australasian College of Medical Administrators
BHSc(Mgt), BBus(IR), MLegSt, MIR, FCHSE, CHE (appointed 11/2009)
Australasian College of Health Service Management
Ms Tanya Gawthorne
BSc, Grad Dip Ed, Grad Dip Pub Hlth, MAppEpid
Dr Patrick Bolton
Department of Health, Western Australia
MBBS, Grad Dip Comp Stud, MBA, PhD, EMBA, FRACGP,
FRACMA, FACHI
Professor Christian Gericke
Australian Healthcare and Hospitals Association
MBBS, MD, MPH, MSc, FACP, FRCP Edin, FAFPHM
Department of Health and Human Services, Tasmania
Ms Liz Callaghan
(appointed 05/2010)
MaSc (Policy and Management), Grad Dip (Human Service
Research), BSW, RN
Dr Michael Hodgson AM
Catholic Health Australia
MBBS, FAMA, FANZCA, FRCA
(appointed 08/2009)
Council Life Member as of 2009

Professor Michael Cleary

Mrs Alice Jones
MBBS, FACEM, FRACMA, MBA, AFACHSE, MHA
RN, RM, CHCNS, BA ppSc (Nurs)
Queensland Health ACT Health
(appointed 06/2010)
Mr Mark Kearin
Dr Margaret Cowling RN, ADCNS(Geront Nurs), BHSc(Mgt), MHSc(Mgt)
MBBS, FFARACS, FANZCA Australian Nursing Federation
Australian and New Zealand College of Anaesthetists
Associate Professor Peter Kendall
Ms Judy Daniel MBBS, DA, FRACP, FCCP
MEcon Royal Australasian College of Physicians
Department of Veterans’ Affairs
(appointed 01/2010) Ms Karen Linegar (Vice President)
RN, RM, BA ppSc (Nursing), MHA, Dip Comm Law, FRCNA, JP
Royal College of Nursing

ACHS ANNUAL REPORT 2009 - 2010 I 41

 CO U N CI L M EMB Er S

Dr David Lord Mr Michael Roff

MBBS, DPM, FRANZCP Grad Cert Mgt
Royal Australian and New Zealand College of Psychiatrists Australian Private Hospitals Association

Dr Sally McCarthy Ms Kathleen Ryan

MBBS, MBA, FACEM FAAQHC
Australasian College for Emergency Medicine Australasian Association for Quality in Health Care
(resigned 10/2009)
Mr Russell McGowan
BA Dr Paul Scown
Consumers’ Health Forum of Australia MBBS, BHA, FRACMA, AFCHSE, CHE
Australian Healthcare and Hospitals Association
Ms Alison McMillan
RN, BEd, MBA Mr John Smith PSM (Treasurer)
Department of Health, Victoria MHA, Grad Dip HSM, AFACHSE, CHE, FAHSFMA,
AFAHRI, AFAIM, FHFM, FAICD
Ms Kae Martin Australian Healthcare and Hospitals Association
RN, RM, BHSc(Nursing), MHA, LLB, ACHSE
Department of Health, South Australia Dr Dana Wainwright
MBBS, FRACP
Ms Maralyn Masters Australian Medical Association
RN, Op Cert, Grad Dip HSM
Australian Day Surgery Council Mr Stephen Walker
Ass Dip Eng, BBus, Grad Dip Acc, AFCHSE, AICD
Dr Jon Mulligan Australian Private Hospitals Association
MBBS, MHA, FRACP, FRACMA, GAICD
Council Life Member Dr Noela Whitby AM
MBBS, Grad Dip Hum Nut, FRACGP, FAICD
Dr Leonard Notaras AM Royal Australian College of General Practitioners
LLB, BA, Dip Comm, BMed, MHA, MA, AFCHSE
Northern Territory Department of Health and Community Professor Andrew J Wilson
Services BMedSci, MBBS, PhD, FRACP, FAFPHM
Queensland Health
Dr Annette Pantle (resigned 01/2010)
MBBS, MPH, FRACMA, GAICD, FAAQHC
Australasian Association for Quality in Health Care Dr Ian Woodforth
(appointed 11/2009) MBBS, FANZCA
Australian Medical Association
Dr Robert Porter
MBBS, FRACGP, FRACMA, AFCHSE Associate Profesor Woodruff (President)
Royal Australasian College of Medical Administrators MBBS, ChM, FRCS, FRACS, FACS
(resigned 11/2009) Royal Australasian College of Surgeons

Dr Eva Raik AM Dr Choong-Siew Yong

MBBS, FRCPA, FRACP MBBS, Grad Cert CAPsych, FRANZCP
Council Life Member Australian Medical Association

6Appointed I 3ResignedI 1LifeMembership

Therearenooutstandingnominations

42 I ACHS ANNUAL REPORT 2009 - 2010

Patient Duane Gilmore undergoes
a physiotherapy workout.

ACHS ANNUAL REPORT 2009 - 2010 I 43

FINANCIAL PErFOrMANCE
dIrECTOrS’ rEPOrT
The Board of Directors of The Australian Council on
Healthcare Standards Limited in office at the date of this
report presents the results of The Australian Council on
Healthcare Standards Limited and its controlled entity for
the financial year ended 30 June, 2010.
The names of the members of the Board in office during
the reporting year are:
Ms Jennifer Baker - (appointed 26 November, 2009)
Ms Helen Dowling
Ms Karen Linegar
Dr David Lord - (appointed 26 November, 2009)
Ms Kae Martin
Mr Russell McGowan
Dr Leonard Notaras AM
Mr Michael Roff
Mr John Smith PSM
Dr Dana Wainwright
Mr Stephen Walker
Associate Professor Peter Woodruff
Directors have been in office since the start of the financial
year to the date of this report unless otherwise stated.
CompanySecretary
The following person held the position of Company
Secretary at the end of financial year:
Mr Brian Johnston - Fellow of the Australian College of
Health Service Executives, the Australian Institute of
Company Directors and the Australian Institute of
Management. He has more than 30 years of Australian
health industry experience.
Principalactivities
The principal activities of the Company during the financial
year remained unchanged and were dedicated to improving
the quality of healthcare in Australia through continuous
review of performance, assessment and accreditation.
There was no significant change in the nature of the
Council’s activities during the 2009-2010 period.
Operatingresults
The consolidated net profit for the financial year ended
30 June, 2010 before extraordinary items was $80,627.
Consolidated operating revenue has increased from
$10,293,578 in 2009 to $11,156,210 in 2010 mainly due
to ACHS International.
44 I ACHS ANNUAL REPORT 2009 - 2010
FinancialPosition
The net assets of the consolidated group have increased by
$80,627 from 30 June, 2009 to $916,891. The increase is
largely due to improved operating performance of the Group.
The consolidated group’s strong financial position has
enabled the group to increase its cash holdings and
maintain a healthy capital ratio. The Group’s cash
holdings have improved from $3,615,323 to $5,144,242.
The Group’s working capital, being current assets less
current liabilities, has decreased from $2,162,411in 2009
to $2,077,142 in 2010.
The Directors believe the Group is in a strong and stable
financial position to expand and grow its current operations.
The parent entity is exempt from the payment of income
tax. The subsidiary, ACHS International Pty Ltd, which
was formed to extend the mission of Australian Council on
Healthcare Standards (ACHS) internationally, is subject to
Australian income tax.
Dividendspaidorrecommended
The Australian Council on Healthcare Standards Limited is
a not-for-profit organisation, and accordingly no dividends
were paid or recommended. Furthermore, as a company
limited by guarantee it is precluded from paying dividends
except on liquidation.
Sharecapital
The company was incorporated on 4 December, 1979 as
a company limited by guarantee.
Reviewofoperations
The result is arrived after providing for the following
expenditures:
launch and printing of EQuIP5 materials
building works
EAT5 development
EQuIP5 eLearning
research and development
A new product ‘EQuIP for Day Hospitals Program’ was
launched early this year. The program was developed in
response to feedback from our day hospital members,
specifically for privately owned, stand-alone day hospitals.
The changes maintain the integrity of the EQuIP 4 standards
whilst tailoring them for the day hospital sector.
During the year the ACHS won a major tender to provide
accreditation framework and services to Country Health

South Australia and was also endorsed by the Network
of Alcohol and Drug Agencies (NADA) as the preferred
provider of accreditation services for its members.
ACHS International enjoyed favourable growth in the past
year with continued interest in the Australian model of
accreditation reflected by international delegation visits to
Australia from China, Korea, Macau and Vietnam together
with expressions of interest from countries including Sri
Lanka, Ireland, Kazakhstan and Greece.
Work on the Hong Kong Hospital Authority Pilot Scheme
of Hospital Accreditation project is expected to be
completed by the end of 2010, approximately 18 months
ahead of schedule. A second tender similar to this project
is expected to be advertised in the latter part of 2010. An
ACHSI wholly owned subsidiary company, ACHS (Asia
Pacific) Private Limited, was registered in Hong Kong and
an office will be set up to manage the next phase of the
project. In addition to the Pilot Scheme project, a number
of private hospitals and clinics in Hong Kong have also
been accredited and others are in the preparatory stage.
The outlook for the 2010/2011 financial year appears
positive with potential prospects anticipated from Bahrain,
Korea and Ireland.
Financial assistance in the form of grants was received
from the New South Wales Department of Health.
Stateofaffairs
In the opinion of the Directors, there were no significant
changes in the state of affairs of the Company that
occurred during the financial year under review or any
significant changes likely to affect the state of affairs of
the Company in future financial years.
Futuredevelopments
Likely developments in the operations of the Company and
the expected results of those operations in future financial
years have not been included in this report as the inclusion
of such information is likely to result in unreasonable
prejudice to the Company.
Environmentalissues
The Directors believe that the operations of the company
are not subject to any specific or significant environmental
regulation under either Commonwealth or State Legislation.
Accordingly, the Directors do not anticipate any effect on
the operations of the Company, or on its operating results,
as a result of environmental regulations.
dIrECTOrS’ rEPOrT
Eventssubsequenttobalancedate
There are no matters or circumstances that have arisen
since the end of the period which significantly affected the
operations of the consolidated entity, the results of those
operations or the state of affairs of the consolidated entity
in subsequent years.
Proceedingonbehalfofcompany
No person has applied under Section 237 of the Corporations
Act 2001 to bring proceedings on behalf of the company or
intervene in any proceedings to which the company is a 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.
Indemnificationandinsurance
ofofficersandauditors
The Company has not, during or since the financial year, in
respect of any person who is or has been an officer or auditor
of the company or a related body corporate:
indemnified or made any relevant agreement for
indemnifying against a liability incurred as an officer,
including costs and expenses in successfully defending
legal proceedings; or
paid or agreed to pay a premium in respect of a contract
insuring against a liability incurred as an officer for the
costs or expenses to defend legal proceedings; with the
exception of the following matters:
During the period the Council paid an insurance premium
indemnifying each of the Directors and Officers of the
economic entity against all liabilities to another person that
may arise from the position as Directors or Officers of
the Council, except where the liability arises out of
criminal or dishonest conduct or behaviour involving a
lack of good faith.
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.
RemunerationReport
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
was made or when the Director received or became entitled to
receive, the benefit with:
a Director, or
a firm of which a Director is a member, or
an entity in which a Director has a substantial financial interest.
ACHS ANNUAL REPORT 2009 - 2010 I 45
 dIrECTOrS’ rEPOrT
Non-auditservices
The Board of Directors report that there was no non-audit
services provided during the year.
Auditor’sindependencedeclaration
The auditor’s independence declaration for the year ended
30th June 2010 has been received and can be found
directly below the directors’ report.
The report of the Directors, incorporating the Remuneration
Report, is signed in accordance with a resolution of the
Board of Directors.
JohnSmithPSM
AssociateProfessor
PeterWoodruff Treasurer
President
Sydney - 28th day of October 2010
46 I ACHS ANNUAL REPORT 2009 - 2010
Auditor’sindependencedeclaration
Auditor’s independence declaration under section 307C
of the Corporations Act 2001 to the Directors of The
Australian Council on Healthcare Standards Limited and
controlled entities.
The Directors received the following declaration from the
auditor of The Australian Council on Healthcare Standards
Limited.
I declare that, to the best of my knowledge and belief,
during the year ended 30 June, 2010 there have been:
no contraventions of the auditor independence
requirements as set out in the Corporations Act 2001
in relation to the audit; and
no contraventions of any applicable code of
professional conduct in relation to the audit.
TALBOTS SAHOLLIER
Chartered Accountants Partner
Level 6
379 Kent Street
SYDNEY NSW 2000
Sydney - 28th day of October 2010
 IN d EP EN d EN T AUd ITO r ’S r EP O r T
TO THE MEMBERS OF THE AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS LIMITED
ReportontheFinancialReport
We have audited the accompanying financial report of The
Australian Council on Healthcare Standards Limited and
controlled entities (the consolidated entity), which comprises
the statement of financial position as at 30 June, 2010 and
the statement of comprehensive income, statement of cash,
statement of changes in equity and cash flow statement for
the year ended on that date, a summary of significant
accounting policies and other explanatory notes and the
Directors’ declaration of the consolidated entity comprising
the company and the entities at the year’s end or from time
to time during the financial year.
DirectorsResponsibilityfortheFinancialReport
The Directors of the Company are responsible for the
preparation and fair presentation of the financial report
in accordance with Australian Accounting Standards
(including the Australian Accounting Interpretations) and
the Corporations Act 2001. This responsibility includes
establishing and maintaining internal control relevant to the
preparation and fair presentation of the financial report that
is free from material mis-statement, whether due to fraud or
error; selecting and applying appropriate accounting policies;
and making accounting estimates that are reasonable in the
circumstances. In Note 1, the Directors also state, in
accordance with Accounting Standards AASB 101:
Presentation of Financial Statements, that compliance with
the Australian equivalents to International Financial Reporting
Standards (IFRS) ensures that the financial report, comprising
the financial statements and notes, complies with IFRS.
Auditors’Responsibility
Our responsibility is to express an opinion on the financial
report based on our audit. We conducted our audit in
accordance with Australian Auditing Standards. These
Auditing Standards require that we comply with relevant
ethical requirements relating to audit engagements and
plan and perform the audit to obtain reasonable assurance
whether the financial report is free from material mis-
statement.
An audit involves performing procedures to obtain audit
evidence about the amounts and disclosures in the financial
report. The procedures selected depend on the auditor’s
judgment, including the assessment of the risks of material
mis-statement of the financial report, whether due to fraud
or error. In making those risk assessments, the auditor
considers internal control relevant to the entity’s preparation
and fair presentation of the financial report in order to design
audit procedures that are appropriate in the circumstances,
but not for the purpose of expressing an opinion on the
effectiveness of the entity’s internal control. An audit also
includes evaluating the appropriateness of accounting
policies used and the reasonableness of accounting
estimates made by the Directors, as well as evaluating
the overall presentation of the financial report and the
remuneration disclosures in the Directors’ report.
We believe that the audit evidence we have obtained is
sufficient and appropriate to provide a basis for our audit
opinion.
Independence
In conducting our audit, we have complied with the
independence requirements of the Corporations Act 2001.
We confirm that the independence declaration required by
the Corporations Act 2001, provided to the directors of
The Australian Council on Healthcare Standards Limited on
28 October, 2010, would be in the same terms if provided
to the Directors as at the date of this auditor’s report.
Audit2010Opinion
In our opinion:
The financial report of The Australian Council on
Healthcare Standards Limited and controlled entities is
in accordance with the Corporations Act 2001, including:
• giving a true and fair view of the Company’s and
consolidated entity financial position as at 30 June,
2010 and of their performance for the year ended on
that date; and
• complying with Australian Accounting Standards
(including the Australian Accounting interpretations)
and the Corporations Regulations 2001
• the financial report also complies with International
Financial Reporting Standards as disclosed in Note 1;
and
• the remuneration disclosures that are contained in the
Directors report comply with Section 300A of the
Corporations Act 2001.
InherentUncertaintyRegarding
AccountingEstimates
Without qualification to the opinion expressed above,
attention is drawn to the following matter. As indicated in
Note 12 to the financial report, The Australian Council on
Healthcare Standards Limited has included as liabilities
$5,981,505 as unearned income and Note 10 $771,993
as Work in Progress. These relate to the Evaluation and
Quality Improvement Program (EQuIP) and the progressive
recognition of income and expenses throughout the contract
cycle based on estimation of each phase completed. As the
figures taken into account are estimates their accuracy
cannot presently be determined with an acceptable degree
of reliability.
TALBOTS SAHOLLIER
Chartered Accountants Partner
Level 6
379 Kent Street
SYDNEY NSW 2000
Sydney - 28th day of October 2010
ACHS ANNUAL REPORT 2009 - 2010 I 47
 F IN AN C IAL S TATEM EN TS

ConsolidatedStatementofComprehensiveIncome
Yearended30thJune2010
Consolidated Parent
Note 2010 2009 2010 2009
Revenue from ordinary activities 2 10,554,878 9,880,880 8,934,611 9,772,321
Cost of sales (3,894,831) (3,723,776) (2,893,298) (3,631,061)
Gross profit 6,660,047 6,157,104 6,041,313 6,141,260
Other revenues from ordinary activities 601,332 412,698 536,332 288,178
Marketing, promotional and publication expenses (323,913) (203,270) (178,566) (86,592)
Occupancy expenses (267,475) (94,820) (265,740) (94,820)
Administration expenses (1,083,005) (1,056,617) (984,105) (1,037,813)
Human resources expenses (5,022,572) (4,739,801) (4,626,572) (4,739,804)
Depreciation (354,717) (292,539) (354,717) (292,539)
Other expenses (129,070) (155,057) (124,134) (153,158)
Profit from operation 3 80,627 27,698 43,811 24,712
Retained profit/(loss) at the beginning of the year 836,264 808,566 794,855 770,143
Retainedprofitattheendofthefinancialyear 916,891 836,264 838,666 794,855

StatementofFinancialPosition
Asat30thJune2010

Consolidated Parent
Note 2010 2009 2010 2009
Currentassets
Cash 4 5,144,242 3,615,323 4,819,556 3,443,743
Trade receivables 5 1,983,321 1,694,580 1,983,321 1,694,580
Totalcurrentassets 7,127,563 5,309,903 6,802,877 5,138,323
Non-currentassets
Plant and equipment 6 378,193 452,779 378,193 452,779
Land and building 7 2,612,494 2,542,202 2,612,494 2,542,202
Intangible assets 8 616
Investments 9 3,346 3,078 3,346 3,078
Totalnon-currentassets 2,994,033 2,998,675 2,994,033 2,998,059
Totalassets 10,121,596 8,308,578 9,796,910 8,136,382
Currentliabilities
Trade payables 10 1,545,400 1,520,321 1,449,689 1,495,321
Provisions 11 1,677,800 1,455,904 1,712,800 1,455,904
Unearned income 12 5,981,505 4,496,089 5,795,755 4,390,302
Totalcurrentliabilities 9,204,705 7,472,314 8,958,244 7,341,527
Totalliabilities 9,204,705 7,472,314 8,958,244 7,341,527
Netassets 916,891 836,264 838,666 794,855
Equity
RetainedEarnings 916,891 836,264 838,666 794,855

48 I ACHS ANNUAL REPORT 2009 - 2010

 FI NAN C IAL S TATEMEN TS

StatementofChangesinEquity

Note RetainedProfit
Balanceasat30June,2008 808,566
Profit attributable to member’s parent entity 27,698
Balanceasat30June,2009 13 836,264

Balanceasat30June,2009 836,264
Profit attributable to members parent entity 80,627
Balanceasat30June,2010 13 916,891

StatementofCashFlows

Consolidated Parent
Note 2010 2009 2010 2009

Cashflowsfromoperatingactivities
Receipts from customers net of payments
to suppliers and employees (67,970) 208,849 (105,402) 211,362
Interest received 133,502 163,837 133,502 163,837
Net cash provided in operating activities 14 65,532 372,686 28,100 375,199

Cashflowfrominvestingactivities
Prepayment of expenses (5,122) 33,867 (5,122) 33,867
Acquisition of property, plant and equipment (124,119) (124,119)
Acquisition of investment and short term deposits
Net cash provided from investing activities (5,122) (90,252) (5,122) (90,252)

Cashflowfromfinancingactivities
Proceeds from borrowings (movement in
unearned income) 15 1,468,509 343,656 1,352,835 343,656
Net cash provided by financing activities 1,468,509 343,656 1,352,835 343,656

Net increase/(decrease) in cash held 1,528,919 626,090 1,375,813 628,603

Cash at the beginning of financial year 3,615,323 2,989,233 3,443,743 2,815,140

Cashattheendoffinancialyear 16 5,144,242 3,615,323 4,819,556 3,443,743

ACHS ANNUAL REPORT 2009 - 2010 I 49

 N O TES TO TH E F IN ANC IAL S TATEM ENTS
Note1:Statementofsignificant Plantandequipment
accountingpolicies
The financial report covers the economic entity of The
Australian Council on Healthcare Standards Limited
and controlled entities, and The Australian Council on
Healthcare Standards Limited as an individual parent entity.
The parent entity is a company limited by guarantee,
incorporated and domiciled in Australia.
a)Basisofpreparation
The financial report is a general purpose financial report
that has been prepared in accordance with:
Corporations Act 2001
Applicable Australian Accounting Standards,
Australian Accounting Interpretations and
Other authoritative pronouncements of the Australian
Accounting Standard Board (AASB)
Australian Accounting Standards include Australian
equivalents to International Financial Reporting Standards
(AIFRS). Compliance with AIFRS ensures that the
consolidated financial statements and notes comply
with International Financial Reporting Standards (IFRS).
Except as described below, the accounting policies have
been applied to all periods presented in these financial
statements and have been applied consistently.
The financial report has been prepared in Australian dollars
on an accrual basis and is based on historical costs and
does not take into account changing money values or,
except where stated, current valuations of non current
assets. Cost is based on the fair values of the consideration
given in exchange for assets.
b)Basisofconsolidation
All inter-company balances and transactions between
entities in the consolidated entity, including unrealised
profits or losses, have been eliminated on consolidation.
Accounting policies of subsidiaries have been changed
where necessary to ensure consistencies with those
policies applied by the parent entity.
Where controlled entities have entered or left the economic
entity during the year, their operating results have been
included/excluded from the date control was obtained or
until the date control ceased.
A list of controlled entities is contained in Note 9 to the
financial statements. All controlled entities have a June
financial year-end.
c)Property,plantandequipment
Property, plant and equipment are brought to account at
cost, less, where applicable, any accumulated depreciation,
impairment losses plus costs incidental to acquisition.
Property
Freehold land and buildings are shown at their original
costs plus costs incidental to acquisition less subsequent
depreciation for buildings.
50 I ACHS ANNUAL REPORT 2009 - 2010
Plant and equipment are measured on the cost basis.
The carrying amount of property, plant and equipment is
reviewed annually by the Board to ensure it is not in excess
of the recoverable amount of these assets.
The recoverable amount is assessed on the basis of the
expected net cash flows which will be received from the
assets employment and subsequent disposals.
The expected net cash flows have not been discounted
to present values in determining recoverable amount.
Depreciation
The depreciable amount of all fixed assets excluding
freehold property are depreciated on a straight line basis
over their estimated useful lives to the entity commencing
from the time the asset is held ready for use.
The useful lives used for each class of depreciable assets are:
ClassoffixedassetsDepreciablerate
Computer and IT Equipment 3 years
Office Equipment 5 years
Furniture and Fittings 10 years
Freehold Building 40 years
The assets’ residual values and useful lives are reviewed
and adjusted if appropriate at each balance date.
An asset’s carrying amount is written down immediately
to its recoverable amount if the asset’s carrying amount is
greater than its estimated recoverable amount.
d)Impairmentofassets
At each reporting date, the group reviews the carrying
values of its tangible and intangible assets to determine
whether there is any indication that those assets have
been impaired. If such an indication exists, the recoverable
amount of the asset, being the higher of the asset’s fair
values less costs to sell and value in use, is compared to
the asset’s carrying value. Any excess of the asset’s
carrying value over its recoverable amount is expensed
to the income statement.
e)FinancialInstrument
Financial instruments are initially measured at cost on trade
date, which includes transaction costs, when the related
contractual rights or obligations exist. Subsequent to initial
recognition these instruments are measured as set out below.
Financialassetsatfairvaluethroughprofitandloss
A financial asset is classified in this category if acquired
principally for the purpose of selling in the short term or if
designated by management and within the requirements
of AASB139: Recognition and Measurement of Financial
Instruments. Derivatives are also categorised as held for
trading unless they are designated as hedges.
 N O TES TO TH E FIN AN C IAL S TATEMEN TS
Realised and 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-maturityinvestments
These investments have fixed maturities; and it is the
group’s intention to hold these investments to maturity. Any
held-to-maturity investments held by the group are stated
at amortised cost using the effective interest rate method.
Fairvalue
Fair value is determined based on current bid prices for all
quoted investments. Valuation techniques are applied to
determine the fair value for all unlisted securities, including
recent arm’s length transactions, reference to similar
instruments and option pricing models.
f)Incometax
The Company has not adopted tax effect accounting.
The Parent Company has received confirmation from the
Australian Taxation Office that its income is exempt from
income tax pursuant to Section 50-5 of the Income Tax
Assessment Act 1997 and accordingly the Company does
not have any liability for income tax.
Where a controlled entity is a taxable entity the charge
for current tax expense is based on the profit for the year
adjusted for any non-assessable or disallowed items. It is
calculated using the tax rates that are applicable during
the financial year.
g)Employeebenefits
Liabilities for wages and salaries, annual leave and related
on-costs are recognised and measured as the amount
unpaid at the reporting date at current pay rates in respect
of employees’ services up to that date.
Long Service Leave provision is based on the remuneration
rates at year end for all employees with five or more years
of service. It is considered that this measurement technique
produces results not materially different from the estimate
determined by using the present value basis of
measurement.
The outstanding amounts of workers’ compensation
insurance premiums and fringe benefits tax, which are
consequential to employment, are recognised as liabilities
and expenses where the employee entitlements to which
they relate have been recognised.
Contributions are made by the Company to employee
superannuation funds and are charged as expenses when
incurred.
h)Provisions
Provisions are recognised when the group has a legal or
constructive obligation, as a result of past events, for which
it is possible that an outflow of economic benefits will result
and that outflow can be reliably measured.
i)Cashandcashequivalents
Cash and cash equivalents include cash on hand, deposits
held at call with banks, other short-term highly liquid
investments with original maturities of six months or less,
and bank overdrafts. Bank overdrafts are shown within short-
term borrowings in current liabilities on the balance sheet.
The Company has no short-term borrowings.
j)Leases
Lease expenditure relating to leases deemed to be
“operating leases” is expensed as incurred. Operating
lease commitments outstanding at balance date include
guaranteed residual values.
k)Unearnedrevenue
The income held in advance at Note 12 of the accounts will
be brought to account on a “time pro rated” basis over the
period of the contract concerned. Sales revenue is also
recognised on this basis.
l)Interestsinjointventure
The Company’s share of the assets, liabilities, revenue and
expenses of joint ventures are included in the appropriate
items of the balance sheet and income and expenditure
account. Details of the joint venture are shown at Note 9,
as shares in associated companies.
m)Goodsandservicestax(GST)
Revenues, expenses and assets are recognised net of the
amount of GST, except where:
the amount of GST incurred by The Australian Council
on Healthcare Standards Limited as a purchaser that is
not recoverable from the Australian Taxation Office is
recognised as part of the cost of acquisition of the
asset or as part of an item of expense;
receivables and payables are stated including the
amount of GST.
n)Comparativefigures
Comparative figures have been reclassified where
necessary for consistency with the current period’s financial
statements and other disclosures.
o)Revenueandincomerecognition
Sales revenue comprises revenue earned (net of returns,
discounts and allowances) from the business activities and
is recognised at point of sale or lodgement.
EQuIP membership fees are brought to account on a
“time pro rated” basis over the period of the contract
concerned.
Interest received is recognised as it accrues.
Revenue from the sale of goods is recognised upon the
delivery of goods to customers.
All revenue is stated net of the amount of goods and
services tax (GST).
ACHS ANNUAL REPORT 2009 - 2010 I 51
 N O TES TO TH E FIN AN C IAL S TATEMEN TS

p)Tradeandothercreditors Grants relating to assets are credited to deferred income at

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

Note2: Operatingrevenuecomprisesrevenue
fromthefollowingoperatingactivities
Consolidated Parent
2010 2009 2010 2009
Membership fees 9,849,398 8,215,367 8,463,506 8,111,003
Education and consultancy 470,485 414,825 236,110 414,825
Projects 11,618 776,798 11,618 776,798
Publications 52,841 38,707 52,841 38,707
Other 170,536 435,183 170,536 430,988
Revenue from ordinary activities 10,554,878 9,880,880 8,934,611 9,772,321
Grants received 151,700 209,220 86,700 84,700
Interest revenue:
Interest received from financial institutions 133,502 163,837 133,502 163,837
Other income 316,130 39,641 316,130 39,641
Totaloperatingrevenue 11,156,210 10,293,578 9,470,943 10,060,499

Note3: Profitfromordinaryactivities

Consolidated Parent
2010 2009 2010 2009
Profitfromordinaryactivitieshasbeendetermined
after:
Cost of sales 3,894,831 3,723,776 2,893,298 3,631,061
Depreciation - plant and equipment 265,992 205,573 265,992 205,573
- buildings 88,725 86,966 88,725 86,966
Remuneration of auditors 33,800 30,360 29,480 30,360
Total 4,283,348 4,046,675 3,277,495 3,953,960

52 I ACHS ANNUAL REPORT 2009 - 2010

 N O TES TO TH E FIN AN C IAL S TATEMEN TS

Note4:Cash

Consolidated Parent
2010 2009 2010 2009
Cash on hand 1,300 1,300 1,300 1,300
Cash at bank 5,142,942 3,614,023 4,818,256 3,442,443
Totalcash 5,144,242 3,615,323 4,819,556 3,443,743

Note5:Receivablesandotherassets

Consolidated Parent
2010 2009 2010 2009
Trade debtors 2,137,355 1,783,734 2,137,355 1,783,734
Less: Provision for doubtful debts (200,000) (130,000) (200,000) (130,000)
Other debtors and pre-payments 45,966 40,846 45,966 40,846
Totalreceivables 1,983,321 1,694,580 1,983,321 1,694,580

Note6:Plantandequipment

Consolidated Parent
2010 2009 2010 2009
Furniture and fittings - at cost 105,994 224,146 105,994 224,146
Less: Accumulated depreciation (55,600) (181,510) (55,600) (181,510)
Net book value 50,394 42,636 50,394 42,636

Office equipment - at cost 105,156 179,788 105,156 179,788

Less: Accumulated depreciation (23,883) (123,397) (23,883) (123,397)
Net book value 81,273 56,391 81,273 56,391

Information technology - at cost 640,630 1,201,418 640,630 1,201,418

Less: Accumulated depreciation (420,302) (888,834) (420,302) (888,834)
Net book value 220,328 312,584 220,328 312,584

Motor vehicle - at cost 74,851 74,851 74,851 74,851

Less: Accumulated depreciation (48,653) (33,683) (48,653) (33,683)
Net book value 26,198 41,168 26,198 41,168

Netbookvalue,plantandequipment 378,193 452,779 378,193 452,779

ACHS ANNUAL REPORT 2009 - 2010 I 53

 N O TES TO THE FIN AN C IAL S TATEMEN TS

Note7:Landandbuilding

Consolidated Parent
2010 2009 2010 2009
Land - at cost 380,000 380,000 380,000 380,000

Building - at cost 1,425,454 1,425,454 1,425,454 1,425,454

Less: Accumulated depreciation (409,818) (374,182) (409,818) (374,182)
Net book value 1,015,636 1,051,272 1,015,636 1,051,272

Building improvements - at cost 1,748,244 1,589,238 1,748,244 1,589,238

Less: Accumulated depreciation (531,386) (478,308) (531,386) (478,308)
Net book value 1,216,858 1,110,930 1,216,858 1,110,930

Netbookvalue,landandbuilding 2,612,494 2,542,202 2,612,494 2,542,202

MovementincarryingamountsforPlantandEquipment,LandandBuildings

Freehold Furniture Office Information Motor

Land Buildings &Fitings Equipment Technology Vehicle Total

Consolidated Group
Balance at 1 July 2008 380,000 2,249,168 52,736 29,223 339,327 56,139 3,106,593
Additions 1,560 2,069 120,490 124,119
Disposals 56,808 56,808
Additions through acquisitions
Revaluation increments/(decrements)
Depreciation expense (86,967) (11,660) (31,709) (147,233) (14,971) (292,540)
Capitalised borrowing cost and depreciation
Balance at 30 June, 2009 380,000 2,162,201 42,636 56,391 312,584 41,168 2,994,980
Additions 159,007 17,651 41,834 37,105 255,597
Disposals
Additions through acquisitions
Revaluation increments/(decrements)
Depreciation expense (88,714) (9,893) (16,952) (129,361) (14,970) (259,890)
Capitalised borrowing cost and depreciation
Disposal of assets on sale of subsidiary
Write-off of assets destroyed during flood
Balanceat30June,2010 380,000 2,232,494 50,394 81,273 220,328 26,198 2,990,687

54 I ACHS ANNUAL REPORT 2009 - 2010

 N O TES TO THE FIN AN C IAL S TATEMEN TS

Note8:Intangibleassets

Consolidated Parent
2010 2009 2010 2009
Formation costs 3,072 3,072
Less: Amortisation (3,072) (2,456)
Totalintangibleassets 616

Note9:Investmentincontrolledandnon-controlledentities

Consolidated Parent
2010 2009 2010 2009
Investment in non-controlled entities
Shares in listed companies
Shares in SAI Global Ltd 3,346 3,078 3,346 3,078
Totalinvestmentnon-current 3,346 3,078 3,346 3,078
Investment in controlled entities
*Shares in ACHS International Pty Ltd - At Cost 10,000 10,000
Totalinvestmentnon-current 10,000 10,000

* Refer to Note 1(B) Basis of Consolidation. All intercompany balances and transfers between entities in the consolidated entity, including
unrealised profits or losses, have been eliminated on consolidation.

Note10:Tradepayables

Consolidated Parent
2010 2009 2010 2009
Accounts payable 664,662 635,984 664,662 635,984
Accrued expenses 108,745 95,437 108,745 95,437
Work in progress 771,993 788,900 676,282 763,900
Totaltradepayables 1,545,400 1,520,321 1,449,689 1,495,321

ACHS ANNUAL REPORT 2009 - 2010 I 55

 N OTES TO TH E F IN AN C IAL STATEMEN TS

Note11:Provisions-current

Consolidated Parent
2010 2009 2010 2009
Employee entitlements 686,018 652,194 686,018 652,194
Provision, overseas market development (35,000) 30,000 30,000
Provision, future costs 63,267 65,000 63,267 65,000
Provision, research and development 200,000 120,000 200,000 120,000
Provision, standards development 8,084 8,731 8,084 8,731
Provision, EQuIP5 review, pilot and printing 317,830 251,000 317,830 251,000
Provision, external evaluation 9,623 24,523 9,623 24,523
Provision, salaries 142,000 78,978 142,000 78,978
Provision, strategic initiatives 11,478 31,478 11,478 31,478
Provision, board education and training 12,950 26,000 12,950 26,000
Provision, ISQua Accreditation and Survey 35,000 35,000
Provision, archive scan 17,150 53,000 17,150 53,000
Provision, eLearning and QI benchmarking 108,400 80,000 108,400 80,000
Provision, building works 136,000 136,000
Totalprovisions 1,677,800 1,455,904 1,712,800 1,455,904

Note12:Unearnedincome

Consolidated Parent
2010 2009 2010 2009
EQuIP membership fees and Education service fees 5,981,505 4,496,089 5,795,755 4,390,302
Totalunearnedincome 5,981,505 4,496,089 5,795,755 4,390,302

Note13: Retainedprofits

Consolidated Parent
2010 2009 2010 2009
Retained profits at the beginning of the year 836,264 808,566 794,855 770,143
Profit attributable to members for the year 80,627 27,698 43,811 24,712
Retainedprofitsattheendofthefinancialyear 916,891 836,264 838,666 794,855

56 I ACHS ANNUAL REPORT 2009 - 2010

 N OTES TO TH E F IN AN C IAL S TATEMEN TS

Note14:Reconciliationofcashflowfromoperations
withoperatingprofit/(loss)afterincometax
Consolidated Parent
2010 2009 2010 2009
Operating profit/(loss) after income tax 80,627 27,698 43,810 24,712
Non cash flows in operating profit
Depreciation and loss on disposal of asset 4,643 236,104 4,028 236,104
Charges to provision 291,896 452,522 291,896 452,522
Changes in assets and liabilities
Increase in trade and term debtors (353,620) (314,435) (353,620) (314,435)
Increase/(decrease) in trade creditors and accruals 41,986 (29,203) 41,986 (23,704)
Totalcashflowsfromoperatingactivities 65,532 372,686 28,100 375,199

Note15: Proceedsfromborrowings

2010 2009 Movement

Work in progress (16,908) 120,149 (137,057)
Future income 1,485,417 223,507 1,261,910
Netmovement 1,468,509 343,656 1,124,853

Note16:Reconciliationofcashflowfromoperations

Consolidated Parent
2010 2009 2010 2009
For the purposes of this statement of cash flows,
cash includes:
(i) Cash in hand and in deposits with banks or
financial institutions, net of bank overdrafts

(ii) Investments in money market instruments

with less that 14 days to maturity

Cash at the end of the year as shown in the balance

sheet is:
Cash on hand 1,300 1,300 1,300 1,300
Cash at bank 5,142,942 3,614,023 4,818,256 3,442,443
Totalcashflowsfromoperations 5,144,242 3,615,323 4,819,556 3,443,743

Note17:Members’guarantee
The Council is incorporated as a company limited by guarantee. limited to $50 per member in the event of the winding up of
In accordance with the Constitution of the Company, every the Company during the time that he/she is a member or
member of the Company undertakes to contribute an amount within one year thereafter.

ACHS ANNUAL REPORT 2009 - 2010 I 57

 N O TES TO TH E FI N ANC IAL S TATEM EN TS

Note18:RemunerationofBoardmembers Treasuryriskmanagement
andotherCouncillors
The Board of Directors and Councillors of The Australian
Council on Healthcare Standards Limited during the financial
year are listed in the Annual Report of the Board.
Apart from amounts received by way of reimbursement for
expenses incurred in the attendance at various Executive
and Committee Member’s meetings, and fees received (for
example, honoraria) by Councillors for services in connection
with Surveys and the Educational programs, no amounts were
received by a Committee Member or Councillor in connection
with the management of the affairs of the Company.
Note19:Relatedpartytransactions
Apart from the transactions referred to in the Annual Report
of the Board there have been no transactions between the
Company and related parties of the Company which require
separate disclosure.
Note20:Segmentreporting
Directors and the senior executive meet on a regular basis to
consider the extent of interest rate exposure and where necessary
evaluate treasury management strategies in the context of the
most recent economic conditions and forecasts.
Financialrisks
The main risks the Company are exposed to through its financial
instruments are interest rate risk, liquidity risk and credit risk.
Foreigncurrencyrisk
The Company’s foreign currency account and the carrying
amount at 30 June, 2010 has been translated using the closing
exchange rate.
Liquidityrisk
The Company manages liquidity risk by monitoring cash flows
and ensuring that adequate un-utilised borrowing facilities are
maintained.
Creditrisk
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 consolidated entity operates in one business segment
being the health care industry where it supports organisations
in their implementation of quality improvement through EQuIP
to develop and continually review quality standards and
guidelines in consultation with the industry.
Note21:Financialinstruments
Financialriskmanagement
The Company’s financial instruments consist mainly of
deposits with banks, accounts receivable and payable. The
main purpose of non-derivative financial instruments is to
raise finance for Company operations. The Company group
does not have any derivative or any financial instruments at
30 June, 2010.
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.
Pricerisk
The Company is not exposed to any material commodity price risk.
Interestraterisk
Interest rate risk is managed by minimising the extent of long-
term interest bearing debt. For further details on interest rate risk
refer to Treasury Risk Management above.
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:

Fixed interest maturing

Weighted average Floating On call More than 1 year Non-interest bearing
effective interest rate interest rate
Financialassets 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009
% % $ $ $ $ $ $ $ $

Cash at bank 5.5 4.0 1,288,559 314,106 3,854,383 3,299,917

Receivables 1,983,321 1,694,580
Totalfinancialassets 1,288,559314,106 3,854,383 3,299,917 1,983,321 1,694,580
Financial liabilities
Accounts payable 664,662 635,984
Provisions 1,677,800 1,455,904
Totalfinancialliabilities 2,342,462 2,091,888

Netfinancialassets 1,288,559 314,106 3,854,383 3,299,917 (359,141) (397,308)

Note22:Companydetails
The registered name of the company is The Australian Council on Healthcare Standards Limited located at
No. 5 Macarthur Street ULTIMO NSW 2007 AUSTRALIA

58 I ACHS ANNUAL REPORT 2009 - 2010

 d Ir EC TOr S ’ d ECL Ar ATIO N

The Directors of the Company declare that:

The financial statements and notes set out on pages 44 to 58 are in accordance with the Corporations Act 2001:
comply with Accounting Standards and the Corporation Regulations 2001; and
give a true and fair view of the financial position as at 30 June, 2010 and of the performance for the year
on that date of the company and economic entity;

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.

The Chief Executive and the Executive Director - Corporate Services have each declared that:

the financial records of the company for the financial year have been properly maintained in accordance
with section 286 of the Corporations Act 2001;
the financial statements and notes for the financial year comply with the Accounting Standards; and
the financial statements and notes for the financial year give a true and fair view.

Signed in accordance with a resolution of the Directors, made pursuant to Section 295(5) of the Corporations Act 2001.

On behalf of the Directors

AssociateProfessorPeterWoodruff JohnSmithPSM
President Treasurer

Sydney - 28th day of October 2010

ACHS ANNUAL REPORT 2009 - 2010 I 59

LISTINGS
OUr MEMBErS
ACHS accredits the majority of
healthcare organisations in Australia.
The organisations participating in
ACHS quality improvement and
accreditation programs range from
hospitals, corporate offices of private
health companies, day surgeries,
nursing agencies, community health
centres, mental health services to
divisions of general practice.
Below is a list of organisations that are
members of ACHS quality improvement
and accreditation programs.
For a more current list of ACHS
member organisations as well as
their accreditation status, excluding
Healthscope organisations, please visit
the ACHS website: www.achs.org.au
and select the ‘Member organisation
list’ option (under the ACHS MEMBERS
tab on the homepage).
ACTPrivate
w Absolute Home Care Pty Ltd
w Calvary John James Hospital
w Health Futures Pty Ltd
w National Capital Private Hospital, The
w Salvation Army, The - Recovery
Services - Canberra
• Salvation Army, The - Recovery
Services - Shoalhaven
ACTPublic
w ACT Health
• ACT Health - Community Health
• Canberra Hospital, The
• Mental Health ACT
w Calvary Health Care ACT
w Department of Defence, ACT/NSW
Area Health Service, Defence Health
Services
NSWPrivate
w ADF - Kathleen York House
(Alcohol/Drug Foundation NSW)
w ahm Dental & Eyecare Practice
w Allowah Presbyterian Children's
Hospital
w Armidale Private Hospital
60 I ACHS ANNUAL REPORT 2009 - 2010
w Ashbrooke Cosmetic Surgery
w Berkeley Vale Private Hospital
w Bondi Junction Private Hospital
w Byrne Surgery
w Calvary Health Care Riverina Ltd
• Calvary Alcohol and Other Drugs
Services
• Calvary Day Procedure Centre
• Calvary Health Care Riverina Ltd
• Calvary Health Care Riverina Ltd -
O'Connor House
• Calvary Health Care Riverina Ltd -
The Peppers
w Castlecrag Private Hospital
w Corporate Bodies International
w Diaverum Pty Ltd
• Diaverum - Diamond Valley
Dialysis Unit
• Diaverum - Lindfield Dialysis Unit
• Diaverum - St Andrew's
Toowoomba Renal Dialysis Unit
w Dubbo Private Hospital
w Dutiful Daughters
w Eastern Heart Clinic
• Sutherland Heart Clinic
w Foundation House
w Garden Court Clinic
w Gosford Private Hospital
w Griffith Nursing Service
w GROW Community
w Hawkesbury District Health Service Ltd
w Haymarket Foundation Limited, The
w HCF Dental Centres
• HCF Dental - Blacktown Dental Centre
• HCF Dental - Bondi Junction
Dental Centre
• HCF Dental - Brookvale Dental Centre
• HCF Dental - Chatswood Dental Service
• HCF Dental - Hurstville Dental Centre
• HCF Dental - Parramatta Dental Centre
w Hirondelle Private Hospital
w Hunter Valley Private Hospital
w Hurstville Private
w Hyperbaric Health Sydney
w Insight Clinic Private Hospital
w Junee Correctional Centre -
Health Centre
w Kamira Farm Inc
w Kareena Private Hospital
w Kedesh Rehabilitation Services
w Kinder Caring Home Nursing Services
w Lady Davidson Hospital
w Lawrence Hargrave Hospital
w Lingard Private Hospital
w Lismore Private Day Surgery
w Lithgow Community Private Hospital
w Lyndon Community, The
w Maitland Private Hospital
w Manly Drug Education &
Counselling Centre (MDECC)
w Marie Stopes International, NSW
• Marie Stopes International, Fairfield
• Marie Stopes International, Homebush
• Marie Stopes International,
Kingswood Centre
• WestMed Day Surgery Centre
w Mater Hospital, North Sydney, The
w Mayo Healthcare Group
w Mercy Community Services
w Mosman Private Hospital
w Nepean Private Hospital
w Newcastle Eye Hospital
w Newcastle Private Hospital
w North Shore Private Hospital
w Norwest Private Hospital
w Nowra Private Hospital
w Odyssey House McGrath Foundation
w ONE80TC
w Oolong Aboriginal Corporation, The
w Prince of Wales Private Hospital
w Quality Health Care
w Regal Health Services
w Regional Imaging Cardiovascular
Centre
w Salvation Army, The - Recovery
Services - Blue Mountains
w Salvation Army, The - Recovery
Services - Alf Dawkins Detox Unit
w Salvation Army, The - Recovery
Services - Central Coast
w Salvation Army, The - Hunter Region
w Salvation Army, The - Recovery
Services - William Booth House
w South Coast Home Health Care Pty Ltd
w South Pacific Private Hospital
w Southern Suburbs Day Procedure
Centre Pty Ltd
w Springboard Health & Performance
Pty Ltd
w St George Private Hospital
w St John of God Health Care
• St John of God Hospital - Burwood
• St John of God Hospital - Richmond
w St Luke's Care
w St Vincent's Hospital - Lismore
w St Vincent's Private Hospital - Sydney
w Sydney Adventist Hospital
w Sydney Clinic, The
w Sydney Southwest Private Hospital
w Tamara Private Hospital
w The Buttery
w Toronto Private Hospital

w Triple Care Farm
w United Gardens Clinic
w Warners Bay Private Hospital
w Watershed Drug & Alcohol Recovery
& Education Centre Inc.
w Waverley Drug and Alcohol Centre
w Wayback Ltd
w Wayside Chapel, The
w We Help Ourselves (WHOS)
w Women's Alcohol and Drug Advisory
Centre (Jarrah House)
w Youth off the Streets Ltd/Dunlea
NSWPublic
w Balmain Hospital
w Bankstown Hospital
w Bowral and District Hospital
w Bulli District Hospital
w Calvary Health Care Sydney
w Calvary Mater Newcastle
w Campbelltown and Camden Hospitals
• Camden Hospital
• Campbelltown Hospital
w Canterbury Hospital
w Central Coast Health
• Gosford Hospital
• Long Jetty Healthcare Centre
• Woy Woy Hospital
• Wyong Hospital
w Children's Hospital at Westmead, The
w Concord Repatriation General Hospital
w Fairfield Hospital
w Family Drug Support
w Greater Western Area Health
Services, Mental Health Services
(Eastern and Southern Clusters)
• Bloomfield Hospital
w GSAHS - Central Sector
• Albury Community Mental Health
Service
• Batlow District Hospital, The
• Boorowa Hospital
• Coolamon - Ganmain Hospital
• Cootamundra Hospital, The
• Culcairn District Hospital
• Gundagai District Hospital
• Henty District Hospital
• Holbrook Hospital & Community
Health Service
• Junee District Hospital & CHS
• Lockhart & District Hospital
• Murrumburrah - Harden District Hospital
• Temora and District Hospital
• Tumbarumba District Hospital
• Tumut District Hospital
• Wagga Wagga Base Hospital & AHS
Gissing House
• Wagga Wagga Community
Mental Health
• Wyalong & District Hospital
• Young District Hospital
w GSAHS - Eastern Sector
• Batemans Bay District Hospital
• Bega & Pambula Hospitals & CHS
• Bombala Health Service
• Bourke Street Health Service
• Braidwood Multi Purpose Services
• Chisholm Ross Centre
• Cooma Hospital
• Crookwell District Hospital
• Crossroads Methadone Clinic
• Delegate District Hospital
• Goulburn Base Hospital
• Kenmore Hospital Psychogeriatric
& Extended Care Rehabilitation
• Moruya District Hospital
• Queanbeyan District Hospital
& Health Service
• Yass District Hospital
w GSAHS - Western Sector
• Barham Koondrook Soldiers
Memorial Hospital
• Berrigan War Memorial Hospital
• Corowa Hospital
• Deniliquin Hospital
• Finley Hospital
• Griffith Base Hospital
• Hay Hospital, The
• Hillston District Hospital
• Jerilderie District Hospital
• Leeton District Hospital
• Narrandera District Hospital
• Tocumwal Hospital
• Urana and District Health Services
w GWAHS Bathurst Health Service
w GWAHS Broken Hill Health Service
w GWAHS Cowra and Grenfell Health
Service
• Cowra District Hospital & CHS
• Grenfell Multipurpose Service
• Quandialla CHC
• Woodstock CHC
w GWAHS Dubbo Base Hospital
w GWAHS Mental Health, Drug and
Alcohol Services - Central and
Castlereagh Clusters
w GWAHS Mudgee Health Service
w GWAHS Orange Health Services
w Hammond Care Health & Hospital Ltd
• Braeside Hospital
• Greenwich Hospital
OUr MEMBErS
• Neringah Hospital
• Northern Beaches Palliative
w Hornsby Ku-ring-gai Hospital & CHS
w Hunter New England Health -
Mehi Cluster
• Boggabri John Prior Multi-purpose
Service
• Moree District Hospital
• Narrabri District Health Service
• Wee Waa Community Hospital
w Hunter New England Health -
Upper Hunter Cluster
• Denman Hospital
• Merriwa District Hospital
• Muswellbrook District Hospital
• Quirindi Community Hospital
• Scone District Health Service
• Werris Creek Community Hospital
• Wilson Memorial Hospital
w Hunter New England Health - Greater
Newcastle Acute Hospital Network
• Belmont District Hospital
• John Hunter Children's Hospital
Kaleidoscope
• John Hunter Hospital
• Royal Newcastle Hospital
w Hunter New England Health - Greater
Newcastle Cluster
• Eastlakes Community Health Centre
• Hunter Brain Injury Service
• Nelson Bay Community Health Centre
• Newcastle Community Health Centre
• Raymond Terrace Community Health
Centre
• Spinal Cord Injury Service
• Westlakes Community Health Centre
w Hunter New England Health -
Lower Hunter Cluster
• Cessnock District Hospital
• Dungog and District Hospital
• East Maitland Community Health
• Kurri Kurri District Hospital
• Singleton Health Services
w Hunter New England Health -
Lower Mid North Coast Cluster
• Aged Care Services
• Bulahdelah Community Hospital &
Community Health Centre
• Forster/Tuncurry Community Health
Centre
• Gloucester Soldiers Memorial Hospital
& Community Health Services
• Hawks Nest Community Health Centre
• Taree Community Health Centre
• Wingham Community Hospital
ACHS ANNUAL REPORT 2009 - 2010 I 61
 OUr MEMBErS
w Hunter New England Health -
Maitland Hospital
w Hunter New England Health -
Manning Rural Referral Hospital
w Hunter New England Health -
McIntyre Cluster
• Ashford Community Health Centre
• Bingara Community Hospital
• Bundarra Community Health Centre
• Inverell District Health Service
• Tingha District Hospital
• Warialda District Hospital
w Hunter New England Health -
Peel Cluster
• Barraba Community Health Centre
• Gunnedah District Health Service
• Manilla District Health Service
• Nundle Community Health Centre
• Walcha Community Health Centre
w Hunter New England Health -
Tablelands Cluster
• Armidale Community Health Centre
• Emmaville Multi Purpose Centre
• Glen Innes District Health Service
• Guyra Multipurpose Service
• Tenterfield Community Hospital
w Hunter New England Health -
Tamworth and Armidale Hospital Group
• Armidale Health Service
• Tamworth Hospital
w Hunter New England Mental Health
Service
• Armidale Hospital Clark Centre
• Hunter Mental Health
• James Fletcher Hospital Campus
• John Hunter Hospital Nexus Unit
• Maitland Hospital Mental Health Unit
• Manning Mental Health Unit and
Community Mental Health
• Morrisset Hospital
• Tamworth base Hospital - Banksia
Mental Health Unit and Dean House
w Justice Health
w Karitane
w Liverpool Hospital
w Lourdes Hospital, Health & Aged
Care Service
w Mercy Care Centre, Young
w Mercy Health Service Albury Limited
w Navy Ward (St Vincent's Hospital)
w NCAHS Coffs Clarence Network
• Bellinger River District Hospital
• Coffs Harbour Health Campus
• Dorrigo Multipurpose Service
• Grafton Base Hospital & Community
Health Southern
62 I ACHS ANNUAL REPORT 2009 - 2010
• Macksville District Hospital, the
• Maclean Hospital & Community Health
Services
w NCAHS Hastings Macleay Network
• Camden Haven Community Health
Centre
• Kempsey District Hospital & Kempsey
Community Health Centre
• Port Macquarie Base Hospital
• Port Macquarie Health Campus
• South West Rocks Community Health
Centre
• Wauchope District Memorial Hospital
& Wauchope Community Health Centre
w NCAHS Richmond Network
• Ballina District Hospital
• Ballina Community Health Service
• Bonalbo Health Service
• Casino Hospital
• Coraki Hospital
• Kyogle Health Service
• Lismore Base Hospital
• Nimbin Health Service
• Urbenville Health Service
w NCAHS Tweed Byron Network
• Byron Shire Hospitals & Community
Health Service
• Mullumbimby & District War Memorial
Hospital
• Muwillumbah Hospital & Muwillumbah
Community Health Northern
• Tweed Hospital & Community Health
w North Coast Area Health Service,
Mental Health Services
w North Shore Ryde Health Service
• Royal North Shore Hospital &
Community Health Service
• Ryde Hospital & Community Health
Services
w Northern Beaches Health Service
• Dalwood Children's Services
• Manly Hospital & Community Health
Service
• Mona Vale Hospital & Community
Health Service
• Queenscliff Community Health Centre
w Northern Sydney Central Coast Area
Health Service Mental Health Drug
& Alcohol Service
w Prince of Wales Hospital and
Community Health Services
w Royal Hospital for Women
w Royal Prince Alfred Hospital
w Royal Rehabilitation Centre Sydney
w Rural Health Directorate Southern
Hospital Network
• David Berry Hospital
• Milton Ulladulla Hospital
• Shoalhaven Memorial District Hospital
w SESIH Central Hospitals Network
• St George Hospital & Community
Health Service
• Sutherland Hospital & Community
Health Service, The
w Shellharbour & Kiama Hospitals
• Kiama Hospital & Community Health
Service
• Shellharbour Hospital
w South Eastern Sydney & Illawarra
Area Mental Health Drug and Alcohol
• Euroa Centre
• Illawarra Area Mental Health Service
• Prince of Wales Hospital Emergency
Department
• Shellharbour Mental Health Services
• South East Health Mental Health
Service
• St George Hospital and Community
Health Drug and Alcohol Services
• St George Hospital Emergency
Department
• St George Mental Health Centre
• Sutherland Hospital and Community
Health Drug and Alcohol Services
• Sutherland Mental Health Centre
• Sydney Children's Hospital - Child
& Adolescent Inpatient Service
• The Kiloh Centre
• The Langton Centre
• Wollongong Mental Health Inpatient
Services
w St Joseph's Hospital - Auburn
w St Vincent's Hospital - Sydney (Public)
w SWAHS - Central Cluster
• Blacktown - Mt Druitt Health
w SWAHS - Eastern Cluster
• Auburn Hospital & Community
Health Services
• Westmead Health
w SWAHS - Mental Health & Drug
& Alcohol Program
• Cumberland Hospital
w SWAHS - Western Cluster
• Blue Mountains District ANZAC
Memorial Hospital
• Lithgow Integrated Health Service
• Nepean Hospital
• Springwood Hospital
w Sydney Children's Hospital
w Sydney Hospital & Sydney Eye Hospital
w Sydney South West Area Health
Service - Community Health

w Sydney South West Area Mental
Health Service
• Central Sydney Area Mental Health
Services
w Sydney South West Oral Health
Services and Sydney Dental Hospital
w Tresillian Family Care Centres
w War Memorial Hospital, Waverley
w Wollongong Hospitals and Community
Health Services
• Coledale District Hospital
• Community Health Service
• Diabetes Service
• Port Kembla Hospital - Rehabilitation,
Aged & Extended Care Services
• Wollongong Hospital
NTPrivate
w Darwin Private Hospital
NTPublic
w Alice Springs Hospital
w Clinic 34 Darwin
w Gove District Hospital
w Katherine Hospital
w Northern Territory Mental Health
Services
• Central Australian Mental Health
Service
• Top End Mental Health Service
w Oral Health Services
w Royal Darwin Hospital
w Tennant Creek Hospital
QLDPrivate
w Allamanda Private Hospital
• Allamanda Surgicentre
• Pacific Private Hospital
w Belmont Private Hospital
w Blue Care - Logan/Ipswich & South
Coast Clusters
• Beaudesert Community Care Service
• Beenleigh Community Care Services
• Burremah Place Respite Services
• Commonwealth Carelink & Carer
Respite Centre - Ipswich (West Moreton)
• Commonwealth Carelink & Carer
Respite Centre - Logan Outpost
• Commonwealth Carelink & Carer
Respite Centre - Varsity Lakes
(South Coast)
• Coomera Community Care Services
• Fassifern Community Care Services
• Gold Coast Allied Health Service
• Ipswich Allied Health
• Ipswich Community Care Services
• Ipswich Multicultural Liaison Service
• Ipswich Respite Services
• Lower South Coast/Tweed
Community Care
• Lower South Coast Community
Nursing & Care
• Milpera Cottage
• Redbank Respite Services
• Southport/Surfers Paradise Blue Nurses
• Southport/Surfers Paradise
Community Care Services
• Springwood Community Care
• Tweed Coast Community Care Services
w Blue Care Brisbane
• Acacia Ridge Day Respite Centre
• Allied Health Services - Carina Heights
and Wynnum
• Ashgrove Day Respite Centre
• Carramar Cottages
• Continence Advisory Service
• Coopers Plains Day Respite Centre
• Eastside Community Care Services
• Henderson Day Respite Centre
• Mt Gravatt Day Respite Centre
• Northside Community Service Centre
• Southside Community Service Centre
• Unicare "Fulcher House"
• Volunteers Metropolitan
• West End Day Respite Centre
• Wynnum Lifestyle Services
w Blue Care Central Queensland/Wide
Bay Region
• Biggenden Respite Services
• Bundaberg Blue Nursing
• Bundaberg Respite Services
• Bundaberg Therapy Centre
• Callide Valley/Biloela Blue Nursing
& Respite Services
• Capricorn Coast Community Services
• Capricorn Coast Day Respite Services
• Central Queensland Allied Health
• Eidsvold Respite Services
• Emerald Community Care
• Fraser Coast Allied Health
• Gayndah Blue Nursing and Respite
Services
• Gladstone Blue Nursing and Respite
Services
• Hervey Bay Blue Nursing
• Hervey Bay Respite Services
• Longreach Respite Services
• Maryborough Blue Nursing
• Maryborough Respite Services
• Monto Blue Nursing & Respite Services
• Moura Blue Nursing & Respite Services
OUr MEMBErS
• Munduberra Blue Nursing
• Rockhampton Blue Nursing
• Rockhampton Respite
• Wide Bay Continence Advisory Centre
w Blue Care North Queensland Region
• Bowen Blue Nursing
• Bowen Respite Centre
• Burdekin Blue Nursing Centre
• Burdekin Respite Centre
• Cairns Respite Centre
• Carins Blue Nursing
• Charters Towers Dom
• Charters Towers Respite
• Cloncurry Blue Nurses
• Collinsville Blue Nurses
• Commonwealth Carer Respite
& Carelink
• Commonwealth Carer Respite
& Carelink
• Ingham Blue Nurses
• Ingham Respite Centres
• Innisfail Blue Nurses
• Mackay Blue Nurses
• Mackay Carer Respite
• Mackay Galaxy Program
• Mackay Homecare Dementia
• Mackay Respite
• Mareeba Blue Nurses
• Mareeba Respite Centre
• Mossman Blue Nurses
• Mount Isa Blue Nurses
• Mount Isa Respite Centre
• Prosperine Blue Nurses
• Sarina Blue Nurses
• Sarina Respite Centre
• Tablelands Blue Nurses
• Tablelands Respite Centre
• Townsville Blue Nurses
• Townsville Homecare Dementia
• Townsville Respite Centre
• Tully Blue Nurses
• Tully Respite Centre
w Blue Care South West Queensland
Region
• Blue Care Allied Health
• Blue Care Allora/Clifton
• Blue Care Charleville
• Blue Care Chinchilla/Miles
• Blue Care Crows Nest
• Blue Care Cunnamulla
• Blue Care Dalby
• Blue Care Goondiwindi
• Blue Care Injune
• Blue Care Lockyer
• Blue Care Millmerran
• Blue Care Mitchell
ACHS ANNUAL REPORT 2009 - 2010 I 63
 OUr MEMBErS
• Blue Care Pittsworth
• Blue Care Regional Office
• Blue Care Roma
• Blue Care Stanthorpe
• Blue Care Toowoomba Centre
Based Day Care
• Blue Care Toowoomba Community
• Blue Care Warwick
• Commonwealth Respite & Carelink
Centre - Toowoomba
• Maranoa Health Enhancement Program
w Blue Care Sunshine Coast Cluster
• Blue Care Brisbane Valley
• Blue Care Caboolture
• Blue Care Caloundra
• Blue Care Caloundra Respite
• Blue Care Cooloola District
• Blue Care Cooloola District
Respite Services
• Blue Care Coolum Respite
• Blue Care Maroochy
• Blue Care Murgon
• Blue Care Noosa
• Blue Care Redcliffe
• Blue Care Sandgate
• Blue Care South Burnett
• Caloundra Respite
• Coolum Respite
w Brisbane Endoscopy Services
w Brisbane Private Hospital
w Caboolture Private Hospital
w Cairns Private Hospital
w Caloundra Private Hospital
w Clifton Co-op Hospital Ltd
w Currumbin Clinic
w Eden Rehabilitation Centre Inc.
w Greenslopes Private Hospital
w QLD Healthvax
w Henry Dalziel VC Dialysis Centre
w Hillcrest Rockhampton Private Hospital
w Holy Spirit Northside Private Hospital
w Hopewell Hospice Services Inc.
w Ipswich Hospice Care Incorporated
w Karuna Hospice Service
w Mater Health Services North
Queensland Ltd
• Women's & Children's Hospital,
Mater Hyde Park
w Mater Hospitals - Rockhampton,
Yeppoon & Gladstone
• Mater Hospital Gladstone
• Mater Hospital Rockhampton
• Mater Hospital Yeppoon
w Mater Misericordiae Health Services
Brisbane Limited
64 I ACHS ANNUAL REPORT 2009 - 2010
• Child Youth Mental Health Service
(CYMHS) - Dutton Park Clinic
• Child Youth Mental Health Service
(CYMHS) - Greenslopes Clinic
• Child Youth Mental Health Service
(CYMHS) - Inala Clinic
• Mater Adult's Public Hospital - Brisbane
• Mater Children's Private Hospital
• Mater Misericordiae Private Hospital -
Redland
• Mater Mother's Private Hospital
• Mater Mother's Public Hospital -
Brisbane
• Mater Private Hospital Brisbane
• Mater Public Children's Hospital -
Brisbane
w Mater Misericordiae Hospital -
Bundaberg
w Mater Misericordiae Hospital - Mackay
w New Farm Clinic
w Noosa Hospital, The
w Peninsula Private Hospital
w Pine Rivers Private Hospital
w Pittsworth & District Hospital Friendly
Society Ltd
w Premion
w Salvation Army, The - Recovery
Services - Brisbane
w Salvation Army, The - Recovery
Services - Gold Coast
w Salvation Army, The - Recovery
Services - Townsville
w Spendelove Private Hospital
w St Andrew's Ipswich Private Hospital
w St Andrew's Toowoomba Hospital
w St Andrew's War Memorial Hospital -
Brisbane
w St Stephen’s Hospitals Maryborough
and Hervey Bay
w St Vincent's Hospital Brisbane
w St Vincent's Hospital - Toowoomba
w Sunnybank Private Hospital
w Sunshine Coast Private Hospital, The
w Toowong Private Hospital
w Toowoomba Hospice Association Inc.
w Wesley Centre for Hyperbaric
Medicine, The
w Wesley Hospital, The
QLDPublic
w Banana Health Service District
• Baralaba Hospital
• Biloela Hospital
• Moura Health Service
• Taroom Hospital
• Theodore Council on the Ageing
• Theodore Hospital
w Cairns Community and Primary
Prevention Services
• Cooktown District Hospital
• Douglas Shire Multi Purpose
Health Service
• Gordonvale Hospital
• Yarrabah Health Service
w Cairns Base Hospital and Mental
Health & ATOD Services
• Atherton & Mareeba Hospitals
• ATODS Community Centre
• ATODS, Qld Alcohol Diversion program
& Day detox program
• Community Mental Health Centre
• Edmonton Community Health
• Forensic Mental Health & Evolve Team
• Homeless Health Outreach Team
• Innisfail Hospital
• Mental Health Child & Youth Team
• Mental Health Executive Team
• Mental Health Unit; Consultation
Liaison team; Older Persons MH team;
Lakeside Clinic – Cairns Base Hospital
• Mossman Hospital
• Remote Area MH Team
• Smithfield Community Health
w Central Highlands Hub - Central
Queensland Health Services District
• Blackwater Hospital
• Capella Clinic
• Emerald Hospital
• Gemfields Multi Purpose Clinic
• Springsure (MPHS)
• Tieri Outpatients Clinic
w Central West Health Service District
• Alpha Hospital and Jerico Shire
Multi-Purpose Health Service
• Aramac Hospital
• Barcaldine Hospital and Multi-Purpose
Health Service
• Blackall Hospital
• Boulia Primary Health Centre
• Isisford Primary Health Centre
• Jundah Primary Health Centre
• Longreach Hospital
• Muttaburra Primary Health Centre
• Tambo Primary Health Centre
• Windora Primary Health Centre
• Winton Hospital and Multi-Purpse
Health Service
• Yakara Clinic
• Children's Health Services

w Darling Downs - West Moreton Health
Service District - Division of Mental
Health
• Acute and Community Mental Health
Service
• Extended Inpatient Services
• Integrated Mental Health Service -
Ipswich
• Northern Downs MHS
• Southern Downs MHS
• The Park
w Darling Downs - West Moreton Health
Service District Toowoomba Sector
• Gatton Health Services
• Oakey Health Service
• Toowoomba Health Service District
w Darling Downs - West Moreton Health
Service District (Darling Downs Rural
Division)
• Chinchilla Health Service
• Dalby Health Service
• Goondiwindi Health Service
• Ingleweood Health Service
• Jandowae Health Service
• Miles Health Service
• Millmerran Health Service
• Stanthorpe Health Service
• Tara Health Service
• Texas Health Service
• Wandoan Primary Health Care Centre
• Warwick Health Service
w Fraser Coast Health Service District
• Hervey Bay Hospital
• Maryborough Hospital
w Gallipoli Barracks Health Centre
(Department of Defence - SQ)
w Gladstone Health Service - Central
Queensland Health Service District
w Gold Coast Health Service District
• Gold Coast Hospital - Robina Campus
• Gold Coast Hospital - Southport
Campus
w Mackay Health Service District
• Bowen Hospital
• Clermont Multipurpose Service
• Collinsville Hospital
• Dysart Hospital
• Glenden Community Health Centre
• Mackay Base Hospital
• Middlemount Community Health Centre
• Moranbah Health Campus
• Proserpine Hospital and Whitsunday
Community Health Centre
• Sarina Hospital & Primary Health
Care Centre
w Metro North Health Service District
Redcliffe, Caboolture & Kilcoy
Hospitals and MNHSD Sub-Acute
& Residential Care Service
• Caboolture Hospital
• Kilcoy Hospital
• Redcliffe Caboolture Health Service
District
• Redcliffe Hospital
• Redcliffe - Caboolture Mental Health
& Disability Services
• Redcliffe-Caboolture Oral Health
Service
w Metro North Service District - Royal
Brisbane and Women's Hospitals and
MNHSD Oral Health Services
• Community Forensic Mental Health
Service
w Metro North Health Service District The
Prince Charles Hospital and MNHSD
Primary and Community Health Services
• Jacana Centre, The
• Prince Charles Hospital Health Service
District, The
w Metro South Health Service District -
Logan/Beaudesert Hospitals
• Beaudesert Hospital
• Logan Hospital
w Metro South Health Service District -
QEll Jubilee Hospital
w Metro South Health Service District -
Redland & Wynnum Hospitals
• Dunwich Health Service Centre Marie
Rose Centre
• Redland Hospital
• Wynnum Hospital
w Metro South Health Service District
(Southside Community & Primary
Services)
• Moreton Bay Nursing Care
w Metro South Mental Health
• Logan Hospital Mental Health
• Princess Alexandra Hospital Mental
Health
• Redland Hospital Mental Health
w Mount Isa Health Service District
• Burketown Primary Health Care Centre
• Camooweal Primary Health Care Centre
• Cloncurry Hospital
• Djarra Health Centre
• Doomadgee Hospital
• Julia Creek Hospital
• Karumba Health Centre
• Mornington Island Primary Health
Care Centre
• Normanton Health Services
w Princess Alexandra Hospital
OUr MEMBErS
w Queensland Tuberculosis Control Centre
w Rockhampton & Yeppoon Hospitals
& Integrated Mental H/S
• Rockhampton Hospital
• Yeppoon Hospital
w Sunshine Coast Wide Bay Health
Service District
• Caloundra Hospital
• Gympie Health Service District
• Maleny Soldiers Memorial Hospital
• Nambour General Hospital
w Torres Strait & Northern Peninsula
Area Health Service Dist.
• Central Islands - Poruma Primary
Health Care Centre
• Eastern Islands - Murray -
Primary Health Care Centre
• Northern Peninsula Area - Cape York
and Bamaga - Primary Health Care
Centres
• Thursday Island Hospital
• Thursday Island Primary Health
Care Centre
• Top Western Islands - Boigu - Primary
Health Care Centre
• Western Islands - Mabuiag - Primary
Health Care Centre
w Townsville Health Service District
• Ayr District Hospital & CHS
• Charters Towers Rehabilitation Unit
• Cleveland Youth Detention Health
Centre
• Eventide Aged Care Complex
• Home Hill Hospital
• Hughenden Health Centre
• Ingham Health Service
• Institute of Rural Health - Charters
Towers Health Centre
• Joyce Palmer Health Service
• Kirwan Health Service
• Kirwan Rehabilitation Unit
• Magnetic Island Health
• North Ward Health Campus
• Parklands Residential Aged Care Facility
• Richmond Health Centre
• Townsville General Hospital
w Darling Downs West Moreton Health
Service (West Moreton South Burnett
Sector)
• Boonah Health Service
• Cherbourg Community Health Centre
• Cherbourg Hospital
• Downtown Community Health
• Esk Hospital
• Goomeri Primary Care Clinic
• Ipswich Hospital
ACHS ANNUAL REPORT 2009 - 2010 I 65
 OUr MEMBErS
• Kilkivan Primary Care Clinic
• Kingaroy Hospital & Kingaroy
Community Health Centre
• Laidley Health Service
• Murgon Community Health Centre
• Murgon Hospital
• Nanango Hospital & Nanango
Community Health Centre
• Park - Centre for Mental Health, The
• Proston Primary Care Centre
• West Moreton Health Service District
• Wondai Hospital & Wondai Primary
Health Centre
w Wide Bay Health Service
• Biggenden Hospital
• Bundaberg Hospital
• Childers Hospital
• Eidsvold Hospital
• Gayndah Hospital
• Gin Gin Hospital
• Monto Hospital
• Mt Perry Health Centre
• Mundubbera Hospital
w Woorabinda Multi-purpose
Health Service
SAPrivate
w ACHA Health
• Ashford Community Hospital Inc.
• Flinders Private Hospital
• Memorial Hospital, The
w Adelaide Surgicentre Pty Ltd
• Wakefield Surgicentre
w Burnside War Memorial Hospital Inc.
w Calvary Central Districts Hospital
w Calvary Rehabilitation Hospital
w Calvary North Adelaide Hospital
w Calvary Wakefield Hospital
w Clinical Care Professionals
w Epiclinic Pty Ltd
w Glenelg Community Hospital Inc.
w Griffith Rehabilitation Hospital
w Home Support Services
w Keith & District Hospital Inc.
w Kerry Day Surgery
w Moonta Health & Aged Care
Service Inc.
w Parkwynd Private Hospital
w Ramsay Health Care (SA),
Mental Health Services
• Adelaide Clinic, The
• Fullarton Private Hospital
• Kahlyn Private Hospital
w St Andrew's Hospital Inc.
w Western Hospital
66 I ACHS ANNUAL REPORT 2009 - 2010
SAPublic
w Central Northern Adelaide Health
Service, Mental Health Directorate
• Glenside Campus Mental Health
Service
w Children, Youth and Women's Health
Service
• Child and Adolescent Mental Health
Services
• Child and Family Health
• Women's and Children's Hospital
• Women's Health Statewide
• Yarrow Place
w CHSA - Adelaide Hills, Southern
Fleurieu and Kangaroo Island Cluster
• Kangaroo Island Health Service
• Mount Barker District Soldiers Memorial
Hospital
• Northern Adelaide Hills Health Service
• South Coast District Hospital
• Strathalbyn & District Health Service
w CHSA - Eyre & Western Cluster
• Ceduna District Health Service
• Lower Eyre Health Services
• Mid-West Health
• Port Lincoln Health Services
w CHSA - Inner North Country Health
Services
• Barossa Health
• Eudunda Hospital
• Gawler Health Service
• Kapunda Hospital
w CHSA - Lower South East Cluster
• Millicent District Hospital & Health
Service
• Mount Gambier & Districts Health
Service
• Penola War Memorial Hospital
• South East Regional Community
Health Service
w CHSA - Mallee Coorong Health
• Coorong Health Service - Meningie &
Districts Soldiers Memorial Hospital &
Health Service
• Coorong Health Service - Tailem Bend
District Hospital
• Mallee Health Service - Karoonda &
Districts Soldiers Memorial Hospital
• Mallee Health Service - Lameroo
District Health Service
• Mallee Health Service-Pinnaroo Soldiers
Memorial Hospital
• Mannum District Hospital
• Murray Bridge Soldiers' Memorial
Hospital
• Murrray Mallee Community Health
Service
w CHSA - Port Augusta Hospital, Hawker,
Roxby Downs, Woomera, Leigh Creek
& Quorn Health Services
• Flinders Terrace Community Health
Centre
• Hawker Memorial Hospital
• Leigh Creek Health Services
• Port Augusta Hospital and Regional
Health Services
• Quorn Health Services
• Roxby Downs Health Services &
Woomera Community Hospital
• Woomera Community Hospital
w CHSA - Upper South East Cluster -
Bordertown Kingston & Naracoorte
• Bordertown Memorial Hospital
• Kingston Soldiers' Memorial Hospital
• Naracoorte Health Service
w CHSA - Whyalla, Eastern Eyre & Far
North Health Services
• Coober Pedy Hospital and Health
Services & Oodnadatta Health Service
• Eastern Eyre Health & Aged Care
• Whyalla Hospital & Health Services
w CHSA - Yorke & Lower North Health
Services
• Balaklava Hospital & Health Service
• Burra Hospital & Health Service
• Clare Hospital & Health Services
• Maitland Hospital & Health Service
• Melaleuca Court
• Northern Yorke Peninsula Health
Services
• Riverton Hospital & Health Service
• Snowtown Hospital & Health Service
• Wallaroo Hospital and Health Services
• Yorketown Hospital & Health Service
w CHSA Pt Pirie, Mid North, Southern
Flinders & Pt Broughton Cluster
• Booleroo Centre District Hospital and
Health Services
• Crystal Brook District Hospital
• Jamestown Hospital
• Laura Hospital & Gladstone Health Centre
• Mid North Health
• Orroroo Health Service
• Peterborough Soldiers' Memorial
Hospital
• Port Broughton Hospital
• Port Pirie Regional Health Service
w CHSA Riverland Health Services
• Bamera Hospital
• Bamera Hospital - Community Health
• Berri Hospital

• Loxton Hospital
• Renmark Hospital
• Riverland Regional Health Service Inc.
and Riverland Private Hospital
• Waikerie Health Services Inc.
w CNAHS - Ambulatory and Primary
Health Care Directorate
• CNAHS Prison Health Service
w CNAHS - Statewide Service - SA
Dental Services
w CNAHS, Statewide Services
Directorate, BreastScreen SA
w Flinders Medical Centre
w Lyell McEwin Hospital
w Modbury Hospital
w Noarlunga Health Services
w Queen Elizabeth Hospital, The
w Repatriation General Hospital -
Southern Adelaide Health Service
w Royal Adelaide Hospital
• Hampstead Rehabilitation Centre
w Royal District Nursing Service of SA Inc.
w Southern Adelaide Health Service
(SAHS) - Population & Primary Health
Care Directorate
• Aboriginal & Torres Strait Islander
Health Teams
• Aboriginal Family Clinics
• GP Plus Aldinga
• GP Plus Health Care Centre Marion
• GP Plus Health Care Centre Noarlunga
• GP Plus Strategies Directorate Office
• Health Service Integration
• Southern Primary Health (SPH)
Inner Southern
• SPH Marion Youth
• SPH Morphett Vale
• SPH Noarlunga Village
• SPH Seaford
w St Margaret's Rehabilitation Hospital
TASPrivate
w Calvary Health Care Tasmania
• Calvary Hospital Hobart Inc.
• St John's Hospital Hobart
w Calvary Health Care Tasmania -
Launceston Campuses
• Calvary Health Care Tasmania,
St Luke's Campus
• Calvary Health Care Tasmania,
St Vincent's Campus
w Hobart Clinic, The
w Hobart Private Hospital & St Helen's
Private Hospital
w North Tas Urology
w North West Private Hospital
TASPublic
w Alcohol and Drug Services - Statewide
Tasmania
w Correctional Primary Health Services -
Statewide Tasmania
w Forensic Mental Health Services -
Statewide Tasmania
w Launceston General Hospital
w Mental Health Services - North
Tasmania
w Mental Health Services - North-West
Tasmania
w Mental Health Services - South
Tasmania
w North West Area Health Service -
Acute Services
• Mersey Community Hospital
• North West Region Hospital
w North West Area Health Service -
Primary Care Services
w Royal Hobart Hospital
VICPrivate
w Albert Road Clinic
w Ambicare Patient Transfer Service
w Anam Cara House Geelong
w Avenue Hospital, The
w Ballan & District Soldiers Memorial
Bush Nursing Hospital
w Ballarat District Nursing & Healthcare
(BDNH)
Bellbird Private Hospital
w w
Berwick Surgicentre
w w
w Brunswick Private
w Cabrini Health
• Cabrini Brighton
• Cabrini Health Hawthorn Campus
• Cabrini Malvern
• Cabrini Prahran
w Chesterville Day Hospital
w Cobden District Health Services Inc.
w Community Connections (Victoria) Ltd
w Como Private Hospital
w Cotham Private Hospital
w Delmont Private Hospital
w Diaverum North Melbourne Dialysis
Clinic
w Donvale Rehabilitation Hospital
w Dorset Rehabilitation Centre
w Eastern Palliative Care Association Inc.
w Epworth HealthCare
• Epworth Freemasons
• Epworth Rehabilitation - Brighton
• Epworth Rehabilitation Camberwell
OUr MEMBErS
• Epworth Rehabilitation Richmond
• Epworth Richmond
w Euroa Health Inc.
w Frances Perry House
w Fulham Correctional Centre -
Medical Centre
w Geelong Clinic, The
w Geelong Private Hospital
w Glenferrie Private Hospital
w Goulburn Valley Hospice Care
Service Inc.
w Healthe Care (comprising La Trobe,
The Valley and South Eastern Private
Hospitals in Victoria)
• La Trobe Private Hospital
• South Eastern Private Hospital
• Valley Hospital, The
w Healthe Work
w Healthscope Community Programs
w Hyperbaric Health Brunswick
w Hyperbaric Health Pty Ltd
w John Fawkner Private Hospital
w Kew Private Dialysis Centre
w Knox Private Hospital
w Linacre Private Hospital
w Maryvale Private Hospital
w Masada Private Hospital
w Medical Connect Pty Ltd
w Melbourne Citymission Palliative Care
w Melbourne Clinic, The
w Melbourne Private Hospital
w Mildura Base Hospital
w Monash Surgical Private Hospital
Neerim District Health Service
North Eastern Rehabilitation Centre
w Northpark Private Hospital
w Pacific Shores Healthcare
w Ringwood Private Hospital
w Royal District Nursing Service
w Sea Lake and District Health Service Inc.
w Shepparton Private Hospital
w Sir John Monash Private Hospital
w South East Palliative Care Ltd
w St John of God Health Care - Bendigo
w St John of God Health Care - Geelong
w St John of God Health Care - Nepean
Rehabilitation
w St John of God Health Care -
Pinelodge Clinic
w St John of God Health Care Berwick
w St John of God Healthcare - Ballarat
w St John of God Hospital - Warrnambool
w St Vincents & Mercy Private Hospital Ltd
• Mercy Private Hospital Inc.
• St Vincent's Private Hospital
• Vimy Private Hospital
ACHS ANNUAL REPORT 2009 - 2010 I 67
 OUr MEMBErS
w Supported Housing Development
Group Pty Ltd
w Very Special Kids
w Victorian Rehabilitation Centre, The
w Warringal Private Hospital
w Waverley Private Hospital
w Yackandandah Bush Nursing Hospital
VICPublic
w Albury Wodonga Health
• Albury Wodonga Health -
Albury Campus
• Albury Wodonga Health -
Wodonga Campus
w Alexandra District Hospital
w Alfred Health
• Alfred, The
• Caulfield Hospital
• Sandringham Hospital
w Austin Health
• Austin Hospital
• Heidelberg Repatriation Hospital
• Royal Talbot Rehabilitation Centre
w Bairnsdale Regional Health Service
w Ballarat Health Services
• Ballarat Base Hospital
• Queen Elizabeth Centre, Ballarat, The
w Banksia Palliative Care Service Inc.
w Barwon Health
• Barwon Health - Aged and
Continuing Care
• Barwon Health - Surf Coast
Community Health Service
• Barwon Health - The Geelong Hospital
w Bass Coast Regional Health
• Wonthaggi and District Hospital
w Beaufort & Skipton Health Service
w Beechworth Health Service
w Benalla & District Memorial Hospital
w Bendigo Health Care Group
• Anne Caudle Centre Campus
• Bendigo Hospital Campus
• Stewart Cowan Community
Rehabilitation Centre
w Boort District Health
w Calvary Health Care Bethlehem
w Casterton Memorial Hospital
w Castlemaine Health - Incorporating
Maldon Hospital
• Maldon Hospital
w Central Gippsland Health Service
• Heyfield Hospital Inc.
• Maffra District Hospital
w Cobram District Hospital
• Cohuna District Hospital
68 I ACHS ANNUAL REPORT 2009 - 2010
w Colac Area Health
w Dental Health Services Victoria
w Djerriwarrh Health Services
w Dunmunkle Health Services
w East Grampians Health Service
w East Wimmera Health Service
• EWHS Birchip Campus
• EWHS Charlton Campus
• EWHS Donald Campus
• EWHS St Arnaud Campus
• EWHS Wycheproof Campus
w Eastern Health
• Angliss Hospital
• Box Hill Hospital
• Healesville Hospital
• Maroondah Hospital
• Peter James Centre and Wantirna
Health
• Yarra Ranges Health
• Yarra Valley Community Health
w Echuca Regional Health
w Edenhope & District Memorial Hospital
w Gippsland Southern Health Service
w Goulburn Valley Health
w Hepburn Health Service
w Hesse Rural Health Service
w Heywood Rural Health
w Inglewood & Districts Health Service
w ISIS Primary Care Ltd
w Kerang District Health
w Kilmore & District Hospital, The
w Kooweerup Regional Health Service
w Kyabram & District Health Services
w Kyneton District Health Service
w Latrobe Regional Hospital
w Lorne Community Hospital
w Maryborough District Health Service
w McIvor Health and Community
Services
w Melbourne Health
• Royal Melbourne Hospital, The -
City Campus
• Royal Melbourne Hospital, The -
Royal Park Campus
w Mercy Hospital for Women
w Mercy Health O'Connell Family Centre
w Mercy Palliative Care
w Moyne Health Services
w Nathalia District Hospital
w Northeast Health Wangaratta
w Northern Health - Clinical
• Northern Health Stream 1
• Northern Health Stream 2
• Northern Hospital, The
• Numurkah District Health Service
• Omeo District Health
• Orbost Regional Health
• Orbost and District Hospital
w Peninsula Health
• Frankston Hospital
• Rosebud Hospital
w Peninsula Hospice Service
w Peter MacCallum Cancer Centre
w Portland & District Health
w Rochester and Elmore District Health
Service
w Royal Children's Hospital
w Royal Victorian Eye and Ear Hospital
w Royal Women's Hospital, The
w Rural Northwest Health
• Rural Northwest Health Beulah
Campus
• Rural Northwest Health Hopetoun
Campus
• Rural Northwest Health Warracknabeal
Campus
w Seymour District Memorial Hospital
w South West Healthcare
• South West Healthcare Camperdown
Campus
• South West Healthcare Hamilton
• South West Healthcare Lismore
Campus
• South West Healthcare Macarthur
Campus
• South West Healthcare Portland
• South West Healthcare Warrnambool
Campus
w Southern Health - Clinical Stream - Acute
• Casey Hospital
• Cranbourne Integrated Care Centre
• Dandenong Hospital
• Jessie McPherson Private Hospital
• Kingston Centre
• Monash Medical Centre - Clayton
• Monash Medical Centre - Moorabbin
w Southern Health - Clinical Stream -
Continuing Care & Mental Health
w St Vincent's Health
• Caritas Christi Hospice
• St George's Health Service
• St Vincent's Correctional Health Service
• St Vincent's Hospital Melbourne
w Stawell Regional Health
w Swan Hill District Health
w Take Two Program
w Tallangatta Health Service
w Terang & Mortlake Health Service
w Timboon & District Healthcare Service
w Tweddle Child & Family Health Service
w Victorian Institute of Forensic Mental
Health (VIFMH)

w Werribee Mercy Hospital
• Mercy Mental Health - Community
Rehabilitation Centre
• Mercy Mental Health - Saltwater Clinic
• Mercy Mental Health - Wyndham
Community Treatment Program and
Consultations Partnerships Team
• Mercy Mental Health Community
Care Units
w West Gippsland Healthcare Group
w West Wimmera Health Service
w Western District Health Service
• Coleraine District Health Services
• Penshurst District Health Service
• Western District Health Service
w Western Health Service
• Sunshine Hospital
• Western Hospital
• Williamstown Hospital, The
w Wimmera Health Care Group
w Yarram and District Health Service
w Yarrawonga District Health Service
w Yea & District Memorial Hospital
WAPrivate
w Abbotsford Private Hospital
w Albany Community Hospice
w Attadale Private Hospital
w Bethesda Hospital Inc
w Glengarry Private Hospital
w Hollywood Private Hospital
w Joondalup Health Campus
w Kings Park Day Hospital
w Marian Centre, The
w Mercy Hospital Mount Lawley
w Midland Dialysis Centre
w Mount Hospital
w Mount Lawley Private Hospital
w Peel Health Campus
w Perth Clinic
w Silver Chain Nursing Association
• Silver Chain Hospice Care Services
including Hospital at the Home, Post
Acute Services
• Silver Chain Nursing Association Central
• Silver Chain Nursing Association East
• Silver Chain Nursing Association
Lower Great Southern
• Silver Chain Nursing Association North
• Silver Chain Nursing Association Peel
• Silver Chain Nursing Association South
w South Perth Hospital Incorporated
w St John of God Health Care - Murdoch
• St John of God Murdoch Community
Hospice
w St John of God Hospital - Bunbury
w St John of God Hospital - Geraldton
w St John of God Hospital - Subiaco
w Waikiki Private Hospital
WAPublic
w Armadale Health Service
w Bentley Health Service
w Child and Adolescent Health Service
• Child and Adolescent Child and
Community Health
• Child and Adolescent Community Health
• Princess Margaret Hospital for Children
w Department of Corrective Services -
Health Services
w Fremantle Hospital and Health Service
• Fremantle Kaleeya Hospital
w North Metropolitan Area Health Service
Mental Health
• Graylands Hospital
w Oral Health Centre of WA
w Osborne Park Hospital Program
w Rockingham Peel Group
• Mandurah Community Health
• Murray District Hospital
• Peel and Rockingham Kwinana Mental
Health Service
• Rockingham Kwinana District Hospital
w Royal Perth Hospital
w Sir Charles Gairdner Hospital
w Swan Kalamunda Health Service
• Kalamunda Health Service
• Swan Health Service
w WA Country Health Service -
South West
• Augusta Multi Purpose Health Service
• Boyup Brook & Districts Soliders
Memorial Hospital
• Bridgetown District Hospital
• Bunbury Health Service
• Busselton District Hospital
• Collie District Hospital
• Donnybrook Balingup Health Service
• Harvey District Hospital
• Margaret River District Hospital
• Nannup Health Service MPS
• Northcliffe Nursing Post
• Pemberton District Hospital
• Warren District Hospital
• Yarloop Hospital
w WACHS, Goldfields
• Coolgardie Health Centre
• Coonana Health Centre
• Esperance Community Health
& Mental Health Unit
OUr MEMBErS
• Esperance Hospital
• Kalgoorlie Hospital
• Kalgoorlie-Boulder Community
Mental Health
• Kalgoorlie - Boulder Population
Health Unit
• Kambalda Health Centre
• Laverton District Hospital
• Leonora Hospital
• Menzies Health Centre
• Norseman Hospital
• Ravensthorpe Health Centre
w WACHS, Great Southern
• Bremer Bay Health Centre
• Gnowangerup District Hospital
• Jerramungup Health Centre
• Katanning District Hospital
• Kojonup District Hospital
• Plantagenet District Hospital
• Tambellup Health Centre
w WACHS, Kimberley
• Broome Health Services
• Derby Health Services
• Fitzroy Crossing District Hospital
• Halls Creek District Hospital
• Kununurra District Hospital
• Northwest Mental Health Service &
Kimberley Com. Drug Service Team
• Wyndham District Hospital
w WACHS, Midwest- Gascoyne District
• Burringurrah Nursing Post
• Carnarvon Hospital
• Coral Bay Nursing Post
• Exmouth Hospital
w WACHS, Midwest Murchison,
Central West Mental Health
• WACHS, Central West Mental Health
Carnarvon
• WACHS, Central West Mental Health
Meekatharra
w WACHS, Midwest Murchison,
Geraldton Health Campus
w WACHS, Midwest Murchison,
Midwest District
• Dongara Eneabba Mingenew Health
Service
• Morawa Perenjori Health Service
• Mullewa Murchison Health Service
• North Midlands Health Service
• Northampton District Hospital
• Northampton Kalbarri Health Service
w WACHS, Midwest, Murchison District
• Cue Health Centre
• Meekatharra District Hospital
• Mount Magnet Health Centre
• Sandstone Nursing Post
ACHS ANNUAL REPORT 2009 - 2010 I 69
 OUr MEMBErS
• Yalgoo Nursing Post
w WACHS, Pilbara
• Newman Health Services
• Nickol Bay Hospital
• Onslow District Hospital
• Paraburdoo District Hospital
• Port Hedland Regional Hospital
• Roebourne District Hospital
• Tom Price District Hospital
• Wickham Health Centre
w WACHS, Wheatbelt Region
• Beverley Hospital
• Boddington Hospital
• Bruce Rock Hospital
• Corrigin Hospital
• Cunderdin Hospital
• Dalwallinu Hospital
• Dumbleyung Hospital
• Goomalling Hospital
• Jurien Bay Health
• Kellerberrin Hospital
• Kondinin Hospital
• Kununoppin Hospital
• Lake Grace
• Merredin Hospital
• Moora Hospital
• Narembeen Hospital
• Narrogin Hospital
• Northam Hospital
• Pingelly Hospital
• Quairading Hospital
• Southern Cross
• Wagin Hospital
• Wongan Hills Hospital
• Wyalkatchem Hospital
• York Hospital
w Women and Newborn Health Service
• King Edward Memorial Hospital for
Women
• Women's and Newborn Health Service
Breastscreen WA
• Women's and Newborn Health Service
Community Midwifery WA
• Women's and Newborn Health Service
WA Cervical Prevention Program
EQuIPCorporate w
MemberServices
NSW
w Mental Health Co-ordinating Council
w Network of Alcohol and Drug
Agencies (NADA)
70 I ACHS ANNUAL REPORT 2009 - 2010
EQuIPCorporate QLD
HealthServices
ACT
w National Health Call Centre Network Ltd
NSW
Alliance Health Services Group Pty Ltd
w EQuIPforDayHospitals
w Greater Southern Area Health Service
w Healthe Care Australia
w Hunter New England Area Health
Service
w Medibank Health Solutions -
Telephonic & On-line Services
w North Coast Area Health Service
w Northern Sydney/Central Coast Area
Health Service
w Salvation Army, The - Recovery
Services Department Head Office
w Sydney Clinic for Gastrointestinal
Diseases, The
w Sydney West Area Health Service
SA
w Central Northern Adelaide Health
Service, Regional Office
w Smith Sterilising
w Southern Adelaide Health Service
TAS
w Mental Health Services - State Office
Tasmania
w North West Area Health Service
VIC
w Coach Program Pty Ltd, The
w Healthscope Ltd
w Mercy Health
w Moira Healthcare Alliance Inc.
w Northern Health
w Southern Health - Corporate Services
w Spotless Services Australia
w Unified Healthcare Group
EQuIPCertification
NSW
w Armidale & District Home Nursing
& Home Help Service Pty Ltd
w Healthways Australia Pty Ltd
w Surgery Centre Hurstville, The
w ROQ (Toowoomba) Pty Ltd
WA
w Kimberley Aboriginal Medical Services
Council Inc.
ACT Private
w Canberra Eye Hospital
w Canberra Surgicentre, The
w Marie Stopes International ACT
w Mugga Wara & Brindabella
Endoscopy Centres
NSW Private
w Adori Day Clinic
w City West Day Surgery
w Dee Why Endoscopy Unit
w Diagnostic Endoscopy Centre
w Excel Endoscopy Centre
w Healthwoods Specialist Centre
w Liverpool Day Surgery
w Marsden Eye Surgery Centre
w Metwest Surgical
w Miranda Eye Surgical Centre
w Presmed Australia
• Ophthalmic Surgery Centre (North Shore)
• Epping Surgery Centre
w Preterm Foundation
w Primary Health Care Day Surgeries
• Bankstown Primary Health Care
Day Surgery
• Sydney Day Surgery
• Warringah Mall Day Surgery
• Western Plains Day Surgery
w Riverina Cancer Care Centre
w Rosebery Day Surgery
w Rosemont Endoscopy Centre
w Skin & Cancer Foundation Westmead
Day Clinic
w Surry Hills Day Hospital
Vista Laser Eye Clinic of NSW
QLD Private
w Eastern Endoscopy Centre
w Haematology & Oncology Clinics
of Australasia
• Haematology & Oncology Clinics of
Australasia Chermside Medical Centre

• Haematology and Oncology Clinics
Australasia Gold Coast Cancer Centre
w Ipswich Day Hospital
w Logan Endoscopy Services Pty Ltd
w Marie Stopes International, Queensland
w NephroCare Queensland
• Allamanda Dialysis Clinic
• Chermside Dialysis Unit
w Peninsula Eye Hospital
w QFG Day Theatres
w Queensland Eye Hospital
w Southside Endoscopy Centre
w Townsville Day Surgery
SA Private
w Adelaide Day Surgery
w Brighton Day Surgery
w Glenelg Day Surgery Pty Ltd
w Hamilton House Day Surgery
w NephroCare South Australia
• Hartley Dialysis Clinic
• Modbury Dialysis Centre
w Oxford Day Surgery Centre
w Parkside Cosmetic Surgery
w Renal Therapy Services - Payneham
w Waverley House Plastic Surgery Centre
TAS Private
w Eye Hospital, The
w Steele Street Clinic
VIC Private
w Coburg Endoscopy Centre
w Croydon Day Surgery, The
w Digestive Health Centre, The
w Glen Endoscopy Centre, The
w Heidelberg Endoscopy and Day
Surgery Centre
w Marie Stopes International,
East St Kilda
w Melbourne Endoscopy Group Pty Ltd
w NephroCare VIC
• Forest Hills Dialysis Centre
• Malvern Dialysis Centre
w Peninsula Endoscopy Centre Pty Ltd
w Reservoir Private Hospital Day
Procedure Centre
WA Private
w Diaverum Pty Ltd WA
• Diaverum - Cannington Dialysis Clinic
• Diaverum - Rockingham Dialysis
Clinic
• Diaverum - Stirling Dialysis Clinic
w GI Clinic
OUr MEMBErS
w Marie Stopes International, WA w Southern General Practice Network
w Perth Day Surgery Centre w Southern Highlands Division of
w Sentiens Pty Ltd General Practice
w St George Division of General Practice Inc.
EQuIPforDay w Sutherland Division of General Practice Inc.
HospitalsCertification
NT
NSW Private w General Practice Network NT Ltd
w Central Coast Day Hospital QLD
w Crows Nest Day Surgery
w Macquarie Street Day Surgery w Moreton Bay General Practice Network
w NephroCare Bondi Dialysis Clinic
w Northern Cancer Institute (Frenchs SA
Forest) Pty Ltd
w Adelaide North East Division of
w Spearwood Dialysis Clinic
General Practice
QLD Private
WA
w Cairns Central Day Hospital
Greenslopes Day Surgery w Great Southern GP Network Ltd
w
w Osborne GP Network Ltd
w Pilbara Health Network
QualityforDivisions
Network(QDN)
NSW
w Barwon Division of General Practice
w Blue Mountains Division of General
Practice
w Dubbo Plains Division of General
Practice
w GP Access
w Hastings Macleay General Practice
Network Ltd
w Hawkesbury - Hills Division of General
Practice
w Hunter Rural Division of General
Practice
w Illawarra Division of General Practice
w Macarthur Division of General Practice
w Mid North Coast (NSW) Division of
General Practice Ltd
w Nepean Division of General Practice Inc.
w New England Division of General
Practice
w North West Slopes (NSW) Division
of General Practice
w NSW Central West Division of General
Practice
w Riverina Division of General Practice
& Primary Health Ltd Incorporating
Barrier Division
• Barrier Division of General Practice Ltd
• Riverina Division of General Practice
and Primary Health Ltd
w Shoalhaven Division of General Practice
ACHS ANNUAL REPORT 2009 - 2010 I 71
LISTINGS
OUr SUrvEyOrS

Our surveyor workforce totals more than 350 dedicated
healthcare professionals and health consumers from
throughout Australia and overseas.
Surveyors, who conduct peer reviews, all have recent
experience within health services, many still in full-time
roles such as health service managers, physicians, allied
health professionals and nurses. ACHS surveyors
participate in regular training sessions and are able to
gather relevant information to verify the healthcare
organisation’s achievement in the standards being assessed.
Our surveyor training program has been recognised
internationally and is accredited by the International Society
for Quality in Health Care.
Thankyoutothesurveyorslistedbelowfortheir
contribution.

ACT Ms Darryl (Lynn) Davis Mrs Jo McGoldrick Ms Andrea Taylor

Dr Peggy Brown
Mr Grant Carey-Ide
Dr Robert Griffin
Ms Kaye Hogan AM
Ms Irene Lake
Ms Mary Martin
Ms Yvonna McCann
Mr Russell McGowan
Ms Patricia O'Farrell
Ms Christine Waller
NewSouthWales
Dr Teresa Anderson
Dr Dinesh Arya
Mr Peter Avery
Mr Mark Ayling
Mr Peter Barber
Dr Winton Barnes
Mrs Shirley Batho
Mrs Karen Becker
Dr Alexander Bennie
Dr Sameer Bhole
Dr Claire Blizard
Ms Heather Brown (Simon)
Dr Susan Buchanan
Mrs Christine Bulters
Ms Margo Carberry
Ms Sandie Carpenter
Ms Desley Casey
Ms Connie Chan
Mr Sam Choucair
Dr Matthew Chu
Ms Elizabeth Clarke
Mrs Marie Clarke
Mr Peter Clout
Mrs Sue Colley
Dr Jean Collie,
Dr Jeanette Conley
Mr Timothy Coombs
Mr Chris Crawford
Mr Robert Cusack
Mr Matthew Daly
Ms Tracey Davidson
Mrs Helen Dowling Mr Bernard McNair Mrs Anne Temblett
Ms Jenny Duncan Ms Helen Milne Mrs Solly Toefy
Ms Barbara Durrant Dr Katherine Moore Ms Helen Vaz
Ms Helen Eastwood Dr John Murray Mr Tony Wallace
Ms Karen Edwards Associate Professor Mr Robert Walsh
Mr Michael Edwards Ganapathi Murugesan Conjoint Professor
Professor Joan Englert AM Ms Judith Nelmes Jennie West
Dr Jean Evans Mr Danny O'Connor Adjunct Professor
Ms Caroline Farmer Ms Anne O'Donoghue Richard West
Dr Terence Finnegan Ms Marilyn Orrock Ms Jan Whalan
Mr Frank Flannery Mr Terrence O'Shea Dr Arthur Wooster
Ms Lynnette Ford Mrs Rosalind O'Sullivan
Prof Adrian Gillin Dr Charles Pain NorthernTerritory
Ms Robyn Goffe Mrs Glenna Parker
Dr Deane Golding Dr Richard Parkinson Mr Peter Frendin
Associate Professor Mr Ian Paterson Ms Dianne Gray
Jane Gordon Ms Carmel Peek Dr Sharon Miskell
Ms June Graham Mrs Nancye Piercy Ms Penny Parker
Ms Pamela Gulbis Mrs Sandra Platt Mr Arnold Tammekand
Mr Ken Hampson Mr David Poon Ms Vicki Taylor
Ms Paula Hanlon Dr Robert Porter Ms Sara Watson
Mr Garth Healey Ms Toni Powell
Dr Ralph Higgins OAM Dr John Powers Queensland
Dr Kim Hill Mr Geoff Rayner
Mr John Hodge Ms Cindi Rees Ms Julie Ashwell
Mrs Sally Holmes Associate Professor Mr Rick Austin
Dr Roger Hooper Ian Rewell Mr Mark Avery
Ms Suzy Hudson Mr Raad Richards Dr Stephen Ayre
Mr Peter Hurst Dr Grahame Robards Associate Professor
Dr Helen Jagger Dr Pauline Rumma Brian Bell
Mr Peter Johnson Dr Margaret Sanger Ms Marian Bills
Ms Diane Jones Mr Anthony Schembri Ms Mary Bonner
Ms Ann Kelly Dr Kevin Sesnan Dr Nick Buckmaster
Ms Dianna Kenrick Ms Susan Shaw Ms Cheryl Burns
Ms Didi Killen Ms Sue Shilbury Ms Patricia Cashmore
Dr Friedbert Kohler Ms Mary Simpson Dr Wilbur Chan
Dr Peter Kramer Mr Ben Skerman Ms Gillian Clark
Dr Harvey Lander Ms Valerie Smith Dr Michael Cleary
Ms Deborah Latta Ms Rosemary Snodgrass Mr Peter Conaghan
Ms Deborah Lewis Mrs Jean Spurge Ms Anne Copeland
Ms Judy Lovenfosse Ms Gowri Sriraman Ms Val Coughlin-West
Mr Stuart MacKinnon Ms Alison Stevens Associate Professor David
Dr Alison Maclean Mr John Stuart Crompton OAM
Ms Carol Martin Dr Christopher Swan Mr Kenneth Denny
Ms Louise McFadden Dr George Szonyi Ms Vicki Eckart

72 I ACHS ANNUAL REPORT 2009 - 2010


Associate Professor
Brett Emmerson
Ms Lisa Fawcett
Ms Joan Fellowes
Mr Kevin Fjeldsoe
Dr Jacqueline Flynn
Mr Kevin Freele
Associate Professor
Jagmohan Gilhotra
Mrs Deborah Grant
Ms Diana Grice
Mr Charlie Grugan
Mr David Gunderson
Mr Phillip Hawkins
Ms Garda Hemming
Dr David Henderson
Mrs Cheryl Herbert
Adjunct Associate Professor
Leonie Hobbs
Dr John Hooper
Ms Judith Hoskins
Mr Terry Hughes
Ms Catherine James
Mr David Kelly
Ms Dianne Knight
Ms Debra Le Bhers
Ms Moina Lettice
Dr William Lindsay
Ms Bernadette Loughnane
Mr Keith Love
Ms Cherryl Lowe
Dr Donald Martin
Mrs Patricia Matthews
Dr Chris Ma
Mr Ian Mill
Mr Anthony Milverton
Dr Clare Morgan
Ms Virginia Morris
Associate Professor
Alan O'Connor
Dr Donna O'Sullivan
Dr Scott Phipps
Dr Jacinta Powell
Dr John Reilly
Mrs Monica Seth
Ms Tracey Silvester
Associate Professor
Patricia Snowden
Ms Lorraine Stevenson
Ms Glynda Summers
Mrs Penny Thompson
Ms Theresa Thompson
Mr Robert Troy
Ms Val Tuckett
Mrs Michelle Turnbull
Mrs Kym Volp
Dr John Waller AM
Mr Brendon Weavers
Dr Noela Whitby AM
OUr SUrvEyOrS
Ms Raewyn Wolcke Mrs Ann Cassidy Mr Trevor Sanders
Dr John Youngman Dr Wayne Chamley Ms Vivienne Sandler
Dr Alex Cockram Dr Susan Sdrinis
SouthAustralia Ms Julie Collette Mr Matt Sharp
Ms Annette Coy Ms Suzanne Sinni
Dr Dianne Barrington Dr Catherine Crock Mr Darrell Smith
Ms Toni Bickley Ms Lydia Dennett Ms Kaye Smith
Mrs Lorraine Bruun Dr Harry Derham Ms Mavis Smith
Ms Adrienne Copley Dr Sherene Devanesen Mrs Marilyn Sneddon
Ms Tina De-Zen Ms Clare Douglas Ms Catherine Steele
Dr Maria Fedoruk Mr Sid Duckett Mrs Maria Stickland
Mrs Sharon Godleman Mr Tim Elrington Dr Lakshmi Sumithran
Mrs Marion Holden Dr Peter Fahy Mr Raymond Sweeney
Dr Philip Hoyle Ms Lee Fairley Mr Denis Swift
Ms Sharon Kendall Ms Anna Fletcher Ms Jennifer Taylor
Mr Alan Lehman Ms Marg Foulsum Ms Melanie Taylor
Ms Janne McMahon Mr Vince Gaglioti Associate Professor
Dr Susan Merrett Ms Michele Gardner Melinda Truesdale
Mrs Cathy Miller Mrs Leigh Giffard Mr Peter Turner
Mr David Miller Mrs Sue Gilham Mrs Lee Vause
Dr Ea Mulligan Ms Diane Gill Dr Ruth Vine
Ms Kathy Nagle Dr Lee Gruner Dr Arlene Wake
Mrs Dianne Norris Dr Richard Harrod Mr Dan Week
Ms Karen Parish Ms Lyn Hayes Mr John Wigan
Mr Neville Phillips Ms Marguerite Hoiby Mrs Wendy Wood
Ms Pam Schubert Ms Janine Holland
Ms Lesley Siegloff Ms Bridget Howes WesternAustralia
Mr Wayne Singh Dr David Huppert
Mrs Margaret Smith Ms Mary Hyland Ms Diane Barr
Ms Michele Smith Dr Sajeev Koshy Dr William Beresford
Dr Rima Staugas Dr Ian Kronborg Mrs Lynda Campbell
Dr Tony Swain Dr Tony Landgren Ms Patricia Canning
Ms Rosemary Taylor Ms Marie Larkin Mr Trevor Canning
Ms Andrea Leonard Ms Geraldine Carlton
Tasmania Mr Alan Lilly Dr Wing Cheong Chiu
Ms Jill Linklater Dr Donald Coid
Mr Ken Campbell Miss Janine Loader Ms Elaine Cooke
Associate Professor Dr Michael Loughnan Adjunct Associate Professor
Des Graham Dr Mark Lubliner Nola Cruickshank
Ms Karen Linegar Ms Jigi Lucas Mr Kim Darby
Dr Peter Renshaw Ms Kate Dyson
Dr Martin Lum
Mr Kannan Srinivasan Mrs Marcia Everett
Mrs Ionela Manescu
Mrs Eve Thorp Dr Heather Gluyas
Mrs Josephine Maprock
Ms Jenny Tuffin Dr Peter Kendall
Dr Chris Maxwell
Ms Lena Lejmanoski
Ms Christine Minogue
Victoria Dr John Monagle
Adjunct Associate Professor
Patricia Letts
Associate Professor Mrs Grace Ley
Mr Peter Abraham
Richard Newton Dr David Lord
Dr Maxwell Alexander
Mr George Osman Mr Shane Matthews
Dr Cathy Balding
Ms Marrianne Beaty Dr Karen Owen Ms Moira Munro
Ms Christine Best Mr Ric Pawsey Dr Clive Purcell
Dr Peter Bradford Mr Ormond Pearson Ms Anne Rutherford
Mrs Lorraine Broad Ms Ros Pearson Dr Mark Salmon
Ms Therese Caine Ms Sally Percy Ms Joan Sheppard
Dr Tom Callaly Ms Susan Perrott Mr Warwick Smith
Mr Alex Campbell Mr David Plunkett Professor Marc Tennant
Ms Jillian Carson Ms Merrin Prictor Mrs Sandy Thomson
Mr Wesley Carter Ms Jenny Rance Dr Deborah Wilmoth
Ms Julie Cartwright Mrs Nelly Ross Ms Fay Winter
ACHS ANNUAL REPORT 2009 - 2010 I 73
 OUr SUrvEyOrS

SurveyorsfromoutsideAustralia

HongKong Bahrain Malaysia India

Dr Derrick Au Dr Bahaa Fateha Mr Stuart Rowley Dr Bidhan Das
Ms Grace Cheng Dr Timothy Gardner
Dr Alexander Chiu Dr G. Arun Govind
Dr Lily Chiu Dr Hari Sivadas
Dr Jack Hung
Dr Anne Kwan Dubai,UAE
Dr Lawrence Lai
Dr Clarence Lam Dr Deena Alani
Dr Chor Chiu Lau Dr Oussama Kayali
Mr Tarcisius Law Ms Kim Primmer
Ms Bernadette Lee Dr Samy Sidky
Dr Ares Leung Mr Richard Turner
Dr Michael Ling
Dr Joseph Lui Sharjah,UAE
Dr Hing Yu So
Dr William Tsang Dr Alan Sandford
Dr Victoria Tan
Dr Chung Ngai Tang
Mrs Mary Wan
Mrs Fan Wong
Dr Loretta Yam

74 I ACHS ANNUAL REPORT 2009 - 2010

 LISTINGS
PUBLICATIONS ANd PrESENTATIONS

ElectronicMedia Hennessy, D. Testing innovative accreditation methods:

piloting the patient journey survey methodology. ISQua
Quality Initiatives. Entries in the 12th Annual ACHS
conference, Dublin. October 2009.
Quality Improvement Awards and Student Award 2009.
The Australian Council on Healthcare Standards,
Johnston, B. Global Trends in Accreditation Healthcare
Sydney, 2009.
of Healthcare Facilities and Services. Presented to
Malaysian Society for Quality in Healthcare. ISQua
The ACHS Clinical Indicator Summary Guide 2010.
Accreditation Council Seminar. June 2009.
Performance and Outcomes Service, The Australian
Council on Healthcare Standards, Sydney, 2010.
Johnston, B. Performance Measurements: strategies,
issues and future directions. Presented to Malaysian
The ACHS Clinical Indicator Users’ Manuals 2010.
Society for Quality in Healthcare. ISQua Accreditation
Performance and Outcomes Service, The Australian
Council Seminar. June 2009.
Council on Healthcare Standards, Sydney, 2010.
Johnston, B. ACHS Clinical Indicators: what have we
The ACHS EQuIP Day Hospitals Guide. Accreditation,
learnt and where are we heading? ACHSE National
standards and guidelines. The Australian Council on
Conference, Queensland. July 2009 (with Dr Brian
Healthcare Standards, 2009, Sydney.
Collopy)

The ACHS EQuIP Day Hospitals Guide. Requirements

for Private Healthcare Organisations not required to be
licensed. The Australian Council on Healthcare
Standards, 2009, Sydney.
Monographs
Australasian Clinical Indicator Report 2001-2008.
Determining the Potential to Improve Quality of Care:
10th Edition. Australian Council on Healthcare
Standards, 2009, Sydney.
Johnston, B. Why choose the ACHS for Health Services
Accreditation. AAQHC (WA Network) State Seminar.
December 2009.
Johnston, B. Beyond Hospital Accreditation. ACHSE
Fellows dinner address, Hong Kong. February 2010.
Johnston, B. From Hospital Accreditation to Continuous
Quality Improvement. HKHA - Joint Symposium on
Quality Improvement, Hong Kong. March 2010.

The ACHS National Report of Health Services PublishedPapers

Accreditation Performance 2007-2008. Australian
Council on Healthcare Standards, 2009, Sydney.
Presentations
Gibberd, R. Chuang, S. Stark, H. Are Clinical Indicator
Reports Used or Useful When Accrediting Australian
Hospitals ISQua conference, Dublin. October 2009.
Hennessy, D. An introduction to Quality Improvement.
Centre for Health Service Management, Faculty of
Nursing, Midwifery and Health, University of Technology,
Sydney. August 2009.
Greenfield, D., Pawsey, M., Lancaster, J., Johnston, B.
and Braithwaite, J. (2010) Tools to Conduct Healthcare
Accreditation Research, Centre for Clinical Governance
Research, Australian Institute of Health Innovation,
University of New South Wales.
Lancaster J, Braithwaite J and Greenfield D. Benefits of
participating in accreditation surveying. International
Journal of Health Care Quality Assurance 2010; 23(2):
141-151.

Hennessy, D. Phipps, S. The EQuIP 4 Quality

Improvement program. Office for Aboriginal and Torres
Strait Islander Health. Canberra. August 2009.

ACHS ANNUAL REPORT 2009 - 2010 I 75

LISTINGS
OvErvIEw OF PrOdUCTS
ANd SErvICES

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

Other products and services that ACHS offer to health
services include:
EQuIPCertification– for newly established healthcare
organisations and other organisations that have not yet
developed formal quality improvement programs.
EQuIPCorporateHealthServices– designed for
corporate offices with or without direct care
responsibility.
EQuIPCorporateMemberServices– developed for
colleges, professional associations, health insurers,
and others involved in supply, human resources,
learning and development, to identify how well they
meet member and customer needs.
ClinicalIndicatorProgram– a data repository, analysis
and reporting service provided by the ACHS to
healthcare organisations. It provides comparative
information on the processes and outcomes of
healthcare. With more than 360 indicators and over 800
participating member organisations, the ACHS Clinical
Indicator Program is the most comprehensive program
of its kind in Australia. Customised reporting of data
allows single healthcare organisations or groups to
compare their own performance to National, State
and Territory aggregates.
Customisedqualityimprovementprograms– For
example, ACHS has designed tailored programs for
South Australia and mental health services in Tasmania.

EQuIPforDayHospitals– a tailored, three-year version EducationSupportService– provides a range of

of our EQuIP accreditation program specifically for education services to its members, surveyors,
private owned, stand-alone day hospitals. consumers and staff. ACHS offers an ongoing calendar
of workshops which cover many aspects of health
EQuIPIn-DepthReviews– conducted by the ACHS to quality management; also offered are customised on-
determine how well specialist services (for example site workshops for up to 25 staff, these can be tailored
mental health services, palliative care, pharmacotherapy to cover interest areas which are determined in
services) have addressed the ACHS standards and the consultation with the individual organisations.
relevant ACHS Guidelines against industry standards.
For more detail on any of our products and services, please
QualityforDivisionsNetwork(QDN)– developed for
visit our website: www.achs.org.au
divisions of general practice and State Based
Organisations (SBO) aiming to deliver a service that is
member focussed; the ACHS QDN accreditation
standards have been approved by the Commonwealth
Department of Health and Ageing and are the only
standards specifically developed for divisions of
general practice.

76 I ACHS ANNUAL REPORT 2009 - 2010

 GLOSSARY OF TERMS

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

Accreditation Public recognition of achievement by a health care organisation, of

requirements of national health care standards1

ACHS The Australian Council on Healthcare Standards, Australia’s leading

independent, not-for-profit organisation dedicated to improving the
quality and safety of health care through continual review of
performance, assessment and accreditation

Certification ACHS’ quality management program for newly established and other
health care organisations that have not yet implemented a formal
quality program

Clinical indicator A measure of the clinical management and outcome of care; a method
of monitoring consumer/patient care and services which attempts to
‘flag’ problem areas, evaluate trends and so direct attention to issues
requiring further review

Consumer/patient People who directly or indirectly make use of health services2

Corporate governance Understood to be the system by which organisations are directed,

controlled and held to account3

Credentialling The process of accessing and conferring approval on a person’s

suitability to provide a defined type of healthcare4

Criteria The measurable key components of a standard; that are necessary

for meeting the standard

EQuIP Evaluation and Quality Improvement Program, ACHS’ framework to

improve the quality and safety of health care

Judging the value of something by gathering valid information about

it in a systematic way and by making a comparison. The purpose of
Evaluation evaluation is to help the user of the evaluation to decide what to do,
or to contribute to scientific knowledge5

Inter-rater reliability Ensuring consistency between and within survey teams on ratings of
the criteria within each standard

ISQua The International Society for Quality in Health Care, a non-profit,

independent organisation with members in over 70 countries that
works to provide services to guide health professionals, providers,
researchers, agencies, policy makers and consumers, to achieve
excellence in health care delivery, and to continuously improve the
quality and safety of care

Member An organisation participating in an ACHS accreditation program

Performance improvement Continuous study and adaptation of processes in order to achieve 1. Australian Council for Safety
desired outcomes and meet the needs and expectations of customers and Quality in Health Care
(ACSQHC), 2006, Shared
Meanings.
Policy A documented statement that formalises the approach to tasks and
concepts which is consistent with organisational objectives 2. Department of Public Health
and Flinders University/SA
Procedure A set of documented instructions conveying the approved and Community Health Research
recommended steps for a particular act or sequence of acts Unit. Improving health services
through consumer participation
Process A series of actions, changes/functions that bring about an end or a - a resource guide for
result organisations. Canberra:
Department of Health and
Quality The extent to which the properties of a service or product produces Ageing, 2000.
a desired outcome4 3. Financial Reporting Council
London Stock Exchange.
Risk management The culture, processes and structures that are directed towards Cadbury Report: The Financial
realising potential opportunities whilst managing adverse effects6 Aspects of Corporate
Governance. 1992.
Safety Freedom from hazard1 4. ACSQHC, List of Terms and
Definitions for Safety and
Standard Describes the overall goal; for example, high quality care for patients Quality.
with desirable outcomes
5. Øvretveit J. Action Evaluation
Surveyor A health professional trained by ACHS to assess the performance of of Health Programmes and
health care organisations against EQuIP standards Changes. Radcliff Medical
Press, 2002: 12.
Virtualisation An IT term to describe server “virtualisation” as the masking of server 6. Standards Australia. AS/NZS
resources including the number and identity of individual physical 4360 - 2004 (2004) Risk
servers, processors and operating systems from service users management.
 The Australian Council on Healthcare Standards (ACHS)
5 Macarthur Street Ultimo NSW 2007 Australia
T. 61 2 9281 9955 F. 61 2 9211 9633
E. achs@achs.org.au W. www.achs.org.au

Additional copies of this Annual Report may be obtained by emailing the Communications Manager at achs@achs.org.au
or visiting the ACHS website (under the Publications and Resources menu option) at www.achs.org.au