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Health Service Accreditation

Establishing Quality Health Standards (EQHS) Newsletter No.6

This page provides a PDF and HTML version of the EQHS newsletter 6th edition

PDF printable version: EQHS Newsletter 6 - March - June 2010 (PDF 2990 KB)

March 2010 - June 2010 Edition

Welcome…

Welcome to the sixth EQHS Newsletter. In this edition we want to remind everyone that time is running out for organisations to access accreditation support provided under the Establishing Quality Health Standards (EQHS) initiative.

The final Accreditation Support Grant funding round is now open, and closes 15 September 2010. Also organisations wishing to access one-on-one accreditation support from an EQHS Accreditation Facilitator need to apply to OATSIH by 31 August 2010.

We also want to introduce three new accreditation resources that have been developed for the sector, and give you an update on EQHS achievements to date. We’ll also update you on the new Quality Improvement Council (QIC) 6th Edition standards and the draft 4th Edition Royal Australian College of General Practitioners (RACGP) standards.

But, our main message is, that if you’re currently not accessing accreditation support under EQHS – hurry and jump on board as time is running out!

From the OATSIH Quality and Accreditation Team (Q&A)

Final Chance to Access Facilitator and Accreditation Support Grant Funding

The final Accreditation Support Grant round is now open, and closes on 15 September 2010. Applications must be received by your relevant state or territory office by this date to be considered for funding.

Accreditation Support Grant funds can be used to address identified barriers to accreditation under accreditation standards relevant to your organisation’s service delivery type.

These standards include RACGP standards for organisations with a general practitioner, and QIC or International Organization for Standardization standards for organisations seeking organisational accreditation and/or organisations without a general practitioner.

For organisations wishing to seek one-on-one support provided by an EQHS Accreditation facilitator, you need to apply before 31 August 2010.

For more information about Accreditation Support Grants and Facilitator support, call the OATSIH Accreditation Information Line on 1800 723 676, or talk to your Affiliate Accreditation Officer or OATSIH Project Officer.

New Accreditation Resources for Indigenous Health Sector

Three new publications are now available to help Indigenous health organisations to achieve accreditation under Australian accreditation standards. These are:

• RACGP Interpretive Guide of the Standards for General Practices (3rd Edition) for Aboriginal and Torres Strait Islander Health Services which interprets RACGP standards as they apply to Indigenous health organisations
• QIC Interpretive Guide for Aboriginal and Torres Strait Islander Health Services - Health and Community Services Standards 6th Edition which interprets QIC accreditation standards as they apply to Indigenous health organisations
• OATSIH Accreditation Manual which outlines accreditation choices and processes for Indigenous health organisations seeking accreditation under relevant mainstream Australian standards with support provided under EQHS.

Interpretive Guide Workshops

Training for Aboriginal and Torres Strait Islander health organisations on the use of the Guides took place during April and May 2010, at jurisdictional workshops co-ordinated on behalf of OATSIH by NACCHO and its affiliated state and territory organisations. There was high organisational representation at the workshops, where the publications were very positively received.

Workshop attendees were able to take their copies of the publications away with them, and additional copies have now been posted to all organisations eligible for accreditation support under EQHS.

Thanks to everyone involved with organising the workshops, and to those individuals and organisations that took time out from their busy schedules to attend and share their accreditation experiences.

Training and Development Scheme

The Training and Development Scheme aims to enhance the capacity of organisations, and to help develop a culture of continuous quality improvement, through support for staff to undertake training and development courses. There are two streams of training available under the Scheme, short term courses to support an organisation to achieve accreditation, and long term courses aimed at the non-clinical development of staff.

As at 1 June 2010, there are 52 current participants in the Long Term stream, as well as 28 who have completed a long term course.

There are 17 currently enrolled participants in the Short Term stream as well as 15 who have completed a short term course. In the last Long Term Stream funding Round (4), 22 people from 13 organisations are being funded for courses ranging from a Masters in Business Administration to Post Graduate Diplomas in Health Management, Quality and Leadership. See the website, www.tds.org.au for more information on this Scheme.

Everyday at WACHS is a quality day......

The accreditation journey commenced at Wellington Aboriginal Corporation Health Service (WACHS) in 2006 when the clinic staff prepared for, and were successfully granted accreditation through Australian General Practice Accreditation Limited (AGPAL) in 2007.

Approximately 18 months later, the service engaged the facilitators - Accreditation Specialists (AS) to review the whole organisation, to assess its readiness for accreditation with the national body, the Quality Improvement Council (QIC).

The process began with a review of services and organisational structures and processes. The representative from AS felt the organisation was ready for an initial review and the organisation registered with the licensed provider for QIC accreditation in NSW, Quality Management Systems (QMS).

The first step involved three managers attending training by QMS to familiarise themselves with the standards and the process of the review. This training was sponsored by the Aboriginal Health and Medical Research Council (AHMRC) of NSW with funding from OATSIH.

The training was excellent and gave us a real platform to start the process. We formed a Quality Working Party to concentrate on the QIC Quality Journal and evidence collection, and also a Quality Committee to enable the process to be communicated to all staff and so staff could be instrumental in the process.

The same three managers also completed reviewer training as provided by QMS. The training was also supported with funding from the AHMRC. As the Review Contact, this was most beneficial for me. Reviewer training gave me valuable insight into the review, what level of evidence was required and how best to present that evidence.

The review date was set as February 2010. Both review teams (AGPAL and QMS) came during the same time period. The total time the reviewers stayed was four days. AGPAL and QMS only shared one day, with QMS staying on to complete their part of the review. They were non-intrusive and very pleasant to all staff. Our QMS review team was particularly culturally sensitive as the senior reviewer had worked with many other Aboriginal organisations. This was a big plus in how the review ran and we appreciated her skill very much.

Choosing a Review Contact

A Review Contact should be identified by the organisation, to drive the accreditation process. This person should be a senior person and have some delegation. The Review Contact would then organise a Quality Working Party.

Quality Working Party

We found it really useful to set up a Working Party to concentrate on the Quality Journal and to track what we needed to. The WACHS Quality Working Party identified the evidence needed and compiled evidence as we worked through the Quality Journal. The Quality Working Party consisted of three senior staff members. The Review Contact headed the group, issues were identified during the process and the Working Party reported to the CEO.

Quality Committee

The Quality Committee has been one of the best outcomes for WACHS. The Quality Committee was convened to assist WACHS to formally process and document quality initiatives in the service. The Committee also helped staff to recognise that the work they were currently doing, including the documentation, the processes the policies and procedures, all contribute to a quality organisation.

Staff representatives from all areas and two Board members sit on the Quality Committee. The Committee is a vehicle for educating staff about quality and normalising the processes. The Committee will now develop the Quality Work Plan and assist the organisation to work through the Plan. The Quality Committee will also review all policy and procedures when they are due.

Dual accreditation

What a great idea!!! The impact on the service is far less when both teams are here at the same time. The two teams share information and discuss the service from a “holistic” perspective. Having both teams here highlights the integration of all aspects of the organisation. (.....and it gets both over with in the one week- so less stress on staff).

Using facilitators

Using facilitators to assist the process was incredibly beneficial. The AS team was able to direct us in how best to collate evidence as well as support us in developing policy and support the implementation processes . AS also sat on the Quality Committee as guests and were able to articulate “what quality improvement is and how the culture of quality should be reflected in all that we do”.

Accreditation Support Grants

One of the major external factors that assisted WACHS in working towards accreditation was the support offered by OATSIH through its Accreditation Supports Grants initiative. The implementation of identified systems and processes were subsidised by the Accreditation Support Grants which were essential in progressing WACHS towards the organisation’s QIC accreditation.

The newsletter

A newsletter was developed to facilitate communication to the staff and Board. The newsletter is compiled monthly and incorporates information about quality activities as well as OHS, new staff, and other interesting news as well a message from the Quality Committee.

What it means to be accredited

It means a lot!!
Being recognised by an external body really makes you feel proud of what you do and proud that you work in an organisation that has systems in place to support clients, services and staff and does them well. The staff feel happy and know they contributed to this outcome and are very enthusiastic about continuing on the quality path.

Final thought

This is a process that needs all staff to be involved as the organisation heads toward accreditation as one. The WACHS Board and CEO were instrumental in supporting this journey and we would not have made it through without their leadership.

Trish Bullen

Review Contact
Wellington Aboriginal Corporation Health Service

Q&A would like to say a special thank you to Trish for taking the time to contribute this article!

ISO Certification

We’ve recently had a number of organisations seeking support through EQHS to achieve certification under ISO 9001:2008 Quality Management Systems Requirements. Also, a number of organisations that attended the recent jurisdictional workshops expressed an interest in learning more about the ISO certification process.

In response, Q&A is currently liaising with Standards Australia to discuss the possibility of developing a guide that interprets ISO 9001:2008 standards in an Indigenous health organisation setting. It is expected that the proposed guide would follow the successful format of the RACGP Interpretive Guide and the QIC Interpretive Guide. We’ll keep organisations posted on any progress made on this project.

• If you or your organisation would like to find out more about accreditation options and processes, check out the new OATSIH Accreditation Manual, which looks in some detail at accreditation standards relevant to the Indigenous health sector.
• You’ll see in this newsletter that some organisations have recently been awarded ISO certification with support provided under EQHS.

Standards Agency News

New QIC Standards Launched

Steve Einfeld, Executive Director, Quality Improvement Council
The QIC launched its new 6th Edition standards on 10 May at the First National Forum on Safety and Quality in Primary and Community Health in Sydney.

The new Standards emphasise good governance arrangements, especially regarding safety and quality. Good governance is linked to strong engagement of communities, families and individuals in planning, reviewing and shaping health and social services.

A new standard has been added requiring a consistent approach to quality and safety across organisations using methods such as a Quality Coordinating Committee, organisation-wide policies, and clear reporting of clinical risk management. Changes from the previous edition also further strengthen standards on rights and advocacy.

All organisations commencing a QIC accreditation after 10 May will use the 6th Edition standards. Those already using the 5th Edition standards will

have to complete their external review before the end of 2010. All organisations in the QIC program get the standards and materials without further cost.

QIC has upgraded all its assessment tools and Guides to match the 6th Edition standards, and has produced the Interpretive Guide for Aboriginal and Torres Strait Islander Health Services, which has been very well received in Indigenous health services.

The launch of the QIC 6th Edition Standards and its new tools and Guide is a move by the QIC to make its standards and program clearer, simpler, more rigorous in some areas, and more user-friendly.

Copies of the new standards can be obtained by downloading the Publications Order Form from the QIC website www.qic.org.au. The website also explains how to participate in the QIC accreditation program.

RACGP 4th Edition Standards

The RACGP is currently developing its 4th Edition Standards for general practices. Draft 4th Edition Standards are available for comment and can be viewed at http://www.racgp.org.au/standards. Written submissions can be emailed to standards@racgp.org.au, or by post to National Expert Committee on Standards for General Practices, RACGP, 1 Palmerston Crescent, South Melbourne 3205 VIC. Please provide your comments by Friday 16 July 2010.

RACGP National Faculty of Aboriginal and Torres Strait Islander Health

The RACGP has recently established a new National Faculty of Aboriginal and Torres Strait Islander Health. In establishing a new Faculty, the RACGP recognises that improving the health of Aboriginal and Torres Strait Islander people is one of Australia’s highest health priorities.

Through the establishment of the Faculty, the RACGP is committed to raising general practitioner awareness of Aboriginal and Torres Strait Islander health needs and their cultural context, and to advocating for culturally appropriate health delivery systems, which improve health outcomes.

CONGRATULATIONS!

Since our last newsletter to you in February 2010, the following organisations have achieved accreditation with support provided under EQHS.

Wunjuada Aboriginal Corporation for Alcoholism and Drug Dependence Service (QLD)

ISO 9001 QMS Requirements - New accreditation

Ngangganawili Aboriginal Community Controlled Health and Medical Services Aboriginal Corporation (WA)

ISO 9001 QMS Requirements - New accreditation

North Coast Aboriginal Corporation for Community Health (QLD)

ISO 9001 QMS Requirements - New accreditation

Thubbo Aboriginal Medical Service (NSW)

RACGP - Reaccreditation

Jungami-Jutiya Alcohol Action Council Aboriginal Council of Halls Creek (WA)

ISO 9001 QMS Requirements - New accreditation

Ngwala Willumbong Co-operative Limited (VIC)

QIC - New Accreditation

Formal Independent Evaluation of EQHS

Consultants, Yaran Business Services, in conjunction with Australian Healthcare Associates, have been engaged by OATSIH to conduct a formal independent evaluation of the EQHS program. In the course of this evaluation, they may contact you or your organisation seeking feedback on the EQHS program. It is anticipated that this evaluation will be completed by earlyAugust 2010.

Mid-Term Review of EQHS

Q&A has recently undertaken a survey of EQHS stakeholders to get an indication of the effectiveness of EQHS at the mid point of its implementation and to identify options for ensuring the sustainability of accreditation for eligible organisations into the future. A summary of the review findings is included with this newsletter for your information.
For further information on the accreditation support available please visit
www.health.gov.au/OATSIHaccreditation
or call the OATSIH Accreditation Information Line on 1800 723 676.

Accreditation Support Grant Update

Round Four of the Accreditation Support Grants resulted in funding for 32 organisations. The Hon Warren Snowdon MP, Minister for Indigenous Health, Rural and Regional Health and Regional Services Delivery, announced the outcome of this Round on 1 June 2010. Each organisation was then informed via the email address provided on the application form. If you are unsure about the outcome of your funding application, please ring Q&A on 1800 723 676 or contact your State or Territory OATSIH project officer.

The main items funded continue to be accreditation fees, medical and office equipment, and staff backfilling.

Round Five Accreditation Support Grant outcomes will be announced in July 2010.

Please mark your calendar with the closing date for the last Funding Round, which closes: 5.00pm EST Wednesday, 15 September 2010.

Get your Application Form and Guidelines from: www.health.gov.au/OATSIHaccreditation. Send your application to your OATSIH Project Officer, remembering to give as much supporting detail as possible, particularly for items costing over $5,000.

Facilitator Update

As at 17 June 2010, 119 organisations have nominated to work with an EQHS Facilitator (65 in 2008-09 and 54 so far for 2009-10). The table below provides a state by state breakdown for 2009-10.
Eighteen organisations have accessed a second round of facilitator support for accreditation under a different accreditation framework.

State/Territory	Number of organisations that have engaged a Facilitator
NSW	10
NT	15
QLD	18
SA	3
VIC	1
WA	7
Total	54

Please note: The final Accreditation Support Grant Round closes 5.00pmThursday 15 September 2010And the cut-off date for new Facilitator engagements is 5.00pm 31 August 2010

Q&A Section Contacts

Team Responsibilities	Contacts	Phone
Director	Sunita Dhindsa	02 6289 7569
Team Leader National Quality Network Activities Local Accreditation Support (Affiliates)	Wendy Richardson Claire Clack	02 6289 7172 02 6289 3932
Team Leader Facilitators Accreditation Support Grants Training and Development Scheme STO & Sector Newsletter	Thilani Mulrine Giselle De Ruyter Giorgina Williams	02 6289 7781 02 6289 4667 02 6289 8155
Team Leader EQHS Evaluation Continuous Quality Improvement & accreditation policy State & Territory Government Liaison	Rebecca Hosemans Aurysia Hii Brian Whitton	02 6289 4967 02 6289 4423 02 6289 8918

If you are interested in participating in accreditation and/or would like to find out more about EQHS, please contact OATSIH by email: OATSIHqualityenquiries@health.gov.au or phone: 1800 723 676