Conference Report Community Health: Making Accreditation Work for You By Sue Schreiner

Community Health: Making Accreditation Work for You  July-December 2014

Workshop held 26 September at Canberra Hospital

The workshop went from 9am-4pm with half hour lunch break.

There were 16 participants - all from Community Health (except me).

The presenter was Sue Gilham whose background is in nursing but who now is a Surveyor with The Australian Council on Healthcare Standards(ACHS).  She trains other Surveyors and has been involved in training hospitals in India, Asia the Middle East and Ireland in how to reach accreditation standards.

ACHS is one of 13 bodies whose  business is accrediting health entities’ compliance with National Safety and Quality Health Service Standards(NSQHS) and accreditation. It has a number of Surveyors, including a Surveyor who is a consumer. This organisation is the one chosen by ACT Health. Services to be accredited can choose whoever they wish and significantly, the accrediting bodies do not operate in the same way- so that what one finds acceptable another may not.

The purpose of the workshop was to explain what the Surveyors employed by ACHS expected and would be looking for when deciding accreditation of Community Services provided by Community Health - in particular looking at how Community Health could and should  comply with the Standards. Safety and quality of care for the patient is paramount. The standards and principles which apply to Acute health services also apply to Community health. The measures are the same. There is close scrutiny of claims about how the standards are met - “we look at the clinical content of the record and its quality”.

NSQHS standards consist of 10 Standards and 41 Criteria (209 Core actions and 47 developmental actions)   

Basically what the Surveyors are looking for is how the Standards are met by the organisation (ACT Health) as a whole and by each of the services. The Standards will be surveyed “by discussions with all groups. Reviews of policy and related documents,committee and departmental minutes,mandatory audits and reviews, active use of the findings, communication to senior level and to clinical teams, review complaints,clinical handovers and feedback both positive and negative; visits to community sites, talk to managers and staff members about their outcomes of care, review the clinical indicator reports; review client records for the use of screening and assessment tools. documentation of care plans and intervention, evidence of the engagement of clients in planning care.”

We went through in small groups what 3 of the Standards required. Services are required to prove how they comply with each Standard.  There was much discussion as to what constitutes proof. e.g. policies and procedures,clinical performance indicators, copies of internal and external audits contracts, department and committee quality activities staff training records, feedback and communication,keeping minutes, written records of activity, patient satisfaction surveys.

In greater detail for example against" NSQHS 1 (Governance for safety and quality in health service organisations was : “Measure of patient experience of admitted overnight patients - there could be a list of mechanisms such as surveys,interviews or focus groups used to seek feedback about experiences from admitted overnight patients where feedback is monitored within the organisation’s governance system”.

“Other Performance Measures” were complaints,incidents, near misses, safety assessments, patient satisfaction surveys.”

“Surveyor Verification” consists of; 

1. examining evidence demonstrating how the service has achieved the standards and how they have been incorporated into everyday practice
2. Interviews-staff, client focus groups, service providers, consumers, stakeholders
3. observation
4. review documentation

This is an attempt to summarise the workshop, some of it taken from powerpoint slides. Written material was given to participants and is available if you would like it.

The main points from my perspective are that Community care is judged in the same way as Acute care and that there is close scrutiny of each stage of the accreditation.It is all spelled out and available and gives Community Health clear guidelines as to what is expected. If these guidelines are followed the consumer will be well cared for.

Sue Schreiner 

National Blood Authority Transfusion (NBA) Update Melbourne 15 May 2014 By Jo Bothroyd

I attended the day-long Clinical Practice update session of this event as the Consumer Lead on the ACT Standard 7 Blood and Blood Products Committee.  HCCA sponsored my registration.

Most presentations were very well received and focused on projects or programs designed to help health services develop their Transfusion Quality Improvement Systems so that they comply with Standard 7 which requires;

“Clinical leaders and senior managers of a health service organisation implement systems to ensure the safe, appropriate, efficient and effective use of blood and blood products. Clinicians and other members of the workforce use the blood and blood product safety systems.”

and on the accreditation criteria listed at the bottom of the post.*

Both the Australian Red Cross Blood Service and the National Blood Authority have developed of smart phone/IPad applications (apps) to provide information and support for transfusion services. A WA Red Cross Blood Service app designed for services treating people with high iron/ferritin levels was reported as achieving reduced times from referral to treatment and cost savings for health services.  High iron and related conditions are apparently becoming more common because people are living longer and are more readily diagnosed.

Through the NBA app transfusion service can access information about:

1. Use and management of blood and blood products in accordance with national evidence-based guidelines.

2. Risk mitigation, education and safety and quality improvement programs for the management and use of blood and blood products.

3. Reporting and feedback mechanisms into risk management processes for adverse events, incidents and near misses relating to transfusion practice.

4. Policies, procedures and protocols for documenting transfusion details in the patient clinical record.

5.  Appropriate management of blood and blood products.

6. Informed consent is documented for transfusions.

From my point of view development of smart technology apps will provide a new level of immediate access to evidence based information and therefore should reduce delays in determining the best approach to treatment. The alternative up until now (when beside computers were not available) was access to information via a desktop.

A presentation on informed consent revealed that there is no agreed approach to obtaining consent in terms of blood and blood products.  Some services get separate consent for each type of blood product; some services appear to use the general consent signed on admission to hospital as consent for blood and blood products; and some presenters suggested their organisation is considering getting separate consent for each unit of blood or blood product given to a consumer.

My impression was that there is good communication between the NBA and State Based Transfusion Services and between individual State and Territory services.

Participants did say that they valued the opportunity to network and develop links with other services and individual clinicians.

Jo Bothroyd

*Standard 7 four key Accreditation Criteria

Governance and systems for blood and blood products prescribing and clinical use - Health service organisations have systems in place for the safe and appropriate prescribing and clinical use of blood and blood products.

Documenting patient information - The clinical workforce accurately records a patient’s blood and blood product transfusion history and indications for use of blood and blood products.

Managing blood and blood product safety - Health service organisations have systems in place to receive, store, transport and monitor wastage of blood and blood products safely and efficiently.

Communicating with patients and carers - Patients and carers are informed about the risks and benefits of using blood and blood products, and the available alternatives when a plan for treatment is developed.