Report on Hospital Accreditation 2011-2013_Final

SPITAL ACCREDITATION HOSPITAL ACCREDITATIONTACCIOCRRNHCEERHDOEDIOSTDIAPSITTTIPHARTAIOOTAITESTN2HILPOIAPOI0TONAALO1LSC1ARCPC-HAARCTO2CCIRCECSTRE0RPEHDDDOEIAOITDIT1TIAAISTTTNAL3LPAIOTATINAITIOOTACANNCLIORCAENHCDCCOITRSRAEPTDIETIIOATNDALTIIOTNATIONACCREDITATION HOSPITAL ACCREDITATIONPSHITPOAISLTHPAOAISCLTPCAIRATELACDLCAITARCACETCCIDORREINETDDAITITATITAOIOTHNNOIOSANPCCIRTEAADHLITCOATASCIOPCHRNCIOTERHSAPEDLOITDIAASITLTCPAAACTCITRCTIORIEAOEDNDLIITTAATTHIAOOICONSCRPNEITDAITLATAIOCNCREDITATIL ACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION HOSPITHOSPITAL ACCREACCREDITATIONCREDITATIONPITAL ACCREDITATION HOSPITAL ACCREDITATION ACCREDITATION HOSPITAL ACCREDITATIONDITATIONHOSPITAL ACCREDITHOASTPITIOALNACCREDITATIONHLSAOPCHSCIORTPESAIDPTILTIATATALAIOLCANACCCCRCRREEEDDDIITITTAAAHTTOTISOIIPOONHITNNOASLPAITHCAOCSLRPEIATDACLICTARACETCDRIOEITDNAITTATIOIONNCTACIOCRNCERHEDODISITTPAATITTIOIAONL ACCREDITATIONCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION ACCREDITATIOHNOSPITAL ACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION HOSPITAL HOSPITAL ACCREDITATIONACCREDITATIONHOSPITAL ACCREDITATIONPITAL ACCREDITATIONSPITAL ACCREDITATIONHOSPITAL ACCREDITATIONAL ACCREDITATION

HOSPITAL AC HOSPITAL HOSAPCCIRTEAADLITCATACIOCRNCERHEDODISITTPA HOSPITAL ACCREDITAT H HOSPI ACCREDITATION HOSPITAL HOSPITAL ACCRE HOSPITAL AC HOSPITA HOSPITAL ACCRED ACCREDITATION HOSPITAL ACC H HOSPITAL ACCREDITA HOSPITAReport on Hospital Accreditation 2011–2013Published by Quality and Safety Division, Hospital AuthorityPlease forward your enquiries or suggestions to: ACCREDITATIONDepartment of Quality and Standards HOSPITALHospital AuthorityHospital Authority Building HOSPITAL ACCRE147B Argyle StreetKowloon, Hong Kong HTel : (852) 2300 7305 HOSPITALFax : (852) 2300 7576Email : [email protected]© Copyright 2014 by the Hospital AuthorityAll rights reserved. No part of this publication may be reproduced by any process without prior written permissionAfrom the copyright owner. HOSPITAL A

CCREDITATION ACCREDITATION 3CONTENTSTATION PITAL ACCREDITATIONTATIO HOSPITAL ACCRECDhaITptAeTr I1O: ONverviewTION CHhOapStPerIT2:AALccreditation Standards 9 HOSPITAL ACCREDITATIONITAL ACCREDITATIOCNhapter 3: Surveyor Component 13N Chapter 4: Engagement and Communication 19L ACCREDITATIONEDITATION Chapter 5: Learning and Sharing 27CCREDITATIONAL ACCREDITATION Chapter 6: RAeCcCoRmEDmITeAnTIdOaNtions and Improvements 33DITATION HOSPITAL ACCREDITATION 51 Chapter 7: HHoOspSiPtaITlsASLhAaCriCnRgEDITATIONHCAOTRHIESOONDPSIPITTITAAALTLIAOACCNCCRREDEITDAITTIAONTIALOipstpNoefnFdiigcuerses HOSAPCCIRTEAADHLITCOATASCIOPCHRNCIOTERHSAPEDLOITDIAASITLTCPAAACTCITRCTIORIEAOEDNDLII11TT84AA12TTHIAOOICONSCRPNEI ACCREDITATION List of AbbrevHiaOtiSoPnITAL ACCREDITATION 182AL HOSPITAL ACCRED HOSPITAL ACCREDITA HOSPITALACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONL ACCREDITATION HOSPITAL ACCREDITATIONEDITATION HOSPITAL ACCREDITATION ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCRE HOSPITAL ACCRALTCATACIOCRNCERHEDODISITTPAATITTIOIAONL ACCREDITATIONACCREDITATION HOSPITAL ACCREDITATION

HOSPITAL AC HOSPITAL HOSAPCCIRTEAADLITCATACIOCRNCERHEDODISITTPAHOSPITAL ACCREDITAT H HOSPI ACCREDITATION HOSPITAL HOSPITAL ACCRE HOSPITAL AC HOSPITA HOSPITAL ACCRED ACCREDITATION HOSPITAL ACC H HOSPITAL ACCREDITA HOSPITA ACCREDITATION HOSPITAL HOSPITAL ACCRE H HOSPITAL AACCREDIT HOSPITAL A

CCREDITATIONACCREDITATIONTPATITIOANLOverviewTATIOACCREDITATION CHAPTER 1HOSPITAL ACCREDITATIONTION HOSPITA1L.1 Participating Hospitals of Phase II HOSPITAL ACCREDITATION Hospital Accreditation ProgramITAL ACCREDITATION 1.2 Program ScheduleNL ACCREDITATION 1.3 Continuation of Hospital Accreditation in Pilot HospitalsEDITATIONCCREDITATIONAL ACCREDITATION ACCREDITATIONDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONCREDITATION HOSPITAL ACCREDITATION HOSAPCCIRTEAADLITCATACIOCRNCERHEDODISITTPAATITTIOIAONL HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION ACCREHOSPITAL ACCREDITATION HOSPI ATION HOSPITAL ACCREDAL ACCREDITATION HOSPITAL ACCREDITA HOSPITALACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONL ACCREDITATION HOSPITAL ACCREDITATIONEDITATION HOSPITAL ACCREDITATION ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCRE HOSPITAL ACCRALTCATACIOCRNCERHEDODISITTPAATITTIOIAONL ACCREDITATIONACCREDITATION HOSPITAL ACCREDITATION

CHAPTER 1OverviewHA launched the Pilot Scheme of Hospital Accreditation (Pilot Scheme) in 2009 in collaboration withthe HK Private Hospitals Association (PHA). Under the Pilot Scheme, five HA hospitals and three privatehospitals 1 have attained full accreditation by the partnering accrediting agent, The Australian Councilon Healthcare Standards (ACHS). A uniform Hong Kong (HK) accreditation standards (EQuIP 4 HKGuide) was developed and the HK surveyor system was established with 49 local surveyors appointed.Experience of the Pilot Scheme suggested that hospital accreditation contributed to the fosteringof patient safety culture and strengthening of quality management framework. The Government issupportive of rolling out hospital accreditation to more HK hospitals and continued developmentof the local surveyor system and standards. Accordingly, HA implemented the Phase II HospitalAccreditation Program (Phase II Program) in continued collaboration with ACHS after the tenderingexercise.東方日報2011 年 11 月 15 日 星島日報 2012 年 7 月 5 日 1 Five HA Hospitals : Caritas Medical Centre, Pamela Youde Nethersole Eastern Hospital, Queen Elizabeth Hospital, Queen Mary Hospital & Tuen Mun Hospital Three Private Hospitals : Hong Kong Baptist Hospital, Hong Kong Sanatorium & Hospital and Union Hospital4

Chapter 1 | OverviewThe key objectives of the Phase II Program are:• To integrate the quality management framework and continuous quality improvement (CQI) principle of hospital accreditation into daily practices by adopting a prudent and pragmatic approach• To support 15 participating hospitals to enhance quality management through staff training and gap analysis in preparation for external accreditation by the partnering agent, ACHS• To continually update the uniform Accreditation Standards for HK• To continually train and develop the local surveyors workforceThis report summarises the major progress of hospital accreditation from April 2011 to March 2013.It is contributed by our partnering agent, ACHS, participating hospitals, and the related Committeesand Working Groups.1.1 Participating Hospitals of Phase II Hospital Accreditation ProgramThe Phase II hospital accreditation program intended to include all seven clusters andhospitals of different service types and nature. Fifteen (15) hospitals voluntarily participated inthe Phase II Accreditation Program. They are:CLUSTER HOSPITALHong Kong East Tung Wah Eastern Hospital (TWEH)Hong Kong WestKowloon Central Tung Wah Hospital (TWH)Kowloon EastKowloon West Hong Kong Buddhist Hospital (BH) Kowloon Hospital (KH)New Territories East Tseung Kwan O Hospital (TKOH)New Territories West United Christian Hospital (UCH) Our Lady of Maryknoll Hospital (OLMH) Princess Margaret Hospital (PMH) Yan Chai Hospital (YCH) Alice Ho Miu Ling Nethersole Hospital (AHNH) North District Hospital (NDH) Prince of Wales Hospital (PWH) Tai Po Hospital (TPH) Castle Peak Hospital (CPH) Pok Oi Hospital (POH) 5

Chapter 1 | Overview 1.2 Program Schedule The Phase II Program was kicked off in October 2011 by series of engagement and communication visits to hospitals and experience sharings by colleagues from pilot hospitals. For better project management, HA has capped the numbers of hospital undergoing gap analysis (GA) and organisation-wide survey (OWS) at six respectively in a year. The program schedule is summarised in Figures 1a and 1b below. Figure 1a : Program Schedule of Phase II Program Schedule of Phase II Accreditation Program 2011 2012 2013 2014 2015 2016 (Tentative) (Tentative) (Tentative) 4Q16 3Q16 2Q16 1Q16 4Q15 3Q15 2Q15 1Q15 4Q14 3Q14 2Q14 1Q14 4Q13 3Q13 2Q13 1Q13 4Q12 3Q12 2Q12 Mar Feb Jan Dec Nov Oct Engagement & Hospital Ongoing, as and when required Communication Visits & Experience Sharing Training 1st 2nd 3rd Refresher Refresher round round round New Surveyor Training & Annual Development Accreditation Local adaptationof Feedback and Evaluation Standards EQuIP 56

Chapter 1 | OverviewFigure 1b : Hospital Survey Schedule 2012 2013 (tenta-ve) (tenta-ve)2Q 3Q 4Q 1Q 2Q 3Q 4QOLMH TWH NDH UCH PMH TKOH TWEH OLMH POH YCH)PYNEH QEH QMH TMHBy March 2013, seven Phase II hospitals have completed their gap analysis in preparation fortheir OWS. Our Lady of Maryknoll Hospital was the first Phase II hospital completed its OWS inMarch 2013 and recommended for 4-year full accreditation by the survey team. 7

Chapter 1 | Overview 1.3 Continuation of Hospital Accreditation in Pilot Hospitals Hospital accreditation is a continuous improvement process. Five pilot hospitals continued with their accreditation cycle with satisfactory completion of Periodic Review (PR) in 2012. The survey team reviewed the progress on recommendations from the OWS, with particular focus on any High Priority Recommendations (HPR), and reviewed improvements and outcomes for the mandatory criteria and make further recommendations. All five pilot hospitals are recommended to continue their accreditation status. Quality Times Issue 5 & 78

CCREDITATIONACCREDITATIONTPATITIOANLTATIO CHAPTER 2TION HAOCCSRPEITDAITLATAIOCNCREDITATIOASN tcacnreddairtdastionHOSPITAL ACCREDITATION HOSPITALITAL ACCREDITATION 2.1 EQuIP 5N 2.2 Local Adaptation of EQuIP 5L ACCREDITATIONEDITATION 2.3 EQuIP 5 Hong Kong GuideCCREDITATIONAL ACCREDITATION ACCREDITATIONDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONCREDITATION HOSPITAL ACCREDITATION HOSAPCCIRTEAADLITCATACIOCRNCERHEDODISITTPAATITTIOIAONL HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION ACCREHOSPITAL ACCREDITATION HOSPI ATION HOSPITAL ACCREDAL ACCREDITATION HOSPITAL ACCREDITA HOSPITALACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONL ACCREDITATION HOSPITAL ACCREDITATIONEDITATION HOSPITAL ACCREDITATION ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCRE HOSPITAL ACCRALTCATACIOCRNCERHEDODISITTPAATITTIOIAONL ACCREDITATIONACCREDITATION HOSPITAL ACCREDITATION

CHAPTER 2 Accreditation Standards Under the governance of The Steering Committee on Hospital Accreditation at the Government level (Appendix 1), the Committee on Standards was established, comprising members from Department of Health (DH), PHA and HA, to review the accreditation standards for local adaptation. The ACHS’s accreditation standards, the 4th edition of Evaluation and Quality Improvement Program (EQuIP 4), were adopted under the Pilot Scheme as the first uniform accreditation standards in HK. As an internationally recognised practice, accreditation standards have to be reviewed periodically in order to stay current with contemporary practices in healthcare delivery, advances in technology and changes in health policy. Under its cyclical review, ACHS has published its latest EQuIP 5 standards accredited by The International Society of Quality in Health Care (ISQua) in July 2011. The EQuIP 5 standards were also introduced for ACHS surveys in other countries (including HK) starting from January 2012. Moreover, adopting the common standards in HK and other countries will be beneficial to HK surveyors participating in ACHS surveys. 2.1 EQuIP 5 Basically, the framework of EQuIP 5 and EQuIP 4 standards is the same. The numbers of criteria in the EQuIP5 have increased from 45 to 47, as a result of the following changes: • A new criterion on nutritional needs; • The criterion on healthcare incidents and complaints is separated into two individual criteria; • The criterion on record management is separated into health record management and corporate record management; • Criteria on information on data management and effective use of data are combined to one criterion. Achievement rating of individual criterion remains at five levels. However, the label for level 3 rating of “MA” has changed from “Moderate Achievement” to “Marked Achievement” to reflect the high standard of achievement that organisations reach within the MA award level. Other changes are largely editorial in nature which make the EQuIP 5 standards more succinct and user-friendly.10

Chapter 2 | Accreditation Standards2.2 Local Adaptation of EQuIP The Committee on Standards (Appendix 2) was entrusted with the responsibility of local adaptation of the EQuIP 5 standards. The Committee adopted the same adaptation framework of EQuIP 4 which focused on three aspects, namely legality, adaptability and practicality. Great care was taken to ensure that the equivalent laws in HK were included in the standards and the standards are applicable in both public and private hospitals irrespective of the size. In addition to the original references in the EQuIP 5, local references were added to each criterion.2.3 EQuIP 5 Hong Kong Guide With the experience of EQuIP 4 Hong Kong Guide and the commitment of members, The Committee on Standards had completed the local adaptation and developed the “EQuIP 5 Hong Kong Guide” 1. The effort of the Committee was recognised with the approval of the EQuIP 5 Hong Kong Guide by the ACHS Board in April 2012 and accredited by ISQua in June 2012. The EQuIP 5 Hong Kong Guide is being used in all accreditation surveys in HK. The Committee on Standards will continue to evaluate comments from hospitals and surveyors to refine the standards.SECTION 5Standards, criteria, elements and guidelinesStandard 2.4: The organisation promotes the health of the population Criterion 2.4.1 ReferencesBetter health and wellbeing is promoted by the organisation for consumers / patients, 1. World Health Organization (WHO). Health promotion glossary. staff, carers and the wider community. Geneva CH: WHO; 1998. Accessed from http://www.who.(continued) int/hpr/NPH/docs/hp_glossary_en.pdf on 1 September 2010.Local References 2. World Health Organization - Europe. Standards for health promotion in hospitals. Copenhagen DK; WHO; 2004.a Food and Health Bureau. http://www.fhb.gov.hk 3. Segal L and Chen Y. Priority setting models for health - The b Department of Health. http://www.dh.gov.hk role for priority setting and a critique of alternative models. Melbourne VIC; Centre for Health Program Evaluation; 2001.c Hospital Authority. http://www.ha.org.hk; 4. World Health Organization. Ottawa Charter for health d Leisure and Cultural Services Department. http://www.lcsd. promotion. First international conference on health promotion. gov.hk; Ottawa Canada, 21 November 1986. Accessed from http:// www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf on 1 e Food and Environmental Hygiene Department. http://www. September 2010. fehd.gov.hk; 5. World Health Organization (WHO). Public health surveillance. f The Hong Kong Council on Smoking and Health. http://www. Geneva CH; WHO. Accessed from http://www.who.int/ fhb.gov.hk; immunization_monitoring/burden/routine_surveillance/en/ index.html on 2 September 2010.g The Occupation Safety and Health Council http://www.oshc. org.hk 6. Zwar NA, Richmond R, Borland R et al. Smoking cessation guidelines for Australian general practice: Practice handbook. h Centre for Health Protection, Department of Health at: http:// Sydney NSW; RACGP Guideline Development Group; 2004. www.chp.gov.hki Health Zone, Central Health Education Unit, Department of Health. http://www.cheu.gov.hk/eng/info/family.htmj Promoting Health in Hong Kong: A Strategic Framework for Prevention and Control of Non-communicable Diseases. http://www.change4health.gov.hk/en/strategic_framework/ Smart Patient Website: http://www21.ha.org.hk/smartpatient/ en/home.html1 Electronic version of “EQuIP 5 Hong Kong Guide”: 11 http://qsdportal/qs/Website/Hospital%20Standards/Hospital%20Accreditation/Accreditation%20Program/ EQuIP%205%20Standards.html 366 The ACHS EQuIP 5 Hong Kong Guide Book 2 - Accreditation, Standards and Guidelines - Support and Corporate Functions

Chapter 2 | Accreditation Standards12

CCREDITATIONACCREDITATIONTPATITIOANLTATIO CHAPTER 3 ACCREDITATION Surveyor ComponentHOSPITAL ACCREDITATIONTION HOSPI3T.A1 LTraining of New Batch of Surveyors HOSPITAL ACCREDITATIONITAL ACCREDITATION 3.2 Continuous Training and Development of SurveyorsNL ACCREDITATION 3.3 Surveyor ExperienceEDITATIONCCREDITATIONAL ACCREDITATION ACCREDITATIONDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONCREDITATION HOSPITAL ACCREDITATION HOSAPCCIRTEAADLITCATACIOCRNCERHEDODISITTPAATITTIOIAONL HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION ACCREHOSPITAL ACCREDITATION HOSPI ATION HOSPITAL ACCREDAL ACCREDITATION HOSPITAL ACCREDITA HOSPITALACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONL ACCREDITATION HOSPITAL ACCREDITATIONEDITATION HOSPITAL ACCREDITATION ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCRE HOSPITAL ACCRALTCATACIOCRNCERHEDODISITTPAATITTIOIAONL ACCREDITATIONACCREDITATION HOSPITAL ACCREDITATION

CHAPTER 3 Surveyor Component A robust system of trained surveyors is essential to the credibility and sustainability of accreditation program. Local surveyors qualified under the HK surveyor system are given the same recognition by ACHS as their Australian counterparts, and can participate in accreditation surveys in HK and overseas. Under the Pilot Scheme, the Steering Committee on Hospital Accreditation at the Government level has endorsed the setting up of the ACHS HK Program Support Committee (PSC) to formulate strategy, policy and system for HK surveyors and select local candidates to be trained as surveyors. The PSC comprises members from DH, HA, PHA and ACHS (Appendix 3). 49 ACHS(HK) surveyors were appointed under the Pilot Scheme. 3.1 Training of New Batch of Surveyor To support the Phase II program in HK, it is estimated that 100 local surveyors are required. During the reporting period, one surveyor induction workshop was conducted from 29 February to 2 March 2012 for 24 surveyor candidates from DH, public and private hospitals. Based on the candidates’ knowledge of quality management, surveying and interpersonal skills, the ACHS consultants had recommended 20 candidates to proceed to training surveys in HK or Australia. Candidates’ evaluation and feedback on the workshops are detailed in Appendix 4. Surveyor Induction Workshop14

Chapter 3 | Surveyor ComponentAs at 31 March 2013, 9 out of 20 surveyor trainees had completed training surveys withsatisfactory evaluation and appointed as ACHS(HK) Surveyors. The total number of appointedlocal surveyors was 58 (Appendix 5). QUALITY TIMES . Issue 9 . Nov 2012 The Hospital Authority Periodic Publication on Quality Improvement for Healthcare Professionals Building Capability of Local Surveyors for Hospital Accreditation Hospital accreditation, in essence, is an “independent external peer assessment of a healthcare organization or hospital’s performance in relation to the “Standards” set by an accrediting organization”. The “Surveyors” (who are the external peer assessors) and accreditation “Standards” are therefore the two central pillars to assure the credibility and sustainability of all accreditation systems. Recognizing the important contribution of trained surveyors, we have been developing our local surveyor system and enhancing our surveyors’ competencies and capabilities ever since the launching of the Pilot Scheme of Hospital Accreditation, in partnership with the Australian Council of Healthcare Standards (ACHS) in Hong Kong in 2009. Our Local Surveyor System is characterized by: • A Balanced and Diversified Surveyor Workforce • Local and Overseas Recognition 52 ACHS (HK) Surveyors (as at 31 Oct 2012) • The training and appointment of ACHS (Hong Kong) surveyors basically follow that of the Australian By Professions ACHS surveyors with reciprocal recognition. Our HK surveyors can join the ACHS survey teams to conduct Allied Health Admin/Others accreditation surveys in Australia and overseas. 8 (15%) 5 (10%) Path for Appointment as ACHS (HK) Surveyor Nurse Medical Nomination by Organization 16 (31%) 23 (44%) Group Interview by HK Program By Organizations Supported Committee (PSC)Certificate Department Private Retired Attendance at 3-day Surveyor Induction Workshop of Health Hospital 1 (2%) 1 (2%) 14 (27%) Hospital Attendance at Training Survey(s) Authority in Hong Kong and Overseas 36 (69%) Appointment as ACHS(HK) Surveyors for 2 years Re-appointment for 4 years Subject to Participation Way Forward in Surveys and Annual Development Programs Under the Phase II Hospital Accreditation program, 15 with Good Performance additional HA hospitals will undergo ACHS accreditation in the coming 5 to 7 years. With this expanded accreditation • A Territory-wide Surveyor System in HK program, it is envisaged that we will need to train up more • The HK Program Support Committee (PSC) comprises ACHS (HK) surveyors to sustain the local surveyor system. representatives from Department of Health (DH), Accordingly, two more surveyor induction workshops Private Hospitals Association (PHA) and HA. PSC will be conducted in the coming few years. The HK PSC is charged with the responsibility to develop and will decide on the timing of induction workshops and oversee the local surveyor system, as well as to select selection of surveyor candidates for training, taking into local candidates for surveyor training. To ensure consideration the numbers of local surveys, potential balanced development of the local surveyor system, wastage of surveyors and the need to maintain a balanced local surveyors are selected from both the public and local surveyor workforce in the future. private sectors and are arranged to conduct cross- sector surveys between public and private hospitals. Feedbacks on Surveyor Induction Workshop 2012 Editorial Dr KL Choo, NDH “Never before have I witnessed so many hands Comments raised during question time… These were the scenes after every presentation of an ACHS Local surveyor workforce is an in valuable asset to our criterion by fellow surveyor trainees. Perhaps, health care system. Experienced surveyors are indeed our knowing that we’d be assessed on how actively mentors and partners as they can guide and accompany we participated in the workshop had driven the us to walk through our quality and safety journey. energy level of this group rocket high!” Mr Daniel LO “I found this program very challenging and Ms Louisa Leung, POH Senior Manager (Allied Health) exciting. I gained deeper insight into the contents of EQuIP by participating in criteria presentation HAHO and preparing pre-course assignment. I was most impressed by Helen and David during the induction training workshop when they were doing role play with our group.” Quality Times 15

Chapter 3 | Surveyor Component 3.2 Continuous Training and Development of Surveyors Surveyors have to build on their experience through participating in surveys and continuous training and development. As part of the mandatory requirement for re-appointment, all appointed surveyors have to participate in the annual development program. To obviate need for overseas travel, ACHS has tailor-made the annual development program for HK surveyors to cover training on professional skills, technical domains and developments in contemporary health service practice. Annual Development Workshop Two annual surveyor development workshops were conducted by ACHS in HK in March of 2012 and 2013 respectively. In 2012, two identical 2-day sessions of Annual Development Program were conducted in March. All participants of the workshop expressed satisfaction with the program. There were also some suggestions to include more training on report writing and surveying skills (Appendix 6). For 2013 Annual Development Program, to better address the training needs of surveyors, ACHS introduced a modular training. The workshops included two identical 1-day mandatory module covering training on National Standards of Australia and three identical 1-day optional module of advanced communication and writing workshop provided by a communication consultancy. The overall feedback from the participants were positive in terms of its relevance, discussion and interaction (Appendix 7). Annual Development Workshop16

Chapter 3 | Surveyor ComponentA Surveyor Gathering Day was organisedas a closing of the Annual DevelopmentProgram 2013 and provided a platform forsurveyors to share their local or overseassurvey experiences and to meet withACHS consultants. The PSC will continue toevaluate the Annual Development Programand organise relevant training for localsurveyors.HK vs Aus HK AUS Single hospital Large area, different types of facilities Relatively uniform practiceStaff are well prepared, rehearsed Variable practiceMany powerpoints, presentations Staff prepared, also more candidProtection from senior staff on site Governing body more stable More time for interviews, chats, they wait for you to ask questions Exciting and enjoyable Free-er walk around Frequent re-organizations, change of top management Exciting and enjoyableSharing from Surveyors – Quality of a Surveyor 17

Chapter 3 | Surveyor Component 3.3 Survey Experience Local surveyors have proactively participated in local and overseas surveys to enrich their survey experience. During the fiscal year of 2011 and 2012, local surveyors attended a total of 28 and 83 surveys respectively. As accreditation in HK is still in an early stage of development, the survey opportunities in HK are increasing. Details of the local and overseas survey experience and surveys days are summarised in figure 2 and 3. Figure 2 Figure 3 Ratio of Local & Overseas Survey Ratio of Local & Overseas Survey Days Ratio of 2012/13 65% R(2a36t5/i%8o3o) f 2012/13 69% 31% Local & Local & Overseas 2011/12 (57/83) Overseas 2011/12 (238/346) (108/346) Survey 18% 50% Survey Days 12% 88% Local & Macau (5/28) 82% (15/121) Overseas 0% (106/121) (2Lo3/c2a8l )& Macau Overseas 0% 50% 100% 100% Local & Macau    Overseas Local & Macau    Overseas18

CCREDITATIONACCREDITATIONTPATITIOANLTATIO CHAPTER 4TION HAOCCSRPEITDAITLATAIOCNCREDITATIOCEN nogmamgeumniecnattioanndHOSPITAL ACCREDITATION HOSPITALITAL ACCREDITATION 4.1 Engagement and Communication Visits and ForumsNL ACCREDITATION 4.2 Working Group on Engagement and CommunicationEDITATIONCCREDITATION 4.3 Reflection and Sharing onAL ACCREDITATION ACCREEnDgITaAgTeIOmNent and CommunicationDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONCREDITATION HOSPITAL ACCREDITATION HOSAPCCIRTEAADLITCATACIOCRNCERHEDODISITTPAATITTIOIAONL HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION ACCREHOSPITAL ACCREDITATION HOSPI ATION HOSPITAL ACCREDAL ACCREDITATION HOSPITAL ACCREDITA HOSPITALACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONL ACCREDITATION HOSPITAL ACCREDITATIONEDITATION HOSPITAL ACCREDITATION ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCRE HOSPITAL ACCRALTCATACIOCRNCERHEDODISITTPAATITTIOIAONL ACCREDITATIONACCREDITATION HOSPITAL ACCREDITATION

CHAPTER 4 Engagement and Communication 4.1 Engagement and Communication Visits and Forums Learning from the experience of Pilot Scheme, hospital accreditation is an organisation-wide change program building on the understanding and support of staff. More engagement and communication works were done to clearly communicate HA’s approach of adopting accreditation as a CQI tool and to enlist views of staff. The Phase II accreditation program was kicked off by a series of hospital visits and staff forums by Department of Quality and Standards of HA Head Office, ACHS and staff from pilot hospitals to meet with the executives and staff to introduce the objectives of CQI, accreditation program and implementation, as well as experience sharing from the peers of pilot hospitals. To engage the stakeholders at different levels, Department of Quality and Standards, HA Head Office has also visited different groups and committees, including Staff Group Consultative Committees, Patient Group Meetings and Regional Advisory Committees to brief the HA’s approach on accreditation and the Phase II program.20

Chapter 4 | Engagement and Communication4.2 Working Group on Engagement and Communication The Working Group on Staff Engagement and Communication set up under the Pilot Scheme was entrusted to work on the strategy of staff engagement and communication. To better support the Phase II program, the chairmanship and membership of this Working Group were reviewed to incorporate representatives from different disciplines and levels of staff (Appendix 8). Under the new chairmanship of a physician from Pok Oi Hospital, Dr Tung Wai Au Yeung, who has participated in the Pilot Scheme, the Working Group focused on promulgating the use of accreditation as a CQI tool. The Working Group had initiated works on enhancing peers sharing and use of audio-visual communication tools for more interaction. (i) Experience Sharing Forum Peers experience and sharing were considered an effective way of staff engagement. The Working Group invited hospitals having completed their gap analyses to share their experience with other hospitals preparing for that. During the period, five experience sharing forums were held and attended by over 700 hospital staff.MONTH/YEAR HOSPITALS ATTENDANCEJune 2012 Sharing for all Phase II hospitals by OLMH 88September Sharing for NTEC by POH 251January 2013 Sharing for UCH by PWH 164February Sharing for CPH by KH 224 21

Chapter 4 | Engagement and Communication (ii) Staff Feedback To enlist views of staff on hospital accreditation and the Phase II program, hospitals after completing their surveys have collected staff feedback in written or video format. The feedback was published on hospital accreditation website. In addition, the accreditation website was enhanced with the introduction of “Quality Tubes” to provide easy access to videos on staff feedback, forums and training materials. Accreditation newsletters and websites of hospitals/clusters are collected and shared at website as well. Feedbacks from Colleagues… Any pressure during this period? 把壓力化為力量，跟上司指示，把符合認證的 沒有壓力，因為只是做回平常工作上 工作盡量做好，認證使我們認識更多。 應有的本份 ! … don’t know where to identify the relevant documents, time- line pressure, extra-job on top of ordinary clinical and administrative duties etc. What did you learn from the gap analysis? Did it help? Yes, it stated weak parts that we Know the hospital need to improve; it stated good services more. parts we need to maintain & promote. 有，比想像中 的困難少22

Chapter 4 | Engagement and Communication4.3 Reflection and Sharing on Engagement and Communication This section is contributed by The Working Group on Engagement and Communication and participating hospitals to share their views and experience on engagement and communication.4.3.1 Dr Tung Wai AU YEUNG, Chairman of The Working Group on Engagement and Communication 選擇以中文寫這篇文，一來是因為自己英文程度有限，二來是希望用坦率一些、自然一些的 語來表達我對「Accreditation」的看法。   最初收到總部邀請我做這個「Working Group Chairman」，有點意外，但也不去猜測背後原因， 便欣然接受。我曾目睹 Accreditation 確實曾引起前線怨氣，或許我能做一點點甚麼為大家評 評理、消消氣，但從不奢望可以達到「Engagement」這麼高層次的效果。   前線醫生對「Accreditation」的看法「管理層好大喜功！」這想法或宣之於口（在 Canteen Only）；或埋藏心底；這對機構的殺傷力，遠超認證帶來的任何好處。我心底想法是，也許我 的工作就是把認證的 High Profile Damp Down. 為它踩踩 Brake. 挪出一些時間和空間，讓同事 適應、接受，也不敢期望同事認同。   我想前線和管理層都要確認一重點，我們的本業是「醫病」，「認證」只是檢討我們「醫病」 的工具，主客地位不容混淆。如果「工具」破壞了「本業」，是何其戇居的舉措。所以如果因 為認證而破壞了「Team Spirit」，破壞了「本業」，那麼拿乜 A 物 A 也是多鬼餘。   有一點奇怪，一些同事，想利用「認證」去「晒冷」，「演嘢」，Aim at EA, OA，我想提醒他們， 這是認證，不是做 Show。每間醫院的歷史背景，發展重點也不一樣，得不到 EA, OA, 並不表 示同事技不如人，只是條件不同而已。相反來說，拿到「Recommendation」，才是認證的最 終目標，因為這是檢討過程，是 CQI。有了「Recommendation」，才有工作方向。我說的不 是反話，這確是 CQI 的真諦。   最後，我想說說這年來，我對「認證」的一些觀察：氣氛沒有那麼緊張了，Profile 下降， Surveyors 和善了，鬧「Accreditation」的醫生少了。試想想，二年一小考，四年一大考，若 你吓吓「死谷」，人也敗，車也壞。看你頂得幾多次。其實認證只是恒常工作的一部分，不應 當納入日常工作表中，並沒有甚麼特別處理的需要。當所有同事都覺得「Accreditation」並沒 甚麼大不了之時，便是「認證」成功之日。只望這日及早來臨，那我們的「Working Group」 也完成歷史任務，及早收工！我是樂天派，估量這天應不遠矣！ 23

Chapter 4 | Engagement and Communication 4.3.2 Castle Peak Hospital It has always been a deep rooted culture among CPH colleagues to strive for better hospital services. Since the formation of the accreditation team, we focused in communicating with our colleagues on how the accreditation could synergise with the existing continuous improvement culture in CPH. The accreditation team set up more than 100 meetings with various stakeholders of different hospital services, in which we explained to them the essence of the accreditation, and discussed on the potential improvement work in these services. With time, we were happy to see most colleagues agreed that accreditation is an effective tool for service improvement, as evidenced by numerous improvement works that are in accord with the standards set out by the accreditation framework. CPH would undergo the gap analysis survey in 2013. We learned from the pilot hospitals that participation of all staff was a key to the success in a survey, so we tried the best to engage all frontline staff as we were preparing for the gap analysis exercise. Newsletters with succinct information to all colleagues were published at very frequent intervals. A number of education sessions about the accreditation programme was organised for the frontline in the year before the gap analysis. In one of these sessions, peers from Kowloon hospital generously shared their accreditation experience with us. We were pleased to see colleagues being so eager to learn more about the accreditation. It was seldom the lecture rooms so occupied as in these forums. We acknowledged the continuous needs for active communication work in order to have colleagues embracing the accreditation as a means of continuous improvement of our services.24

Chapter 4 | Engagement and Communication4.3.3 Our Lady of Maryknoll Hospital By HUI Tze Shau, Advanced Practice Nurse, Central Nursing Division It is my great honor to be nominated by my management as a working group member of the Engagement & Communication in Hospital Accreditation. Hospital accreditation occasionally created unnecessary rumors and negative feeling among frontline staff. Therefore, one of the reasons forming this work group was to engage staff by enhancing ownership of the improvements through day-to-day practice in a reasonable and agreeable manner that supported by all levels and disciplines of staff. During the group meetings, various strategies on engaging hospital staff were discussed among different hospitals. It gave me great platform to share and learn how to increase awareness and understanding of engagement in the accreditation processes. In short, it is vital for frontline staff to participate and provide feedbacks for decision makers at ward, departmental and hospital levels. Throughout the gap analysis and organisation wide survey in OLMH, a series of staff feedback were collected through staff forums, questionnaires, on site visits and face to face interviews with video records. All the valuable comments from staff were consolidated and share to management and the hospital accreditation team for continuous quality improvement. It is a memorial but worthwhile journey for all OLMH staff working towards one goal in accreditation. 25

Chapter 4 | Engagement and Communication Our hospital staff were delighted to be accredited in 2013 and special thanks goes to HO Quality and Standards team which provide appropriate guidance and resources to our hospital including training, learning and sharing and continue to enhance the transparency through communication to frontline staff. I extend my best wishes to the coming accreditation project in HA hospitals in the future. I am sure that both patients and colleagues will benefit through continuous quality improvement on patient services in Hospital Authority.26

CCREDITATIONACCREDITATIONTPATITIOANLTATIO CHAPTER 5 ACCREDITATION andTION SLehaarrnininggHOSPITAL ACCREDITATIONHOSPITAL ACCREDITATION HOSPITALITAL ACCREDITATION 5.1 Training on EQuIP Standards by ACHSN 5.2 Topic Workshops on Hospital Accreditation by HAHOL ACCREDITATIONEDITATIONCCREDITATION 5.3 Resources of 47 CriteriaAL ACCREDITATION ACCREDITATIONDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONCREDITATION HOSPITAL ACCREDITATION HOSAPCCIRTEAADLITCATACIOCRNCERHEDODISITTPAATITTIOIAONL HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION ACCREHOSPITAL ACCREDITATION HOSPI ATION HOSPITAL ACCREDAL ACCREDITATION HOSPITAL ACCREDITA HOSPITALACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONL ACCREDITATION HOSPITAL ACCREDITATIONEDITATION HOSPITAL ACCREDITATION ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCRE HOSPITAL ACCRALTCATACIOCRNCERHEDODISITTPAATITTIOIAONL ACCREDITATIONACCREDITATION HOSPITAL ACCREDITATION

CHAPTER 5 Learning and Sharing The experience and foundation built by the Pilot Scheme in HA provide valuable reference for other participating hospitals. Learning and sharing across hospitals reduce duplication of work and support improvements in HA as an organisation. From 2011 to 2013, major initiatives support learning and sharing include the followings: 5.1 Training on EQuIP Standards by ACHS To support the Phase II hospitals participating accreditation, ACHS had organised two identical 4 day workshops for the hospital colleagues in February 2012. It covered all aspects of the ACHS EQuIP 5 Standards and accreditation program. Furthermore, two identical forums were held for Hospital Quality Teams to cover the role of Quality Manager and the preparation for survey. The post-workshop evaluation revealed satisfactory outcome which is in summarised Appendix 9.28

Chapter 5 | Learning and Sharing5.2 Topic Workshops on Hospital Accreditation by HAHO Starting April 2012, eleven monthly Topic Workshops on Hospital Accreditation have been organised to provide platform for learning and sharing among both HA and private hospitals. The workshops were organised according to the EQuIP criteria and standards. Local surveyors, colleagues from both public and private hospitals and relevant HA subject officers were invited as speakers to share their experience from different perspectives. To cater for operational needs of staff, all training materials were uploaded to the Hospital Accreditation website for easy access.DATE TOPIC OF MONTHLY WORKSHOPS NO. OF PARTICIPANTSApr 2012 IT Platform for Accreditation – CQIs 73May 2012 138 C• oAnstisneussitmy eonf tC,acraere planning, consent, discharge &Jun 2012 122 transfer, ongoing care, care of dying, health recordJul 2012 137Aug 2012 •S afPeattyi ent fall, pressure ulcer, blood and blood 235Sep 2012 components, correct patient, correct procedures, 161Oct 2012 correct sites 138Nov 2012 Quality Improvement and Risk Management 158Dec 2012 Credentialing and Scope of Clinical Practice 152Jan 2013 (Commission Training) 30 Document ManagementFeb 2013 Safe and Effective Medication Management 157 Infection Control Human Resources Management Preparation of Organisation Wide Survey (Targeted hands-on workshop) C• oErpxtoerrantaelFsuenrvcitcieonpr(o1)vider, building management, waste management, security management 29

Chapter 5 | Learning and Sharing In general, participants had positive interactions and discussions in the workshops. Most, participants revealed that the topic workshops had provided good platform for sharing and learning from both public and private hospitals. In particular, the experience sharing from Pilot hospitals was most appreciated. Participants indicated further understanding on the EQuIP criteria and the concept of hospital accreditation. It was also encouraging from the feedback that participants’ interest on the topics had increased after attending the workshops. Meanwhile, suggestions were received from participants to include more sharing of the recommendations and follow up actions from different hospitals. Evaluation of workshop Very Satis ed 0.5% Satis ed Neutral 0.7% Dissatis ed 6% Very Dissatis ed 16.7% 76% Meanwhile, workshops on some specific topics will be organised in collaboration of ACHS to enable in-depth discussion, like clinical documentation and handover. Monthly Topic Workshop Monthly Topic Workshop Monthly Topic Workshop Effective and Safety Infection Control Human Resources Medication Management Management Date: 2 November, 2012 Time: 2:00pm – 5:00 pm Venue: Lecture Theater, M/F, HAHO Date: 9 October, 2012 Collaborative Effort for Continuous Quality Improvement. Date: 3 December 2012 Time: 9:30am – 12:30 pm Collaborative Effort for Continuous Quality Improvement.Time:9:30am – 12:30pm Venue: Lecture Theater, G/F, CHP Program Schedule Collaborative Effort for Continuous Quality Improvement.Venue:Lecture Theater, G/F, CHP Speakers: Mr. Michael Ling 2:00- PhD. Josepha Tai Infection Control and Hospital 2:45pm QMH SNO(ICT) Accreditation ACHS (HK) Surveyor, 2:45- Sharing from PYNEH Speakers: Ms Joyce Leung KWH/WTSH DM(PHAR) 3:30pm Mr. Louie Chan Mr. Benjamin Kwong 3:30- PYNNSD SNO(HA) ACHS (HK) Surveyor / HKWC CGM(HR) 3:45pm Ms Cindy Chan HOCS SP(PP&CS) Break Ms. Betty Au Yeung 3:45- Senior Manager (HR) 4:15pm Hong Kong Baptist Hospital CMC SNO(Q&S)/Quality Manager 4:15- Ms. Connie Chu Sterilization Service Ms Pauline Leung 4:45pm HOCS M(N) Enhancement for Operating Manager (HR) 4:45- Theatres Hong Kong Baptist Hospital 5:00pm Mr. Mooris Lai Sharing from Union Hospital Ms Rita Agnes Wong ICN, Union Hospital Manager (Staff Development) Hong Kong Baptist Hospital Q&A Enquiry: Ms. Bonita Kwok 23006307 Enquiry: Ms. Bonita Kwok 2300 6307 Ms. Gloria Ho 2300 6190 Enquiry: Ms. Bonita Kwok 2300 6307 Ms. Gloria Ho 2300 619030

Chapter 5 | Learning and Sharing5.3 Resources of 47 criteria For the early adopters of accreditation, the focus and requirements of 47 criteria in EQuIP 5 may look too general. To facilitate a more comprehensive understanding, a one-stop platform was developed to link related information, from the accreditation criteria content, related indicators, policies and training materials to other hospitals’ CQI programs and comments from previous surveys. 31

Chapter 5 | Learning and SharingCriterion ContentRelated CQIsMeasuring Performance ACHS Clinical Indicators HA Clinical IndicatorsTraining MaterialsComments from surveysOther Resources (HA policies/website etc) HA policies Websites Example of Pre-Survey Assessment Others Organisation: Organisation Wide Survey - OWS Orgcode: XXX hospital 12345 Function: Clinical Std 1.1 Standard 1.1 Consumers / patients are provided with high quality care throughout the care delivery process. Criterion 1.1.1 The assessment system ensures current and ongoing needs of the consumer / patient are identified. Key Improvements 1. Key Improvement Patient assessment and care plan What did you change Reviewed the patient assessment and care planning framework Developed a new set of patient assessment form and care plan Result / Outcome Piloted in M&G in 1Q 2010.32 Result was encouraging and high compliance rate. Based on the version developed and used in M&G, similar version is developed other specialties, with slight local adaptation as appropriate.

CCREDITATIONACCREDITATIONTPATITIOANLTATIO CHAPTER 6TION HAOCCSRPEITDAITLATAIOCNCREDITATIOaRN nedcoImmmpreonvdeamtieonntssHOSPITAL ACCREDITATION HOSPITALITAL ACCREDITATION 6.1 ACHS EvaluationN 6.2 Recommendations and ImprovementsL ACCREDITATION with Corporate-wide Implications in HAEDITATIONCCREDITATIONAL ACCREDITATION ACCREDITATIONDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONCREDITATION HOSPITAL ACCREDITATION HOSAPCCIRTEAADLITCATACIOCRNCERHEDODISITTPAATITTIOIAONL HOSPITAL ACCREDITATION HOSPITAL ACCREDITATION ACCREHOSPITAL ACCREDITATION HOSPI ATION HOSPITAL ACCREDAL ACCREDITATION HOSPITAL ACCREDITA HOSPITALACCREDITATION HOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONL ACCREDITATION HOSPITAL ACCREDITATIONEDITATION HOSPITAL ACCREDITATION ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCRE HOSPITAL ACCRALTCATACIOCRNCERHEDODISITTPAATITTIOIAONL ACCREDITATIONACCREDITATION HOSPITAL ACCREDITATION

CHAPTER 6 Recommendations and Improvements 6.1 ACHS Evaluation This section is contributed by ACHS, our collaborating accrediting agent based on the surveys it conducted from 1 April 2011 to 31 March 2013. In general, there are three types of surveys: Organisation-wide Survey (OWS), Periodic Review (PR) and Gap Analysis. Figure 4: The 4-year EQuIP Cycle34

Chapter 6 | Recommendations and ImprovementsThe accreditation system, EQuIP, is based on a four-year membership program wherebyhospitals are required to undergo two onsite surveys. The first of these is the OWS.The OWS involves the achievement of the hospital against all the EQuIP criteria and the aimsare:• To verify the hospital’s self-assessment• To conduct an external peer assessment of the hospital’s performance• To provide feedback and offer advice to the hospital that may assist with further improvement• To award accreditationThe PR is an onsite survey conducted two years after the OWS. The hospital is surveyed againstthe mandatory criteria and progress on the recommendations from the OWS is assessed. Theaims of the PR are:• To verify that levels of patient care remain satisfactory• To maintain momentum for continuous quality improvement beyond the OWS• To assess progress against recommendations from the OWS• To adjust accreditation status if necessaryA Gap Analysis is conducted, prior to joining the EQuIP accreditation program and theobjectives are:• To provide the hospital with a written assessment of its readiness to undergo an ACHS EQuIP OWS in accordance with the Standards.• To undertake an analysis of how the hospital has endeavoured to meet the Standards and identify where there are some opportunities for improvement or areas that need to be strengthened prior to the OWS.• To supplement the hospital’s own gap analysis process being undertaken by ongoing self- assessment.• To provide education to staff in the principles associated with the EQuIP process.• To provide the ACHS with an assessment of the duration of the OWS together with a proposed composition of the OWS survey team. 35

Chapter 6 | Recommendations and Improvements A team of experienced ACHS Consultant Surveyors conduct the consultancies to determine the readiness of the hospital for an OWS. The process used by the Consultants equates to a sampling technique of gathering evidence against each Standard by having discussions with staff, undertaking visits to areas and making an analysis on the evidence provided to determine the status of the hospital’s readiness. The Consultants do not assign ratings but will acknowledge the strengths in service areas across the hospital whilst at the same time identify opportunities for improvement based on best practice, identify those areas that require to be strengthened prior to an OWS and provide education to staff in the principles associated with accreditation. There will be an emphasis by the Consultants on those Standards that have mandatory criteria; all Standards will be covered during the course of the consultancy. The Consultants will provide a written assessment of their findings that outline the hospital’s strengths against each Standard together with opportunities for improvement and areas that need to be strengthened prior to an OWS. An executive summary for the Standards associated with each Function is provided together with comments for each criterion. The Gap Analyses were also used to identify those services which are provided to the hospital by the Cluster and which will be subsequently surveyed as a Cluster based service. A Priority Action Item (PAI) is made where the Consultants believe that there is a risk of not meeting an appropriate rating for the criteria during the OWS. 6.1.1 Periodic Review (PR) of Five Pilot Hospitals Five pilot hospitals had their PR conducted during the reporting period: HOSPITAL SURVEY DATE (MONTH/YEAR) Pamela Youde Netheroslole Eastern Hospital (PYNEH) June 2012 Caritas Medical Center (CMC) July 2012 Queen Elizabeth Hospital (QEH) July 2012 Tuen Mun Hospital (TMH) September 2012 Queen Mary Hospital (QMH) October 201236

Chapter 6 | Recommendations and ImprovementsThe OWS of five pilot hospitals were undertaken in accordance with the HK EQuIP 4 Guidelineswhereas the PR of these hospitals was undertaken in accordance with the HK EQuIP 5Guidelines.Results of the PR for five pilot hospitals indicated an overall favourable performance. Therecommendations from the OWS were all appropriately addressed with some exceptionswhere the timeframe for completion exceeded the period between the two onsite surveys.All hospitals had achieved an MA (Marked Achievement) or higher rating in the 15 MandatoryCriteria.Summary of the recommendations from the PR of five pilot hospitals, under the mandatorycriteria, are at Appendix 10.6.1.2 Gap Analyses of Seven Phase II HospitalsOf the 15 participating Phase II hospitals, seven underwent their Gap Analyses in 2012 and 2013.HOSPITAL SURVEY DATE (MONTH/YEAR)Our Lady of Maryknoll Hospital (OLMH) June 2012Pok Oi Hospital (POH) August 2012Tung Wah Hospital (TWH) September 2012Kowloon Hospital (KH) October 2012Prince of Wales Hospital (PWH) November 2012North District Hospital (NDH) November 2012United Christian Hospital (UCH) March 2013Gap Analysis provided each hospital with an opportunity to gain more understanding of theaccreditation process and the areas which they needed to focus on in strengthening care andservice delivery in preparation for an OWS. After Gap Analysis, the ACHS Consultants, wouldprovide guidance and advice to assist each hospital preparing for accreditation as part of itsCQI journey and the support has been warmly welcomed by the hospitals. 37

Chapter 6 | Recommendations and Improvements Comments from hospitals on the Gap Analyses included: “It is a precious experience to work with you and your team! BTW, I have a new perspective on hospital accreditation - It is not only a process for continuous quality improvement, but an activity of pulling all staff members in the hospital together working as a big team and removing the boundaries between departments. This is what I treasure most”. “The hospital had a fire … Thanks to the regular fire drills in preparation for accreditation, the evacuation was orderly. There was no panic and no injury. This can be a good example of the importance of safety that is emphasised by ACHS”. Summary of PAIs by criterion is detailed in Appendix 11 6.1.3 Organisation Wide Survey of One Phase II Hospital During the reporting period ending 31 March 2013, only one hospital, Our Lady of Maryknoll Hospital (OLMH), had undergone an OWS. In summary, the surveyors recognised the hospital’s efforts in providing holistic care. Patient care was provided in aged, but extremely well maintained buildings. The survey team was provided with ample evidence to demonstrate satisfactory performance in all criteria. More details on the achievement rating and recommendations are provided at Appendix 12.38

Chapter 6 | Recommendations and Improvements6.2 Recommendations and Improvements with Corporate-Wide Implications in HA Recommendations from surveys provide hospitals with opportunities to review their practices and identify areas for further improvement. While most recommendations are specific to individual hospitals and being followed up at hospital level, there are recommendations which are common across hospitals and/or have corporate implications requiring HA Head Office co- ordination. Usually, Department of Quality and Standards, HA Head Office would seek local expert opinions, coordinate appropriate follow up actions with relevant stakeholders, and communicate with ACHS on the corporate direction, if required. This section summarises the common recommendations and their progress in HA.6.2.1 Sterilization Enhancements Since the first round of gap analysis in five pilot hospitals in 2009, HA was advised to review and enhance its surgical instrument sterilization services in the operating theater (OT) in par with contemporary international standards. (i) Establishing the Task Force on the Sterilization Standards of Operating Theatres In view of the scale, complexity and financial impact, the Task Force on the Sterilization Standards of Operating Theatres (Task Force) comprising members from various divisions and clusters was formed in May 2010. Working Groups were also set up under the Task Force to review the service standards and oversee the implementation of enhancement initiatives across clusters with due consideration of factors such as financial viability and physical setting constraints. Directors’ Meeting Task Force on Sterilization Standards of Operating Theatre Consultancy Study on external Sterilization Enhancement consultancy Working Group on Working Group on Working Group on ImplementationDisinfection & Sterilization Surgical Instrument Review of Governance Working Group Structure & Work ow De ned & of Surgical Instrument Tracking System De ned workout scope Review standards of De ned tracking governance & of renovation work practice on to ‘tray level’ work ow disinfection & Agreed on sterilization of standardization of surgical instrument coding WG on Cataloguing WG for User Speci cationStructure of Task Force on Sterilization Standard of Operating Theatre 39

Chapter 6 | Recommendations and Improvements The Working Groups examined the disinfection and sterilization standards, service policies, instrument tracking system, governance structure, quality of linen in OT, and facility enhancement in two levels : • Priority/short-term improvement plans included the overall implementation of proper steam sterilization for critical instruments, enhancement of the sterile barrier system for surgical instrument pack, and elimination of flash sterilization as a routine practice. • The long-term solution was the development of corporate-wide surgical instrument tracking and tracing system and the establishment of a centralised sterilization unit with robust operational and corporate governance structure. (ii) Update on the Improvements As of 2013, progress had been made in the following aspects: • Launch of HA Guidelines The first corporate guideline, titled “HA Guidelines on Disinfection and Sterilization of Reusable Medical Devices for Operating Theaters”, was developed and launched in February 2011. External consultants from the United Kingdom and Australia were tasked to review the corporate guidelines in 4Q 2011. Input was also enlisted from the local experts with reference to international standards and discipline-specific guidance documents. Consultation and reality check were conducted by frontline end users in 4Q 2012, and the updated version is expected to issue in 4Q 2013. • Implementation of Proper Steam Sterilization for Surgical Instrument To address the increasing demand of OT services, some hospitals have performed flash sterilization and chemical disinfection in OTs to compensate for the insufficient inventory of instruments. The use of routine flash sterilization for surgical instruments and chemical disinfectant for rigid endoscopes that enter the sterile cavity is no longer acceptable globally for infection control and patient safety. HA has sought funding from the Government to support hospitals rectify their practices. All hospitals with OT services had successfully eliminated the use of chemical disinfectants for rigid endoscopes and flash sterilization for surgical implants. With the completion of facility enhancement in Tuen Mun Hospital in 2012 and the support from the corporate management team, multi-disciplinary work groups comprising surgeons, nurses, facility managers, and business support staff, are working towards total elimination of routine flash sterilization practices in all HA hospitals by 2015.40

Chapter 6 | Recommendations and Improvements• Quality Enhancement of the OT Linen Packaging and wrapping of surgical instruments for sterilization provide an effective barrier against sources of potential contamination in maintaining sterility. With collaborative efforts of the Sterilize Supplies Services Special Core Group and Business Support Services of HA Head Office, and additional resources in 2013 and 2014, all conventional linen wrappers used in OT would be replaced by modern disposable sterile barrier wrappers, thus improving the sterility of OT instruments. This enhancement does not only maintain an efficient microbiological barrier but also has long-term financial benefit, as recommended in the Linen Management– Cost Analysis Working Paper in 2012. 41

Chapter 6 | Recommendations and Improvements • Development of a Corporate Electronic Surgical Instrument Tracking and Tracing System The main objective of surgical instrument tracking and tracing is to safeguard patient safety in times of product recalls and contagious diseases such as the Creutzfeldt- Jakob disease (CJD). An effective tracking and tracing system is also essential to ensure timely delivery of sterile instruments for scheduled operations. A corporate electronic Surgical Instrument Tracking System (SITS) which links with the Clinical Management System (CMS), in providing patient’s information required surgical procedures to be undertaken and instruments required, is planned. The framework for a common catalogue of surgical instrument was developed in 2011 to ensure data consistency and quality. The Work Group on SITS adopted a phased approach which was first piloted the system in Prince of Wales Hospital, Queen Mary Hospital and United Christian Hospital in March 2013. After evaluation, the system will subsequently be rolled out to five other hospitals by 2014, nine hospitals by 2015, and all HA hospitals by 2016. • Enhancement of Sterilization Facilities An external consultancy study 1 conducted by experts in decontamination and sterilization services was conducted from 2011 to 2012. The study recommended the establishment of a centralised sterilization unit, conducting capacity planning, minimising manual wash, and proper segregation of clean and dirty zones. Since most sterilization facilities in HA were built in 1970’s and 1980’s, there was a need to review the current design, including inspection on the physical construction, temperature and humidity control, and cleaning and disinfection practices. The planning for service enhancement requires design solutions that not only satisfy functional requirements but also ensure maximum economy in terms of capital and running costs. Funding from the Government was secured to support improvements in four hospitals, namely, Queen Mary Hospital, Queen Elizabeth Hospital, Kwong Wah Hospital, and Yan Chai Hospital which had been reviewed by external consultants. 1 Review and Recommendations on the Enhancement of Disinfection and Sterilization Standards and Practices in Operating Theaters in Public Hospitals by The Third Horizon Consulting Partners from 12 September 2011 to 25 April 2012. The report summary is attached as Appendix 1042

Chapter 6 | Recommendations and Improvements The improvement projects were planned from 2013 to 2015 to cover capital works, equipment beef up and staff training. With the service commencement of newly renovated Central Sterile Supplies Department cum Theater Sterile Supplies Unit in Tuen Mun Hospital in 2013, HA will no longer perform routine flash sterilization practices for elective surgeries 2.• Establishment of a Consistent Governance Structure Accreditation surveys commented that the prevailing governance and organisational arrangements of sterilization services were fragmented and local which were not conducive to effective and efficient instrument reprocessing service planning and delivery. The external consultancy study also recommended a robust operational and governance framework to sustain the improvement momentum. To this end, a cluster lead was nominated from each cluster to oversee and monitor service quality and operations. A blueprint for centralised service model was developed to facilitate an efficient integration and co-ordination of operational activities and enhancement initiatives.2 All hospitals would completely disregard routine flash sterilization by 2013, except Yan Chai Hospital (YCH) due to its physical limitation. Improvement in YCH will be completed by 2015, after completion of facility renovation. 43

Chapter 6 | Recommendations and Improvements 6.2.2 Document Control and Management Document control and management was identified as one of the common gaps in the Pilot Accreditation program. Areas for improvement focused on document control framework, improving access and search of policies and guidelines relevant to area of practice. (i) Developing Corporate Guidelines on Documentation To fill the gap at the corporate level, “Guidelines on Patient Care Documentation” was developed in 2011 to align the document control principles and provide guidance on document control process at hospitals. (ii) Piloting Electronic Document Management System (eDMS) To streamline the document control process, an electronic document management system was piloted in two hospitals, Queen Mary Hospital and Caritas Medical Centre and some departments in HA Head Office, liked Nursing and Pharmacy in 2011/12. Post-pilot evaluation was positive The electronic system provides a repository of updated clinical guidelines, policies and procedures as well as linkage of documents between Head Office and hospitals. Document owners at hospitals are notified automatically for any document change at HA Head Office, and reminded when document is due for review. Topic Workshop on Document Management and CMC User Training (iii) Strengthening the Management Structure and Process The Directors’ Meeting (October 2012) at HA Head Office supported further strengthening the structure and process of document control and management. A Working Group on Document Control and Management was thereby set up in early 2013. A series of engagement and consultation sessions were conducted in 2012/13 for clinical Co-ordinating Committees/Central Committees (COC/CCs), who are the key owners of corporate clinical guidelines/procedures. More COC/CCs, HO departments and hospitals have planned to adopt the electronic document management system in phases in 2013/14.44

Chapter 6 | Recommendations and Improvements (iv) Improving Access to Clinical Policies and Guidelines Clinical policies and guidelines are important document to guide clinical operation. These policies and guidelines were currently posted at different sites at HA web. While staff expressed difficulties in accessing these policies/guidelines, document owners also made duplicated efforts in updating document at various sites. Collaborative efforts were made amongst the COC/CCs, HA web master, Electronic Knowledge Gateway (eKG), Information Technology (IT) and Quality and Safety (Q&S) to improve this situation. By July 2013, COC/CCs would have completed review most of their guidelines and the single platform for clinical policies and guidelines would be launched in October 2013.6.2.3 Credentialing and Defining Scope of Practice Modern healthcare is complex and is constantly changing with the introduction of new clinical services, procedures and technologies. There needs a system to ensure the initial and ongoing competency of healthcare practitioners for safety and quality in care provision. Credentialing and defining scope of practice help to assure the care is provided by the right practitioners, with the right skills, doing the right task, with the right support, in the right place. (i) Definition Note Credentialing refers to the formal process used to verify the qualifications, experience, professional standing and other professional attributes of practitioners for the purpose of forming a view about their competence, performance and professional suitability to provide safe, high quality health care services within specific organisational environments. Defining Scope of Practice follows on from credentialing and involves delineating the extent of an individual practitioner’s clinical practice based on credentials, performance and peer reviewed competence.Note Reference source: Australian Council for Quality and Healthcare, National Standard on Credentialing and Defining the Scope of Practice, Canberra 2004 45

Chapter 6 | Recommendations and Improvements (ii) Progress Update Credentialing and defining scope of practice were identified as areas for improvement during the pilot hospital accreditation program in 2009. The five pilot hospitals started to develop their credentialing policies while some Co-ordinating Committees/Central Committees (COC/CC) explored identifying procedures for defining the professional requirements. At HA corporate level, in 2011, a Task Force comprising representatives from clinical COC/ CCs, grade management of doctors, nursing and allied health, Human Resources and Quality & Safety (Q&S) was formed to deliberate on the potential impact of credentialing development in HA and propose the way forward. The direction and strategies for credentialing development in HA were discussed in the Medical Policy Group (MPG) Meeting in April 2012, subsequently at the Medical Service Development Committee (MSDC) Meeting in May 2012 and Directors Meeting in July 2012. With the comments from various management committees, a cautious and step by step approach was adopted and focus was put under four major aspects: • Strengthening communication with both internal and external stakeholders –– Completed consultations with COC/CCs and professional grade management. In 2013, HA representatives started to participate in the Credentialing Working Group of the Hong Kong Academy of Medicine on developing related policy. • Improving information sharing –– A Central Registry on Credentialing and Defining Scope of Practice would be launched in July 2013 to share information on related structure/policies/ guidelines and procedures being credentialed at clusters/hospitals and clinical specialties.  • Engaging clinical specialties in developing competency led standards –– Clinical specialties through their COC/CCs were engaged to identify procedures and establish the standards/ criteria for defining scope of practice.46

Chapter 6 | Recommendations and Improvements • Developing corporate policy to guide implementation –– In 2012, a “Framework on Credentialing” was developed which set out the principles and key domains in credentialing. The Framework was being widely consulted at COC/CCs and clusters.(iii) Work Plan After wide consultation with stakeholders, a proposed framework for credentialing and defining scope of practice development in HA has been developed which will be submitted to MSDC at Board level for discussion and endorsement. With the Board’s approval, the governance structure will be set up to launch the corporate policy, oversee its implementation, as well as to identify prioritised procedures/activities requiring defining scope of practice. Meanwhile, staff consultation at different levels will continue to enhance communication and alignment. In addition to collaborating with COC/CCs in enhancing clinical specialty led competency standards, HA will also explore IT support to facilitate tracking and verification of credentialing information. 47

Chapter 6 | Recommendations and Improvements 6.2.4 Cessation of Cotton Wool Balls in Clinical Area Using of cotton wool ball for cleaning open wound was a common practice in hospitals. Surveyors recommended review of this practice as cotton wool balls shed lint which should not be used on or near wounds. The lint would stick to the wound and suture line which may delay wound healing. It was recommended to replace the cotton wool ball with non-woven gauze when dealing with wounds. Local expert advice from the Task Force of Infection Control (TFIC) was sought which agreed that literature review does not support the use of cotton wool ball for dressing, so non-woven dressing material should be used instead. Business Support Services (BSS) of HA Head Office acknowledged the recommendation and had replaced all cotton wool balls with non-woven gauze in the dressing sets. 6.2.5 Developing Count Sheet in Operating Theater (OT) that Complies with International Standard To ensure safe surgery practice, counting of instruments and consumables is an important process during surgery or procedure. In some hospitals, although instrument count was undertaken at relevant points during a procedure, only a summary of the check was recorded and filed in the patient record. A non-permanent record such as a markings on whiteboard was used to manage the counts during the procedure before a summary of the check was recorded in some instances. Surveyors commented that the best practice was Temp: 134OC Infiniti Vision System Ozil (Alcon) x 15 F122 to document the instrument and consumable Alcon 8065803602 counts and keep it in the patient’s history. There were many examples of count sheets for reference Qty Particulars and the one designed or adopted by HA should Instruments: comply with a published standard. Audits should also be undertaken to evaluate compliance. Silicone Matress 135mm x 240mm A Working Group was formed under the 1 Operating Theatre Specialty Advisory Group (OTSAG) of Nursing Services Department of Head Handpiece Infiniti Ozil w/cable & metal cap (please cap before washing) Office to work out a standardised count sheet that complies with international standard. After 8065750469 consultation with OT colleagues, the Working Group has developed guiding principles and 1 generic count sheet for hospital use. The generic count sheet guides individual OT department in I/A Handpiece infiniti, Coaxial, w/ white protective cap x 1 (set of 2) (8178 XXXXXX) documenting the counting process to meet their perioperative needs. Four staff briefing sessions 8065817801 were conducted, with comments and feedback collected for further improvement. 8065751012 1 8065740749 Infiniti Ozil Intrepid I/A 0.3mm tip (keep in pouch) 1 Wrench for Ozil handpiece - metal 1 Handpiece,Bi-Manual (Irr. 8-652, Asp. 8-657 ) (Set of 2) Irr. 8-652, Asp. 8-657 1 22/11/2011 Chemical Indicator 148