Report on Hospital Accreditation 2011-2013_Final

Chapter 7 | Hospitals SharingThe nursing-initiated pilot of near miss reporting of medication incidents places usin a strong position to enhance the reporting of near misses more broadly across thehospital. It is important that all departments and staff groups are actively contributingto a positive near miss reporting culture.To enhance the near miss reporting culture across all departments and staff groups,complemented with the Advanced Incident Reporting System (AIRS) 3, a near-missreporting forum was held in March 2013. Among the over 350 attendance of clinicalstaff, over 98% agreed that the forum enhanced alertness of staff towards quality andsafety issues with a view to effecting behavioral changes in daily work practices.A new cluster-wide reporting form was implemented in May 2013 for departmentsto report near-misses and for Q&S Office to capture data for review and analysis to becarried out in August 2013. Two identical training forums for staff and a designatedforum for AIRS filter-person were conducted in June 2013 to enhance understandingand facilitate smooth rollout of the new AIRS 3 system in July 2013.Staff sharing forum on the new AIRS 3AIRS 3 99

Chapter 7 | Hospitals Sharing Criterion 3.2.4  Standardisation of Emergency Trolley The layout of items in emergency trolleys was found to be different among wards. In the Periodic Review of 2012, surveyors recommended to strengthen the risk management in relation to resuscitation. The Cluster Resuscitation Committee endorsed and developed staged plan to standardise layout, content and checklist of different models of resuscitation trolleys in use, and also segregation of paediatric and adult airway management equipment. The standardisation of emergency trolley was completed by phases in 2Q2013. A paediatric box is also placed in related trolleys. Audit on the trolleys would then be conducted in 3Q2013. Briefing session on standardisation on emergency trolley Department representatives, Nursing Services Department Staff, Cluster Resuscitation Committee Chairperson after the briefing session100

Chapter 7 | Hospitals SharingCriterion 1.5.2  Infection Control related to EndoscopesEar Nose and Throat (ENT) endoscopy is undertaken in the Accident and EmergencyDepartment (AED), however the recording of the use of individual scopes is not properlytracked. Based on recommendation from surveyors in the Periodic Review of 2012, a ‘WorkingGroup on Tracking & Tracing of Reprocessing of Flexible Endoscopes in PYNEH’ was thusformed in December 2012. Measures including assigning a unique code for departmentowned endoscopes, creating a unit based data tracking file/record book, standardising theendoscopes reprocessing record in hospital were taken.Surveyors also recommended to ensure that clean and dirty endoscopes in satellitedecontamination areas should be properly separated. Review on workflow ofdecontamination and disinfection was conducted in Combined Endoscopy Unit (CEU),Department of Clinical Oncology (OPD), Department of ENT (LG5, SOPD), Department ofAnaesthesia (C10) and ICU (B10) in October 2012 and subsequent review would be conductedin August 2013 to ensure that there was adequate separation of clean and dirty equipment.The hospital also encouraged the use of disposable items to minimise risk of contamination.Reusable suction connecting tubing had been replaced by disposable one since January2013. “Endo Carry On” device was sourced for trial run since June 2013 for transportation ofendoscopes to reduce risk of cross-contamination of soiled and clean scopes. There was alsoa hospital long-term plan to relocate the Combined Endoscopy Unit (CEU) to a bigger areafor better separation of dirty and clean zones. In the interim, renovation works to improve theEndoscopy suite in Department of Clinical Oncology and CEU was completed in January andJuly 2013 respectively.Improvement work at Oncology LG1 Endoscopy 101

Chapter 7 | Hospitals Sharing Improvement work at C5 – CEU Endoscopy room Criterion 1.5.1  Multi-dose Vials of Insulin Multi-dose vials of insulin are commonly used for more than one patients in the hospital, instead of dispensing to a single patient. In the Periodic Review of 2012, surveyors pointed out that multi-dosing of any medication between patients was no longer recommended. Hospital should identify best practice guidelines in relation to the use of insulin which comes in multi-dose vials and make any required changes. Hence, our hospital explored international guidelines/best practice such as Centers for Disease Control and Prevention (CDC), Australian Government National Health and Medical Research Council, and The Royal Children’s Hospital Melbourne. Furthermore, the issue was raised in HAHO Improvement Liaison Group in November 2012. Clusters shared the difficulty and concern of using single dose insulin. Apart from insulin, stock take other multi-dose drugs (e.g. heparin) in clinical departments was conducted in April 2013 to determine the magnitude of issue. Tens of multi-dose drugs were identified and a preliminary assessment revealed that administration of most of the items could be changed to single-use or multi-dose for single patient. Cost implication and proposed action plans would be reviewed in 3Q2013. The hospital would consider progressive replacement of some multi-dose vials to single use vials/ampoules subject to availability of supply and budget.102

Chapter 7 | Hospitals Sharing7.7.2 Staff Engagement, Communication, Learning and Sharing Staff engagement, teamwork and communication among different levels of staff are important throughout the accreditation journey. Various communication platforms with staff were created and staff engagement activities directing towards better understanding and stronger motivation on quality improvement initiatives were held.(i) Staff Sharing Forums and Training WorkshopsVarious staff sharing forums and training workshops were organised in 2011 and 2012with over 600 staff attended and positive staff feedback received.October 2011 Sharing Forum on Phase 3 Self AssessmentFebruary 2012 Training Workshop on Transition to EQuIP 5 standardsMarch 2012 Phase 4 Periodic Review ‘Warm-up’ SessionJune 2012 Pre-Periodic Review Sharing ForumSeptember 2012 Post-Periodic Review Celebration Forum and Preparation of Phase 1 Submission 103

Chapter 7 | Hospitals Sharing (ii) Department Visits and Meetings Communication network was established to enable efficient information dissemination and alignment of practice. Regular department visits and meetings were held with Department Coordinators and Quality Champions to facilitate departments to integrate the quality management framework and CQI principle of hospital accreditation into our daily practices, as well as better equip departments for on-site survey. (iii) Newsletters Newsletters on the accreditation journey were published to share with all staff the achievements in accreditation, the latest accreditation status and express gratitude to our colleagues for their hard work and unfailing support.104

Chapter 7 | Hospitals Sharing(iv) Website Information and useful materials are available on the accreditation website for staff learning about accreditation and departments’ preparation for report submission to ACHS and on-site surveys.(v) Experience SharingOur accreditation experience is shared with other hospitals and healthcare institutions:May 2011 Department Visit and Sharing on Accreditation Experience at YCHJuly 2011 Sharing of Accreditation Experience by CCE at HAHO Administrative Grand RoundNovember 2011 Sharing Forum at TWHDecember 2011 Sharing Forum at YCHApril 2012 Sharing Forum at TWEHNovember 2012 Monthly Topic Sharing Session on Infection Control at HAHOFebruary 2013 Monthly Topic Sharing Session on corporate functions at HAHO 105

Chapter 7 | Hospitals Sharing 7.8 Queen Elizabeth Hospital 7.8.1 Recommendations and Improvements (i) Safe Use of Patients Physical Restraint A Cluster based multi-disciplinary task group on physical restraint was established in 2011 to review the current situation and formulate a comprehensive care model on physical restraint use. This is partly in response to a recommendation made in the 2010 Organisation Wide Survey (OWS) to review the use of patient physical restraint based on a set of pre-determined evaluation criteria including use of equipment and documented compliance with prevailing policy and guidelines. The task group started by gathering inputs on current practice gaps from members representing a broad cross-section of the clinical and non-clinical services – including allied health, patient services and administrative support colleagues. This led to the review of the current cluster policies and practice guidelines and the renewal of the entire set of documents related to physical restraint through a joint effort of the cluster Quality and Safety (Q&S) and Central Nursing Departments. A new Cluster Standard Operating Procedure was endorsed in 2012, and the accompanying documentation forms and patient information leaflets were later updated and incorporated into the Standard Operating Procedure (SOP). Cluster wide point prevalence surveys on physical restraint were conducted in May 2011 and 2012 which were also part of the HA-wide annual nursing quality audit. An extended review of the compliance with documentation and patient observation requirements was also conducted in the 2012 audit. Surveys in both years showed similar rate and prevalence of physical restraint across different wards and specialties, and in the 2012 audit, variable completion rates for the necessary documentation were evident, and areas for improvement in inter-disciplinary collaboration and patient observation were identified. Physical Restraint – Bilingual Patient Information Fact Sheet106

Chapter 7 | Hospitals Sharing(ii) Risk RegistriesSince the publication of the fifth edition of the EQuIP guidelines and standards in 2010,QEH had since made reference to the updated standards and hospital accreditationframework in planning the risk registry initiatives. 2012 also marked the time for theHAHO to review and renew the corporate risk management approach with the aid of anappointed external Consultant. The Kowloon Central Cluster (KCC) and QEH 2012 and2013 risk registry initiatives rode on the above and evolved to embrace the followingcritical changes:• Establishment of Departmental Risk Registries were promulgate among all clinical and non-clinical departments, embracing clinical and non-clinical risks in interrelated and dynamic webs to avoid “silo” approach.• A bottom-up approach from operating fronts was promulgated, but risk identification is also underpinned by a top-down, overarching framework that highlighted significant shared risks and common concerns.• The risk identification and mitigation are action focused and outcome driven, emphasising the need for a quantitative assessment of risk before and after risk reduction strategies with evaluation of the effectiveness.• Risks are under constant scrutiny throughout the year with a “dynamic” approach so that emerging risks are being added to the registry, and stable, controlled risks can either be retired from the active registry or transferred to a “watch list” after fulfilling a set of pre-defined criteria.To promote staff understanding and engagement, Risk Register Workshopannual risk registry workshops conducted by theCluster Quality and Standard Senior Managerhad been held for departmental subject officersbefore planning and discussions of the registriesfor the next 12 months. On the managementside, the Hospital Risk Registries are endorsed bythe hospital management and promulgated tocolleagues in various management meetings andon the Quality and Safety website. The progressof risk mitigation responses were updated usingthe calendar year scheduling in phase with theyearly activities of hospital accreditation, annualplan and mid-year reviews (the so-called “QualityCalendar”). Summary of priority risks identification,reduction and monitoring are reported to thehospital management in the annual GovernanceReport. 107

Chapter 7 | Hospitals Sharing KCC / QEH Risk Registry 2013 Quality “Calendar” (iii) Credentialing and Defining Scope of Clinical Practice The QEH has continued work on credentialing and defining scope of clinical practice started since the earliest phase of the Hospital Accreditation Pilot Scheme in 2009. The Credentialing Steering Committee and the three Credentialing Committees for Medical, Nursing and Allied Health Professionals were established in 2010. The Cluster Policy on Credentialing and Defining Scope of Practice for Healthcare Professionals was also endorsed in the same year and updated in 2012. The Credentialing Steering Committee continues to refine the frameworks under which credentialing will occur and had been working collaboratively with the Task Force on Credentialing in HA to align the development of the credentialing system. Regular meetings are held with the medical, nursing and allied health Credentialing Committees. For the Medical Credentialing Committee, regular checking of the gazette and HK Medical Council Specialist Register by Human Resources (HR) was implemented. A risk and activity based approached has been adopted in the credentialing framework, and defining scope of practice would be focused on special skills required in high- risk, high complexity procedures as well as procedures using new technology. The KCC credentialing procedure list for medical specialists included both department specific and centralised procedures. The credential list would be reviewed in every 12 months, and departments could update the credential list upon staff movement and changes of credentialing criteria. The maintenance of the credential list is by one single central database for the credentialed of high risk/high complexity procedures. The credential list is currently maintained by HR using eLearning platform. HR would update the staff movement and inform respective departments on the updates in due course.108

Chapter 7 | Hospitals SharingFor credentialing of nursing professionals, the Central Nursing Department maintained therecord of the licensure state of all nursing staff practicing in the hospital. The high risk/volumeprocedures were agreed to be submitted to the HA Specialty Advisory Group for revisionand to the HA Co-ordinating Committee (Nursing) for endorsement. Nursing proceduresthat required specific qualification, high risk procedures done independently by nurses orby doctors and nurses collaboratively. Centralised database would eventually migrate to theNursing Record System or to the to be developed HAHO database.The membership of the Allied Health professional Credentialing Committee includedrepresentatives of all HA Allied Health Disciplines including Dispensing, Medical Social Work,and Clinical Psychology. In view of the complexity of the staff groups, it was suggested tofocus credentialing and defining scope of practice initially on those disciplines that performhigh risk procedures. Progress of different disciplines are understandably variable, and notdissimilar to the approach taken by the Medical and Nursing Credentialing Committees,departmental specific high risk/high complexity are looked into in the first phase. Establishedsystems are found in the Physiotherapy and Diagnostic Radiology and Imaging department,and they had already submitted departmental specific high risk / high complexity procedures.Governance Structure of Credentialing in KCC / QEH 109

Chapter 7 | Hospitals Sharing 7.8.2 Staff Engagement and Communication Throughout the hospital accreditation journey, the QEH has been putting the top priority in staff engagement and communication. A cascading structure of quality and safety had been built into all operational departments in the past few years, to promote ownership and accountability. It is hoped that departmental Quality Champions will serve as the bridge between the Hospital Q&S leaders and the frontline colleagues, leading local quality and safety initiatives through formal governance structures that report to the Department Heads, Chiefs of Service and to the Hospital Management. In this respect, subject officers for essential quality functions in the department e.g. medication safety, document control, risk registry etc., have been appointed by the Department Heads. The Quality Champions also work closely with the Hospital Accreditation Project Team in the collaboration of accreditation activities. The QEH Hospital Accreditation website serves as a nidus for chronologic record and sharing of accreditation journey information, and has attracted a high number of hits since its commensuration at the beginning of the Pilot Scheme. Accreditation roll out governance structures, meeting notes, presentation files, etc., are all easily accessible on the web site. 7.8.3 Learning and Sharing In continuing the rolling “Years of Safety” program in •th一e心K一CC意Q”uwalaitsycoCnodnuvecntetdionon“Q11uaNliotyve•mObUeRr KCC, WAY 質素 2011 in the Chinese University of Hong Kong – Tung Wah Group of Hospitals Community College. Since quality improvement is an on-going process, this convention would not be a conclusion of the “Years of Safety”. Rather, the aim was to highlight the continuous momentum of Plan-Do-Check-Act cycle in quality improvement and safety through collaborative team work and commitment of everyone. The message has been clearly shown in the design of the logo for the convention. Poster for the KCC Quality Convention on 11-11-11110

Chapter 7 | Hospitals SharingThe Australian Council on Healthcare Standards (ACHS) Periodic Review (PR) survey wascompleted in QEH on 23 to 27 July 2012. After the Periodic Review, QEH has gone through afull cycle along the ACHS EQuIP hospital accreditation framework. With an aim to review thejourney of ACHS hospital accreditation in terms of improvement actions taken and theoutcomes achieved, a retreat: ‘Quality & Excellence in Healthcare – Our Way to Success 2014’was held on 3 November 2012. The key objective was to engage key stakeholders to discussthe way forward in quality improvement towards the 2014’ OWS and to line up the actions tobe taken. Target participants were the unit/department heads and the Quality & SafetyCoordinators. Discussion had focused on 5 key areas namely medication safety, clinicaldocumentation, clinical handover for doctors, patient assessment and care planning, and theway forward to Hospital Accreditation. A total of 72 colleagues participated the retreat andshort and long term goals for each subject were identified.Poster for the retreat: Quality & Excellence in Healthcare – Our Way Engagement of key stakeholders in theto Success 2014 Retreat 111

Chapter 7 | Hospitals Sharing 7.9 Queen Mary Hospital 7.9.1 Recommendations and Improvements Following the Organisation Wide Survey in 2010, there were several areas identified as gaps in the hospital that required significant improvement actions. (i) Outdated Disinfection and Sterilization System RECOMMENDATIONS ACTION PROGRESS Eliminate satellite sterilization • Review utilisation • Eliminated all satellite • Explore alternatives Lack of surgical • Devise policy on reuse of disinfection since May 2011 instrument tracking system disposable items • 2 operation theatres, K11- Reduce/eliminate the use of linen • Plan central reprocessing OTS and F-6 OTS of QMH have started the pilot run in 1Q Eliminate chemical by Central Sterile Supply 2013 disinfection for rigid Department (CSSD) endoscopes • Replaced all operation theatre • Participate in working (OT) instrument packs to non- group organised by IT team woven material in 2011/12 of HAHO • Plan to replace all linen items • QMH as one of 3 pilot sites to disposable non-woven to test the newly developed material in 2013/14 system • From 2011 to the July • Review on extent of 2012, 2 of 7 OTSs have problem eliminated Cidex usage with consumption decrease by • Plan to phase out linen by 63% stages • By the end of March 2013, • Stock-take of usage in chemical disinfection for rigid endoscopes and the use of hospital Flash Sterilization for implants and related instrument has • Explore and trial of been eliminated alternative methods such as enclosed disinfection systems • Estimate the total no. of endoscopes and financial resources required for each alternative solution112

Chapter 7 | Hospitals SharingRECOMMENDATIONS ACTION PROGRESSEnhance sterilizationand disinfection • Participate in HA’s Task • CSSD relocation andframework andfacility to cater for Force on Sterilization renovation plan developedanticipated increased Standards of Operation and endorsedtheatre service Theatredemand for the • Plan to be carried out in 4cluster • Establish HKWC Central phases from January 2014 to Sterile Services Committee December 2015 • Develop CSSD • Relocation of medical record improvement plan office and Milk Kitchen started in 2013 to make room for CSSD renovation Eliminated flash sterilization Stopped satellite disinfectionSterilization & Disinfection(ii) Document Management SystemRECOMMENDATIONS ACTION PROGRESSProgress the workto update the • Participate in HA initiated • HAHO has created DMS sitepolicies and clinical • QMH started live run ofguidelines to ensure pilot project on web-basedthat documents are Document Management system in August 2012written, disseminated System (DMS) since 2011and reviewed in • Sites created for 25accordance with QMH • Provide input on userpolicy framework departments, 5 divisions andDevelop a master requirement 18 committeesindex to facilitate staffaccess to the HKWC • Facilitate pilot project • Over 20 briefing sessions heldpolices and guidelines • Individualised coachingwith a link to HApolicies provided 113

Chapter 7 | Hospitals Sharing(iii) Risk Register Framework RECOMMENDATIONS ACTION PROGRESS QMH strengthen risk identification and • Briefing sessions for • Over 60 briefing and management by ensuring staff: hospital workshops Risk registers are departments had been established and • Departmental/ divisional conducted for hospital, maintained at departments and divisions department level briefings • Departmental risk • Workshops with key management teams participants for each established with Quality and department/ division Safety Department’s input • Advise on improvement measures • Facilitate cross- department quality improvement initiatives Document Management System Risk register framework114

Chapter 7 | Hospitals Sharing7.9.2 Staff Engagement and Learning Staff engagement forums had been organised on a monthly basis leading up to Periodic Review in October 2012. Topics of the forums include:DATE TOPIC23 Apr 2012 Communication Forum on Hospital Accreditation31 May 2012 Data Privacy & Security26 Jun 2012 Medication Safety, Occupational Safety & Health and Environment31 Jul 2012 Surgical & Procedural Safety and Blood Transfusion Safety30 Aug 2012 Resuscitation, Incident Learning & Sharing4 Oct 2012 Information Technology, Data Privacy, & Issues related to Incident ReportingAccreditation – Periodic Review October 2012 Quality and Safety Forum 質素及安全論壇 115 Periodic Review Report — Recommendations & Follow up 定期檢討報告 — 建議及跟進事宜 Blood Transfusion Safety 輸血安全 Date 日期: 30 January 2013 (Wednesday) 2013 年 1 月 30 日 (星期三) Time 時間: 12:30 noon – 2 pm 中午 12 時 30 分至下午 2 時正 Venue 地點: Underground Lecture Theatre 2, New Clinical Building, Queen Mary Hospital 瑪麗醫院新教授樓地庫 2 號演講廳 Speakers 講者: Dr. Clarence LAM Service Director, Quality & Safety Hong Kong West Cluster 港島西醫院聯網質素及安全部服務總監林俊傑醫生 Dr. Rock LEUNG Associate Consultant Department of Pathology & Clinical Biochemistry Queen Mary Hospital 瑪麗醫院病理及臨床生化學部副顧問醫生梁毓恩 All Staff are Welcome 歡迎所有員工參與 Light lunch will be provided at QMH only 將於瑪麗醫院提供簡便的午餐 This forum will be conducted in Cantonese supplemented with English 本論壇將以廣東話輔以英語形式進行 Video conferencing will be conducted at other HKWC hospitals 本論壇屆時將於港島西聯網其他醫院以視像會議形式播放 Enquiries 查詢 : Ms. Sania Kwan at 2255 4509 or Ms. Kate Choi at 2255 3383 關姑娘 2255 4509 或 蔡姑娘 2255 3383 Periodic Review Report Sharing

Chapter 7 | Hospitals Sharing 7.10 Tuen Mun Hospital 7.10.1 Recommendations and Improvements Tuen Mun Hospital (TMH) has undergone Organisation Wide Survey (OWS) and Periodic Review (PR) in year 2010 and 2012 respectively. The four year cycle of continuous improvement will enable our organisation to maintain the standards and strive to achieve the highest possible level of improvement. The following areas were identified during the surveys and significant improvement has been made. (i) Physical Restraint of Adult Patients The New Territories West Cluster (NTWC) commits to the protection and safety of our patients. A taskforce was formed in July 2012 under the NTWC Patient Pacification Committee with representatives from general wards and Quality and Safety Division with the aim of providing guidance in applying physical restraint. Different measures have been put in place to address the use of physical restraint in all general wards. Cue cards on suggested physical restraint alternatives for adults in general wards have been distributed to frontline staff in April 2013. It aids in deciding on the use of alternative strategies before applying physical restraint. An electronic based learning website has been launched in February 2013. It provides updates on knowledge of physical restraint and is followed by a self-assessment quiz. A pilot study on the use of a validated decision support tool in applying physical restraint will be conducted in July 2013. The pilot trial will be done in rehabilitation wards, isolation ward and neurosurgical ward. These wards were chosen as they showed a higher rate of physical restraint use.116

New limb holders with ‘quick release’ buckle Chapter 7 | Hospitals Sharinghave been purchased. The initial trial was Quick release bucklesuccessfully carried out in the intensive care limb holderunit and it would be on trial in the wardsenrolled in the aforementioned pilot trial inJune 2013. Patient safety walk rounds werefrequently conducted in assessing physicalrestraint compliance. Feedback andcomments were received and necessarymodification to the assessment tool will bemade.(ii) Pressure Ulcer Prevention and Management The Pressure Ulcer Prevention and Management Committee had organised an ‘Advanced Pressure Ulcer Prevention and Management Symposium 2012’ with over 300 attendees from seven HA clusters and private hospitals in June 2012. A concurrent exhibition was set up with ten booths displaying advanced pressure ulcer relieving devices, pressure ulcer management materials and information on nutritional supplements to enhance pressure ulcer care. 117

Chapter 7 | Hospitals Sharing Our cluster adopted the pressure ulcer staging system from the National Pressure Ulcer Advisory Panel (NPUAP), an authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research. Based on this, a cue card with measurement tool was revised and distributed to every nursing staff in the cluster. It helps to provide nursing staff with quick reference while assessing patient’s pressure ulcer at bedside. Pressure ulcer staging assessment tool With the donation from the S. K. YEE Medical Foundation, pressure ulcer preventive devices including pressure reducing seat-cushions and adjustable chairs were purchased and they were applied to high risk patients. To better manage and maintain the devices, a central pressure ulcer preventive devices management system was established and managed by occupational therapists.118

Chapter 7 | Hospitals Sharing Continued education is believed to be an essential tool for quality improvement. A series of posters with important information on preventing pressure ulcers were produced and they were posted in clinical areas. They not only serve as a quick reference for frontline staff but also help to raise the public awareness of pressure ulcer management. In addition, two classes of advanced certificate courses on pressure ulcer management (Level 2) for professional staff and two classes of pressure ulcer management (Level 1) course for supporting staff were organised with overwhelming participation. Series of preventing pressure ulcers posters(iii) Surgical Quality and Safety Circle (SQSC) The annual report published by HA on Surgical Outcomes Monitoring and Improvement Program (SOMIP) compares performance of morbidity and mortality across HA participating hospitals is available and shared throughout HA. Based on the report benchmark, TMH has established a Surgical Quality and Safety Circle (SQSC) to monitor and enhance safety among surgical patients. 119

Chapter 7 | Hospitals Sharing The SQSC was established in February 2011 with healthcare professionals from departments of Anaesthesia and Intensive Care (A&IC), Surgery, and Quality and Safety (Q&S) Division. High risk surgical patients would be managed peri-operatively by a multidisciplinary team to optimise their medical condition. SQSC meeting was held monthly to monitor the mortality and surgical complication rates. Selected cases were reviewed by members to ensure collaborative efforts and communication had been made between each parties. A joint meeting would be held quarterly to bring up interesting cases and to share learning points. (iv) TMH Sterilization Service Enhancement Project During the Gap analysis in 2009, a few priority action items were identified in TMH Central Sterile Supply Department (CSSD), and as a result, significant improvement work has been done. The cluster decontamination safety committee was set up in 2012 to govern the decontamination practice in the NTWC. CSSD TMH was re-designed with reference to the Hospital Authority guidelines and it complied with the international standards. A decontamination consultant from United Kingdom was invited to give us valuable advice on the re-engineering on the existing decontamination system. CSSD was modernised with the introduction of advanced instrumentation, and a tracking system with ISO 13485 quality management system was implemented. CSSD was back in service in Apr 2012. TMH was the first CSSD in HA for renovation. It served as a model for the improvement of sterilization services for other clusters.120

Chapter 7 | Hospitals Sharing7.10.2 Staff Engagement and Communication TMH engaged staff in the early stage of the preparation phase for hospital accreditation. We started from large scale communication forum to small group discussion with individual criterion stakeholders. It is important to disseminate the information regarding the hospital accreditation scheme through a transparent system. Therefore, we developed multiple channels such as TMH Hospital Accreditation website and Accreditation Newsletter ‘ 認證通 迅 ’ to promulgate the information related to hospital accreditation. TMH Hospital Accreditation website Accreditation Newsletter ‘ 認證通迅 ’ Apart from using the aforesaid methods, we believe that it is crucial to enhance the two-way communication between hospital management and frontline colleagues. So, a ‘TMH Hospital Accreditation Taskforce’ with representatives from clinical and non-clinical departments was set up before the Periodic Review (PR). To get well prepared for the PR, members met weekly and discussed accreditation related issues and invited experts to share their views in the meeting. Information related to operational practices would be shared by the representatives to concerned parties afterwards. 121

Chapter 7 | Hospitals Sharing 7.10.3 Learning and Sharing In order to solicit more suggestions and opinions in preparing the survey conducted in the OWS in 2010 and PR in 2012, senior management paid friendly visits to various departments in July and August in 2010 and 2012 respectively. During the visits, senior staff showed their support to frontline colleagues and encouraged them to share their daily work experiences, speak out their opinions and raise their concerns. The collected information and feedback were then brought back to the hospital accreditation meetings to discuss if any follow up actions could be taken to improve the quality of daily operation of each unit. Before undergoing the OWS and PR, a total of 13 Ward Manager Forums and 11 Weekly Sharing Forums with over a thousand attendees were held in 2010 and 2012 respectively. Experts from different departments were invited to share the topics in their related areas, including medication safety, informed consent, fall prevention and management and infection control to enhance colleagues’ understanding of the criteria required to be assessed in the survey. Summary of sharing were posted in the TMH Hospital Accreditation website. Tuen Mun Hospital Tuen Mun Hospital Periodic Review (PR) Periodic Review (PR) Weekly Accreditation Sharing Forum 4th Weekly Update Weekly Accreditation Sharing Forum on Medication Safety on Informed Consent 16 July 2012122

Chapter 7 | Hospitals Sharing7.11 Tung Wah Hospital7.11.1 Recommendations and Improvements Recommendations on Criterion 1.1.2 Develop specific-care planning procedures for the infirmary patients to ensure that activities are arranged to improve the mobility and quality of life of chronic patients. Improvements: • Developed infirmary nursing care plan and implemented in March 2013 • Formed a work group to conduct “Sit Out Program” for infirmary patients who have been bedriddened for years. Members included physician, nurses, physiotherapist and occupational therapist. Daily activities for improvement of mobility and quality of life were set and the schedule was displayed on the board for healthcare providers and relatives information. • Collaborated with Patient Resources Center and volunteers to conduct activities and ward decoration to express seasonal greeting, such as in Lunar New Year. 123

Chapter 7 | Hospitals Sharing Recommendations on Criterion 1.5.1 • Review the protocol for issuing dangerous drugs (DD) and recording of unused dangerous drugs in the operating theatre to ensure practice is contemporary and in line with regulations. • Implement a strategy to ensure that appropriate cold chain management systems and protocols are in place for the management of medication and vaccination fridges. Improvements: • DD Issue: –– DD was issued only upon the anesthetist’s request and case by case. –– WM/nurse supervisors monitor the proper issue of DD • Cold Chain Management: –– The Guidelines on Cold Chain and Medication Fridge Management was published on 18 February 2013. –– Replacement of Drug Fridges in all clinical setting in 2Q 2013 Guidelines on Cold Chain and Medication Fridge Management124

Chapter 7 | Hospitals SharingRecommendations on Criterion 1.5.3• Introduce a permanent record (count sheet) that complies with a published standard such as Australian College of Operating Room Nurses (ACORN) or Association of Perioperative Registered Nurses (AORN). The record should be filed in each patient’s history.• Introduce site marking in the Ear Nose and Throat (ENT) procedure area.Improvements:• Briefed medical & nursing staff on HAHO guidelines on Surgical Safety on 26 Nov 2012• Kept count sheet in patient’s record and implemented in main Operating Theatre and ENT procedure room in December 2012 and February 2013 respectively.• Nursing staff act as gatekeepers to reinforce site marking during procedures• Endorsed ‘No Site Marking’ list on 29 February• Conducted retrospective audit on compliance with 100% and 66.7% in January and February 2013 respectively. TUNG WAH HOSPITAL Patient Gum Label Operation: TUNG WAH HOSPITAL Patient Gum Label OPERATING THEATRE OPERATING THEATRE PERIOPERATIVE COUNT RECORD (ENT) Date of Operation: / / Accountable PERIOPERATIVE COUNT RECORD Date of Operation: / / Added During Operation Items Added During Operation Initial CountOperation: Initial ShortAccountable Items Count RaytecShort LongRaytec RaytecPlain Abd. SwabGauzePaddies PlainGauzeL/M/SPaddies DentalL/M/S Roll LapGauzeRibbon BladeBladeSuture SutureSutureReel VasoCauteryPad Loop SutureReel CauteryPadThroat Count Correct: □Yes □No Initial Count First Count Final CountPack In time: Out time: Surgeon Informed: □Yes □No Circulating Nurse If Discrepancies in Count: X-Ray Taken□ Result:__________ Scrub Nurse:Count Correct: □Yes □No Initial Count First Count Final CountSurgeon Informed: □Yes □No Circulating NurseIf Discrepancies in Count: X-Ray Taken□ Result:__________ Scrub Nurse: OT Count SheetENT Count Sheet 125

Chapter 7 | Hospitals SharingRecommendations on Criterion 1.5.7Adopt a robust approach to improve compliance of nutritional screening and the referralmechanism via the Generic Clinical Request System (GCRS) to ensure the nutritional needsof patients are met.Improvements:• Conducted 3 training sessions on HKC-MUST in November 2012• Uploaded HKC-MUST Manual to website in November 2012• Developed & distributed HKC-MUST User Kits to wards in January 2013• Revised Nursing Assessment form in December 2012• informed HAHO IT to enhance GCRS MUST description• Trended Referral number                                            Please add MUST & change to : Enrollment: Please submit the enrolment form by FAX to 2589 8564 or MUST (Malnutrition Universal Screening Tool) via e-mail to Catherine M Y Kwong, TWH EA IIIA(CND) before Deadline Session 1: 29 Oct 2012, Session 2: 9 Nov 2012, Session 3: 12 Nov 2012 Enquiry: Please contact CND office Ms. Kwong at 2589 8225  HKC-MUST User Kit Nursing Assessment Form126

Chapter 7 | Hospitals SharingRecommendations on Criterion 3.2.3• As part of the risk management plan, covered trolleys be introduced for the transport of waste generated throughout the hospital to the designated waste collection area.• Immediate arrangements be made whereby clinical waste collected from the ward areas be taken directly to the designated secure clinical waste storage area to await collection by the licensed contractor.Improvements:(i) New Red Containers for Clinical Waste • To enhance waste segregation, 19 new red containers with clinical waste label for clinical waste were delivered and distributed to departments.(ii) Staff Awareness • To raise staff awareness of safe handling of clinical waste, exhibition panels on the Clinical Waste Control Scheme from Environmental Protection Department were displayed at G/F, Centenary Building in TWH from 19 to 30 November 2012. • Leaflet and poster on ‘Do Not Recycle Clinical Waste’ was distributed to clinical departments in November 2012.(iii) Stock-take of Bins With Red Cover for Municipal Waste (in Black Bags). There Were 15 Waste Bins With Red Cover for Municipal Waste. Replacement of the Red Covers is in Progress in Order to Minimise the Risk of Misidentification of Municipal Waste and Clinical Waste.(iv) New 660 Litre Green Covered Trolleys Are Used for Collection of Municipal Waste.(v) Drafting New Collection Schedule of Clinical Waste From Ward Areas to the Designated Secure Clinical Waste Storage Area.(vi) A Trial Run Was Arranged on March 2013 By Cleansing Service Contractor. The Schedule Was Fine-tuned and the New Workflow Will Be Piloted in March 2013.(vii) Drafting of Guidelines on Waste Management is in Progress. 127

Chapter 7 | Hospitals Sharing 醫療廢物 醫療廢物 不可回收 棄置的利器 針筒、針咀、刺針、刀片、 化驗所廢物 常見的醫療廢物來自醫院、 傳染體培養物 診所、化驗所或護養院 手術刀及其他鋒利器具 血 人體和動物組織 一般廢物 血包、流動血液、 醫護、科研，所棄置的 (並非醫療廢物) 染有大量血液的敷料 人體部分、動物屍體 醫療廢物的包裝及收集 利器箱 保護衣物 食物容器 尿片 尿袋 紅色膠袋 黃色膠袋 寵物屍體 大型流動收集箱 可回收物料 沒受污染的 塑膠物料 其他 廢紙 金屬 Leaflet and poster on 'Do Not Recycle Clinical Waste' 再造紙印製 Exhibition panels on the Clinical Waste Control Scheme from Environmental Protection Department128

Chapter 7 | Hospitals Sharing7.11.2 Staff Engagement and Communication (i) Organised 8 Hospital Accreditation Forums No. of Participants: 489學員意見調查報告 Hospital Accreditation Forums (total 177 data, 177 valid data)問題 分數 1 分 2 分 3 分 4 分 5 分 6 分 Missing 極不同意 <------------------------------------------> 極同意（一） 此課程已達到所訂 0 2 24 45 84 20 2 目標 0.0% 1.1% 13.6% 25.4% 47.5% 11.3% 1.1%（二） 講座內對工作有實 0 3 26 47 80 20 1 用之處 0.0% 1.7% 14.7% 26.6% 45.2% 11.3% 0.6%（三） 導師能助長你在講 1 2 21 57 78 17 1 1.1% 11.9% 32.2% 44.1% 9.6% 0.6% 座中的學習 0.6%（四） 此講座的時間長短 1 3 24 56 77 15 1 適中 0.6% 1.7% 13.6% 31.6% 43.5% 8.5% 0.6%（五） 你對整個講座是否 0 2 20 50 86 18 1 感到滿意 0.0% 1.1% 11.3% 28.2% 48.6% 10.2% 0.6% 129

Chapter 7 | Hospitals Sharing (ii) Organised Hospital Accreditation Fun Day 醫院認證同樂日 No. of Participants: 200 Quality and Safety Forums (total82 data, 82 valid data) 問題 分數 1 分 2 分 3 分 4 分 5 分 6 分 Missing 極不同意 <------------------------------------------> 極同意 （一） 此課程已達到所訂 0 0 6 15 54 7 0 目標 0.0% 0.0% 7.3% 18.3% 65.9% 8.5% 0.0% （二） 講座內對工作有實 0 0 6 14 51 11 0 用之處 0.0% 0.0% 7.3% 17.1% 62.2% 13.4% 0.0% （三） 導師能助長你在講 0 0 6 13 54 9 0 座中的學習 0.0% 0.0% 7.3% 15.9% 65.9% 11.0% 0.0% （四） 此講座的時間長短 1 1 7 13 50 10 0 適中 1.2% 1.2% 8.5% 15.9% 61.0% 12.2% 0.0% （五） 你對整個講座是否 0 1 5 13 57 6 0 感到滿意 0.0% 1.2% 6.1% 15.9% 69.5% 7.3% 0.0%130

Chapter 7 | Hospitals Sharing(iii) Organised 3 Quality & Safety Forums No. of Participants: 110(iv) Conducted 29 Integrated Quality & Safety Round With 39 Workplaces Visited(v) Hospital Chief Executive (HCE) Visit(vi) Banners 131

Chapter 7 | Hospitals Sharing (vii) Screen Saver (viii) Published Practical Tips for Staff References and Information 7.11.3 Learning and Sharing Total 8 hospital Accreditation Forums were organised. Dr. Alexander Chiu, CD, Q&S, HKWC, Mrs. Mary Wan, CGM(AS), HKEC, Dr. Clarence Lam, SD, Q&S, HKWC and Ms. Kate Choi, AC, QMH, HKWC were invited to share their valuable experiences in preparing Hospital Accreditation with positive feedback from staff.132

Chapter 7 | Hospitals Sharing7.12 United Christian Hospital7.12.1 Recommendations and Improvements (i) Fall Prevention Program Inpatient falls had ranked amongst the top risk areas in HA hospitals as it could cause unnecessary harm to patients. Being listed as one of the hospital top risks in 2011, the multi-disciplinary ‘Task Force on Hospital Fall Prevention’ was set up in August 2011. Its prime objectives were to review patient fall incidents, identify & recommend strategies on fall prevention and monitor effectiveness of fall prevention measures in UCH. Based on the results of environmental assessments conducted in end 2011, focuses and strategies were developed from various prongs in addressing the improvement needs: • Toileting need assessment and care planning The review of past incidents revealed that over 50% of reported fall incidents were related to patients’ toileting needs. Those high risk fallers were assessed for toileting needs with care plan initiated. This was further strengthened by enhancement of facilities in bathrooms/toilets. 133

Chapter 7 | Hospitals Sharing • Enhancement of aids and support Walking aids were provided to those frail but mobile patients, coupled with provision of informative guides to ward staff to facilitate patient education. • Education for staff, patients and relatives A staff forum was conducted in July 2012 to promote awareness and knowledge of fall prevention. Patient education pamphlets and publicity posters were designed for all wards to educate targeted patients on risk factors of fall. Call bell posters were displayed in all toilets to alert patients to seek help when needed.134

Chapter 7 | Hospitals Sharing • Unit-based fall prevention program Fall prevention ward coordinators were appointed who played a leading role in identifying ward-specific intervention & fall prevention strategy in order to address needs of patients. • Timely support and intervention Patients identified as high risk category were referred to the Fall Assessment Specialist Team for acquiring expert assessment and appropriate intervention during hospital stay as well as rehabilitation & follow up after discharge. With the concerted efforts, an improvement trend was observed on the hospital patient fall incidents, which was reduced from the peak of 1.14 per 1,000 inpatient bed days occupied to an average of 0.73 per 1,000 inpatient bed days occupied.(ii) Clinical Waste Management UCH generates around 73,000 kg of clinical waste a year. The hospital follows the Code of Practice of the Environmental Protection Department and the Clinical Waste Management Manual of the Hospital Authority in the disposal of clinical waste. Following two mishandling incidents in March and April 2012, the overall strategy and workflow were revisited and revamped. Improvement measures were introduced as follows: 135

Chapter 7 | Hospitals Sharing • Segregation and storage To render clear instructions and sufficient facilities, the ‘red’ colour code was adopted for bins and bags containing clinical waste. These containers were also more sizeable and affixed with designated labels. Clear delineation of storage zoning was marked inside the floor waste rooms, coupled with posters and notices being displayed prominently. Zoning in waste rooms Affixed with Colour coded bins of designated labels different size • Collection and transportation The waste collection frequency was increased for ‘high-generation’ floors. The waste collection timetable and ad hoc collection hotline were shown at the floor waste rooms. A designated lift was also available to streamline the logistic flow.136

Chapter 7 | Hospitals Sharing• Staff awareness and education To upkeep staff knowledge and awareness, trainings were conducted including the refresher course, staff forum, training kit, orientation training, ward/unit level training as well as recirculation of guidelines & policies. Posters and notices Pictorial Training Kit• Ongoing monitoring and review To ascertain sustainability of the introduced measures, ongoing monitoring and review were in place like joint audits with the infection control team, close supervision of the cleaning services contractor together with checks and supervision on the clinical waste collection process. The role of involved staff in proper management of clinical waste was also reiterated to ensure a safe and healthy environment for all. 137

Chapter 7 | Hospitals Sharing 7.12.2 Staff Engagement and Learning In paving way for preparing the hospital accreditation program and the gap analysis in March 2013, the UCH Accreditation Project Steering Committee was set up in July 2012, chaired by the Hospital Chief Executive. Under the direction of the committee, the Quality and Safety (Q&S) Office had coordinated a number of capacity building, staff engagement & communication and experience sharing programs/activities. A brief summary was as follows: (i) Website Launching of the UCH Gap Analysis Website in Aug 2012 – the hit rate was near to 10,000 as at end March 2013 UCH Accreditation Kick-Off Ceremony and Quality Seminars on 16 Jan 2013 – around 260 staff had participated in the event138

Chapter 7 | Hospitals Sharing(ii) ForumsExperience Sharing Forum by PWHon Preparation of Gap Analysis on3 January 2013 – around 160 staffhad joined the forum(iii) Trainings Communication Forum by HAHO on 16 Apr 2012 – The Department of Quality & Standards of HAHO updated UCH staff on the latest roadmap of hospital accreditation and solicited our feedback. Around 200 staff had attended the forum. Five Gap Analysis Preparation Workshops (Jan & Feb 2013) and two Gap Analysis Preparation Forums (Jan & Feb 2013) – organised for frontline staff in preparing for the gap analysis. A total of around 700 staff had attended these workshops. 139

Chapter 7 | Hospitals Sharing (iv) Actvivities Q&S Quiz for supporting staff during Dec 2012 to Mar 2013 – tailor made for supporting staff in building up their need-to-know knowledge for the gap analysis. Prizes were awarded for winners. Good Practice Sharing following Executive Safety Walkround from Apr 2012 onwards – competition on casting of votes by staff on ‘Most-Likes’ departments was arranged. The two winning departments, Laundry and Accident & Emergency, were invited to share on their good work practice.140

CCREDITATIONACCREDITATIONAppendicesTPATITIOANLTATIO ACCREDITATION HOSPITAL ACCREDIATpApTenIOdiNx 1TION Steering Committee on Hospital AccreditationHOSPITAL ACCREDITATION HOASppPeInTdAixL2ITAL ACCREDITATIONCommittee on StandardsN Appendix 3 ACHS Hong Kong Program Support CommitteeL ACCREDITATIONEDITATION Appendix 4CCREDITATION Evaluation of Surveyor Induction Workshop 2012AL ACCREDITATION AppendixA5CCREDITATIONDITATION Overview on ApHpoOinStmPeInTtAoLf LoAcaClCSuRrvEeDyoIrTs ATION OAAnpvneprueaanllldfDeixeeHvd6eObloaScHpPkmIOTfreAoSnLmtPPAtIrhTCoeCgAHprRaLaEOmrDtAiSc2ITi0PCpHA1aCIO2TTnRIStAOsPENoLITDf AtAhILTeCAASCuTCRrCvIOReEyEDNoDrIITTAATTIOIONNAL ACCREDITATIONCREDITATION HOSPITAL ACCREDITATIONACCREHDOISTPAITTIAOLHOSPITAL ACCREDITATIONATION Appendix 7 froAmCCthReEDpIaTrAtTicIiOpNants of the Surveyor ACCRE Overall feedback Annual DevHelOopSmPeInTt APrLogrAamCC20R1E3 DITATION HOSPI Appendix 8 HOSPITAL ACCRED Working Group on EngagemHenOt &SCoPmITmuAnLicatAionCiCn REDITA Hospital Accreditation HOSPITALACCREDITATION Appendix 9 Evaluation on Hospital TraHinOinSgPIWTAorLksAhCoCpRs EDITATION ARDepisvpiineefwencdatiinxodn1R0aencdoSmtHemrOielinzSdaPtaitoHIiTonOnASstSLaonPndAItaThHCredAOCsESLnRaPnhEIAdaTnDACPcLrIeCaTmcARAteiCEcTnCeDtRIioOnEIfTDNAITTATIOIONNL ACCREDITATIONEDITATION Operating Theatres in HospiAtaClCREDITATION HOSPITAL ACCREDITATIONHOSPITAL ACCREDITAAppTendIiOx 11N HOSPITAL ACCRE HOSPITAL ACCREDITATIONSummary of Recommendations from PeriodHROevSiePwITofAL ACCR Five Pilot HospitalsALCACCRCERHEDODISITTPAATITTIOIAONLTATION Appendix 12 Summary ofAPrCioCritRy EAcDtioITn AIteTmIsO(PNAIs) by Criterion ASupmpemnadryiHxo1fO3OrSgaPnisIaTtiAonL-WidAe CSuCrveRy E(ODWSI)TofAOTurILOadNyACCREDITATION of Maryknoll Hospital in March 2013

Appendix 1 Steering Committee on Hospital Accreditation Terms of Reference 1. To devise, implement and evaluation a pilot scheme for accreditation of public and private hospitals in HK. 2. Based on the outcome of the above pilot, to advise the Food and Health Bureau on an accreditation system appropriate for the needs of public and private hospitals in HK. Membership (as at 30 March 2012) Chairman Dr Gloria TAM, Deputy Director of Health, Department of Health Members Department of Health Dr Cindy LAI, Assistant Director of Health (Health Administration & Planning) Mr Simon KWONG, Senior Hospital Administrator (Regulatory) Food and Health Bureau Ms Estrella CHEUNG, Principal Assistant Secretary for Food and Health (Health) Mr LEE Sheung-yuen, Principal Assistant Secretary for Food & Health (Health) Special Duties 2 Hospital Authority Dr Hing Wing LIU, Director (Quality & Safety) Dr Lawrence LAI, Senior Advisor (Medical Affairs) (up to 31.12.2011) Dr Lawrence LAI, Honorary Senior Advisor (Medical Affairs) (from 1.1.2012) Dr Fei Chau PANG, Chief Manager (Quality & Standards) (up to 16.8.2011) Dr Alexander CHIU, Chief Manager (Quality & Standards) (from 1.9.2011) Dr Derrick AU, Chairman of Committee on Standards cum Head of Human Resources (from 30.3.2012)142

Appendix 1 | Steering Committee on Hospital AccreditationHong Kong Private Hospitals AssociationDr Alan LAU Kwok-lam, ChairmanDr Anthony LEE, Vice ChairmanMs Manbo MAN, Director of Nursing Services, HK Sanatorium & HospitalDr Jack HUNG, Medical Superintendent, Evangel Hospital (up to 31.12.2011)Dr Jack HUNG, Consultant (Hospital Planning & Development), Evangel Hospital (from 1.1.2012)SecretaryDr Tina MOK, Principal Medical & Health Officer 143

Appendix 2 Committee on Standards Terms of Reference 1. To identify local limitations and gaps in the Standards 2. To advise Hospital Authority on interpretation of ACHS Standards with reference to local situation 3. To report to Working Group on Implementation of Hospital Accreditation and collaborate with private hospitals to develop towards a territory-wide Standards for Hong Kong Membership (as at 31 March 2013) Co-chairman Dr Derrick AU, Head of Human Resources, Hospital Authority Ms Manbo MAN, Director of Nursing Services, HK Sanatorium & Hospital Members Allied Health representative: Mr Jimmy WU, Senior Manager (Allied Health), Hospital Authority Central Coordinating Committee (COC) representatives: Dr Edward HUI, Associate Consultant (Surgery), Ruttonjee and Tang Siu Kin Hospitals, COC Surgery Dr T H KWAN, Consultant (Medicine & Geriatrics), Tuen Mun Hospital, COC Medicine Hospital Administration representative: Mrs Mary WAN, Cluster General Manager (Administrative Services), Hong Kong East Cluster Human Resources representative: Ms Katherine SHIU, Senior Manager (Corporate Human Resources), Hospital Authority144

Appendix 2 | Committee on StandardsNursing representative:Dr Eric CHAN, Senior Manager (Nursing), Hospital AuthorityPharmacy representative:Mr Winham LOK, Senior Pharmacist (Professional Development and Practice Management), HospitalAuthorityPilot Hospital representatives:Dr Y W SHUM, Senior Medical Officer (Medicine & Geriatrics), Tuen Mun Hospital (up to February 2013)Ms Kate CHOI, Clinical Audit Manager (Central Nursing Division), Queen Mary HospitalQuality & Safety representative:Dr Alexander CHIU, Chief Manager (Quality & Standards), Hospital AuthorityRepresentative from Private Hospitals:Mrs Fanny WONG, Quality Assurance Manager, Union HospitalRepresentative from Department of Health:Dr Tina Mok, Principal Medical & Health Officer, Department of HealthSecretaryMs Bonita KWOK, Manager (Quality & Standards), Hospital Authority 145

Appendix 3 ACHS Hong Kong Program Support Committee Terms of Reference 1. The ACHS Hong Kong Program Support Committee (PSC) will support and assist the ACHS by: 2. Providing advice to the ACHS on any relevant issues that may impact on ACHS activities 3. Participating, as requested, in consultations with members and key stakeholder groups in the region 4. Appointing a representative on the ACHS Standards Committee which will be responsible for coordinating the adaptation of the standards for application in HK 5. Providing advice and supporting the HK based surveyor workforce including selection, providing advice on appointment and reappointment, ensuring currency of skills, monitoring of performance and allocation to surveys 6. Participate in relevant activities to promote the ACHS vision and its programs. Membership (as at 31 March 2013) Chairman Dr Lawrence LAI, Senior Advisor (Medical Affairs), Hospital Authority (up to 31.12.2011) Dr Lawrence LAI, Honorary Senior Advisor, Hospital Authority (from 1.1.2012) Members Australian Council on Healthcare Standards Dr Desmond YEN, Executive Director (International Business) Department of Health Dr Tina MOK, Principal Medical & Health Officer (up to 17.9.2012) Dr Raymond HO, Principal Medical & Health Officer (from 18.9.2012 to 20.5.2013) Dr Ying FUNG, Principal Medical & Health Officer (from 21.5.2013)146

Appendix 3 | ACHS Hong Kong Program Support CommitteeHospital AuthorityDr Hing Wing LIU, Director (Quality & Safety)Ms Nancy TSE, Director (Finance) (up to 8.2012)Dr Alexander CHIU, Chief Manager (Quality & Standards)Mr Desmond NG, Chief Manager (Business Support Services)Private HospitalsDr Jack HUNG, Consultant (Hospital Planning & Development), Evangel HospitalMs Manbo MAN, Director of Nursing Services, Hong Kong Sanatorium & HospitalCo-opted MemberDr Derrick AU, Chairman, Task Force on Standards, Hospital AuthoritySecretaryMs Fion LEE, Senior Manager (Quality & Standards), Hospital Authority 147

Appendix 4 Evaluation of Surveyor Induction Workshop 2012 Surveyor Induction Workshop Overview A total of 112 health care professionals were nominated from the public and private sector hospitals, Department of Health and the Hospital Authority of which 24 were selected by the Program Support Committee to attend the three-day surveyor induction workshop held on 29 February to 2 March 2012. Content of the Workshop Prior to attending the workshop, participants were given a written exercise to complete and submit prior to the workshop. The exercise involved commenting on a criterion submitted by a dummy. During the workshop, there were presentations on various topics such as: • Guidelines on writing a survey report • Recommendations versus suggestion for improvement • Standards development and Clinical indicators • Overview of EQuIP 5 and National Standards • Verify evidence against mandatory criteria • Electronic Assessment Tool • Report writing • Accreditation results • Surveyor attributes • Ratings and recommendation • Summation conference Participants where then made to role-play as surveyors, by conducting focus group interviews, making recommendations and presentations at a summation conference.148