Report on Hospital Accreditation 2011-2013_Final

Appendix 4 | Evaluation of Surveyor Induction Workshop 2012Evaluation of ParticipantsDuring the three days, the presenters monitored the participants’ performance and evaluated ongathering evidence and interpersonal skills such as interactions other participants, report writing andoral presentations. Each presenter applied a rating, based on a Rating Scale 1-5 (1= Very good), on thefollowing attributes:• Pre workshop exercises: timeliness, writing, content• Scenarios: teamwork, spontaneity• Presentation: skills, content, questions• Interviews: questions, manner• Interview/evidence gathering• Oral skills: articulate, relevant• Writing skills: content, English• General interpersonal skills.Based on a final score for each participant, determined through consensus of the presenters, theparticipants were classified under the following Group definitions:Group 1 Elite group which team recommends to progress immediately to next stage of trainee surveys (n=11, av. Score = 11.7).Group 2 Mid-level group which team recommends up skilling and understanding on EQuIP before progressing to trainee surveys (n=8, av. Score = 20.0).Group 3 The team recommends HA consider our suggestions for improvement before progressing them further as surveyors (n=5, av. Score 20.8).The presenters also commented on the five participants in Group 3:1. Lack of participation during the course until prompted. Inability to formulate appropriate interview questions (Score =19).2. Poor oral English skills. Apparent lack of confidence in a peer environment. Initial lack of enthusiasm in participation but improved over the course (Score =20.5)3. Inability to respond and learn from feedback. Did not demonstrate a wide range of knowledge in subject matter (Score =20).4. Difficulty in extracting key issues from information. Difficulty in identifying key issues during the interview process. Lack of content in presentations. Did not demonstrate a wide range of knowledge on subject matter (Score =21.5).5. Lack of technical knowledge and its application at the operational level in order to apply the EQuIP criteria. Inability to apply learning over the period of the training. Inability to benefit from the team environment to foster positive team dynamics (Score =22.8). 149

Appendix 4 | Evaluation of Surveyor Induction Workshop 2012 Evaluation of the Workshop by Participants The participants’ responses to the questions on the workshop are graphically illustrated below: Question 1 The information presented enabled me to understand the role and responsibilities of being a surveyor? Question 2 The information presented enabled me to understand how the key concepts of EQuIP and the ACHS standards are applied to my role as a surveyor? Question 3 Do you feel that the information provided has given you the necessary skills required to participate as part of a survey team? Q3 46% 54% Q2 37.5% 62.5% Q1 25% 75% Agreed Strongly Agreed Question 4 Please give an overall rating on the training program 21% Good Very Good 79%150

Appendix 4 | Evaluation of Surveyor Induction Workshop 2012The following are responses to questions:Question 5 What was good about the training and what was not? Favourable responses: • Role-play & immediate feedback from ACHS team (n=8) • Presentation & reporting skills (n=4) • Simulation of summation conference (n=3) • Very interactive & stimulating (n=5) • Facilitate participants to be actively engaged, simulates real situation, actual experience in survey (n=5) • Passion of instructors, efficient & experienced, and encouragement (n=3) • Venue too far (n=1) • Interactive, simulates the real situation, actual experience in different stages of the survey (n= 2) • Mock interview (n=2) • The guide to completing the surveyor report (n=1) • Practical (n=2) • Prompt points under each criterion (n=1) • Enrich my knowledge on EQuIP5 (n=1) • Compact (n=1) • Teamwork and group work (n=2) • Public speaking (n=1) • Well-organised, well presented in appropriate level (n=1) • Key consideration note is very useful (n=1) • Comprehensive training with abundant info, good chances for practicing interview skill, group discussion, and questioning skill (n=1) • Eye opening experience. Comfort zone challenged, encouraged to unleash our potential & handle situations under pressure (n=1). 151

Appendix 4 | Evaluation of Surveyor Induction Workshop 2012 Unfavourable responses: • Time was tight/too rushed, should be 4 days, should be 1 week, time too tight for summation preparation, short time to group salient points of each criterion (n=11) • Too intense; out of my expectation (n=2) • Having to write things long handed as this is not done much nowadays in our daily work (n=1) Question 6 What would be 3 key areas that you would like to learn more about through ACHS education/ training sessions? • Report writing skills (n=14) • Public presentation/speaking skills/summation conference (n=7) • Interview skills (n=4) • Practical experience on surveying individual criterion (n=4) • Ratings (n=3) • Dos & don’ts during summation meeting, especially for making exceptional ratings- SA or OA (n=2) • More scenarios (n=2) • EAT (n=2) • Understanding of overlapping criteria (n=1) • Dos & don’ts during survey (n-1) • How to handle difficult institutions (n=1) • Design of the system (n=1) • Linkage between the EQuIP Guide & actual considerations for assessing achievements in real situations/example on ‘gray cases’ (n=1) • EQuIP5 (n=1) • Peer sharing & updates (n=1) • Preparation of documentation before survey (n=1) • Use of performance indicators (n=1) • How to do and review quality (n=1) • Giving recommendations (n=1) • Core requirements of mandatory criteria (n=1).152

Appendix 4 | Evaluation of Surveyor Induction Workshop 2012Question 7 Were your expectations met for the induction workshop? Is the role of a surveyor after this induction training as you expected? • Expectations met (n=21)Question 8 Is role of surveyors as expected? • The role of a surveyor is much more than I have expected • Yes sure. It is more than my expectation. This training gives me a more vivid understanding of the role of surveyor. • Very well done. Thank you very much!! • Become a fair & smart surveyor. I strongly agree that a surveyor is an educator & an advisor rather than auditor after 3 days of workshop. • I appreciate that the work as a surveyor is more in participating in a peer review process in helping healthcare organisation to continue to improve. • Surveyors are not auditors. • It helps me to have a much clearer picture on EQuIP5 • I am looking forward to continuous learning and exposure in a real survey scenario • Exceptionally challenging and inspiring training workshop which is of great benefit to the candidate as individual and potentially for our parent organisation • Very compact • I am very impressed by diligence and effectiveness of the teaching team, which has made the learning very interactive, efficient and we can have fun too.SummaryOverall the expectations of the participants were met. Of the 24 participants, 19 will progress to thenext stage of training and the results of the five participants, classified into Group 3, will be submittedto the Program Support Committee to consider the suggestions for improvement before progressingthem further as surveyors. 153

Appendix 5 Overview on Appointment of Local Surveyors List of 58 ACHS (Hong Kong) Surveyors as at Mar 2013 Name Title / Organisation Dr Derrick AU Head of Human Resources Hospital Authority Ms Betty AU YEUNG Senior Nursing Officer (Quality & Safety) Caritas Medical Centre Hospital Authority Dr Eric CHAN Senior Manager (Nursing) / Principal Nursing Officer Ms Queenie CHAN Hospital Authority Dr Yiu Kay CHAN Senior Sister (Quality Assurance) Hong Kong Sanatorium & Hospital Consultant (Medicine & Geriatrics) Caritas Medical Centre Hospital Authority Dr Grace CHENG Cluster Coordinator (Quality & Standards) Ms Stella CHENG Kowloon Central Cluster Dr Yin Chi CHENG Hospital Authority Dr Michael CHEUNG Cluster Coordinator (Occupational Therapy) Kowloon West Cluster Hospital Authority Consultant (Anaesthesiology & Operating Theatre Services) Queen Elizabeth Hospital Hospital Authority Coordinator (Clinical Service) / Consultant (Surgeon) North District Hospital Hospital Authority154

Appendix 5 | Overview on Appointment of Local SurveyorsName Title / OrganisationDr Alexander CHIU Chief Manager (Quality and Standards)Dr Lily CHIU Hospital AuthorityMs Kate CHOI Consultant (Centres of Excellence) Hospital AuthoritySr Lucy CHOY Clinical Audit ManagerMs Mary CHU Queen Mary Hospital Hospital AuthorityDr Billy CHUI Nursing DirectorDr Tak Yi CHUI Canossa Hospital (Caritas) Clinical Stream Co-ordinator (Allied Health)Dr Kin Lai CHUNG Hong Kong West ClusterMr John CHUNG Hospital AuthorityMs Becky HO Senior Family Physician Evangel HospitalDr Jack HUNG Deputy Chief Manager (Patient Safety & Risk Management)Dr Anne KWAN Hospital AuthorityMs Charlene KONG Service Director (Occupational Medicine & Care Service) Kowloon East ClusterMr Yiu Wing KWAN Hospital Authority Chief Manager (Integrated Care Programs) Hospital Authority Chief Physiotherapy Officer St Teresa’s Hospital Deputy Cluster General Manager (Nursing) New Territories East Cluster Hospital Authority Consultant (Hospital Planning & Development) Evangel Hospital Hospital Superintendent Evangel Hospital Cluster General Manager (Finance) Kowloon West Cluster Hospital Authority Manager In-charge (Quality & Safety) Hong Kong Baptist Hospital 155

Appendix 5 | Overview on Appointment of Local Surveyors Name Title / Organisation Dr Lawrence LAI Honorary Senior Advisor Dr Clarence LAM Hospital Authority Service Director (Quality & Safety) Dr Yonnie LAM Hong Kong West Cluster / Dr Chor Chiu LAU Consultant (Haematology) Dr Herman LAU Queen Mary Hospital Ms Esther LAW Hospital Authority Principal Medical & Health Officer Mr Tarcisius LAW Department of Health Cluster Chief Executive Dr Benjamin LEE Hong Kong East Cluster Ms Bernadette LEE Hospital Authority Dr Ares LEUNG Hospital Chief Executive Ms Civy LEUNG Cheshire Home, Shatin Ms Louisa LEUNG Hospital Authority Cluster Coordinator (General Support Services) New Territories East Cluster / General Manager (Administrative Services) Cheshire Home, Shatin Hospital Authority Medical Director Wellman Integrative Medical Centre & Honorary Consultant (Training Centre) Pamela Youde Nethersole Eastern Hospital Hospital Authority Cluster Coordinator (Pharmacy) New Territories East Cluster Hospital Authority Deputy General Manager (Clinical Operations) Matilda International Hospital Deputy Medical Director Union Hospital Cluster General Manager (Nursing) Hong Kong East Cluster Hospital Authority Senior Nursing Officer (Nursing Service Department) Pok Oi Hospital Hospital Authority156

Appendix 5 | Overview on Appointment of Local SurveyorsName Title / OrganisationMs Joyce LEUNG Cluster General Manager (Human Resources) Hong Kong West Cluster Hospital AuthorityMr Hans LI Deputy General Manager (Administrative Services) Pamela Youde Nethersole Eastern Hospital Hospital AuthorityMs Julie LI General Manager (Administration Services) Tung Wah Eastern Hospital / Wong Chuk Hang Hospital Hospital AuthorityDr Teresa LI ACHS (HK) SurveyorMr Michael LING Pharmacist (Pharmacy) Kwong Wah Hospital Hospital AuthorityMs Wing On LOU Manager (Quality & Safety) New Territories West Cluster Hospital AuthorityDr Joseph LUI Cluster Chief Executive Kowloon East Cluster Hospital AuthorityProf Siu Fai LUI Clinical Professional Consultant Division of Health System, Policy and Management The Jockey Club School of Public Health and Primary Care The Chinese University of Hong Kong / Hospital AuthorityMs Manbo MAN Director of Nursing Services Hong Kong Sanatorium and HospitalMs Rebecca NG Deputy General Manager (Nursing) Queen Elizabeth Hospital Hospital AuthorityMrs Yon Fah NG LEE Senior Nursing Officer (Quality Assurance) St Teresa’s HospitalMs Bernadette QUIGLEY General Manager, Clinical Operations Matilda International Hospital 157

Appendix 5 | Overview on Appointment of Local Surveyors Name Title / Organisation Dr Hing Yu SO Service Director (Quality and Safety) New Territories East Cluster / Dr Victoria TAN Director of Intensive Care Prince of Wales Hospital Dr Chung Ngai TANG Hospital Authority Dr William TSANG Clinical Assistant Professor Department of Medicine Mrs Mary WAN Hong Kong University & Ms Bonnie WONG Queen Mary Hospital Mrs Fan WONG Deputy Hospital Chief Executive / Consultant (Surgeon) Ms Michelle WONG Pamela Youde Nethersole Eastern Hospital Dr Loretta YAM Hospital Authority Ms Rosa YAO Service Director (Quality & Safety) Dr Karl YOUNG Kowloon Central Cluster / Consultant Pathologist Queen Elizabeth Hospital Hospital Authority Cluster General Manager (Administrative Services) Hong Kong East Cluster Hospital Authority Cluster Manager (Quality & Safety) New Territories West Cluster Hospital Authority Quality Assurance Manager Union Hospital Nursing Officer (Patient Safety Officer) Alice Ho Miu Ling Nethersole Hospital Hospital Authority Honorary Advisor Pamela Youde Nethersole Eastern Hospital Hospital Authority Cluster Allied Health Service Coordinator (Pharmacy) Kowloon West Cluster Hospital Authority Consultant (Adult Intensive Care Unit) Queen Mary Hospital Hospital Authority158

Appendix 6Overall feedback from theparticipants of the Surveyor AnnualDevelopment Program 2012Annual Development Program 2012 – OverviewTwo surveyor development workshops were conducted to Hong Kong ACHS appointed surveyors(n=43) on 5–6 and 8–9 March 2012. All, but two surveyors did not attend the workshops because theywere participating in Australian surveys.Content of the Workshop• Lesson learnt from the Pilot Scheme• Major changes from EQuIP 4 to EQuIP 5• Medication management and nutrition• National Standards• Electronic Assessment Tool• Surveyor conduct and performance• Writing comments, recommendations and suggestion for improvement• Advance completion in 60 days recommendation (Australia)Participants participated in exercises and discussions on a variety of topics including:• Interviewing skills• Framing feedback• Critiquing of recommendations• Surveying against governance and safety management systemsDiscussions were also held on the Hong Kong surveyors’ surveying experience and issues of concernidentified while attending a survey. 159

Appendix 6 | Overall feedback from the participants of the Surveyor Annual Development Program 2012EvaluationThe graph below illustrates the overall satisfaction of the workshops.Stongly Agree Agree 53% 47% Positive comments from the participants included: • Reinforced learning • Relevant content and topics • Enjoyable team members • Writing skills • Positive discussions, activities and interaction • Materials improved my knowledge • Good advice and guidance / Relevant content and topics • Positive interaction and activities • Reinforced learning • Good advice and guidance • Good networking and positive exchange of ideas • Well-planned workshop160

Appendix 6 | Overall feedback from the participants of the Surveyor Annual Development Program 2012Opportunities for improvement feedback included:• Could be condensed into 1/1.5 days• More information on department visits• More on writing and interview skills including hints and samples• More on team dynamics and executive interaction during survey• Hong Kong follow-up in 6 months• More information on support and corporate functions• Linkages between various criterion• Evidence requirements for EA and OA• On-line training• More information on organisational performance and benchmarking• Managing cultural differences• More information on credentialing, transition EQuIP4 to EQuIP5 and National Standards• More sharing on gap analysis experience• More exercises, add some pre-reading, preparing for summation conference and pre training assignment• More local sharing• Information on patient tracer methodology• Problem solving techniques• Less didactic sessions• Co-ordinator feedback and pre survey planning information• More survey techniques, surveying tips and guidance in surveying criteria• Opportunities to do more surveys• More encouragement to get participants to contributeSummaryThe evaluation indicates a high-level of satisfaction with the workshop. Nonetheless opportunities forfuture workshops were also identified. 161

Appendix 7 Overall feedback from the participants of the Surveyor Annual Development Program 2013 Annual Development Program 2013 Mandatory Module - Overview Two surveyor development workshops (including Mandatory and Optional Classes) were conducted to Hong Kong ACHS appointed surveyors (n=69) on 14-15 and 19, 20-21 March 2013. All, but 1 surveyor could not attend the whole Mandatory Module (due to overseas teaching engagement) and 2 surveyors could not attend the part on National Standards (due to work engagement). Evaluation Q1. The overall program was relevant to your needs as a surveyor Q2. The presentation / information provided was relevant and useful Q3. Were you given the opportunity to contribute and make comments? Q6. The maintenance program venue and travel arrangements were appropriate Q1. Relevance of the Program 25% 71% Q2. Relevance of Presentation 77% 3% 100% 18% 68% 5% Q3. Opportunity to make comment 0% 0% Q6. Appropriateness of Venue 25% 7% 0 20 40 60 80 100 (%) Strongly agree / Yes Agree Neutral162

Appendix 7 | Overall feedback from the participants of the Surveyor Annual Development Program 2013Q4. Are there any aspects of the maintenance program that could be improved? • National Standards • Using scenarios and practical examples (n=10) • More details and elaborations (n=5) • Provision of pre-workshop reading materials (n=6) • More interactive sessions with group discussion (n=2)Q5. What would be 3 key areas that you would like to learn more about through ACHS education / training sessions? • National Standards (n=18) • Report writing skill (n=12) • Interviewing / Surveying skill (n=5)Q7. Any other comments Positive Feedbacks • Good refresher course and inspiring (n=6) • Good sharing session with good feedback from speakers (n=5) Suggestions • Provide interactive discussion of scenarios or situations (n=4) • Use real example and case study to illustrate recommendations and suggestions (n=3) • Provide pre-workshop reading and an overview on National Standards (n=2) • Shorten the lunch hour (n=3) Others • A bit too much and in a rush (n=2) 163

Appendix 7 | Overall feedback from the participants of the Surveyor Annual Development Program 2013Optional Module – Advanced Business Communication WorkshopSummarised Evaluation36 out of 40 participants completed the Evaluation Questionnaire at the end of the Workshop. Insummary, 56.5% of the aggregated scores are “Excellent”, 37% are “Very Good” and 6.5% “Good”.The Workshop Evaluation is based on:A. “The Three Most Important Things I have learned from the Workshop” • Be coherent & cohesive (n=16) • Plan before writing (n=9) • Write for the readers (plain and simple English) (n=8)B. Workshop Objective I feel the Workshop will help me improve my written business communication skills in the futureC. Workshop Content What I have learned will be useful in my work in the futureD. Effectiveness of TrainersVery Good Good Excellent 34% 5% 61% Ratings used: Scale 1 – 6 1 = Unsatisfactory 2 = Satisfactory 3 = Fair 4 = Good 5 = Very Good 6 = Excellent164

Appendix 8Working Group on Engagement& Communication in HospitalAccreditationTerms of Reference1. To develop engagement and communication strategies which promulgate: –  the use of accreditation as a tool of continuous quality improvement (CQI). –  staff ownership of CQI2. To share information and collaborate with the Co-ordinating Group on Project Teams of Hospital Accreditation when appropriate3. To report to The Committee on Hospital Accreditation of HAMembership (as at 15 August 2012)ChairmanDr T W AU YEUNG Dr, TMH CON(M&G)MembersHospital Authority Head Office Quality & SafetyDr Alexander CHIU Dr, HOQ&S CM(Q&St)Ms Fion LEE, HOQ&S SM(Q&St)Hong Kong West Cluster – Tung Wah HospitalMs S M LEE, TWH APN(MED)Kowloon West Cluster – Our Lady of Maryknoll HospitalTze Shau HUI, OLMH APN(CND) 165

Appendix 8 | Working Group on Engagement & Communication in Hospital Accreditation New Territories West Cluster – Pok Oi Hospital Robin LI, POH DM(PHARM) New Territories East Cluster – Prince of Wales Hospital Dr Wing Yee SO, HOCS AC(IP)/PWH C(CS)/PWHMED Cons(MED) Ms Eleanor Siu Lan WONG, PWHSUR WM(SUR) New Territories East Cluster – North District Hospital Alick Hak Fai CHIU, NDHCND Deputy GM(N)/NDHOT DOM(OT) Co-op members New Territories West Cluster – Pok Oi Hospital Louisa LEUNG, POH SNO(NSD) Secretary Edwin CHOW, HOQ&S M(Q&St)166

Appendix 9Evaluation on Hospital TrainingWorkshopsOverviewTwo four-day workshops were held on 16–21 and 23–28 February 2012 for the 15 public and fourprivate hospitals. as the launch of the Accreditation Scheme.Content of WorkshopsOn the first day of the workshops, participants (n=163) were provided with:• An overview of the EQuIP accreditation program including the functions, standards and criteria and how to use the resource material available from ACHS• An outline of the concept of continuous quality improvement including methodologies, how to apply them to all operations of the hospital and the role of the Quality Manager / Team• An understand of how to prepare for accreditation survey together with preparation of pre-survey documentation and evidence• Information on how to use clinical and other performance indicators to improve service quality• Pilot Scheme project experiences on preparation for survey presented by local hospital quality team members• Lessons learnt from the Pilot Scheme project.In total, 436 participants, mainly specialty subject officers, attended presentations conducted on awide range of specialties topics such as:• Care evaluation• Infection control, single used devices and sterilisation practices• Nutrition• Incidents and complaints management• Human resources management 167