ou may recall we mentioned in last year's July/August issue that the HA plans to conduct a pilot hospital accreditation programme. The Australian Council on Healthcare Standards (ACHS) has been appointed as our partner for this through an open tender process, and it will get underway in five of our hospitals within this year. What expectations do these hospitals have about the programme? And what does the ACHS have to say about it? Here are some answers.

"Supported by our Cluster Chief Executive and our Hospital Chief Executive, the Caritas Medical Centre is fully committed to the pilot hospital accreditation project. This project provides a valuable opportunity to comprehensively evaluate our healthcare services and to benchmark ourselves against international peers so as to improve all aspects of patient care."

"We are now moving into a challenging era of responsibility and accountability for quality, safety and performance. This calls for a sharper focus on a seamless approach to corporate and clinical governance. We see the pilot hospital accreditation programme as a means of fostering a safety culture and driving continuous improvement at all levels of our Hospital."

"Hospital accreditation is a journey into a new era. Facilitated by our accreditation agency, the Australian Council on Healthcare Standards, the project engages the staff of Queen Elizabeth Hospital and the Kowloon Central Cluster to look at our system and other issues, with the aim of eventually bringing hospital services to international healthcare standards on all fronts. Because of the differences in healthcare provision in different countries, variations in standards may have to be accepted at present. This should be the exception rather than the rule, and the aim is to devise a Hong Kong set of standards that are reviewed from time to time."

"Our expectation for the pilot hospital accreditation programme is not simply to get 'accredited', but to take this as an opportunity to drive changes to our culture and practice. Our biggest challenge is how to get staff engaged. The project involves staff participation at all levels; without their understanding and involvement, we will not be able to get fruitful results."

"Through accreditation, we hope to take a step further towards spreading our 'Kaizen' (Japanese for 'improvement') culture and fulfilling our vision of becoming a 'preferred healthcare provider'."

"Our standards and the surveyor training programme are all accredited by the International Society for Quality in Health Care (ISQua). The accreditation programme is internationally recognised and has been adopted in New Zealand, the Middle East and India. The standards are developed by health professionals for the healthcare setting using a model of peer review.

The standards and criteria set broad goals which encourage continuous quality improvement (CQI) and require hospitals to demonstrate outcomes sustained across a four-year cycle. Local adaptation to the Hong Kong setting will be made, as it has been in New Zealand, and trained Hong Kong surveyors will participate to provide necessary local peer review.

We have some key messages about the model of accreditation:
	Focus on core business — look at each staff member's role, unit, department, division and facility to identify where to start with quality improvement and risk management.
	Look at the service, not the criteria first — all criteria may apply as they are interlinked.
	Look at the intent of standards and criteria — be flexible in how they are interpreted for the setting and the circumstances.
	Elements are guidelines for surveyors and organisations — they describe what peers might expect to find or to practise in achieving the intent of the criteria. "

The programme's ultimate objective is to develop a sustainable CQI system. Consultants from the ACHS visited the participating hospitals in May this year in order to enlist the support of senior, front-line and Head Office staff members in promoting this concept as a means of delivering cost-effective healthcare in a safe environment.

The long-term aim is to have one accreditation standard that applies to all our hospitals. In the meantime, United Christian Hospital and North District Hospital have joined the programme as shadow hospitals in order to learn more about it. Colleagues who would like to find out more about the programme, please visit http://qsd.home/.