About EQuIP

The ACHS Evaluation and Quality Improvement Program (EQuIP) was launched in 1996 providing healthcare organisations with an organisation-wide framework to deliver a consumer-centred service. The framework includes standards, a self-assessment process and systematic external peer review survey.

EQuIP was developed by the ACHS to help healthcare organisations strive for excellence and was designed to be used by all types of organisations which provide health care. The ACHS assists healthcare organisations to prepare for ACHS accreditation by guiding them through EQuIP. The program provides a framework for establishing and maintaining quality care and services.

Effective use of EQuIP requires an integrated organisational approach to quality improvement. The framework will assist healthcare organisations to:

focus on customers
develop strong leadership
build effective systems through ongoing improvement
measure and evaluate outcomes
strive for best practice.

The ACHS undertakes a comprehensive EQuIP standards review and consultation process at least every four years to ensure the standards remain current, continue to promote best practice through new evidence and are achievable.

The EQuIP Framework - The ACHS Standards

The starting point for EQuIP is the ACHS standards. The standards address the essential elements of quality care across the organisational functions that support the provision of care.

The ACHS standards are structured in a hierarchy, as follows:

Functions
Standards
Criteria
Elements

Function

A function is a group of standards.

Standard

The standard describes the overall goal; for example, consumers / patients are provided with high quality care throughout the care delivery process.

Criterion

The criterion describe key components of the goal, that are necessary for meeting the goal; for example, planning care with patients, families and carers and working in partnership with them to achieve the best possible results.

Element

For each criterion there is a series of elements. Each element identifies what should be in place to achieve the criterion at a certain rating level (please refer to rating levels details later in this section).

The EQuIP 4 standards have a strong focus on clinical care and consumer participation than previous editions of EQuIP.

There are three functions, 13 standards, and 45 criteria.

Function 1 – Clinical

The Clinical function sets out the standards that are mostly associated with clinical care. Achievement of these standards is mostly the responsibility of all clinicians.

6 standards

Continuity of care
Access
Appropriateness
Effectiveness
Safety
Consumer focus

Function 2 – Support

The Support function contains those standards and criteria which all providers should work together to achieve.

5 standards

Quality improvement and risk management
Human resources management
Information management
Population health
Research

Function 3 - Corporate

The Corporate function includes those standards and criteria for which the governing body and senior executives of the organisation will have primary responsibility.

2 standards

Leadership and management
Safe Practice and environment

Each of the 45 EQuIP 4 criteria has five possible levels of achievement or ratings levels

Level 1 Little Achievement (LA)

Organisations that achieve an LA rating will have an awareness or knowledge of responsibilities and systems that need to be implemented but may have only basic systems in place. At this level there will be compliance with legislation and policy that relates to the criterion.

Level 2 Some Achievement (SA)

An organisation that achieves an SA rating will have achieved all the elements of LA and will have implemented systems for the organisation's activities in relation to the criterion. At this level there is very little or no monitoring of outcomes or efforts towards continuous improvement.

Level 3 Moderate Achievement (MA)

An MA rating requires that all the elements of LA and SA have been achieved and there are efficient systems for collecting relevant outcome data, monitoring performance, evaluating procedures and responding to improve outcomes.

Level 4 Extensive Achievement (EA)

To achieve a rating of EA in the EQuIP 3^rd edition, organisations were required to benchmark their performance against other organisations or internally in order to demonstrate extensive achievement. In the EQuIP 4 program, all the elements in LA, SA and MA must be achieved but in addition, EQuIP 4 recognises that extensive achievement can be demonstrated in other ways.

Organisations will be able to demonstrate extensive achievement in a criterion if they satisfy one or more of the following requirements:

internal or external benchmarking and subsequent system improvement, and / or
the conduct of research that relates to that particular criterion, and / or
the implementation of what would be considered to be advanced systems that relate to that criterion, and / or
proven, excellent outcomes in that particular criterion.

Some organisations may be able to demonstrate achievement in more than one of these elements.

Level 5 Outstanding Achievement (OA)

The elements of LA, SA, MA and EA must be achieved as well as a demonstration of leadership in this criterion. Leadership in a criterion does not necessarily mean that the organisation is the best in Australia. It may mean that the organisation can demonstrate that it is one of the best performing organisations or is outstanding amongst its peers.

Mandatory criteria

Within the standards there are 14 mandatory criteria. Mandatory criteria are those where a rating of Moderate Achievement (MA) or higher is required to gain or maintain ACHS EQuIP accreditation. A criterion is mandatory if it is considered that a moderate achievement level is essential to ensuring the quality of care and / or service or the safety of people within the organisation. A rating of MA applies when effective systems are in place, relevant outcome data are collected, monitored and evaluated and improvements are made as required.

For further information on EQuIP 4, contact achs@achs.org.au