The Australian Council on

Healthcare Standards
International

Quality Program
Scoping Form

Version 2019.3
The Australian Council on Healthcare Standards (ACHS)
Quality Program Scoping Form
Version v3 June 2019

Introduction

Thank you for your interest in the Australian Council on Healthcare Standards (ACHS).

Founded in 1974 by the Australian Hospital Association and the Australian Medical Association, ACHS has
become Australia’s oldest, largest, and most well-regarded healthcare quality improvement organisation. We
are passionate about strengthening patient safety, quality, and outcomes both domestically and internationally
through our unique approach to focusing on assessment, evaluation, and improvement of systems provided by
trusted health institutions around the world.

Australia consistently ranks as one of the top healthcare systems internationally for the efficiency, outcomes,
and overall care process provided by its public and private organisations. ACHS proudly represents the heart of
the world-renowned Australian healthcare industry and looks forward to sharing our experience, expertise, and
the unique Australian spirit with you on your continuous quality improvement journey.

We are very pleased that you are considering partnering with ACHS through our range of product and service
offerings focused on quality and safety. To provide you with a proposal tailored to your organisation, we ask
that you complete the following form with as much information as possible. This will allow us to determine the
scope of services, pricing, and resources to best meet the needs of your organisation.

We are excited to be your potential partners in continuous quality improvement to provide the best services,
experiences, and outcomes for your patients.

Once you have completed this form, please submit it to our team by emailing achsi@achs.org.au. If you have
any questions, please also do not hesitate to email using this same address. After receiving this completed form,
our team will provide you with a detailed pricing schedule and proposal for the requested services.

We look forward to hearing from you!

Sincerely,

Mr Michael L Giuliano
Executive Director – ACHS International

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The Australian Council on Healthcare Standards (ACHS)
Quality Program Scoping Form
Version v3 June 2019

Section 1 – Contact Details

Main Contact Details

This will be the person we contact regarding all correspondence.

Salutation Mr / Ms / Dr
First Name
Last Name
Position Title

Office Address
City
Country
Telephone Number
Fax Number
Email Address
WeChat ID If applicable
Preferred Contact Indicate telephone, email, fax, mail, other, etc.

Quality Department Details

Who is the main contact of your Quality Department?

Same as Main Contact details above

Name
Title

Address
City
Country
Telephone Number
Fax Number
Email Address
WeChat ID If applicable
Preferred Contact Indicate telephone, email, fax, mail, other, etc.

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The Australian Council on Healthcare Standards (ACHS)
Quality Program Scoping Form
Version v3 June 2019

Director Contact Details

For future contractual documentation, ACHS requires the names of two directors or equivalent that have the delegation
and authority to sign on behalf of the organisation:

# Full Name Title Email Address

1

Section 2 – Quality Program Details

Select the edition of the ACHS Evaluation & Quality Improvement Program (EQuIP) for which you would like to apply
for your organisation’s facilities:

EQuIP Core – 4 year Membership (most suitable for hospitals)

EQuIP Healthcare Support Services – 4 year Membership
EQuIP Day Procedure Centres – 3 year Membership
EQuIP Aged Care Services – 3 year Membership
EQuIP Haemodialysis Centres – 3 year Membership
EQuIP Oral Health Services – 3 year Membership

Select all the products for which you would like to receive a proposal (select all that apply):

Readiness Diagnostic
A Readiness Diagnostic (RD) is an optional ‘mock assessment’ conducted onsite to provide guidance,
education, and an indication of readiness to progress to either ACHS Certification and/or ACHS
Accreditation

ACHS Recognition
A certificate of recognition from ACHS indicating that your organisation has commenced its quality
improvement journey and has made initial progress in one or multiple aspects of the ACHS EQuIP criteria.
This requires healthcare organisations to demonstrate at least a Some Achievement (SA) rating for the
criteria related to the selected modules for which they are seeking Recognition.

Please select the modules from the list below for which you would like to achieve an ACHS Recognition
Award (select all the apply):

Infection Control Incident Management

Surgical Safety Complaints Management
Health Record Documentation Appropriateness & Effectiveness
Assessment & Care Planning Governance
Clinical Handover & Discharge Environmental Management
Medication Management

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The Australian Council on Healthcare Standards (ACHS)
Quality Program Scoping Form
Version v3 June 2019

ACHS Certification
ACHS Certification requires organisations to achieve a Some Achievement (SA) rating for all mandatory
criteria and no more than 6 Little Achievement (LA) ratings on all other criteria. Membership to this
program is valid for 18 months.

ACHS Accreditation
ACHS Accreditation requires organisations to achieve a Marked Achievement (MA) rating for all
mandatory criteria as this demonstrates evaluation of process, systems, and outcomes that provide and
support safe patient care. Membership is valid for either 3 or 4 years.

ACHS Exemplar Award

The Exemplar Award is granted to a specific service or department of an accredited organisation that has
demonstrated distinctive performance and outcomes.

If selected, please indicate below which department or service for which you would like to apply for the
Exemplar Award

Section 3 – Facility Details

Please complete the following for all facilities to be included in the quality program. Be sure to include all locations
that you want included that may not be physically located to a main site:

# Facility Name Address Size (# beds or chairs)

1

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The Australian Council on Healthcare Standards (ACHS)
Quality Program Scoping Form
Version v3 June 2019

Section 4 – Scope of Onsite Services

By better understanding your service profile, ACHS can tailor the timetable and assessor selection to meet the specific
needs of your organisation.

Please indicate below which services are provided onsite by the facilities indicated in Section 3 (select all that apply)

Clinical Services Non-Clinical / Support Services

Pathology Patient Transport

Medical Imaging Engineering

Pharmacy Biomedical Engineering

Sterilisation / CSSD Security

Interventional Radiology Purchasing & Stores

Emergency Department Food Services / Catering

Outpatient Department Cleaning Services

Day Procedures / Endoscopy Waste Management

Intensive Care Services Human Resources

Operating Theatres Information Technology

Dialysis Services Finance & Audit

Section 5 – Finalisation

If there is any other information about the provision of services that you would like us to know, please provide it as
an attachment when submitting this form.

Declaration

The information we have provided above regarding the organisation details in supporting the provision of ACHS services
is true and correct at the time of this application.

Name of person completing this form:

Date form completed:

Please submit this completed form to achsi@achs.org.au

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