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Unlock the Secrets of Accreditation

September 11, 2013 (Wednesday) ● 1:00 PM – 5: 00 PM ● Shangri-La Hotel, Bangkok

  • Learn how it leads to quality improvement
  • International trends revealed
  • Discover the motivations of clinicians as surveyors
  • Understand the Challenges of implementation

Presented by an all-star expert team put together by the Australian Council on Healthcare Standards



  • Models of external evaluation: Regulatory vs. Peer Review
  • Accreditation as a framework for quality improvement: What it is and what it is not?
  • International trends


Worldwide, accreditation is generally the accepted quality framework within the health care sector in the absence of “real” parameters or criteria to measure quality delivery of care. What are the factors that have created the increase in demand for accreditation internationally?

The aim of accreditation is to provide a framework for continuously achieving quality in the delivery of health care services. Nonetheless, many opponents or skeptics of accreditation viewed the accreditation process as a compliance exercise whereby the health care organization prepared for a few months prior to the survey; policies and procedures are dusted from the shelves and answers rehearsed to the anticipated questions during on-site interviews with surveyors.  After the survey everything goes back onto the shelves until the next survey in three years’ time.

Is the role of accreditation one of training and education, or is it one of monitoring and control? Can it be both?

Desmond YenDr. Desmond Yen
ACHS Executive Director – International Business

Since 2005 Desmond Yen has been a a surveyor for the International Society for Quality in Health Care (ISQua) and surveyed in South Africa, Malaysia and Jordan. He has presented on quality improvement and concepts of accreditation in a number of countries.

Desmond was the team leader for the Hong Kong Hospital Authority’s pilot scheme of accreditation project and is currently the team leader for HKHA’s accreditation scheme project.




  • • Strength of the evidence base
  • • Gaps and opportunities for improvements
  • • Key issues and challenges for accreditation stakeholders


Improvements in healthcare have been driven by innovation and research. Additionally, increasingly consumers and governments are demanding a strong evidence base for health programs and clinical care regimes. This expectation also applies to accreditation programs. Hence the question: what is the evidence base underpinning healthcare accreditation programs? The evidence base will be reviewed, noting the gaps and opportunities for improvements. The key issues and challenges that this gives rise to for accreditation stakeholders, including consumers, health professionals and governments will also be discussed.

David GreenfieldDr David Greenfield
Senior Research Fellow, Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales

Dr David Greenfield is a Senior Research Fellow in the Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales.

Dr Greenfield’s research work is investigating the regulation of organisations and clinical practice, via both formal (accreditation) and informal (interprofessional collaboration) mechanisms. Dr Greenfield’s work is progressing understanding of how individually and collectively, in ‘communities of practices’ and networks, the actions and interactions of professionals can be effectively regulated to mediate improvements in organisational, professional and care outcomes.




  • • What motivates medical clinicians to become surveyors
  • • Influences on accreditation outcomes
  • • Techniques to deal with survey reliability


Research tells us that peer review has been widely accepted as suitable for QI in medical practice where medical clinicians are deemed the largest and most influential group of professionals best qualified to evaluate the clinical competence of their colleagues. It is therefore important to understand what motivates them to take on the role of accreditation surveyor and this session will review the research findings.

Reliable, credible survey results are critical to the health care accreditation process. An in-depth understanding of the types of influences that might bias the results and how surveyors deal with the issue of survey reliability is important to accreditation agencies. This session will discuss the influences that can impact accreditation survey results and the range of techniques which surveyors employ to mitigate this risk.

Lena LowDr Lena Low
ACHS Executive Director – Corporate Services

Dr Low has been with the Australian Council on Healthcare Standards (ACHS) since November 1995 and ACHS International (ACHSI) since its inception in 2005; she has been involved in developing healthcare accreditation systems for over 15 years.  Her portfolio covers finance reporting for both ACHS and ACHSI, information technology, human resources management, business development, business support services and organisation wide risk management.  She is a regular presenter of ACHS’s healthcare accreditation tools to international delegations and at training sessions for surveyors both nationally and internationally.




  • • Overview of the accreditation implementation
  • • What are the challenges of accreditation implementation?
  • • Has accreditation made a difference?


Under the directive of the Hong Kong Government, public and private hospitals in Hong Kong commenced the journey for hospital accreditation in 2009. Over the last few years, there are six public hospitals and seven private hospitals that have attained hospital accreditation. There are also currently another 18 hospitals planning for accreditation within the next 5 years.

The single most significant challenge of accreditation implementation is staff engagement. As this is a relatively new concept in Hong Kong, it is of utmost importance that the correct objective of such is articulated and conveyed to different levels of staff. In particular, many may perceive accreditation as an examination or inspectorate, and throughout our engagement process, much effort has been made to demystify and clarify the purpose of accreditation as a continuous quality improvement exercise.

Despite Hospital Accreditation has only been launched for less than five years, we have seen impact over several areas. These include the modernization of sterilization and disinfection services and the introduction of the concept of credentialing and defining scope of practices in the medical scene of Hong Kong.

Alex CHIUDr Alexander Chiu
Chief Manager, Hong Kong Hospital Authority, Quality and Safety Division

Dr Alexander CHIU is an intensivist by training. He led Queen Mary Hospital, a university affiliated hospital in Hong Kong to go through ACHS Hospital Accreditation in 2009. Dr Chiu then took up the position of Director for Quality and Safety of a seven hospital cluster in Hong Kong in 2010 and manages all quality and risk related matters. He is currently the Chief Manager for Quality and Standards of Hospital Authority Hong Kong, overlooking the hospital accreditation program of 41 public hospitals. Dr Chiu is also a member of the steering committee of Hospital Accreditation commissioned by the Hong Kong Government, providing inputs for the development of Hospital Accreditation in both public and private sector in Hong Kong.  Dr Chiu is also a surveyor for the Australian Council on Healthcare Standards, and has surveyed hospitals in Hong Kong, Macau and Australia.  Apart from accreditation, Dr Chiu also manages Credentialing and Practice Privileging, Operation Theatre efficiency, Waiting time performances, Surgical Outcome Performances and Clinical Indicators within its organization.


Rates for Overseas Participants Rates for Local Participants:
HMA Delegates: US$ 65
Non HMA Delegates: US$ 75
HMA Delegates: THB 1,550
Non HMA Delegates: THB 1,800



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