The Commission is responsible under the National Health Reform Act 2011 for the formulation of standards relating to health care safety and quality matters and for formulating and coordinating the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme (the Scheme).
The Scheme provides for the national coordination of accreditation processes. The Commission has undertaken a comprehensive review of assessment processes and the performance of accrediting agencies. As a result, the Commission developed six strategies to improve the AHSSQA Scheme’s reliability to more accurately assess an organisation’s compliance with the NSQHS Standards. These strategies are supported by states and territories as well as the private and public sectors.
The Review of the Australian Health Service Safety and Quality Accreditation Scheme: Improving the reliability of health service organisation accreditation processes details the changes to the Scheme, which will be implemented in January 2019.
There are also a series of fact sheets (below) which outline the changes to accreditation processes for health service organisations.
Fact Sheet 1: Standardised accreditation cycles
Updated October 2018
From January 2019, health service organisations will move to a three-year assessment cycle, with no further mid-cycle assessments.
Health service organisations will be assessed once every three years, unless they meet the criteria for a repeat assessment (see Fact Sheet 3 – Repeat assessments of health service organisations).
For health service organisations currently on a four-year cycle, there will be a staged process to allow organisations and accrediting agencies to manage the transition.
Health service organisations currently on a three year cycle will continue with their scheduled cycle. Any mid cycle assessments scheduled after 1 January 2019 will not occur.
An accreditation award for the second edition of the NSQHS Standards can be issued for up to three years. Exceptions to this requirement will only be considered on a case by case basis by the Commission.
Health service organisations will be required to complete their assessments before their current accreditation award expires. This means that organisations will need to schedule assessments at least four months before their accreditation award expires to allow three months (60 business days) for remediation of not met actions at initial assessment, and one month (generally 20 business days) for the accrediting agency to complete their final report.
Organisations should review this information before confirming future assessment dates with their accrediting agency.
Further transition arrangements for health service organisations scheduled to undertake their next assessment in 2019 are outlined in Fact Sheet 2 – Transition arrangements for assessments in 2019.
Download the PDF to view the attached tables and figures that provide guidance for health service organisations to determine when their next assessment should be.
Fact Sheet 2: Transition arrangements for assessments in 2019
Updated October 2018
Transition arrangements will be in place to support health service organisations undertaking assessment to the second edition of the NSQHS Standards in 2019.
Provision has been made for health service organisations to apply for assessment to the second edition of the NSQHS Standards from October 2018.
Health service organisations will be required to schedule their assessment at least 80 business days before their accreditation expires. This will allow 60 business days for the remediation period and generally 20 business days for the accrediting agency to finalise the assessment report. More information on this is available in Fact Sheet 1 – Standardised accreditation cycles.
The Commission recognises that these changes may impact on health service organisations scheduled for assessment in 2019.
These transition arrangements recognise that these health service organisations have had less time to implement the second edition of the NSQHS Standards and plan for the changes to the accreditation arrangements.
Transition arrangements will cease on 31 December 2019.
Extended remediation period
In 2019 the remediation period (that is the period between initial and final assessment) can be up to 80 business days for health service organisations with not met actions at their initial assessment.
After 31 December 2019 the remediation period will be 60 business days.
Extended accreditation period
From January 2019, health service organisations will be required to complete their assessments before their current accreditation award expires. With the extension of the remediation period in 2019, this could require some health service organisations to bring their assessment forward as much as 100 business days (or five months) which may not be feasible.
Health service organisations that need to move their assessment date forward to complete their assessment before their accreditation award expires will be given up to 80 additional business days to their accreditation period.
These arrangements only apply to health service organisations with assessments scheduled in 2019.
Health service organisations should retain their current scheduled assessment date if the assessment process can be completed before the current accreditation award expires.
Organisations with an accreditation award expiring in January 2020 or later will need to schedule their assessment to allow sufficient time for the assessment process to be completed. If their assessment date is scheduled in 2019, these organisations may have up to 80 business days for their remediation period, if required.
A hospital has their assessment scheduled in June 2019, with an accreditation award expiring on 30 June 2019. Under the new requirements they would usually be required to commence their assessment no later than March 2019, at least 80 business days before their award expires.
With the flexible transition arrangements in 2019, the hospital can extend their accreditation period by 80 business days until the end of October 2019. This allows the assessment to be conducted in June 2019 as currently scheduled.
Fact Sheet 3: Repeat assessment of health service organisations
If a health service organisation is found to have a large numbers of not met actions at initial assessment and is subsequently awarded accreditation, they will be required to be reassessed within six months of the assessment cycle being completed.
This reassessment is to ensure the organisation has fully embedded the necessary improvements in their safety and quality systems to maintain compliance with the NSQHS Standards.
From January 2019, health service organisations will move to a three-year assessment cycle. At the end of each assessment cycle, health service organisations may not be assessed again for three years (see Fact Sheet 1 – Standardised accreditation cycles).
An assessment cycle for a health service organisation is conducted over a period of one to four months. The assessment cycle involves an initial assessment, and where actions are not met, a final assessment. The final step is a report on the assessment, notifying the organisation if they have been awarded accreditation.
If an organisation has actions which are not met at their initial assessment, there is a remediation period in which they must demonstrate sufficient change has been implemented for actions to be rated met or met with recommendations at their final assessment, and to be awarded accreditation.
Criteria for reassessment
There are two criteria for determining repeat assessment, reflecting the overall number of not met actions at initial assessment and the significance of any not met actions.
Accrediting agencies will be required to flag with the Commission any health service organisations that meet either criteria for reassessment.
The Commission in collaboration with the health service organisation’s regulator will confirm the need for reassessment and notify both the health service organisation and the accrediting agency.
A repeat assessment will be required if:
- 16 percent of all actions assessed are not met
- Eight or more actions from the Clinical Governance Standard are not met.
For health service organisations on an announced assessment pathway 16 percent will equal approximately 24 not met actions. This will vary depending on the number of not applicable actions. For health service organisations undertaking a short notice assessment, the number will be 16 percent of the standards being assessed.
Accrediting agencies will be required to confirm a reassessment date with the Commission and the health service organisation within 10 business days of being notified a reassessment is required.
Reassessment will involve an onsite assessment at which all not met actions from the initial assessment and all actions rated met with recommendations will be reassessed.
Following completion of the reassessment:
- Where all actions are either met or met with recommendations, then accrediting agencies will submit data to the Commission on the reassessment in their routine monthly data submissions. The organisation’s accreditation award will remain in place and the expiry date will be unchanged.
- Where there are any not met actions, the accrediting agency will be required to notify the relevant regulator and the Commission. There will be no 60 business day remediation period associated with this process. The organisation’s accreditation will be withdrawn. They will be required to work with their regulator to comply with regulatory requirements for unaccredited health service organisations for that state or territory. This will include re-assessment to all eight NSQHS Standards within 12 months.
Fact Sheet 4: Rating scale for assessment
Whenever the NSQHS Standards (2nd ed.) are assessed, actions are to be rated using the revised rating scale outlined below.
All requirements of an action are fully met.
Met with recommendations
The requirements of an action are largely met across the health service organisation, with the exception of a minor part of the action in a specific service or location in the organisation, where additional implementation is required.
Met with recommendations may not be awarded at two consecutive assessments where the recommendation is made about the same service or location and the same action. In this case an action should be rated not met.
Met with recommendations may only be awarded at initial assessment if there are no other not met actions.
Part or all of the requirements of the action have not been met.
The action is not relevant in the service context being assessed.
The Commission’s Advisory relating to not applicable actions for the relevant health sector need to be taken into consideration when awarding a not applicable rating and assessors must confirm the action is not relevant in the service context during the assessment visit.
Actions that are not part of the current assessment process and therefore not reviewed.
Process for rating actions met with recommendations
In their reports to the health service organisation and the Commission on assessment outcomes, assessors are to provide a clear and concise explanation of the following for all actions rated met with recommendations:
- The minor part of the action that has not been fully met
- The specific service or location in the service the rating applies to
- Requirements for the action to be fully met.
All actions rated met with recommendations are to be reviewed by assessors at the next assessment. This will include a review of the specific service or location identified when the met with recommendations was reported.
An organisation cannot be awarded met with recommendations for the same action, for the same reason, in the same location for two consecutive assessments. Should this occur, the action is to be rated not met.
All met with recommendations ratings will be reviewed by the Commission to ensure the rating is being applied appropriately and consistently.
Process for rating actions not met
At the summation meeting following an initial assessment, assessors are to specify any actions they have rated not met and provide an explanation for the rating.
A summary report on the initial assessment, including a list of not met actions, is to be provided to the health service organisation within five business days. This report should include a written explanation for all not met ratings.
Not met actions at the initial assessment may be rated met, met with recommendations or not met following the final assessment.
At the summation meeting following the final assessment, assessors are to specify any actions that are rated not met or met with recommendations and provide an explanation for the rating.
Health service organisations with a large number of not met actions may be required to undertake a repeat assessment. Refer to Fact Sheet 3 – Repeat assessment of health service organisations for more information.
Fact Sheet 5: Recognising exemplar practice in health service organisations
This strategy is intended to facilitate the identification and sharing of information on safe and good-quality practice between organisations managing similar issues.
During consultation on the review of the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme, health service organisations asked that a mechanism be established to recognise exemplar practice.
Process for nominating exemplar practice identified at assessment
Accrediting agencies will be invited to nominate exemplar practice identified during a health service organisation’s assessment to the second edition of the NSQHS Standards.
Accrediting agencies will be required to:
- Notify the health service organisation of the intended submission
- Obtain contact details of the responsible officer for the area of practice being recognised
- Submit the following information to the Commission:
- The name of the health service organisation
- The name of the specific service area where the exemplar practice has been identified
- A concise statement of the exemplar practice
- Contact details for the relevant person(s) in the health service organisation.
The Commission will review submissions and contact the relevant health service organisation to invite them to provide further information. This will not involve site visits by the Commission.
If the submission meets the criteria for exemplar practice, and with the health service organisation’s permission, the Commission will:
- Upload a summary of the initiative on the Commission’s website
- Include appropriate contact details for the exemplar organisation so that other health service organisations may review the information, and if appropriate contact them to discuss the initiative in more detail.
A template will be available to collect this information and describe the criteria for exemplar practice against which submissions will be assessed.
Fact Sheet 6: Short notice assessments
Updated October 2018
From January 2019, health service organisations will have the choice of undertaking either announced or short notice assessments.
Short notice assessments are a separate assessment pathway under the AHSSQA Scheme, with specific rules associated with its introduction and application.
Participation in short notice assessments is voluntary for health service organisations, unless directed by the relevant regulator.
The short notice assessment process requires health service organisations to fully comply with the requirements of the NSQHS Standards and have in place processes to demonstrate compliance at any time. Organisations contemplating short notice assessments should ensure their safety and quality systems are well embedded, and routine processes are in place to monitor safety and quality performance against the NSQHS Standards and conduct regular self-assessments and gap analysis.
The process for the short notice assessment pathway is outlined below, including transition arrangements for 2019.
1. Process for the short notice assessment pathway
All eight NSQHS Standards must be assessed during the three year accreditation cycle. Each assessment will involve the review of three to four NSQHS Standards. Up to four NSQHS Standards may be assessed more than once over the accreditation cycle. This will ensure that health service organisations are not able to determine which of the NSHQS Standards will be assessed at any one visit.
The regulator, the Commission, and accrediting agencies are considering mechanisms to determine which standards are to be assessed. The Commission will provided updated advice once this process has been finalised.
Health service organisations will have three assessments in each accreditation cycle with no more than two assessments in any one year. At each assessment there is an initial assessment; if actions are not met, a final assessment after a 60 business day remediation period; and a report on the assessment within 20 business days.
Download the PDF fact sheet below to view a table setting out the assessment required.
The health service organisation will be recognised as accredited whilever they continue to satisfactorily meet the requirements of the short notice assessment pathway. This includes participation in all assessment events and keeping documentation such as self-assessment current.
The process for short notice assessments also includes the following:
- Health service organisations will be given at least 48 hours notice of an assessment commencing and which standards will be assessed
- All actions in the three or four NSQHS Standards selected will be assessed at the initial assessment, with the exception of actions that have been awarded not applicable status by the accrediting agency
- At each assessment, the assessor will review any actions that were rated not met at the previous initial assessment or met with recommendations at the previous final assessment
- There will be a remediation period of 60 business days for any not met actions, or as per the transition arrangements in place for 2019 (see Fact Sheet 2 - Transition arrangements)
- Health service organisations will be given 20 business days from the conclusion of the initial assessment to provide any additional information unavailable at assessment. For not met actions, these 20 business days are included in, not additional to, the 60 business days allowed for remediation
- Health service organisations may nominate up to 20 business days per year when assessments are not to be conducted
- To reduce the risk of conflict of interest, accrediting agencies will prepare a list of all assessors that could participate in assessments, to be reviewed by the health service organisation prior to commencing assessments.
- Potential conflicts of interest should be noted by accrediting agencies and avoided when convening assessment teams
- Health service organisations are to make any applications for not applicable actions at the time of enrolling in the short notice assessment pathway with an accrediting agency
- Health service organisations undergoing interim accreditation are not permitted to participate in the short notice assessment pathway until they have completed the interim accreditation process
- Assessors are to use the PICMoRS structured assessment process
- Annual attestation statements are to be signed by the governing body (see Fact Sheet 7 - Governing body attestation statement).
2. Applying to be assessed using the short notice assessment pathway
Health service organisations wishing to be assessed through the short notice assessment pathway will be required to apply to their accrediting agency.
As part of their approvals process to assess to the NSQHS Standards (2nd ed.), accrediting agencies are required to have processes in place to conduct short notice assessments, including assessor training.
Health service organisations must have current accreditation status to be eligible for the short notice assessment pathway. The first assessment must be conducted before the current accreditation award expires.
During 2019, health service organisations wishing to commence short notice assessments should seek approval from their regulator. Approval to proceed will be on a case by case basis.
3. Transferring between the announced and short notice assessment pathways
Transferring from ‘announced’ to ‘short notice’ assessment pathway
Health service organisations transferring to short notice assessments may do so at any point during their accreditation cycle, but no later than six months before their current accreditation expires. The first short notice assessment should occur before the current accreditation to the NSQHS Standards (first or second edition) expires.
The three year short notice accreditation cycle begins from the date for commencement specified in contracts between the health service organisation and an approved accrediting agency.
Transferring from ‘Short notice’ to ‘announced’ assessment pathway
Health service organisations can transfer to an announced pathway, with requirements determined based on their progress in the short notice assessment pathway as follows:
- Three required short notice assessments complete - the next assessment visit will be announced and all eight NSQHS Standards will be assessed. This assessment must occur before their current accreditation award expires. The accreditation cycle commences from the date accreditation is awarded.
- Two required short notice assessments completed and all eight NSQHS Standards assessed - the next assessment visit will be announced and all eight NSQHS Standards will be assessed. This assessment must occur before their current accreditation award expires.
- One or two required short notice assessments completed but all NSQHS Standards have not been assessed – the health service organisation must commence its assessment to all eight NSQHS Standards within three months.
4. Roles and responsibilities
To ensure the short notice assessment pathway operates effectively and efficiently, the roles and responsibilities for each of the groups involved are outlined below:
- Establish the processes and procedures for conducting short notice assessments
- Schedule short notice assessments
- Train their assessors to undertake short notice assessments
- Work with the Commission to determine which NSQHS Standards will be assessed at each short notice assessment
- Comply with the conditions of approval relating to short notice assessments.
- Assess day to day practice, largely in clinical areas
- Use PICMoRS as the structured approach to assessment.
- Work with the Commission to determine which NSQHS Standards will be assessed at each short notice assessment
- Encourage and support health service organisations being assessed via the short notice assessment pathway.
Health service organisations
- Implement the NSQHS Standards (2nd ed.) and the systems and processes to monitor and review ongoing compliance
- Keep updated self-assessment tools
- Develop schedules and plan for short notice visits by assessors.
- Provide tools and resources to support the implementation of the NSQHS Standards (2nd ed.) and the introduction of short notice assessments
- Coordinate the ongoing evaluation of the short notice assessment pathway.
5. Evaluation of the short notice assessment pathway
The introduction of short notice assessments is a significant departure from current accreditation processes, and has not previously been available for health service assessments.
To learn how and where this methodology can be most effective the introduction and application of short notice assessment will be monitored and evaluated. Those undergoing short notice assessments will be invited to participate in these processes.
Fact Sheet 7: Governing body attestation statement
Updated 10 December 2018
From January 2019, health service organisations will be required to submit an annual attestation statement to their accrediting agency.
Attesting is a formal process. It involves authorised officers from a health service organisation self reporting on past performance. This is in the form of a written affirmation.
It is intended that this process will increase awareness of a governing body’s accountability for safety and quality and clinical governance processes under the NSQHS Standards.
The focus of the attestation statement is Actions 1.1 and 1.2 of the NSQHS Standards (2nd ed.), which explicitly set out key responsibilities for governing bodies.
Process for submitting attestation statements
Health service organisations are required to:
- Identify their governing body. This is the body or individual(s) with ultimate responsibility and accountability for decision-making about safety and quality
- Nominate a member of the governing body to sign the attestation statement
- Specify who will counter-sign the Attestation Statement. This can be a group Chief Executive Officer (CEO) or facility CEO. Where it is not feasible for a CEO to sign, an alternative officer may be nominated by the governing body and their position title specified on the attestation statement
- Submit an attestation statement annually to their accrediting agency between 1 July and 30 September each year using the template provided.
Where a governing body is responsible for more than one health service organisation, a single attestation statement may be submitted along with a schedule listing the names and address of each health service organisation to be covered by the attestation statement.
Organisations where Action 1.2 is not applicable
Some health service organisations can apply for Action 1.2 to be considered not applicable, see Advisory AS18/01. Where not applicable status is granted, point 2 of the Attestation Statement template can be crossed through and signed by the office holder making the attestation.
Accrediting agencies are to review all attestation statement received with point 2 crossed through to ensure that ‘not applicable’ status has been granted for that organisation.
Where the template is crossed through and Action 1.2 has not been granted ‘not applicable’ status by an accrediting agency, a revised Attestation Statement must be sought from the health service organisation.
Assessment of Actions 1.1 and 1.2
For health service organisations that have submitted an attestation statement, accrediting agencies are still required to review evidence of compliance with Actions 1.1 and 1.2 at assessments before rating these actions.
For health service organisations that have not submitted all of the required attestation statements, or have submitted incomplete statements, accrediting agencies will:
- Rate Actions 1.1 and 1.2 as not met at assessment
- Notify the Commission in October each year of all health service organisations that have not submitted, or have submitted an incomplete attestation statement.
Requirements for transition in 2019
Transition arrangements will be in place to support health service organisation undertaking assessment to the second edition of the NSQHS Standards in 2019.
Health service organisations being assessed in 2019 will be required to submit an Attestation Statement at any time prior to their assessment, but not later than 30 September 2019.
Transition arrangements will cease on 31 December 2019.
Requirements for health service organisations changing accrediting agency
At the time of transfer between accrediting agencies, a health service organisation is required to provide their receiving agency with a copy of the attestation statement submitted to their former agency in the previous year.
A template attestation statement is available for download here.
Fact Sheet 8: Accrediting agency performance oversight and feedback
The Commission’s processes of oversight and feedback are being expanded and enhanced with the introduction of the second edition of the NSQHS Standards and review of the AHSSQA Scheme.
These processes are designed to promote improvements in performance across all approved accrediting agencies, ensure consistent implementation of revisions to the AHSSQA Scheme, as well as ensuring assessments are rigorous and completed within agreed timeframes.
An accrediting agency has approval to assess health services organisations using the NSQHS Standards subject to conditions that are designed to ensure:
- Accrediting agencies have the systems and processes in place to effectively convene assessments and award accreditation certificates
- Assessors are skilled, experienced and well-trained in conducting assessments
- Data is provided to the Commission and regulators to monitor accreditation outcomes
- Assessment of the NSQHS Standards is consistent across all approved accrediting agencies.
Oversight and feedback processes conducted by the Commission consist of:
1. Post-assessment surveys
Following the completion of an accreditation assessment, the Commission invites each health service organisation to participate in a short online survey about their experience of the assessment process and their accrediting agency.
The survey includes questions about the assessors’ skills and approach to the assessment and the accrediting agencies processes for organising and preparing for the assessment.
This information is used to measure compliance with approval by accrediting agencies and identify any specific issues with individual accrediting agencies.
2. Observation visits
A representative of the Commission attends at least one assessment visit each year for each approved accrediting agency, to observe assessor performance.
The observation visit provides first-hand information about how an assessment is conducted and insights into the skills of assessors. It also provides insights into the rigor of the assessment process.
This information is used to measure compliance with the conditions of approval by accrediting agencies and identify training requirements for assessors.
Observation visits are only conducted with prior agreement from the health service organisation. The observer does not influence the outcome of the assessment process.
3. Analysis of accreditation outcomes data
Accrediting agencies regularly submit accreditation outcomes data to the Commission for each assessment completed. The Commission analyses this information to determine if there are any anomalies or significant variation between accrediting agencies or across sectors.
The Commission has worked with regulators and accrediting agencies to describe the data elements and definitions that will be collected at each assessment against the NSQHS Standards (2nd ed.). An electronic portal is being developed for the submission of data, and unique identifiers are being allocated to each health service organisation. These mechanisms are expected to improve the data quality and accuracy.
4. Accrediting agency compliance reports
In addition to providing routine data on each health service organisation assessment, accrediting agencies also submit information to the Commission, including:
- Instances of any significant risks identified during an assessment. A significant risk is one where there is a high probability of a substantial and demonstrable adverse impact for patients. In each case, a significant risk will be sufficiently serious to warrant an immediate response to reduce the risk to patients. This may include interventions or changes to systems, the clinical care service environment, or clinical practice
- Health service organisations changing accrediting agency during an assessment or before an accreditation award is determined
- All actions that are awarded not applicable status at assessment
- Information on health service organisations that are not awarded accreditation
- Information on assessors, such as the number of assessment’s they complete each year, and their participation in training.
This information is used both as a compliance measure for accrediting agencies against the terms and conditions of approval, and to identify health service organisations for which there is a potential for increased risk of harm.
5. Accrediting Agency Working Group
The Commission convenes a working group made up of approved accrediting agencies quarterly to support the ongoing implementation of the AHSSQA Scheme. This provides a forum to share information and address emerging issues as well as collaborate with approved accrediting agencies on strategies for improvement. Accrediting agencies are required to send a representative to these meetings.
6. Analysis of issues raised through the Advice Centre
The Commission operates an Advice Centre using a dedicated telephone line and email address which is available to anyone with queries about the NSQHS Standards and AHSSQA Scheme.
The Commission analyses information and issues from Advice Centre queries to determine trends and actions that may need to be taken. This information has been used to develop Advisories, incorporate into assessor training and inform changes to the AHSSQA Scheme.
7. Receipt of information from regulators
The Commission receives information from regulators (state and territory health departments) about their experience of accrediting agencies conducting assessments for health service organisations that they manage.
The Commission collates information from each of these sources in performance reports prepared annually for each accrediting agency. This information is discussed with agencies to determine how the Scheme and their performance in the Scheme can be improved.
Fact Sheet 9: Managing conflicts of interest in accreditation
The Commission is introducing a range of strategies to reduce potential and real conflicts of interest that are associated with accreditation processes.
Safety and quality consultants not to participate in assessments
Health service organisations may engage safety and quality consultants to help them prepare for assessment to the NSQHS Standards. These consultants sometimes participate in assessments and respond to enquiries from assessors. Often in these situations, the safety and quality consultant is the only representative of the health service organisation able to answer assessors’ questions in detail.
Therefore, from January 2019, safety and quality consultants engaged by a health service organisation to prepare the organisation for an assessment, are not permitted to attend or participate in the assessment process for the NSQHS Standards.
A safety and quality consultant is a person who meets one or more of the following criteria:
- Is not identified on the organisational chart
- Is not an employee
- Has no delegated safety and quality responsibilities or accountabilities within the organisation
- Has no line management responsibilities in the organisation
- Does not provide regular and ongoing technical support for the delivery of patient care.
This strategy is specifically aimed at consultants whose work in an organisation is primarily to achieve accreditation, who do not provide or support direct patient care and who do not have as a primary part of their role the transfer of expert knowledge and/or skill to the organisation’s workforce.
This requirement does not apply to consultants who may be engaged by health service organisations to support clinical care, or provide ongoing technical advice and expertise. Consultants providing or supporting clinical services will have a contract for services that specifies the safety and quality requirements of their role and ensures the services provided align with the NSQHS Standards. These consultants may perform services such as:
- Providing expert technical advice and support for clinical care (for example, in pharmacy or infection control)
- Providing organisational training and knowledge transfer on safety and quality matters
- Supporting safety and quality improvements.
Nor does this requirement apply to operations staff from a corporate office, or employees with designated roles and responsibilities related to the organisation.
Accrediting agencies are required to notify health service organisations of these requirements before commencing an assessment.
Accrediting agencies consulting on safety and quality
A known conflict of interest exists in situations where an accrediting agency or assessor both support a health service organisation to implement standards, and then assess them against those standards.
To reduce the likelihood of this conflict of interest occurring, accrediting agencies are to:
- Have in place processes to ensure assessors who also provide safety and quality consulting services do not review organisations where they have consulted
- Provide the Commission with information on how they manage conflicts of interest occurring when assessors provide consulting services on the NSQHS Standards and assess to the NSQHS Standards.
Accrediting agencies must ensure that there is no conflict of interest, or bias, on the part of the Agency or its assessors in conducting assessments and awarding accreditation. Any conflict of interest must be immediately acknowledged and addressed by the accrediting agency.
When an assessor reviews an organisation over multiple accreditation cycles, they can lose their capacity to be objective. Therefore lead assessors and assessor team members may assess the same organisation for a maximum of two consecutive cycles before they are required to have an absence of at least one cycle.
Accrediting agencies will no longer be able to contract assessors on fixed fee-for-service arrangements. This funding arrangement discourages assessors rating actions as not met if they are responsible for funding the return visit for reassessment of these actions from their contracted fee.
Fact Sheet 10: Assessment in private dental practices and public dental services
This factsheet provides details of transitional arrangements for the second edition of the NSQHS Standards for public dental services and private dental practices.
Public dental services
Under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme, assessment to the NSQHS Standards is currently mandatory for the majority of public dental services. State and territory health departments have confirmed that these arrangements will remain in place for public dental services following the implementation of the NSQHS Standards (2nd ed.).
From 1 January 2019, public dental services for which assessment against the NSQHS Standards is mandatory, will be required to transition to the NSQHS Standards (2nd ed.).
Services that are unsure of their accreditation requirements should contact their governing body or state and territory health department. A list of departmental contacts is available here.
Private dental practices
Assessment to the NSQHS Standards is currently voluntary for private dental practices. Private dental practices who voluntarily implement the NSQHS Standards will not transfer to the second edition in January 2019. These services will continue to be assessed against the first edition of NSQHS Standards.
These services should refer to the Commission’s website for information on the first edition.
The Commission is developing a guide to support the implementation of the NSQHS Standards (2nd ed.) in non-acute health care services, including community and dental services.
The Commission is also developing a set of national safety and quality standards specifically for primary health care services. It is expected that these standards will be available for implementation from 2020. Public dental services and private dental practices will transition to the primary care standards once they are implemented.
Fact Sheet 11: Applicability of Clinical Care Standards
Published 10 December 2018
The NSQHS Standards (second edition) refer to the use of Clinical Care Standards in a number of actions, including Actions 1.27b, 3.15d and 5.29a. This factsheet provides advice to health service organisations implementing Clinical Care Standards and assessors reviewing compliance with these actions.
The Australian Commission on Safety and Quality in Health Care (the Commission) has a program of developing and updating Clinical Care Standards. They are written to support standardised practice that is evidence based and nationally agreed.
Clinical Care Standards can play an important role in delivering appropriate care and reducing unwarranted variation, as they identify and define the care people should expect to be offered or receive, regardless of where they are treated in Australia. Each Clinical Care Standard has a small number of Quality Statements and agreed indicators so implementation can be monitored.
All current Clinical Care Standards are available on the Commission’s web site at: www.safetyandquality.gov.au.
When patients receive care in an area covered by a Clinical Care Standard the Commission recommends they be offered the care that is set out in the Quality Statements.
The NSQHS Standards reference Clinical Care Standards on Delirium and Antimicrobial Stewardship. The advisory that describes requirements for the implementation of the Colonoscopy Clinical Care Standard will be released shortly. Implementation of the remaining Clinical Care Standards is at the discretion of health service organisations.
Implementing Clinical Care Standards aligns with one or more of the following requirements in the NSQHS Standards (2nd ed.):
- Action 1.27b: have processes that support clinicians use the best available evidence, including relevant Clinical Care Standards developed by the Australian Commission on Safety and Quality in Health Care
- Action 3.15d: incorporate core elements, recommendations and principles from the current Antimicrobial Stewardship Clinical Care Standard
- Action 5.29a: incorporate best practice strategies for early recognition, prevention, treatment and management of cognitive impairment in the care plan, including the Delirium Clinical Care Standard where relevant.
Health service organisation implementing Clinical Care Standards
When health service organisations are implementing Actions 1.27b, 3.15d and 5.29a it is recommended that they:
- Identify which Clinical Care Standards are relevant to the health service organisation given the services that are provided
- For all relevant Clinical Care Standards:
- provide clinicians with access to the Clinical Care Standards
- document in policies, or protocols, which of the Quality Statements (or part of a quality statement) are the responsibility of the health service organisation and which indicators are to be monitored by the health service organisation, the Quality Statements may be the responsibility of more than one provider.
- provide procedural specialist and other relevant clinicians with its Clinical Care Standards, policy or protocol
- implement the quality statements and monitor indicators that are within the health service organisation’s responsibility.
Assessing compliance with actions related to Clinical Care Standards.
When assessors are reviewing compliance with Actions 1.27b, 3.15d and 5.29a and health service organisations are implementing one or more Clinical Care Standard, it is recommended evidence be sought to confirm the health service organisation has:
- Identified Clinical Care Standard(s) relevant to its service context
- Provided clinicians with access to relevant Clinical Care Standards
- Provided procedural specialist and other relevant clinicians with its policy or protocols that identify the Quality Statement the organisation is responsible for and indicators being monitored for relevant Clinical Care Standards.
- Implemented the requirements set out in the quality statements and are monitoring the Quality Statement indicators
Where the health service organisation has implemented these strategies, this supports compliance with elements of Actions 1.27b, 3.15d and 5.29a.
Fact Sheet 12: Assessment framework for safety and quality systems
Published 10 December 2018
The Commission has developed an Assessment Framework for Safety and Quality Systems (the Framework) to improve the effectiveness, rigour and consistency of assessment to the National Safety and Quality Health Service (NSQHS) Standards. It incorporates a structured assessment method, called the PICMoRS Method, which can be used to comprehensively review the processes that make up the safety and quality systems specified in the NSQHS Standards.
By using a standardised structured assessment method, health service organisations and assessors can be confident all components of safety and quality systems are comprehensively evaluated, and that assessments are based on evidence of actual performance from observations, interviews and records.
This fact sheet provides an overview of the Framework and the PICMoRS Method. The Framework can be found at Figure 1.
Assessment Framework for Safety and Quality Systems
The Assessment framework for safety and quality systems describes the requirements of an assessment in three stages.
Stage 1: Before an assessment
For assessors to be well prepared to undertake an assessment, accrediting agencies need to:
- Establish assessment processes that are effective. They can do this by nominating a lead assessor, providing health service organisation with an audit schedule in a timely way, training assessors to use structured assessment processes, and complying with the requirements of the AHSSQA Scheme
- Ensure assessors understand what safe, good quality care looks like. This can be achieved by training and performance managing the assessor workforce, and providing access to tools and resources developed by the Commission
- Ensure assessors understand the intent of the NSQHS Standards. Assessors can gain this knowledge through completion of the Commission’s orientation program and regular participation in agency training activities
- Ensure assessors understand the service context where they are assessing. Assessors would be expected to have previously worked in the sectors where they assess
- Ensure assessors understand the assessment scope. This would involve them identifying all of the service areas to be assessed, the patient groups involved and key safety and quality systems being assessed.
Stage 2: During an assessment
During an assessment, assessors are required to verify that safety and quality systems are in place by reviewing compliance with the NSQHS Standards. This can largely be done using the PICMoRS Method, which allows for a structured, standardised assessment of the multiple processes that make up each safety and quality system.
As healthcare is complex and health service organisations vary, it is not possible to predict the information or evidence that will be found during an assessment of one service area or at any one level in a health service organisation. By repeating the PICMoRS Method throughout an organisation and for different processes within a safety and quality system, assessors will develop a comprehensive picture of the function of the organisations safety and quality systems.
Assessment using the PICMoRS Method can be undertaken in any part of an organisation, and can include gathering evidence from clinicians, managers, other members of the workforce, representatives of the governing body and consumers. Who is interviewed will depend on who:
- Has overall responsibility for the process
- Is involved in implementing the process
- Is impacted by the system or process.
There are six parts to the PICMoRS Method, and all are inter-related. There may be situations where the assessment is not carried out sequentially. Regardless of the order, an assessor needs to investigate all six parts to fully evaluate the safety and quality process under examination.
Stage 3: After an assessment
Finalising an assessment occurs in two phases. Firstly, information from all assessors in a team is collected and verified, with the findings compared to the requirements of the NSQHS Standards.
Secondly, assessors provide health service organisations with preliminary information about the findings of the assessment at an exit meeting, including not met actions that require remediation.
Assessors provide information to their accrediting agency to determine, firstly the need for a final assessment and then if accreditation should be awarded.
The PICMoRS Method
PICMoRS is a mnemonic that stands for:
I Improvement strategies
C Consumer participation
S Safety and quality systems
All six parts to the PICMoRS Method must be completed to conduct a comprehensive assessment of the safety and quality processes being examined.
Part 1: Process
An assessor should first seek an explanation of the process being reviewed.
This involves identifying who in the organisation is involved in the process and where the requirements for the process are documented. Assessors can then determine who should be interviewed. This information will enable an assessor to determine if actual practice matches practice described in the policy and procedures.
Information about a process can be obtained by asking questions such as:
- How does this process work in your organisation?
- Is this documented? How do you access this information?
- Who is responsible for the other parts of the process?
- Where else is this process used?
- Are there places where this process is not used? Why?
- Where can you access information about this process?
- Would you be confident the information is up to date and accurate?
Collecting this information helps an assessor understand:
- The multiple elements of a process
- Who is responsible for each part of the process, therefore who else may need to be interviewed
- Where the process is being applied
- Where the process is documented
- How the workforce is kept up to date on changes to a process.
Part 2: Improvements strategies
With an understanding of the process, an assessor now needs to determine if the organisation has reviewed the effectiveness of the process and if changes have been implemented.
Where improvements have been introduced, an assessor should seek to understand the rationale for change, how the workforce was made aware of the changes, implementation strategies used and how effective the changes are.
This information could be obtained by asking questions such as:
- Has the process been reviewed?
- What were the issues that lead to the change?
- How would you get to know if there were changes?
- Who is responsible for making the changes?
- Have the changes been fully implemented?
- How did you determine if further changes are needed?
If no improvements have been implemented, the assessor should ask:
- What would prompt you to implement improvement strategies?
This information allows an assessor to understand:
- Improvements that have been made
- If planned changes are being implemented and monitored.
Where no improvements have been made, assessors can determine if the process is effective and monitoring is in place to ensure it is still fit for purpose or if the organisation is not aware of the process or need for change.
Part 3: Consumer participation
Partnering with consumers is at the centre of the NSQHS Standards. Assessors examining the NSQHS Standards are evaluating consumer participation in safety and quality systems and processes, including clinical governance and in their own care.
The form consumer participation takes will vary depending on the safety and quality process being evaluated. For example, the safety and quality systems that relate to the Clinical Governance Standard will involve engaging with consumers in the design, monitoring or evaluation of services within a program, department or the organisation. Being a partner could mean being a full member of a quality improvement and redesign team, or providing input through focus groups, feedback mechanisms, surveys or social media.
Information on consumer partnerships could be obtained by asking the workforce questions such as:
- How were consumers involved in designing, improving or evaluating the process?
- How do you provide consumers with feedback on this process?
Consumers may also be involved through the processes of care. In this case information could be obtained by asking the workforce or consumers questions such as:
- How do you engage consumers in their own care? How is this documented?
- Do you collect feedback from consumers on this process? How?
- Do you report back to consumers on this process? How?
Part 4: Monitoring
Assessors need to examine the extent and type of monitoring a health service organisation conducts on its safety and quality processes and then consider how this information is used to plan, deliver and improve patient care.
Effective monitoring enables health service organisations to understand day to day practice, evaluate the effectiveness of existing safety and quality processes, as well as responds to deviations from expected outcomes. It requires the collection and analysis of data to:
- Identify areas of under and high-performance
- Prioritise areas for improvement
- Measure changes over time
- Evaluate the effectiveness of changes that are introduced.
Information for monitoring can be collected from:
- Routine data sets (sometimes called administrative data)
- Patients, carers and families (for example, patient experience surveys)
- Clinicians and managers (using their reporting and surveillance mechanisms)
- National, jurisdictional or local data sets (such as the national hand hygiene audit data or National Inpatient Medication Chart Audit).
Information about monitoring can be obtained by asking questions such as:
- How is this process monitored? Where is this documented?
- Do you use national, jurisdictional or local measures to monitor this process? Why?
- How have you used data to improve the process?
Answers to these questions allows an assessor to understand what monitoring occurs as well as the frequency, sample size, scope and currency of data collections. It also provides information about who is involved in these processes.
Part 5: Reporting
Having determined what information is collected, assessors need to determine where this information is reported. Tracking reporting provides an example of the governance reporting system at work.
Reporting on processes may occur to and from a service area, direct line managers or committees, and executives and the governing body. An assessor should confirm if information on a process is reported to the workforce, consumers, the community and/or other health services.
This information could be obtained by asking the workforce questions such as:
- Where is information on the process reported? Where is this documented?
- How often does this occur?
- Does the information go to the consumers, workforce, management or governing body?
- Do you get feedback on information that your report?
It is important to understand where information is reported because decision on safety and quality should be driven by reliable, accurate and current information.
Part 6: Safety and quality Systems
Safety and quality systems are most effective when they are integrated and inform each other. For example, processes (such as collecting outcomes data, distributing reports and developing recommendations) from a risk management system should inform policy and training systems, and the incident management system should inform the risk management system.
Information about the integration of safety and quality systems could be obtained by asking the workforce questions such as:
- Is the information from this process used to change other processes, such as risk management, policy development, training and quality improvement?
- Does the information from any other system influence how you use or change this process?
- Where is this documented?
Information on the connectedness of system can be used to understand how effectively an organisation uses their learnings about safety and quality to improve care and improve the effectiveness of its safety and quality processes.
Fact Sheet 13: Implementing the Aboriginal and Torres Strait Islander specific actions
Published 10 December 2018
In relation to the Aboriginal and Torres Strait Islander specific actions, there are no exemptions identified for hospitals. For day procedure services, not applicable status may be granted for Actions 1.2, 1.4, 1.33 and 2.13 where evidence is provided when there is evidence that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general patient population.
Advisory AS18/01 Advice on not applicable actions specifies which actions hospitals and day procedure services may seek not applicable status for. Where the Aboriginal and Torres Strait Islander patient population is small, the scope of strategies should reflect this and be consistent with the risk of harm for these patients.
Determining risk of harm for Aboriginal and Torres Strait Islander people
Advisory AS18/04 Advice on the applicability of Aboriginal and Torres Strait Islander specific actions provides guidance to health service organisations seeking exemptions for Actions 1.2, 1.4, 1.33 and 2.13. It requires organisations to demonstrate that a comprehensive risk analysis has been undertaken that examines the:
- Risk profile of the organisation’s general patient population
- Risk profile of the organisation’s Aboriginal and Torres Strait Islander patient population
The risk profile could be determined by comparing the following information on Aboriginal and Torres Strait Islander patients to non‑Indigenous patients:
- Number and age profile of Aboriginal and Torres Strait Islander patients
- Diagnosis, procedures and rate of complications
- Length of stay
- Type, severity and rate of incidents
- Frequency of discharge against medical advice
- Feedback from Aboriginal and Torres Strait Islander patients
This data can could be collected from a range of resources, including:
- Clinical and administrative data sets
- Audit of patient records
- Incident management systems
- Feedback and complaints systems
- Demographic information on the organisation’s patient catchment
- Risk register
For all actions in the NSQHS Standards, the extent and scope of the strategies health service organisations implement should be determined by the risks to patient care. This is true for the Aboriginal and Torres Strait islander specific actions. Where the number of Aboriginal and Torres Strait Islander patients are small compared to the overall population, the strategies implemented by the health service organisation may be implemented over a longer period or focus on one or two key strategies.
Fact Sheet 14: Assessing high-risk scenarios during an assessment
Published 10 December 2018
At each assessment to the National Safety and Quality Health Service (NSQHS) Standards (second edition) the Commission requires assessors to test an organisation’s ability to provide safe care including at times of high patient risk.
The purpose of this assessment is to ensures that organisations have the systems, processes and personnel to maintain high-quality care at all times including times of increased risk to patients.
Not all risks that impact on patient care relate to clinical care.
There are a broad range of risks that can affect patient safety and quality. These include corporate, financial, legal and compliance, physical or assessment management risks as well as clinical risks.
Everyone in the organisation is responsible for minimising risks, however specific individuals or groups may be delegated accountability for the oversight and management of specific risks.
Increases to patient risk can occur for many reasons, including:
- Changes to service delivery models
- Mergers of existing services
- Relocation of services
- Capital works
- Intakes of new staff, particularly new graduates
- Introduction of new services or technologies
- Disruption to essential utilities
- Gaps in senior leadership
- Periods of low staffing levels including weekends and nights
- Gaps in clinical workforce
- Loss of access to electronic patient records or other electronic clinical data collection or booking systems
- Disruptive or aggressive patient/s, families or other member/s of the community
- Inability of a proceduralist to complete a case
- Failure of vital equipment
- Seasonal fluctuations in patient populations
In the Clinical Governance Standards of the National Safety and Quality Health Service (NSQHS) Standards (second edition) is Action 1.10 that requires health service organisations to identify and manage risk. It states:
Action 1.10 The health service organisation:
a. Identifies and documents organisational risks
b. Uses clinical and other data collections to support risk assessments
c. Acts to reduce risks
d. Regularly reviews and acts to improve the effectiveness of risk management systems
e. Reports on risks to the workforce and consumers
f. Plans for and manages, internal and external emergencies and disasters
Assessing high risk scenarios is part of the assessment of this action, but also should be considered when assessing other actions in the standards that maybe affected by the specific scenario. For example:
- Action 1.16 – health care records may be impacted if the healthcare records are unavailable due to power disruptions or IT outages
- Action 1.26 - supervision of the clinical workforce may be impacted if there are gaps in the senior clinical workforce
- Action 5.4 collaboration and teamwork may be impacted if there are gaps in the clinical workforce overnight or on weekends.
The intent is to assess risks that may be infrequent, but have a significant consequence on patient safety and quality if not managed appropriately. It examines the organisations service continuity and recovery planning for patient safety and quality.
To test a high risk scenario, assessors will be required to identify one or two major risks from the organisations risk register or select one or two risks from the list of common risks developed by the Commission. These risk scenarios are to be assessed using the PICMoRS structured assessment method (see Fact Sheet 12).
Examples of questions assessors could ask using the PICMoRS structured assessment method for high risk scenario are as follows:
- What do you do to manage <high risk scenario>?
- Is this documented?
- How would you escalate your concerns about this risk?
- Has this process been tested?
- Do you know who is accountable for managing this risk?
- Have there been any recent changes to this process?
- Have the changes been tested?
- Are patients told about the increased risk?
- How are consumers involved in designing or evaluating strategies for managing <high risk scenario>?
- How is this risk monitored?
- How would you know if the process to manage <high risk scenario> is being used?
- Where is information on <high risk scenario> reported?
- How is the accountable officer / committee informed about this risk?
- How is information <high risk scenario> used to inform other safety and quality systems?
- Where is this documented?
- Is there a policy related to this risk?
Where processes are not in place to mitigate risks describe in the scenario, Action 1.10 or any other related action should be rated not met.