Safety and Quality > Our Work > Accreditation and the NSQHS Standards > Information for health service organisations


Who needs to implement the National Safety and Quality Health Service Standards?

When do health service organisations need to be accredited to the NSQHS Standards?

Steps for implementing the NSQHS Standards in health service organisations

Transition arrangements from 2014

Significant patient risk

Interim accrediting of new health service organisations

Information for small hospitals

Guide to the NSQHS Standards for community health services

Guide to the National Safety and Quality Health Service Standards for health service organisation boards

Credentialing health practitioners and defining their scope of clinical practice: A guide for managers and practitioners

NSQHS Standards Advisories

Approved accrediting agencies

 


 

Who needs to implement the National Safety and Quality Health Service Standards?

All hospitals and day procedure services and the majority of public dental services across Australia need to be accredited to the NSQHS Standards. Private health service organisations need to confirm their requirements for accreditation to any standards in addition to the NSQHS Standards with the relevant health department.

Further information regarding contact details for health departments can be found using the following link:
Accreditation and the NSQHS Standards – Resources to implement the NSQHS Standards – Contact details

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When do health service organisations need to be accredited to the new Standards?

Accreditation to the NSQHS Standards commenced on 1 January 2013. This means that the next scheduled recertification audit or organisation-wide accreditation visit will involve assessment using all 10 NSQHS Standards.

For a mid-cycle assessment, periodic review or surveillance audit, health service organisations will not need to be assessed against all 10 NSQHS Standards. Any mid-cycle assessment will, at a minimum, involve:

  • Standards 1, 2 and 3
  • the organisational quality improvement plan (or equivalent document such as an operational or strategic plan)
  • recommendations from previous accreditation assessments.

For new health service organisations, interim accreditation to the NSQHS Standards will generally apply for the first 12 months of operation. Further information regarding interim accreditation arrangements can be found using the following link:

Accreditation and the NSQHS Standards – Information for health service organisations – Interim accrediting of new health service organisations

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Steps for implementing the NSQHS Standards in health service organisations

Accreditation programs focus on continuous quality improvement strategies. They usually consist of a process that involves self-assessment, review or assessment of performance against the NSQHS Standards, and ongoing monitoring by the accrediting agency.

Information on the accreditation process can be found by accessing the Accreditation Process Flowchart:
Accreditation and the NSQHS Standards – Resources to implement the NSQHS Standards – General resources

Further information regarding the steps for implementing the NSQHS Standards can be found using the following link:
Accreditation and the NSQHS Standards – Information for health service organisations – Steps for implementing the NSQHS Standards

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Transition arrangements from 2014

The Commission introduced flexible arrangements in 2013 to support the first wave of health service organisations undertaking accreditation to the NSQHS Standards. The arrangements recognised that health service organisations undergoing accreditation in 2013 had less time to prepare for assessment, and that both surveyors and health service organisations were new to the NSQHS Standards. These flexible arrangements ceased on 31 December 2013.

Implementation from 1 January 2014:

  1. The remediation period for a health service organisation to address any ‘not met’ actions following an accreditation assessment reverted from 120 days to 90 days.
  2. A small number of actions which had prescribed (minimum mandatory) requirements as part of the 2013 flexible arrangements had these temporary requirements removed. Health service organisations are now required to fully implement actions as described in the NSQHS Standards document, with the exception of 3.10.1 and 9.6.1 as described below.

 

The following arrangements remain in place:

  • Action classified as developmental will remain developmental
  • Two of the prescribed actions will remain in place – 3.10.1 Training in aseptic technique and 9.6.1 Training in basic life support

Further information regarding Transition Arrangements from 2014 can be found in Advisory A13/08 using the following link:
Accreditation and the NSQHS Standards – Resources to implement the NSQHS Standards – NSQHS Standards advisories

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Significant patient risk

If a significant risk of patient harm is identified during an onsite visit to a health service organisation, accrediting agencies are required to notify the relevant State or Territory health department. The Commission has developed guidance and provided some examples of risks that could result in significant harm to patients.

Further information regarding significant risks can be found in Advisory A13/01 using the following link:
Accreditation and the NSQHS Standards – Resources to implement the NSQHS Standards – NSQHS Standards advisories

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Interim accrediting of new health service organisations

There are specific requirements for new health service organisations to obtain interim accreditation to the NSQHS Standards. New organisations will not necessarily be able to meet all 256 actions in the 10 Standards, and so a number of actions have been prescribed as minimum requirements or have been declared non-applicable for the initial 12 months of operation.

Further information on interim accreditation be found using the following link:
Accreditation and the NSQHS Standards – Resources to implement the NSQHS Standards – Accreditation workbooks

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Information for small hospitals

The Commission released the NSQHS Standards Guide for Small Hospitals in May 2013. For the purpose of this Guide, a small hospital is a service with 50 beds or less.

The NSQHS Standards Guide for Small Hospitals is available for electronic download from the Commission’s website using the following link:
Accreditation and the NSQHS Standards – Resources to implement the NSQHS Standards – Specialist Guides

The Guide is also available in hard copy on request. Contact the Advice Centre on 1800 304 056 or email accreditation@safetyandquality.gov.au to request a copy.

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Guide to the NSQHS Standards for community health services

The Commission released the Guide to the NSQHS Standards for community health services to support community health services implementing the NSQHS Standards.

The NSQHS Standards are designed to drive improvements in safety and quality in health care nationally. There are 10 NSQHS Standards that cover areas where there is an increased risk to patient safety and where there have been incidents of patient harm as a result of care. Accreditation to the NSQHS Standards is mandatory for all hospitals and day procedure services and a majority of public dental services. Community health services may be included in an accreditation assessment as part of a broader health service organisation.

The release of the Guide to the NSQHS Standards for community health services promotes a consistent and shared understanding of the Standards. The development of the guide and accompanying electronic monitoring tool has been a collaborative process with community health stakeholders nationally. The guide has also been piloted with 35 community health services.

The guide contains information on:

  • preparing for accreditation
  • the national accreditation scheme
  • applicability of the NSQHS Standards to different community health services
  • specific strategies to for implementing the NSQHS Standards in community health settings.

The Guide to the NSQHS Standards for community health services is available for download from the Commission’s website using the following link:
Accreditation and the NSQHS Standards – Resources to implement the NSQHS Standards – Accreditation workbooks

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Guide to the National Safety and Quality Health Service Standards for health service organisation boards

Health service organisation boards have roles and responsibilities for clinical governance, safety and quality. The NSQHS Standards outline responsibilities for health service organisations, however it was identified that a specific resource for boards would be useful, especially for smaller boards and boards in rural health service organisations. The Commission developed the Guide to the National Safety and Quality Health Service Standards for health service organisation boards. The guide outlines the roles boards play in ensuring safe and high quality care in health service organisations.

The Guide to the National Safety and Quality Health Service Standards for health service organisation boards is available for electronic download from the Commission’s website using the following link:
Accreditation and the NSQHS Standards – Resources to implement the NSQHS Standards – Specialist Guides

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Credentialing health practitioners and defining their scope of clinical practice: A guide for managers and practitioners

The Commission’s NSQHS Standard 1: Governance for Safety and Quality in Health Service Organisations requires health service organisations to implement a system that determines and regularly reviews the roles, responsibilities, accountabilities and scope of practice for the clinical workforce. Credentialing and scope of clinical practice processes are key elements in ensuring the safety of patients in health service organisations. The Guide was developed at the request of the Commission’s Private Hospital Sector Committee. This is an ancillary guide only. It does not replace or supersede state, territory or organisational policies on credentialing.

The Guide for managers and practitioners: Credentialing health practitioners and defining their scope of clinical practice will assist in determining and managing their scope of practice. This practical guide will also help to ensure that only health practitioners who are suitably experienced, trained and qualified to practice in a competent and ethical manner are appointed to health services.

The guide includes the requirements for assessing and credentialing an individual health practitioner and then determining their scope of practice when:

  • initially appointed and at reappointment
  • renewing their scope of practice
  • concerns arise in respect of their scope of practice.

The principles and processes identified in the guide can be applied to any health practitioners where an organisation considers that patient safety would be improved.

The resource is available for electronic download from the Commission’s website using the following link:
Accreditation and the NSQHS Standards – Resources to implement the NSQHS Standards – Specialist Guides

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NSQHS Standards Advisories

NSQHS Standards Advisory is a formal communication to accrediting agencies from the Commission to provide guidance and direction on the interpretation and/or assessment of the NSQHS Standards. Advisories are numbered and dated before distribution.

The full list of advisories can be found using the following link:
Accreditation and the NSQHS Standards – Resources to implement the NSQHS Standards – NSQHS Standards advisories

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Approved accrediting agencies

The Commission approves accrediting agencies to assess health service organisations using the NSQHS Standards. To be approved, accrediting agencies need to be accredited by an internationally recognised body such as the International Society for Quality in Health Care (ISQua) or the Joint Accreditation Scheme of Australia and New Zealand (JAS-ANZ), and report accreditation information to the Commission and relevant state and territory health departments.

The Commission also approves accrediting agencies to assess health service organisations using the Trauma Recovery Program (TRP) Standards. Accrediting agencies must be accredited as outlined above, and follow the reporting requirements as specified in the National (TRP) Standards Workbook published by the Department of Veterans’ Affairs.

Health service organisations are required to use an approved accrediting agency to be accredited to the NSQHS Standards and/or the TRP Standards. A full list of approved accrediting agencies can be found using the following link:
Accreditation and the NSQHS Standards – Resources to implement the NSQHS Standards – Contact details

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Last updated: 25 February 2016