Short notice assessments

From 1 July 2023, all public and private hospitals and day procedure services undergoing assessment to the NSQHS Standards, and the National Clinical Trials Governance Framework (NCTGF),will be assessed at short notice. Other health service organisations may voluntarily choose to be assessed at short notice, or it may be a requirement of licencing or funding contracts.

Health service organisations implementing the National Safety and Quality Primary and Community Healthcare Standards, or the National Safety and Quality Digital Mental Health Standards, are generally assessed with an announced visit, unless it is a requirement of licencing or funding contracts, or they choose to be assessed at short notice.

Where community services are part of a local health district or network and the contract with the approved accrediting agency is for a combined assessment, all services assessed under the contract will be subject to short notice assessment.

Community health services that implement the National Safety and Quality Primary and Community Healthcare Standards will be assessed via the announced pathway but may choose to be assessed at short notice voluntarily.

For the first three-year assessment cycle, health services will be assessed against a maturity scale as either having initial systems, growing systems or established systems in place for clinical trial services.

Beyond the first accreditation cycle, health services will transition fully to assessment under the AHSSQA Scheme and be assessed as either having met, met with recommendations or not met the actions within the Governance Framework and receive 60 business days to remediate.

Where a clinical trials site is part of a local health district or network and the contract with the approved accrediting agency is for a combined assessment, all services assessed under the contract will be subject to short notice assessment.

Clinical trials sites that implement the National Clinical Trials Governance Framework but are not being assessed to the NSQHS Standards, will be assessed via the announced pathway but may choose to be assessed at short notice voluntarily.

Interim accreditation to the NSQHS Standards will be announced. The initial assessment must occur within 10 days of commencing operation. The final assessment will be announced and must be completed within 18 months of the initial assessment. All subsequent assessments will occur at short notice.

An assessment cycle may include a final assessment if actions are not met or met with recommendations at initial assessment. While the initial assessment occurs at short notice, a final assessment follows a period of remediation (60 business days) and is announced.

Organisations that meet the criteria for mandatory reassessment are required to have a second assessment within six months of achieving accreditation. Mandatory reassessment dates will be announced.

Organisations will generally have 24 hours-notice of their assessment commencing.  That means an assessment commencing on a Wednesday will be notified on Monday. Tuesday is considered the full 24-hour notice. If notice is given on a Friday, the assessment will commence on Tuesday as Monday is taken as the 24 hours-notice period. Weekends are not counted.

Some organisations will have 48 hours-notice. State and territory health departments that regulate health service organisations determine which hospitals are to be assessed at 48 hours or longer notice.  The Commission will work with state or territory regulators to identify organisations to be given 48 hours-notice. These organisations and their accrediting agency will be notified once this is confirmed.

The accrediting agency will contact the person designated by the health service organisation, 24 (or 48) hours before the assessment occurs by phone and email. It will be important for health service organisations to frequently communicate with their accrediting agency to ensure that key contact details are up to date.

The regulator will be copied into the email to health service organisations notifying them of the assessment date and details.

When notice is provided of the assessment, accrediting agencies will provide information about the assessment team, duration of the assessment and sites to be visited. The accrediting agency will be responsible for drafting up a schedule for the visit. Accrediting agencies will seek guidance from health service organisations on transport, catering, and logistics. 

Health service organisations will be required to implement processes to regularly inform the accrediting agency of any key changes within the organisation. This may include confirming not applicable actions, changes in the scope of services provided, facilities changes and changes in key governance arrangements and personnel.

An initial meeting will be required to allow the assessment to commence. It is not intended that this meeting be long or include any presentations.

The aim is to establish administrative and operational processes which may include confirmation of assessment team members, gathering authority statements and distributing IT access and security passes, and identifying whom the assessment team will liaise with and report to, during and after the assessment.

Assessors will not generally require chaperones during the assessment, but will need clear information about the layout, name and purpose of all the operational areas.

During the assessment, the assessor team may need to contact the person in charge (or their delegate) to verify evidence, seek additional information, or data, in order to triangulate and confirm findings.

Assessors will use an assessment framework called PICMoRS. For more information see Fact Sheet 12: Assessment framework for safety and quality systems.

• Fact Sheet 12: Assessment framework for safety and quality systems

The PICMoRS assessment method allows assessors to comprehensively evaluate each component of safety and quality systems in a health service organisation. This method provides a structure for conducting assessments based on evidence of actual performance from observations, interviews and records.

Assessors will spend at least 75% of the assessment time in clinical areas and gather evidence from a range of source including observation of clinical care, discussions with consumers and members of the workforce, and review of documents, such as policies, patient records, minutes of meetings and records of incidents. 

Assessors will require access to governance documents and systems. These documents should be prepared as part of usual business, not specifically for an assessment. This may include reports from incident management systems, reports from audit results, quality improvement programs and risk registers (or similar), credentialing documents and minutes of governance meetings.

Each hospital and day procedure facility is required to be assessed. Sampling can occur where multiple non-hospital and non-day procedure services operate under a single governance structure, such as community based, public dental, prisons and transport services, in line with Advisory AS18/13: Sampling for accreditation assessment.

The accreditation agency will determine the length of an assessment and number of assessors. This will depend upon the size and complexity of the health service, the time available for the assessment and the number of facilities to be assessed.

Health service organisations being assessed under the requirements of the AHSSQA Scheme are allocated a unique identifier. Their purpose is to ensure that assessment data correlates to a specific facility or group of facilities.

Where a health service organisation contains multiple facilities, each facility is allocated a unique identifier. Similarly, sites being assessed against the NCTGF for clinical trial services will have their own unique identifier

Health service organisations that are currently being voluntarily assessed at short notice will complete the current cycle of assessments before transitioning to mandatory short notice assessments. The rules of the assessment of the voluntary SNAP program will apply until transition to mandatory short notice assessment, as per: Fact Sheet 6: Short notice assessments.

At the time of notification of a short notice assessment, risks may be identified that could impact the safety, or ability of assessors to access particular areas or sites. This may include road closures, outbreaks or other environmental disasters.  

Where safety concerns have been identified, the agency should contact the regulator and the Commission to confirm if the assessment should proceed and how the assessment should be conducted at the specific location. If the assessment is to be delayed, or conducted as a hybrid assessment, confirmation should be sought from the Commission via this online form.

If an onsite assessment is to occur, and there are additional costs incurred, these costs are to be met by the health service organisation. 

Accrediting agencies will commence planning for the visit well in advance of the assessment. Timetabling will depend upon the size of the assessment team, number of sites to be visited and their geographic location.

Particularly in small organisations, such as day procedure services, it will be important to provide assessor teams with staff rosters and to communicate material changes so this can be taken into account (such as key personnel, restrictions to clinical areas, or cancelled or changed theatre lists).

Generally, assessor teams will arrive together.  The lead assessor will inform the organisation’s contact person how the assessment team will be allocated and which sites and clinical areas they intend to visit . For organisations with multiple sites or based over a large geographic area, assessment teams may arrive on site at different times.

Flexible timetabling will be important to identify the best time to meet with key personnel or visit wards or clinical areas to observe patient care, or clinical activities such as safety huddles or clinical handover. Assessors will be sensitive to the patient’s clinical needs when seeking agreement to speak with clinicians and patients. 

The accreditation agency will determine the length of an assessment and number of assessors. This will depend upon the size and complexity of the health service, the time available for the assessment and the number and location of facilities to be assessed.

Assessors will need to review some evidence that is available on the organisation’s IT systems.

It is a matter for the health service organisation to determine how access will be granted. This may include generic access that is time limited, restricted access to certain areas of the IT system, or permitting a member of the workforce to guide assessors through the IT systems.

The aim of short notice assessment is for assessors to examine day-to-day practice. There is no requirement for health service organisations to create presentations or provide additional documentation that is not generated as a part of usual business of patient care or management of the health service organisation.

Assessors will spend at least 75% of the assessment time in clinical areas and gather evidence from a range of sources including observation of clinical care, testing high-risk scenarios, discussions with consumers and members of the workforce, and review of hospital performance data, policies, minutes of meetings and records of incidents. 

Assessors will use an assessment framework called PICMoRS. For more information see Fact Sheet 12: Assessment framework for safety and quality systems.

The PICMoRS assessment method allows assessors to comprehensively evaluate each component of safety and quality systems in a health service organisation. This method provides a structure for conducting assessments based on evidence of actual performance from observations, interviews and records. It enables assessors to view aspects of the patient journey and identify how clinical governance and safety and quality systems are operationalised in clinical settings.

Evidence provided to the accrediting agency prior to an assessment (such as a self-assessment) can help to prioritise the assessment schedule Documents do not need to be printed. However, assessors will require access to governance documents and systems see fact sheet: Checklist for Assessors Reviewing information accessed and actioned by the governing body.

These documents should be those that are prepared as part of usual business of providing care, or managing the health service organisation, not documents prepared specifically for an assessment.

This may include reports from incident management systems, reports from audit results, quality improvement programs and risk registers (or similar), credentialing documents and minutes of governance meetings.

Examples of information assessors could reasonably expect to have access to include:

• Previous assessment reports and ratings
• Organisational structure and personnel
• Clinical Governance structures
• Clinical Governance/Clinical Trials framework
• Strategic/operations plan
• Quality improvement plan and schedules
• Reconciliation action plan
• Annual quality and safety report
• Approved policies, procedures and guidelines
• Data and safety and quality performance reports provided to the governing body
• Reports to the governing body of trial service operational metrics
• Reports on clinical trials performance to the governing body
• Material to enable sampling of clinical trials conducted at the site
• Risk register
• Incident reporting system
• Minutes of meetings
• Quality improvement audit reports
• Consumer information
• Results and reports from regulator visit/audit
• Reports, notifications and outcomes from external reviews, such as licensing visits, safety and quality reviews or investigations.

Assessors will spend at least 75% of the assessment time in clinical areas talking to members of the workforce who are available on the day. They will also talk to the executive team, patients their carers and consumer representatives.

It is expected will inform when Regular communication may be used to inform staff of the expected course of an assessment and inform them to respond if they are interviewed by an assessor.  

Patients can be informed with notification on meal trays, notices at nursing stations, information desk and key locations in the facility. Organisations will need to determine which is the most effective mechanism(s) for their setting.

Assessors will expect to speak to consumers, consumer representatives and clinical trial participants during an assessment. Consumers and consumer representatives should be provided with opportunities to provide input into the assessment process in writing, in person, via telephone or electronically, including in confidence or anonymously.

Health service organisations should implement systems to notify consumers and clinical trial participants that an assessment is occurring and that with their consent assessors may observe and/or interview them about the care they receive.

It is recognised that organisations will have a variety of ways to meet the actions of the Partnering with Consumers Standard and the availability of consumer representatives will be different for different settings. If consumer representatives are not available during the assessment (either in person or via the telephone), there are an additional five days post short notice assessment for assessors to gather information, including interviewing consumers who were not available during the assessment.