Advisory CMO 25/03: Sampling for accreditation assessment

Advisory details

Purpose

To describe the sampling methodology to be used by accrediting agencies when sampling mental health community managed organisations at accreditation assessment.

Issue

The Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme requires community managed mental health service providers to be assessed by onsite assessment. Sampling is only permitted in community managed organisations where multiple mental health services operate under a single governance structure, such as psychosocial support, long-term residential and counselling services.

To ensure consistency, the Australian Commission on Safety and Quality in Health Care (the Commission) has developed a sampling methodology, to be applied by all accrediting agencies, to eligible community managed mental health organisations seeking accreditation.

Multi-site service providers

For the purposes of this advisory, the definition of a multi-site service provider is an organisation with multiple services located in separate geographical sites, operating under the same governance, policy, and process arrangements. Multi-site service providers may provide the same type of services however consideration should be given to their consumer cohorts determined by the Model of Care.

Requirements

For a community managed mental service provider with up to 20 separate service sites that are to be assessed and where sampling is approved, the following calculation will be used:

1. 5 sites plus one third of all remaining service sites are to be assessed, (rounded up to the nearest whole number).

For service providers with more than 20 service sites that are to be assessed and where sampling is approved, the following calculation will be used:

2. 10 sites plus one quarter of all remaining service sites are to be assessed, (rounded up to the nearest whole number).

An example of this calculation is at Attachment 1.

Service providers with greater than 100 sites can apply to the Commission to have the number of sites that undergo onsite assessment capped at an upper limit. 

The following rules will apply when selecting the assessment sites:

1. The corporate or main service provider is always to be assessed
2. 75 percent of sites assessed are to be selected based on a risk assessment by the accrediting agency. This assessment will take into consideration factors such as (but not limited to) previous assessment results, the last time the site was assessed, information provided in a gap analysis such as incidents and complaints, information in external reports, information gained in discussions with the service provider.
3. 25 percent of sites assessed are to be selected at random, ensuring a representative sample of the service is assessed
4. Accrediting agencies are to notify the service provider of sample sites just prior to or at the commencement of the assessment, and for rural or regional sites no more than six weeks in advance
5. Sample sites are to be selected by the accrediting agency, without taking into consideration the views of the service provider
6. Exceptions to point 4 and 5 of these rules can be made for service providers where the availability of staff and consumers is unpredictable and therefore requires some advance planning.
   Applications for exemption to point 4 and 5 will be considered on a case-by-case basis by the Commission. Where approval is granted, the approved accrediting agency can work in collaboration with the service provider implementing rules 1-3 to maximise the number of staff, consumers and sites that can be interviewed and visited during an assessment.
7. Organisations seeking exemption from this sampling methodology are to make a submission in writing (which can be in the form of an email), to the Commission via their approved accrediting agency. The Commission will, in collaboration with funding providers, make a determination on these applications.

Attachment 1

Example of sampling methodology calculation