Assessment to the NSQDMH Standards

Assessment methodologies used by accrediting agencies assessing the NSQDMH Standards are approved by the Commission including for desktop assessments. Accrediting agencies follow the policy and advisories for the Australian Health Service Safety and Quality Accreditation Scheme. 

The Commission may also issue guidance for conducting desktop assessments from time to time.

On-site and virtual assessments

PICMoRS is a mnemonic that was designed to help assessors to undertake assessment for accreditation under the AHSSQA Scheme. Originally developed for assessment to the National Safety and Quality Health Service Standards, the same process can be applied to the NSQDMH Standards. PICMoRS stands for:

• Process;
• Improvement;
• Consumer participation;
• Monitoring;
• Reporting and
• Systems.

When undertaking or participating in virtual assessments, accrediting agencies and digital mental health service providers must follow the guidance issued by the Commission relating to virtual assessments.

For further information on the application of PICMoRS, please see the fact sheet below.

NSQDMH Standards - Using PICMoRS for quality improvement and assessment preparation - Fact sheet

2022

Fact sheet or brochure

Digital mental health service providers implementing the NSQDMH Standards should consider their individual circumstances in determining whether specific actions are not applicable. It is not intended that actions be implemented where they are beyond the scope of the clinical and technical practice of the service provider.

Where a service provider considers an action is not applicable, it must provide its accrediting agency with evidence demonstrating the action does not relate to the service being provided.

Further information on not applicable actions in the NSQDMH Standards is outlined in Advisory D25/01: Advice on not applicable actions for the Digital Mental Health Standards.

An Advisory is a formal communication issued by the Commission to accrediting agencies and service providers. Advisories provide guidance and direction on the interpretation and/or assessment of the NSQDMH Standards under the AHSSQA Scheme. Advisories will usually be issued when the Commission identifies that additional support is required to assist with the consistent implementation or assessment of a specific action or topic. An advisory may also be issued where the implementation of an action requires a stepwise process with long implementation timeframes.

Examples of topics where an advisory may be issued include:

• managing conflicts of interest
• informed financial consent
• viewing and providing clinical information to My Health Record.

The list of Advisories related to the NSQDMH is available on the NSQDMH Resources webpage. 

Mediation is the process of an intervention to resolve conflict and can only occur during an assessment. See also Appeals Process.

Accrediting agencies or service providers may request the Commission mediate where there is a difference of opinion regarding applications for not applicable actions, evidence required to assess an action and as a result assessment outcomes.

Accrediting agencies are required to provide formal documentation to service providers as part of the accreditation assessment process. These include:

• an exceptions report, outlining the outcome of the initial assessment including actions that are rated "Met with recommendations" or "Not met"
• a final accreditation report.

For service providers that achieve the accreditation outcomes of Accredited or Working Towards Accreditation, accrediting agencies are required to provide additional formal documentation. These include:

• an accreditation certificate
• a testimonial, which includes the information from the accreditation certificate and further detail of the assessment process and outcome
• for service providers achieving full accreditation, they are provided with the Commission's NSQDMH Standards Accreditation Badge.

The accrediting agency must include the following information in a testimonial that is to accompany the certificate of accreditation:

• service provider name
• list of each digital mental health service provided by the service provider covered by the award
• the relevant standards to which the accreditation relates, and any parts of the relevant standards excluded from the assessment as not applicable or not assessed
• the category of accreditation awarded
• date accreditation is awarded and expiration of the relevant accreditation cycle.

On a monthly basis, the Commission updates its register of accredited services and informs the Medicare Mental Health website team of newly accredited service providers. 

Exemplar practices are real-world examples of digital mental health service providers that demonstrate best practice in the implementation of the NSQDMH Standards. These service providers have safety and quality systems that are substantially higher than the general rating of ‘met’ for relevant standards or actions being assessed.

Approved accrediting agencies will be able to nominate service providers that have been awarded accreditation with all relevant actions rated as ‘met’ and are implementing an initiative that meets specified criteria. Initiatives considered as exemplars are:

• designed to address a significant safety and quality issue
• evidence-based or use best practice
• user-centred
• clearly communicated to all relevant parties
• embedded into day-to-day practice
• regularly measured
• sustainable
• being appropriately evaluated
• improving user outcomes in the safety and quality of care delivered.

Submissions will be reviewed by the industry-based accreditation coordinating committee against specified criteria. Service providers that are formally recognised as exemplars will be issued with a certificate and have their case study published on the Commission’s website. This is intended to facilitate the identification and sharing of information on safe and good quality practice.

If a service provider does not agree with their assessment outcome, an appeal may be submitted to their accrediting agency or directly to the Commission. It is strongly recommended that service providers exhaust all avenues of review or appeal with their accrediting agency before submitting an appeal to the Commission.

The Commission will only consider appeals where there is evidence that the relevant accrediting agency did not comply with Commission-specified policies, processes and/or directions relating to the assessment conducted.

An appeal, whether made to the accrediting agency or directly to the Commission, must be submitted within 20 business days of the service provider receiving its final assessment report from its accrediting agency. Where an appeal is made to the Commission following an appeal to its accrediting agency, it must be made within 20 business days of the accrediting agency ruling on its appeal.

All appeals are to be in writing and submitted to the Safety and Quality Advice Centre via AdviceCentre@safetyandquality.gov.au.

Supporting evidence and documentation should accompany the appeal.

Submissions should include:

• name, title and contact details of the person (with delegated authority) submitting the appeal
• service provider name and address
• name of accrediting agency
• accreditation expiry date, if relevant
• assessment date(s) relevant to the appeal
• reason for submitting an appeal
• evidence supporting the appeal.

On receipt of an appeal, the Commission will seek information from the relevant accrediting agency, and review the evidence provided by the appellant, accrediting agency and regulator (if relevant). The Commission will then establish a panel to review the appeal and make recommendations to the Commission’s Chief Operating Officer.

The outcome of an appeal may involve one or more of the following:

• find any or all matters reviewed not substantiated
• find any or all matters reviewed substantiated and make recommendations to the agency for corrective action
• find any or all matters reviewed substantiated and take further action
• find any or all matters reviewed substantiated but determine further action is not warranted under the specified circumstances.

The Commission will:

• notify the relevant service provider and accrediting agency in writing of the outcome of the appeal, within five business days of the panel being convened
• notify in writing the relevant service provider and accrediting agency of any action to be taken, together with the date of effect of that action.

Once the Commission has issued a determination, there is no further avenue of appeal within the Commission.