Step 1: Getting to know the NSQHS Standards

Step 2: Allocating resources and coordinating implementation

Step 3: Selecting an accrediting agency

Step 4: Conducting a self-assessment

Step 5: Implementing strategies using the Safety and Quality Improvement Guides

Step 6: Gathering evidence

Step 7: Your accreditation assessment

 


 

Step 1: Getting to know the NSQHS Standards

Health service organisations should familiarise themselves with the NSQHS Standards and how they will be applied.

Each NSQHS Standard contains:

  • an outline of the intended actions and strategies to be achieved
  • a statement of intent, which describes the desired outcome of the NSQHS Standards
  • a statement on the context in which the NSQHS Standard is to be applied
  • a list of key criteria; each criterion has a series of items and actions that are required in order to meet the NSQHS Standard.

Assessment takes place at the action level.

The NSQHS Standards and additional resources to implement the Standards can be found using the following link:
Assessment to the NSQHS Standards – Resources to implement the NSQHS Standards – National Safety and Quality Health Service (NSQHS) Standards

Core and developmental actions

Each action within a NSQHS Standard is either:

  • Core – actions which are critical for safety and quality and must be met
  • Developmental – actions that are aspirational and health service organisations should undertake targeted activity to meet requirements. Developmental actions do not need to be fully met to achieve accreditation.

Health service organisations are required to meet 100% of the core actions in the NSQHS Standards in order to be accredited.

Further information regarding core and developmental actions can be found using the following link:

Accreditation and the NSQHS Standards – Resources to implement the NSQHS Standards – Other resources

Non-applicable criteria or actions

In some circumstances a NSQHS Standard, criterion or action may be classified non-applicable. Non-applicable actions are those that are inappropriate in a specific service context or for which assessment would be meaningless.

There are two ways in which a Standard criterion or action can be considered non-applicable:

  • The Commission has designated non-applicable actions for health service organisations by category.
  • When planning for assessment, the health service organisation may decide a criterion or action is not applicable to its circumstance and apply to their accrediting agency for consideration of non-applicable status. Non-applicable actions are only to be granted in exceptional circumstances and applications should provide evidence that there is little or no risk of patient harm in relation to actions.

Further information regarding non-applicable actions can be found in Advisory A13/07 using the following link:
Assessment to the NSQHS Standards – NSQHS Standards advisories

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Step 2: Allocating resources and coordinating implementation

Implementing the NSQHS Standards requires a whole-of-organisation approach with engagement from staff across the health service organisation. Effective implementation of the NSQHS Standards requires:

  • patient safety and quality of care to be considered in all relevant business decision making
  • safety and quality reports to be received and acted upon by the governing body
  • awareness of individual safety and quality roles and responsibilities by the workforce
  • a risk management and quality improvement approach to all aspects of the health service
  • ongoing training in safety and quality.

Health service organisations should work with senior management and executive teams or governing bodies to identify the people and resources required to implement the NSQHS Standards. Additional resources to assist health service organisations with implementation can be found using the following link:
Assessment to the NSQHS Standards – Resources to implement the NSQHS Standards

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Step 3: Selecting an accrediting agency

The Australian Health Service Safety and Quality Accreditation (AHSSQA) scheme requires health service organisations to be assessed to the NSQHS Standards by an approved accrediting agency.

The Commission approves accrediting agencies to assess health service organisations to the NSQHS Standards. While all agencies provide NSQHS Standards assessment services, the process, including the cycle, may differ between agencies.

It is important that health service organisations obtain sufficient information about the assessment process and cycle requirements, available customer support, and timeframes before deciding which accrediting agency to engage.

The list of the approved accrediting agencies can be found using the following link:
Assessment to the NSQHS Standards – Resources to implement the NSQHS Standards – Contact details

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Step 4: Conducting a self-assessment

Health service organisations should complete a self-assessment of their current systems and processes using the NSQHS Standards. Information gathered during this self-assessment process can be used to inform a plan or pathway to implement the NSQHS Standards.

The self-assessment process should include:

  • identification of sources of evidence available to demonstrate actions have been met
  • identification of areas where actions are not met and where improvements are required
  • development of an action plan to cover any identified gaps.

Health service organisations should conduct periodic self-assessments throughout their accreditation cycle to ensure quality improvement activities are targeted in the required areas.

The Commission has developed a number of resources to assist health service organisations prepare for assessment and conduct a self-assessment. Additional resources can be found using the following link:
Assessment to the NSQHS Standards – Resources to implement the NSQHS Standards – Accreditation workbooks and specialist guides

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Step 5: Implementing strategies using the Safety and Quality Improvement Guides

The Commission developed Safety and Quality Improvement Guides (SQIGs) for each of the NSQHS Standards. The SQIGs are designed to assist health service organisations to align their quality improvement programs using the NSQHS Standards as a framework.

The SQIGs provide suggestions for implementing the NSQHS Standards. They are designed to guide and assist preparation for assessment. Health service organisations can choose improvement actions and strategies that are relevant to their local context in order to achieve the standards. The SQIGs use the following structure:

  • introductory information about what is required to achieve each of the criterion and standards
  • tables describing each action required and suggested key tasks, implementation strategies, and examples of outputs from improvement processes
  • additional supporting resources with links to Australian and international resources and tools, where relevant.

The extent to which health service organisation improvements are required is dependent on the outcome of the self-assessment analysis.

The SQIGs can be accessed using the following link:
Assessment to the NSQHS Standards – Resources to implement the NSQHS Standards – Safety and Quality Improvement Guides

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Step 6: Gathering evidence

Evidence required for assessment is normally generated through the everyday activities of the health service organisation. It should not be something created simply for the purposes of assessment.

The self-assessment process (Step 4) assists health service organisations to identify gaps in the evidence required for assessment.

Resources are available to assist health service organisations undertake a self-assessment, including detailed lists of examples of evidence. It is important to note that these are intended as a guide only and are not mandatory.

Additional resources to assist health service organisations can be found using the following link:
Assessment to the NSQHS Standards – Resources to implement the NSQHS Standards – Accreditation workbooks and specialist guides

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Step 7: Your accreditation assessment

Health service organisations are required to participate in an external assessment by an approved accrediting agency to verify that they have met each of the actions in the NSQHS Standards. The timing and requirements of the assessment will be determined by the selected accrediting agency but usually include the submission of a self-assessment followed by an onsite survey or audit.

Health service organisations should only undergo external assessment once they are satisfied that sufficient evidence is available for verification and that all NSQHS Standards have been met.

Assessment and rating scale

Health service organisations will be assessed using a three point rating scale:

  • Not Met – the actions required have not been achieved
  • Satisfactorily Met – the actions required have been achieved
  • Met with Merit – in addition to achieving the actions required, measures of good quality and a higher level of achievement are evident. This would mean a culture of safety, evaluation and improvement is evident throughout the hospital in relation to the action or standard under review.

This rating system is used to rate individual actions within a NSQHS Standard and to rate the NSQHS Standards overall.

When an action is not met

Following external assessment by an approved accrediting agency, the health service organisation will receive a report detailing the findings of the assessment and the ratings of each action and the NSQHS Standards overall.

In the event that a health service organisation does not meet all core actions in the NSQHS Standards, the agency will inform the health service organisation and the state or territory health department, and provide an opportunity for remedial action to occur.

Health service organisations have 90 days from the receipt of their report to address any ‘not met’ core actions before a final determination of accreditation is made. If improvements are not made and patient risks are not addressed within this timeframe, the relevant state or territory health department may initiate a regulatory response to rectify the patient safety risk.

Notification of significant risk

When a significant risk to patient safety is identified, accrediting agencies are required to notify the relevant state or territory health department immediately. The health department will then verify the scope, scale and implications of the reported non-compliance and will take further action if the health service organisation has not rectified the patient safety risk.

Advisory A13/01 Notification of Significant Risk has been developed to assist accrediting agencies and health service organisations determine significant risks when performing assessments.

Further information regarding significant risk can be found using the following link:
Assessment to the NSQHS Standards – NSQHS Standards advisories

Mediation

The Commission offers a mediation service when there is a difference of opinion between assessors and representatives of a health service organisation during an assessment. This service involves a discussion with the assessor and/or approved accrediting agency, representatives of the health service organisation, the Commission and, if necessary, independent technical experts. The purpose of a mediation is to clarify the intent of the NSQHS Standards, explore the different points of view of participants and discuss the evidence that may be available and/or reviewed.

The approved accrediting agency will be responsible for the final determination on actions that are met or not met.

Appeals process

All accrediting agencies have a well-established appeals process by which health service organisations can appeal assessment decisions. Information on these processes should be available from your accrediting agency.

 

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Last updated: 13 December 2016