National Safety and Quality Digital Mental Health Standards

The Commission partnered with service users, consumers, carers, families, clinicians, service providers and technical experts to develop the NSQDMH Standards. The Standards were released on 30 November 2020.

The NSQDMH Standards aim to improve the quality of digital mental health service provision, and to protect service users and their support people from harm.

The three NSQDMH Standards include 59 actions related to clinical and technical aspects of digital mental health services. They describe the level of care and the safeguards that a digital mental health service should provide.

Implementing the NSQDMH Standards is voluntary for digital mental health service providers. Providers include non-government, public or private organisations, or individuals who make a digital mental health service available for others to use.

What is a digital mental health service?

In relation to  the NSQDMH Standards, a digital mental health service is defined as a mental health, suicide prevention or alcohol and other drug service that uses technology to facilitate engagement and deliver care.

Although mental health, suicide prevention, and alcohol and other drug services are recognised as separate specialist sectors that provide services to often distinct cohorts, the NSQDMH Standards refer to these digital services collectively as ‘digital mental health services’.

Digital mental health services include:

• Services that provide information
• Digital counselling services
• Treatment services (including assessment, triage and referral services)
• Peer-to-peer support services.

Digital mental health services may be delivered by:

• Telephone (including mobile phone)
• Videoconferences
• Online services (such as web chats)
• SMS
• Mobile health applications (apps).

Digital mental health services can be standalone supports that are self-managed or therapist-guided, or they can complement in-person services.

Why have the NSQDMH Standards been developed?

There is growing evidence of the importance of digital mental health services in the delivery of services to consumers, carers, families and support people.¹ The Commission developed the NSQDMH Standards to help service providers ensure that the safety and quality of their digital mental health services meet the expectations of service users and their support people.

The Commission’s research and consultation has shown that service users, consumers, carers, families and support people want convenience, reliability, transparency and quality when it comes to accessing health services. They want control of decisions about their own health and access to their personal health information that supports these decisions. Service users and consumers expect their privacy to be respected and their rights protected. They expect strong safeguards to ensure their health information is safe and secure, and that their data are used only when necessary and when they choose.¹

Clinicians also have a strong desire to make greater use of digital health tools and services in their work, but need assurance that the digital systems they might recommend to consumers are safe and effective. This includes keeping service users’ health information secure and private, and ensuring that health data will be used safely and appropriately to improve outcomes.²

Service providers that use the NSQDMH Standards will have systems and processes in place to reduce the risk of harm, protect privacy and increase confidence and assurance in the safety and quality of their digital mental health services. This may take time for some service providers to achieve.

The NSQDMH Standards

There are three NSQDMH Standards.

The Clinical and Technical Governance Standard aims to ensure that the service provider has systems in place to maintain and improve the reliability, safety and quality of care. This includes protecting the privacy of users and being transparent about how their data are used. It also includes ensuring the technology is secure and stable.

Find out more in the Clinical and Technical Governance Standard fact sheet below, or click the link above to view the actions in this Standard.

The Partnering with Consumers Standard aims to ensure that service users – and, where relevant, their support people – are:

• Included in shared decision making
• Partners in their own care
• Involved in the development and design of quality digital mental health care.

Find out more in the Partnering with Consumers Standard fact sheet below, or click the link above to view the actions in this Standard.

The Model of Care Standard aims to ensure that a service provider has systems in place to make sure that digital mental health services are based on the best available evidence and best practice. It aims to ensure that  service users, consumers and support people are provided with information about the services. The Model of Care Standard requires that  service providers have systems for minimising harm to service users and others, for effective communication to support coordinated and safe care, and for recognising and responding to acute deterioration in a person’s mental state.

Find out more from  the Model of Care Standard fact sheet below, or click the link above to view the actions in this Standard.

Applying the NSQDMH Standards

Safe and high-quality digital mental health care requires vigilance and cooperation across all aspects of the service, including the clinical and technical components.

By implementing the NSQDMH Standards, service providers show that they are committed to excellence in safety and quality, and to achieving the best outcomes for service users and their support people.

Services can use the self-assessment tool to monitor their progress towards meeting the NSQDMH Standards. See the Conducting A Self-Assessment Using the NSQDMH Standards and the Applying the NSQDMH Standards Using a Risk Management Approach fact sheets below for how to do this.

By conducting a self-assessment, service providers can identify both areas of compliance and areas for improvement. Implementing the NSQDMH Standards in areas where improvement is required will improve the safety and quality of service provision to service users.

The Commission is developing an independent assessment scheme that can verify a service provider’s self-assessment and conduct independent reviews. The scheme is expected to be available for implementation from late 2021.

Services providers must not declare that they meet the NSQDMH Standards until they have successfully completed an independent assessment.

References

1. Titov, N., Dear, B.F, Nielssen, O., Wootton, B., Kayrouz, R., Karin, E., Genest, B., Bennett-Levy, J., Purtell, C., Bezuidenhout, G., Tan, R., Minissale, C., Thadhani, P., Webb, N., Willcock, S., Andersson, G., Hadjistavropoulos, H., Mohr, D.C., Kavanagh, D., Cross, S., Staples, L. (2020). User characteristics and outcomes from a national digital mental health service: A review of the Australian MindSpot Clinic. Lancet Digital; 2:e582-93.
2. Australian Digital Health Agency. Australia’s National Digital Health Strategy: Safe, seamless and secure: evolving health and care to meet the needs of modern Australia. Sydney; ADHA; 2017.

The Clinical and Technical Governance Standard aims to ensure that service providers have systems in place to maintain and improve the reliability, safety and quality of care. This includes protecting the privacy of users and being transparent about how their data are used. It also includes ensuring the technology is secure and stable.

What is clinical and technical governance?

Clinical governance is an integrated part of a service provider’s corporate governance. It ensures that everyone is accountable to service users, consumers, their support people and the community for assuring the delivery of safe, effective and high-quality services. Accountable groups include those delivering the digital mental health service, and managers and members of governing bodies, such as boards.

Technical governance is the system by which the current and future use of information and communication technology is directed and controlled. It is also an integrated part of a service provider’s corporate governance. Technical governance ensures that the technology systems underpinning the delivery of clinical care are safe, assure privacy and confidentiality, and are able to provide stable and secure services in keeping with  service users’ needs. This includes making sure services are usable and accessible.

Why is this standard important?

The standard recognises the importance of governance, leadership, culture, safety and quality systems, the workforce and the need for a safe environment in which high-quality digital mental health care is delivered.

There is growing evidence of the importance of digital mental health services in the delivery of services to consumers, carers and families.¹ Some digital mental health services can be as effective as in-person services, but others have not been rigorously evaluated. Negative effects can and do occur with digital mental health services^2–4, just as they do with in-person services.

If you meet this standard

• Your organisation has clinical governance, technical governance, and safety and quality systems in place to improve the safety and quality of digital mental health care.
• Your safety and quality systems work effectively with management systems.
• Your organisation promotes safe and high-quality digital mental health care for service users.
• You are confident that the data from service users are kept private and confidential.
• You consider usability and accessibility to be important, and you partner with service users, consumers, carers, families and support people to improve these aspects of care.
• Your workforce has the right qualifications, skills and supervision to ensure they provide safe, high-quality digital mental health care to service users.

What can you do to implement this standard?

• Identify the governing body responsible for the clinical and technical governance of your digital mental health services.
• Review and strengthen your current clinical governance arrangements.
• Review and strengthen your current technical governance arrangements.
• Ensure that roles and responsibilities, reporting lines and accountabilities are clear, and that the culture and leadership of the organisation support safety and quality.
• Consider the high-risk elements in your digital mental health service context – this may include the privacy, transparency, security and stability of your digital services.
• Comply with legislation and regulations, and deliver best practice.
• Implement a systems approach to risk and incident management across clinical and technical domains.
• Fill gaps by partnering with service users, consumers, carers, families and support people, and your organisation’s workforce and leaders to develop or adapt structures and processes.
• Monitor, analyse and report on clinical and technical performance.
• Maintain a safe environment that minimises risk for service users and consumers, and preserves their dignity.

References

1. Titov, N., Dear, B.F, Nielssen, O., Wootton, B., Kayrouz, R., Karin, E., Genest, B., Bennett-Levy, J., Purtell, C., Bezuidenhout, G., Tan, R., Minissale, C., Thadhani, P., Webb, N., Willcock, S., Andersson, G., Hadjistavropoulos, H., Mohr, D.C., Kavanagh, D., Cross, S., Staples, L. (2020). User characteristics and outcomes from a national digital mental health service: A review of the Australian MindSpot Clinic. Lancet Digital; 2:e582-93.
2. Akbar S, Coiera E, Magrabi F. Safety concerns with consumer-facing mobile health applications and their consequences: a scoping review. Journal of the American Medical Informatics Association 2019; 27(2):330–340.
3. Torous J, Firth J, Huckvale K, Larsen ME, Cosco TD, Carney R, et al. The emerging imperative for a consensus approach toward the rating and clinical recommendation of mental health apps. Journal of Nervous and Mental Disease 2018; 206(8):662–666.
4. Australian Humans Rights Commission. Human rights and technology: discussion paper. Sydney: AHRC; 2019.

The Partnering with Consumers Standard aims to ensure that service users – and, where relevant, their support people – are:

• Included in shared decision making
• Partners in their own care
• Involved in the development, design and evaluation of quality digital mental health care.

Why is this standard important?

The Partnering with Consumers Standard recognises the importance of involving service users in their own care. Partnering with service users, consumers, carers, families and support people also allows you to use their knowledge to inform how your services work, including usability and accessibility. When this knowledge is complemented by input from the workforce and other key stakeholders, you can shape the way your digital mental health services operate. Clear communication with service users and their support people is essential for achieving the best outcomes.

Mental health care that is based on partnerships can benefit different groups:

• The individual service user and the health care worker
• The specific digital mental health service
• The service provider overall.

The mental health sector acknowledges that effective partnerships are linked to a positive experience for service users and their support people. They also lead to high-quality mental health care and improved safety. Involving service users, consumers, carers, families and support people in healthcare governance, planning, design, measurement and evaluation can improve service development, communication and clinicians’ attitudes.

Partnerships are effective when people are treated with dignity and respect, information is shared openly, and participation and collaboration in healthcare processes are encouraged and supported. The Partnering with Consumers Standard sets out the expectations for partnerships at all levels, including the:

• Interactions between service users and the workforce that is providing digital mental health services
• Participation of service users, consumers, carers, families and support people in the design of digital mental health services, and their involvement in overall governance, policy and planning at an organisational level.

If you meet this standard

• Service users, consumers, carers, families and support people are partners in the governance, design, planning, measurement and evaluation of your digital mental health service.
• You have systems in place to help you partner with service users, consumers, carers, families and support people.
• You use the views of service users, consumers, carers, families and support people to help inform the usability and accessibility of your digital mental health services.
• Service users are partners in their own care.
• The way you deliver care is based on partnering with service users and, if relevant, their support people.
• You communicate with service users and their support people in a way that supports effective partnerships.

What can you do to implement this standard?

• Develop a plan and systematic processes for partnering with service users, consumers, carers, families and support people.
• Endorse a charter of rights and ensure that all digital mental health services align with the charter, including partnering with service users in their own care and, if relevant, their support people.
• Implement informed consent processes for direct care interventions in line with legislation, regulation and best practice.
• Ensure communications reflect the diversity of service users and provide information that meets their needs.
• Provide leadership and support for your workforce to partner with service users, consumers, carers, families and support people.
• Review the involvement of service users, consumers, carers, families and support people in the governance, planning, design, measurement and evaluation of systems and processes that support the provision of digital mental health services, and identify where these can be improved.
• Consider the context of your digital mental health services, and how service users, consumers, carers, families and support people can help you evaluate and improve your services and processes.
• Fill gaps and improve usability and accessibility by partnering with service users, consumers, carers, families and support people.

The Model of Care Standard aims to ensure that service providers have systems in place to make sure that their digital mental health services are based on the best available evidence and best practice. It requires  service users, consumers and their support people be  provided with information about the services. The Model of Care Standard also makes sure that service providers have systems for minimising harm to service users and others, for effective communication to support coordinated and safe care, and for recognising and responding to acute deterioration in a person’s mental state.

Why is this standard important?

A model of care outlines how an organisation delivers a digital mental health service. Service users and their support people use a variety of digital technologies to access digital mental health services, and the model of care may not always be obvious.

For a particular digital mental health service, service users should understand:

• Its purpose and intent
• How it is meant to operate
• What it intends to achieve
• How it is informed by evidence and best practice.

This can help people make an informed choice about using digital mental health services.

Minimising risk in the digital mental health delivery setting is important, including:

• Risk screening, especially relating to the risk of harm, including self-harm and suicide
• Ensuring that an effective response is available, whether your service provides a response directly or by referral to another agency.

Early identification of deterioration in a service user’s mental state can be more difficult in a digital setting. A systematic approach will help to ensure that the service recognises deterioration and provides an appropriate response.

Effective communication and documentation are critical to the safety of service users and their support people. You should have systems and processes in place to ensure effective communication at all times. You should also have a process to communicate critical information when there is significant change in a service user’s circumstances or care, and when their care is transferred.

If you meet this standard

• The purpose and intent of your digital mental health service is clear to service users, consumers and their support people, and the care delivered is consistent with your model of care.
• Harm to service users and others is minimised.
• Effective and coordinated communication underpins the safety and quality of care.
• You have clear processes for the transition of care.
• Systems are in place to recognise and respond to acute deterioration in mental state.

 What can you do to implement this standard?

• Review and strengthen the models of care for your digital mental health services, so they use the best available evidence and practices.
• Provide information to service users and consumers – and, where relevant, their support people – that they can easily understand and which meets their needs.
• Consider your approach to identifying risk of harm and whether you have strategies in place to prevent and manage harm to service users and others.
• Engage with service users, consumers, carers, families and support people to help evaluate your communication systems.
• Consider whether your system for recognising and responding to acute deterioration in mental state provides a safe and effective response.

Implementing the NSQDMH Standards is voluntary for digital mental health service providers. Providers include non-government, public or private organisations, or individuals who make a digital mental health service available for others to use. Service providers using the NSQDMH Standards should have systems and processes in place to reduce the risk of harm, protect privacy and increase confidence and assurance in the quality of their digital mental health services. This may take time for some service providers to achieve.

Why a risk management approach?

Service providers using a risk management approach will assess the risks associated with each action in the NSQDMH Standards. The risk assessment findings will help you to prioritise and mitigate risks identified and implement the standards.

Not all actions within each standard will apply your organisation and the digital mental health services you offer. The nature, size and complexity of your digital mental health services and the risk to service users and their support people will decide which actions apply and the strategies needed to implement them. The models of care that digital mental health services are using may also inform whether an action is relevant. For example, if your service only provides information, actions about recognising and responding to a deteriorating mental state may be not applicable.

Who may digital mental health services put at risk?

Some service users and support people may be more at risk than other people. For example, children and young people, older people, people from diverse population groups, including Aboriginal and Torres Strait Islander peoples, and those with low digital literacy.

The service provider workforce may be exposed to risk. For example, clinicians, peer workers, technicians and others who provide or support the delivery of digital mental health services.

Service providers may have corporate, clinical or technical risk associated with their services. Such risk may be related to the design of the digital mental health service and how it is delivered.

Risk management process

The first step in the risk management process is to consider each action in the NSQDMH Standards and decide whether it is applicable to them and the digital mental health services they offer. When an action is determined as not consistent with the type of services offered, it should be recorded as ‘not applicable’, along with the rationale for the decision. The self-assessment tool is a good place to record these decisions.

For actions that apply to your organisation, you should conduct a risk assessment of the relevant systems and processes you have in place for your digital mental health services.  

In practice, this means that you should assess the risk associated with each action and what you need to do to manage or mitigate  that risk. Risk assessment considers the:

• Size and complexity of an organisation
• Types of digital mental health services offered
• Levels of risk associated with the services.

For example, a service provider may be an organisation with multiple services and a large workforce, or a sole trader with a single service. The level of risk and the required mitigation strategies will be different for each provider.

In addition to determining the tasks required to ensure that an action is met, you can use the level of assessed risk to set a priority for each task. The tasks and the priority ratings can then be included in an action plan.

See the Conducting a Self-Assessment Using the NSQDMH Standards fact sheet below to learn how you can use the self-assessment tool to monitor your implementation of the NSQDMH Standards.

How to determine risk

To help assess risk, consider the five basic principles of risk management, which are to:

• Avoid risk. Identify strategies that avoid the risk whenever possible; a risk that cannot be eliminated must be managed
• Identify risk. Assess the risk, identify the nature of the risk and who is involved
• Analyse risk. Examine the risk, how likely it is to happen, and what the consequences are if it happens
• Evaluate risk. Determine how the risk can be reduced or eliminated, and document the processes, responses and outcomes
• Treat risks. Manage the risk by determining who is responsible for taking actions, and when and how this will be monitored.

To consider these principles more closely, ask the following questions:

1. Who is at risk?
2. What is involved?
3. What factors allow it to happen?
4. How likely is it?
5. What are the consequences?
6. What can be done?
7. Is there a solution for each identified situation or risk?

Likelihood and possible consequences of the risks

The risk assessment requires you to assess the likelihood of the risk occurring and the potential consequences. Data sources that may help you understand how likely a risk is to occur include:

• Monitoring and audit results
• Surveillance data
• Complaints
• Observations
• Literature
• Benchmarking.

Implementing the NSQDMH Standards is voluntary for digital mental health service providers. Providers include non-government, public or private organisations, or individuals who make a digital mental health service available for others to use. Service providers using the NSQDMH Standards should have systems and processes in place to reduce the risk of harm, protect privacy and increase confidence and assurance in the quality of your digital mental health services. This may take time for some service providers to achieve.

By conducting a self-assessment, you can identify both areas where your organisation meets the standards and areas where improvement is required. Implementing the NSQDMH Standards will improve the safety and quality of service provision for service users.

What is the self-assessment tool?

The self-assessment tool is a resource that initially helps you to determine how well you meet the NSQDMH Standards, and monitor progress towards full conformance. You are encouraged to review the NSQDMH Standards, and assess and record your progress using the self-assessment tool.

Each of the 59 actions in the NSQDMH Standards is listed in the self-assessment tool, along with reflective questions that help you to focus on the key requirements of each action. Each of the three standards has its own worksheet in the self-assessment tool.

The tool allows you to assess and decide which, if any, actions do not apply in the type of digital mental health services that you provide.

Using the tool

The self-assessment tool is a good place to record your plan for improvement for each applicable NSQDMH Standards action. It allows you to assign tasks to a specific person or team, and to set a timeframe for completing tasks.

When you implement the actions, you will need to apply a risk management approach (see the Applying the NSQDMH Standards Using a Risk Management Approach fact sheet above). You can then estimate the extent to which each action is met, and record these estimates as percentages in the self-assessment tool. The tool will then autopopulate the ‘performance rating’ column to match the ‘estimate of percentage complete’ for each action.

The self-assessment tool allows you to list or link the documents, policies and reports that show your progress on the implementation of each action. The documents that are included should:

• Align with your assessed risk for that action
• Reflect the variety and types of digital mental health services that your organisations offers.

The tool lists the types of documents or evidence that can demonstrate you are meeting the requirements in the standards. The list is not exhaustive, and you do not need to include all of the examples given (or any at all) if you have other examples that support your assessment.

Also refer to the How to Guide when using the self-assessment tool.

Upcoming NSQDMH Standards assessment scheme

The Commission is currently developing an independent assessment scheme for the NSQDMH Standards. This will include agreed ways for service providers to use your self-assessment to show service users, consumers and carers how well they conform to the NSQDMH Standards. It will also include an independent assessment process to assess service providers against the NSQDMH Standards. It is anticipated that the assessment scheme will be available for implementation from late 2021.

Services providers must not declare that they meet the NSQDMH Standards until they have successfully completed an independent assessment.

Digital mental health services have grown in popularity in the past decade, and offer new and innovative ways for consumers, carers and families to access care. Evidence shows that digital technology can play an important role in delivering services.

Digital services can benefit you in many ways. You might live in a remote or regional area, or you might not have time to attend in-person appointments. You might want to use other types of services along with the care you receive in-person from your treating practitioner, remain completely anonymous when discussing your mental health, or have more control over your own health care. Digital mental health services can help in many of these situations.

The quality of available services varies. This is why the Australian Commission on Safety and Quality in Health Care (the Commission) collaborated with service users, consumers, carers, families, clinicians, service providers and technical experts to develop the National Safety and Quality Digital Mental Health (NSQDMH) Standards.

The NSQDMH Standards describe the level of care that you should expect to receive from a digital mental health service. They aim to improve the quality of digital mental health services and to protect people who use these services from harm.

What is a digital mental health service?

For the NSQDMH Standards, a digital mental health service is defined as a mental health, suicide prevention or alcohol and other drug service that uses technology to facilitate engagement and deliver care.

Although mental health, suicide prevention, and alcohol and other drug services are recognised as separate specialist sectors that provide services to often distinct groups, the NSQDMH Standards refer to these digital services collectively as ‘digital mental health services’.

Digital mental health services include:

• Services that provide information
• Digital counselling services
• Treatment services (including assessment, triage and referral services)
• Peer to peer support services.

Digital mental health services may be delivered by:

• Telephone (including mobile phone)
• Videoconferences
• Online (including web chats)
• SMS
• Mobile health applications (apps).

What can I expect from a digital mental health service?

The NSQDMH Standards require service providers of digital mental health services to review their systems to ensure you are receiving safe and high-quality care from them. Providers include non-government, public or private organisations, or individuals who make a digital mental health service available for others to use.

Service providers should review all their systems, including clinical and technical systems, to make sure:

• Your privacy is protected
• You know the types of data that will be collected and who has access to the data
• You consent before your data is used for any purpose other than for your direct care
• Your service uses technologies that are stable and secure.

Digital mental health services should be based on the best available evidence and best practice. The services should aim to minimise harm to you and others. You should be able to easily find information about any digital mental health service you may wish to use.

The NSQDMH Standards promote partnering with service users (and, if relevant, their support people) in all aspects of digital mental health care. This means service users, consumers, carers, families and support people are involved in:

• Planning and decisions about their own care
• Governance and design of digital mental health services.

How can the NSQDMH Standards improve care?

The NSQDMH Standards clearly describe your role – and that of your support people – in your own care. They recognise that involving you, your carers and family leads to a more positive experience for you, as well as better and safer health care.

This means service providers using the NSQDMH Standards should help you – or the person you care for – to fully understand the health and treatment options that their digital mental health services offer. Service providers should allow you to ask questions and make decisions about your care, so that the care you receive is right for you.

How do I choose a digital mental health service?

Service providers using the NSQDMH Standards should have systems and processes in place to meet the expected standard of care. Some providers may take longer than others to work towards implementing the Standards.

The NSQDMH Standards are voluntary, but you can ask your service provider whether they are using these Standards to improve their delivery of care.

Service providers can use the Commission’s self-assessment tool to see how they are tracking against the NSQDMH Standards. An independent assessment scheme that can verify a service provider’s self-assessment and conduct independent reviews is currently in development and is expected to be available for implementation from late 2021.

Services providers must not declare that they meet the NSQDMH Standards until they have successfully completed an independent assessment.

The Commission has developed a fact sheet to help you know what to look for when choosing a digital mental health service. If you know what to look for, you will be able to be choose the service most likely to meet your needs:

It can be a challenge to decide if a digital mental health service is the right one for you to use or to recommend. The Commission has developed tip sheets for consumers, carers and clinicians to help them to choose a digital mental health service.

The Commission also developed a checklist that consumers and carers can use to consider the key questions outlined in the tip sheet in a bit more detail before choosing a service.

Action 3.3 of the NSQHDMH Standards requires service providers to provide product information on each service to service users and where relevant, their support people that aligns with the Commission's template, and is easy to understand and meets their needs.

You can download the template here: