Accreditation - Responding to extraordinary circumstances arising from COVID-19 pandemic
Announcement from the Commission
The COVID-19 pandemic is a public health emergency requiring an extraordinary response by the health system and society. Social distancing is a key measure being utilised to limit transmission of COVID-19. This measure is aimed at reducing transmission of the disease in the community, and importantly, the demand on healthcare services.
To assist health service organisations and in line with social distancing measures, the Commission is maintaining requirements for accreditation, to the National Safety and Quality Health Service (NSQHS) Standards, effective immediately. These changes are being enacted as part of the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme.
- The accreditation status of health service organisations will be maintained during the response phase of the COVID-19 pandemic. These arrangements will be monitored with changes anticipated in the recovery phase of the pandemic.
- Organisations that have completed an initial assessment and are in the remediation phase of their assessment cycle, and require an onsite assessment to be finalised, will now complete their final assessment when the recovery phase commences.
- Reintroduction of onsite assessments will take into consideration the lead-time for planning and preparation of assessments.
- There are exceptions to these arrangements. These exceptions include health service organisations that are:
- Required to undergo a reassessment, including those that met the criteria for mandatory reassessment and those where reassessment is required by its regulator
- Newly established and scheduled to undergo an interim assessment as per Advisory AS18/02
Assessments that are required to proceed during the response phase will be conducted by remote access using a mobile device to view clinical areas and practices, and to speak with the workforce. Remote assessment is to be complimented by desktop assessment of documentary evidence submitted by the organisation.
- Advisories with compliance deadlines will be suspended. Amended deadlines, will be issued during the recovery phase of the COVID-19 pandemic.
The intent of these measures is to maximise the capacity of the health system to deliver care during a period of unprecedented demand, and for assessors and the health service workforce to comply with social distancing requirements. As the implementation of the changes is administrative, health service organisations are not required to take any further action at this time.
While the Commission recognises the unprecedented impacts on the day-to-day operations of health service organisations, it is more important than ever that organisations comply with the NSQHS Standards, in particular infection prevention and control measures.
Please email your query to email@example.com and include your contact number. A member of the Advice Centre will then contact you as soon as practical.
FAQ: COVID-19 pandemic and accreditation
What does maintaining accreditation mean for my organisation?
Under usual circumstances, an accreditation cycle is three years. The extraordinary measures enacted will suspend the current accreditation status of an organisation, which will be maintained until the recovery phase of the pandemic begins and these measures are ceased.
For more information, please refer to the FAQ: When will the Commission re-introduce accreditation assessments?
When do these measures commence?
They will be introduced immediately. As the implementation of the changes is administrative, health service organisations are not required to take any further action at this time.
Do efforts to implement the National Safety and Quality Health Service Standards cease?
No. Health service organisations will be relying on their safety and quality systems to ensure patient care is safe and of good quality. All organisations are expected to ensure safety and quality systems are being used, monitored and address any breeches in practice.
Can my organisation continue to access private health insurance or second tier default funding?
Yes. Introducing these measures will not change an organisation’s eligibility for funding.
What is remote access and how do I find out more about it?
Where an assessment is required, organisations will undergo an assessment using remote access. This approach utilises a mobile device (for example Skype or Facetime) to view clinical areas and practice, and to speak with the workforce. Remote access compliments desktop assessment of documentary evidence submitted by the organisation. The Principles on Remote Assessment (IAF ID 12:2015) issued by the International Accreditation Forum, provides a framework for remote assessment that could be applied to the assessments of health service organisations. It is intended that assessments continue to meet the AHSSQA Scheme requirements for 60% of assessment time in clinical areas.
How long will my accreditation be maintained?
It is not possible to predict the length of time that health service accreditation will be maintained under the new arrangements introduced in response to the current COVID-19 pandemic. Onsite assessments will recommence once the pandemic has entered the recovery phase.
How will assessments be re-introduced when we go into the recovery phase of this pandemic?
When the Australian Government announces the beginning of a recovery phase of the pandemic the Commission will start planning for the recommencement of assessments. The Commission will calculate the total number of business days between 25 March 2020, when these arrangements become operational, and the start of the recovery phase. A commencement date for assessments will then be announced that takes into consideration the lead-time necessary for the planning and preparation of assessments. This total number of days will be added to your organisation’s current accreditation certificate expiry date.
When will I need to schedule my assessment?
An organisation will schedule its assessment with its accrediting agency so its assessment is completed before the revised accreditation expiry date. This should be in accordance with Fact Sheet 1: Standardised accreditation cycles, to allow three months (60 business days) for remediation of not met actions at initial assessment, and one month (generally 20 business days) for the accrediting agency to complete their final report.
Did the Australian government, states and territories agree to the changes that have been introduced?
The Commission’s announcement was developed in collaboration with the Australian Government Department of Health and State and Territory Departments of Health as well as the private hospital sector and state and territory regulators. For enquiries and information on implementing the NSQHS Standards and accreditation, contact the Commission's NSQHS Standards Advice Centre: firstname.lastname@example.org.
Will there be changes to the current Advisory deadlines?
The Commission will be reviewing Advisories and updating timeframes. To receive updates when these are published, please consider subscribing to the NSQHS Standards newsletter.
Are health service organisations required to submit an attestation statement from their governing bodies in 2020?
Health service organisations are required to submit an attestation statement annually between 1 July and 30 September. During this period of extraordinary measures enacted in response to the COVID-19 pandemic, submission of an attestation statement is still required.
It is a requirement of the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme that health service organisations assessed to the National Safety and Quality Health Service (NSQHS) Standards submit an attestation statement annually. The attestation statement is confirmation that an organisation’s governing body has fulfilled its responsibilities in relation to Actions 1.1 and 1.2 of the NSQHS Standards (second edition). Further information on submitting an Attestation Statement can be found in Fact sheet 7: Governing body attestation statement.
While the Commission recognises the unprecedented impacts on the day-to-day operations of health service organisations, it is more important than ever that organisations comply with the NSQHS Standards and use their established systems and processes to ensure safety and quality risks are minimised and patient care is safe and of good quality.
What is my organisation is assessed to the Trauma Recovery Programme (TRP) Standards?
The Commission is maintaining requirements for accreditation, to both the NSQHS Standards and TRP Standards, effective immediately. This means there will be no further onsite assessment until these measure are ceased in the recovery phase of the pandemic.
When will the Commission re-introduce accreditation assessments?
The Australian Health Management Plan for Pandemic Influenza, August 2019 identifies four phases of a pandemic – prevention, preparedness, response and recovery. The response phase involves standby, action and standdown. During standdown, measures introduced by Governments in response to the pandemic will be scaled back. It is during the standdown phase, that the Commission will commence planning for the recommencement of accreditation.
The date for recommencement of assessments will take into consideration:
- The length of the suspension of accreditation.
- The health service organisations that are next due for assessment, their size and the likely impact COVID-19 measures had upon day-to-day operations for these services.
- Organisations that have had significant disruption to its usual services will need time to scale back its pandemic responses, return to normal service provision, staffing complement and complete the necessary administrative tasks associated with an assessment.
- Advice from states and territories.
- Feedback from accrediting agencies on their ability to convene assessment teams and schedule assessment visit.
Further advice will be provided as it becomes available.
Open for consultation - Draft NSQHS Standards User Guide for Multi-Purpose Services Aged Care Module
The Commission is seeking feedback on the draft National Safety and Quality Health Service (NSQHS) Standards User guide for Multi-Purpose Services Aged Care Module (the user guide).
This user guide provides information for the MPS workforce to implement actions in the NSQHS Standards MPS Aged Care Module. The user guide includes examples of reflective questions, suggested strategies for improvement and resources that the MPS workforce can use to implement the actions in a way that is appropriate for their context.
Consultation has commenced and will run until Friday, 28 August 2020.
We welcome your comments on this draft user guide.
Our preferred method for receiving your feedback is via SurveyMonkey. Please submit your feedback through this survey. However written submissions can be emailed to NSQHSStandards@safetyandquality.gov.au.
If you have any queries about the survey please contact the National Standards Program by email to NSQHSStandards@safetyandquality.gov.au.
You are invited to provide feedback on the whole resource, or alternatively, specific components of the resource that are important to you. Included below are questions to guide your feedback. You can answer all, some or none of the questions in your feedback.
- Language: How could we improve the language, terminology and glossary used in the resource so that they are more appropriate and applicable to the context of your organisation?
- Usability: How could we make the content in this resource more applicable and easier to use to implement the NSQHS Standards MPS Aged Care Module? For example, changes to the length, layout, and level of detail of the content.
- Clarification: Does any of the content in this resource require further clarification or rewording? Please provide suggestions for these changes.
- Gaps and duplication: Are there any gaps in the content and how should they be addressed? Is there any unnecessarily duplicated content that could be removed?
- Additional functionality: What additional functionality would be helpful in an interactive online resource or as separate resources? For example: links between actions; links to other resources; one-page factsheets; or infographics.
- Other feedback: Please provide any other feedback you have on this resource.
The Royal Children’s Hospital Melbourne receives inaugural exemplar practice award
Congratulations to The Royal Children’s Hospital (RCH) Transition Support Service for receiving the Commission’s inaugural award for exemplar practice shown by a health service organisation implementing the National Safety and Quality Health Service (NSQHS) Standards.
The exemplar practice awards program recognises health service organisations across Australia that model exemplar practice in implementing the NSQHS Standards.
The award celebrates quality practice in hospitals and health services. It seeks to facilitate sharing of information between Australian health service organisations in their ongoing efforts to improve health service delivery.
The RCH Transition Support Service supports and educates adolescent patients and their parents and carers as they transition to adult healthcare services. The Transition Support Service is recognised for exemplar practice for compliance with actions within the Comprehensive Care and the Communicating for Safety Standards.
Commission Chief Executive Officer, Adjunct Professor Debora Picone AO, said: “The Commission congratulates the Royal Children’s Hospital Transition Support Service on receiving the inaugural award and we thank them for their contribution to improving the safety and quality of Australian health care.”
Evelyn Culnane, Manager, Transition Support Service said: “The Royal Children’s Hospital Transition Support Service is proud to be recognised for exemplar practice in implementing the NSQHS Standards.
“Connecting patients and their families to adult health services across Victoria has helped to reduce the anxiety and stress associated with leaving long-standing paediatric care.”
Eligible health service organisations in Australia can be nominated for exemplar practice by their accrediting agency during their assessment to the NSQHS Standards.
Learn more about the exemplar practice initiative.
Exemplar Practice Program and COVID-19
The exemplar practice program is currently on hold, together with assessments for accreditation, due to the COVID-19 pandemic. To assist health service organisations and in line with social distancing measures, the Commission is maintaining requirements for accreditation to the NSQHS Standards. The exemplar practice program will be re-opened when assessments re-commence. Read more about COVID-19 and accreditation.
Open for Consultation – Draft NSQHS Standards Guide for community health services
The Commission has drafted the National Safety and Quality Health Service (NSQHS) Standards Guide for Community Health Services (the Guide) to support community health services implement and prepare for assessment to the NSQHS Standards. This resource is in addition to a suite of resources developed by the Commission to support the implementation of the NSQHS Standards.
The Commission recognises that the COVID-19 pandemic has put unprecedented demand on health services and healthcare workers, and has affected the lives of all Australians. To allow organisations and individuals additional time to help us improve the draft NSQHS Standards Guide for Community Health Services, the draft Guide was released for public consultation in mid May 2020. The Commission would like to ensure all stakeholders have the chance to respond.
The Commission will accept feedback on the consultation draft up to close of business on Friday 18 September 2020.
This resource is for community health services implementing the NSQHS Standards (second edition). Clinicians, managers, safety and quality officers, health departments, private hospital groups, technical experts, accrediting agencies and consumers are invited to participate in this survey.
You are invited to provide feedback on the whole resource, or alternatively, specific components of the resource that are important to you.
Submitting your feedback
When providing feedback, please reference the specific resource, Standard and/or action.
Our preferred method for receiving your feedback via an online survey
Alternatively, feedback can be provided by:
- Email: NSQHSstandards@safetyandquality.gov.au
- Mail: NSQHS Standards Resources
GPO Box 5480
Sydney NSW 2001
Please do not submit your feedback as tracked changes to a copy of the resource, due to difficulties in analysing feedback provided in this way.
Our contact details
If you have any questions in relation to this consultation process please contact the Commission by email: NSQHSstandards@safetyandquality.gov.au
Closed consultation – Draft NSQHS Standards User guide for health service organisations providing care for patients from migrant and refugee backgrounds
Consultation on the draft NSQHS Standards User guide for health service organisations providing care for patients from migrant and refugee backgrounds is now closed. The Commission is now reviewing the information received during the consultation process. This information will be used to finalise the resource.
Draft NSQHS Standards User guide for the review of clinical variation in health care
The Commission has drafted a National Safety and Quality Health Service (NSQHS) Standards User guide for the review of clinical variation in health care. This guide explains how health service organisations can implement Action 1.28 of the Clinical Governance Standard.
Following public consultation in September 2019, a final version of the guide will be published in 2020. This draft version is available for reference in the interim. The Commission will advice when the final guide has been published.
Workshop on implementing AS/NZS4187:2014
On 24 September 2019, the Australian Commission on Safety and Quality in Health Care (the Commission) hosted infection control and sterilisation experts, representatives of health service organisations and governments at a workshop on the National Safety and Quality Health Service (NSQHS) Standards requirements for reprocessing reusable medical devices.
Participants from the public and private sector across the acute, community, dental sectors and policy areas attended.
The workshop was convened to discuss issues health service organisations have identified with implementing the Standards Australia standard AS/NZS4187:2014: Reprocessing of Reusable Medical Devices in Health Service Organisations. Action 3.14a of the NSQHS Standards states "where reusable equipment, instruments".
Workshop participants first heard from Mr Tim Cole, Manager of the Sterilizing Department of South Eastern Local Health District, who outlined the development of AS/NZS4187:2014 and how he had approached implementation of AS/NZS4187:2014. His key message was that ongoing and comprehensive monitoring is essential along with effective quality improvement systems.
Margaret Banks, Director of the Commission’s National Standards program reported on the results of a survey that asked health service organisations about implementing AS/NZS4187:2014. The Commission received over 470 responses to the survey and the results showed:
- Over 90% of respondents had completed a gap analysis as required by Advisory AS18/07
- Approximately 30% of organisations reported they currently comply with AS/NZS4187:2014, with an additional 50% expecting to comply by 2021.
- Most organisations (90%) identified implementation issues.
Participants recognised current sterilisation practices do not meet best practice and agreed AS/NZS4187:2014 and the standards that it references did provide a useful framework for improving the safety and effectiveness of processes for cleaning, disinfecting and sterilising reusable medical devices. Participants agreed simple guidance documents were required to assist health service organisations accurately interpret and apply these standards.
Workshop participants identified a range of strategies to support health service organisations comply with AS/NZS4187:2014 including:
- Clarifying and documenting the governance arrangements for sterilising service units
- Providing in-service and/or access to external training for sterilising technicians
- Developing interpretive and guidance documentation to support a better understanding of the requirements of AS/NZS4187:2014
- Implementing monitoring requirements for water quality as specified in the Standards Australia Amendment 2 to AS/NZS4187:2014
- Adopting a risk-management approach to the implementation of the requirements of AS/NZS4187:2014, prioritising high risk areas
- Using the organisations quality improvement systems to identify, implement and monitor improvements in safety and quality systems in the sterilising service unit. This may include adopting quality improvement systems such as ISO 13485: Medical devices—Quality management systems—Requirements for regulatory purposes
- Including sterilisation services unit equipment on the organisation’s preventative maintenance program.
The Commission has reviewed Advisory 18/07 using the feedback provided by the workshop participants to clarify the requirements health service organisations must meet to comply with the requirements of NSQHS Standards Action 3.14.
Closed consultation – Draft NSQHS Standards Aged care module
Consultation on the draft NSQHS Standards Aged Care Module is now closed. The Commission is now reviewing the information received during the consultation process. This information will be used to finalise the resource.
Closed consultation – National Safety and Quality Primary Health Care Standards
Consultation on the proposed content and format of National Safety and Quality Primary Health Care Standards for primary care providers is now closed.
The Commission has reviewed the information received during the consultation process. Further information about the development of the National Safety and Quality Primary Health Care Standards is available.