Planning for recommencement of Assessments under the Australian Health Service Safety and Quality (AHSSQA) Scheme
Announcement from the Commission
Resumption of onsite assessments to the NSQHS Standards will occur from 26 October 2020. This follows the period from 25 March 2020 where requirements for accreditation to the National Safety and Quality Health Service (NSQHS) Standards for all health services was maintained and no assessments were commenced.
As the reintroduction of onsite assessments will take into consideration the lead-time for planning and preparation of assessments, all health service organisations will have an additional 12 months added to their current certificate expiration date.
The Commission has identified criteria for determining which health service organisations should be assessed first and those that will be assessed during subsequent rounds. On-site assessment will be based upon a risk based approach and will only take place in settings where there is a low risk of transmission of COVID-19.
Answers to frequently asked questions are below.
For further enquiries please email: email@example.com
FAQs - Assessments under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme in health service organisations with a low risk for COVID-19 transmission
When will assessments of health service organisations resume?
From 26 October 2020, assessments can resume for health service organisations with a low risk of COVID-19 transmission. Assessments will not be conducted in organisations where there are active COVID-19 clusters or state or territory restrictions or lockdowns. Restrictions on border crossings will also be taken into consideration.
Your accrediting agencies will work with you, the Commission and the relevant health department to confirm the organisations risk status, and schedule the next assessment.
How do I know when my next assessment should be?
Health service organisations will have 12 months added to their current accreditation expiry date. This means whatever month and year your current accreditation is due to expire, it will now expire in that month, one year later.
Your assessment should be scheduled with your accrediting agency to commence at least 4 months before your revised accreditation expires.
How do I know if my health service organisation is considered low risk?
A health service organisation is low risk if it meets four or more of the following criteria:
- Is not treating patients with active COVID-19
- Is not treating overseas travellers during their quarantine period
- Does not have (or does not suspect they have) a member of the workforce with COVID-19 which could have been transmitted to others in the organisation
- There is limited impact on the normal workforce being available for duty. Members of the workforce are not
- In isolation due to possible or confirmed COVID-19 contact
- Redeployed to support COVID-19 related activities within or across health service organisations
- The health service organisation is not directly affected by
- A public order that has resulted in a lockdown or restriction of movement of citizens
- Known active COVID-19 infections in the area
- The organisation is not supporting an aged care facility with active COVID-19 infections.
These risk criteria are provided as a guide and emerging and real circumstances of each service will be considered in real time when determining if a health service organisation is low risk and an assessment can proceed.
What happens if my organisation is not low risk?
An organisation that is not low risk of transmission of COVID-19, according to this definition, will have its accreditation maintained. The assessment will not be scheduled until the circumstances are considered low risk.
What happens if the risk level of my organisation changes during the remediation period before the final assessment?
Organisations will not be disadvantaged because of COVID, if the risk level of an organisation changes and a final assessment cannot be rescheduled, the remediation period will be extended until the risk has reduced. The Commission will work with regulators, accrediting agencies and health service organisation to identify and manage instances where a review of the remediation period may be required.
When will my health service organisation be assessed?
When scheduling assessments, the Commission has asked accrediting agencies to prioritise:
- Organisations that have completed an initial assessment and are awaiting a final assessment to address any actions that were not met and required remediation
- Organisations that were previously scheduled for assessments from March 2020 and have not yet been assessed.
Your assessment should be scheduled at least four months before the revised accreditation expiry date.
What if I have completed an interim assessment?
Organisations that have completed an interim assessment when operations were first commenced, are required to complete a full assessment to the NSQHS Standards within an 18 month period. This requirement is unchanged for organisations that are assessed as low risk for the transmission of COVID-19.
However, if an organisation that has undertaken an interim assessment is not a low risk health service, interim accreditation will be maintained until an onsite assessment can be conducted.
Will assessments be onsite, as they were before COVID-19?
It is preferable for assessments to be conducted using an assessment model with all assessors on site. However assessments can be conducted using a hybrid assessment methodology where some assessors are on site, and others review the organisation using videoconferencing technologies from a remote location.
Hybrid assessments can occur when assessors are unavailable to be onsite due to:
- Travel or border restrictions
- Locally available assessors.
In these cases, assessments that involve both onsite and remote assessors may be scheduled. However, 50% or more of the assessment team should be onsite.
What is being done to ensure onsite assessments are conducted safety?
The Commission has been working with accrediting agencies to ensure onsite assessments are as safe as possible for patients, the workforce and assessors. To this end, before entering your organisation, assessors will have:
- Completed additional infection prevention and control training
- Passed a screening checklist to ensure they have no signs or symptoms of a respiratory infection
Onsite assessors are also required to comply with any screening requirements put in place by the organisation they are visiting.
Where can I go for further advice?
Enquiries please email the Advice Centre: firstname.lastname@example.org or contact your accrediting agency.
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.
Closed consultation - Draft NSQHS Standards User Guide for Multi-Purpose Services Aged Care Module
Consultation on the draft NSQHS Standards User guide for Multi-Purpose Services 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 – Draft NSQHS Standards Guide for community health services
Consultation on the draft NSQHS Standards Guide for community health services 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 – 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.
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 – 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.