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 example, an organisation that would normally have one year before its scheduled assessment, will have one year before its next assessment from the time when these measures are ceased.
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.
Open for Consultation – Draft NSQHS Standards User guide for health service organisations providing care for patients from migrant and refugee backgrounds
The Commission is seeking feedback on the draft National Safety and Quality Health Service (NSQHS) Standards User guide for health service organisations providing care for patients from migrant and refugee backgrounds (the user guide).
This user guide provides information for health service organisations on recommended approaches to delivering culturally responsive-care that is safe and of high quality to patients from migrant and refugee backgrounds. It contains practical strategies and examples for improving care for people from migrant and refugee backgrounds.
Consultation has commenced and will run until 30 June 2020.
We welcome you to view the draft user guide and have your say.
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 or telephone 1800 304 056.
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 (second edition)? 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.
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.
Closed consultation – Draft NSQHS Standards User guide for medication management in cancer care
The Commission has developed a NSQHS Standards User guide for medication management in cancer care. It is currently being considered by the Commission's standing committees before being forwarded to the Commission's Board for final approval and release in 2020.