Advisory AS21/04: Provisional accreditation to the National Safety and Quality Health Service Standards for primary and community healthcare services

To describe provisional accreditation arrangements for primary and community healthcare services to the National Safety and Quality Health Service (NSQHS) Standards.

Advisory details

Item Details
Advisory number AS21/04
Version number 2.0
Trim number D22-52586
Publication date 14 December 2022
Replaces AS21/04 version 1.1 published 13 April 2022
Compliance with this advisory It is mandatory for approved accrediting agencies to implement this advisory.
Information in this advisory applies to
  • All approved accrediting agencies
  • Primary and community healthcare services seeking accreditation to the National Safety and Quality Primary and Community Healthcare Standards
Key relationship National Safety and Quality Health Service Standards
National Safety and Quality Primary and Community Healthcare Standards
Attachment Transitioning from the National Safety and Quality Health Service Standards to the National Safety and Quality Primary and Community Healthcare Standards
Notes Updated to clarify the model of assessment for healthcare services accredited to the National Safety and Quality Health Service Standards wishing to transition to the Primary and Community Healthcare Standards
Responsible officer Margaret Banks
Director, National Standards
Phone: 1800 304 056
Email: AdviceCentre@safetyandquality.gov.au
To be reviewed November 2024

Purpose

To describe provisional accreditation arrangements for primary and community healthcare services to the National Safety and Quality Health Service (NSQHS) Standards.

Issue

The Australian Commission on Safety and Quality in Health Care (the Commission) has developed the National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards). The Primary and Community Healthcare Standards was launched in October 2021. Assessment to these standards will commence in 2023.

Primary and community healthcare services may need to become accredited to national safety and quality healthcare standards, to satisfy regulatory or funding requirements. This requirement may occur before assessment to the Primary and Community Healthcare Standards becomes available. This Advisory provides a mechanism to transition to the Primary and Community Healthcare Standards in the interim.

The Primary and Community Healthcare Standards have been mapped to the NSQHS Standards 2nd edition. While there are some minor differences, most of the actions from the Primary and Community Healthcare Standards are reflected in the NSQHS Standards, see Table A and Table B. Detailed mapping is also available.


Requirements

Approved accrediting agencies may assess primary and community healthcare services to the NSQHS Standards (Table A) under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme. Assessments are to be conducted via an on-site assessment, as per the requirements of accreditation to the NSQHS Standards under the AHSSQA Scheme.

As a result of the mapping, a subset of actions have been identified that are in both sets of standards. Where primary and community healthcare services are assessed and meet the requirements of the subset (Table A), provisional accreditation may be awarded for a maximum of 18 months.

When assessments to the Primary and Community Healthcare Standards becomes available, healthcare services will be eligible to convert from ‘provisional accreditation to the NSQHS Standards’ to ‘accreditation to the Primary and Community Healthcare Standards’. To do so, healthcare services will be required to be assessed to the six actions in the Primary and Community Healthcare standards outlined in Table B.

Assessment of these six actions may be conducted as a desktop and virtual assessment. Further details regarding models of assessment is available: Assessment to the National Safety and Quality Primary and Community Healthcare Standards.

Upon satisfactory assessment, the healthcare service may be awarded accreditation to the Primary and Community Healthcare Standards. Expiration of accreditation will be three years, less the period of time the healthcare service held provisional accreditation to the NSQHS Standards.

Provisional accreditation is only permitted for primary and community healthcare services intending to transition to the Primary and Community Healthcare Standards.

Healthcare services that do not transition to assessment to the Primary and Community Healthcare Standards will be required to become accredited to the NSQHS Standards, in full, within 18 months of being awarded provisional accreditation.

Information on submissions for approval for a not applicable actions is available: Assessment to the National Safety and Quality Primary and Community Healthcare Standards.

Evidence must be supplied to demonstrate that the action is not applicable within the services provided or results in little or no risk of patient harm in their service context. Applications for not applicable actions should be submitted to the approved accrediting agency well in advance of an assessment.

During a provisional accreditation assessment to the NSQHS Standards, actions will be assessed using the rating scale set out in Fact Sheet 4: Rating scale for assessment. Where healthcare services meet the requirements to be awarded provisional accreditation, this will need to be reflected in their accreditation certificate. Please contact the Commission for further advice regarding the certificate if required. All other rules of the AHSSQA Scheme apply.

Primary and community healthcare services already accredited to the NSQHS Standards may choose to seek provisional accreditation to the NSQHS Standards at their next scheduled NSQHS Standards accreditation assessment, as a pathway to accreditation to the Primary and Community Healthcare Standards.

Healthcare services currently accredited to the NSQHS Standards as part of regulatory or contractual requirements should seek agreement from their regulator and/or funder before proceeding with the Provisional accreditation pathway.

Table A: NSQHS Standards actions to be assessed for provisional accreditation

Total number of assessable actions: 87

  • 1.01
  • 1.07
  • 1.08
  • 1.09
  • 1.10
  • 1.11
  • 1.12
  • 1.13
  • 1.14
  • 1.15
  • 1.16
  • 1.17*
  • 1.18*
  • 1.19
  • 1.20
  • 1.21
  • 1.22
  • 1.23
  • 1.25
  • 1.27
  • 1.28
  • 1.29
  • 1.30 a
  • 1.33*
  • 2.01 a, b
  • 2.03
  • 2.04
  • 2.05
  • 2.06
  • 2.07
  • 2.10
  • 2.11
  • 3.01
  • 3.02
  • 3.03
  • 3.04
  • 3.06
  • 3.10 a,b
  • 3.11 a,d*
  • 3.12
  • 3.13
  • 3.14
  • 3.15
  • 3.16 a–d
  • 3.17*
  • 3.18 b,d*
  • 3.19 a,c*
  • 4.01
  • 4.02
  • 4.03
  • 4.05*
  • 4.09
  • 4.10 c
  • 4.11
  • 4.12*
  • 4.14*
  • 4.15*
  • 5.01
  • 5.02
  • 5.03
  • 5.04 c
  • 5.05 a
  • 5.06
  • 5.07 a
  • 5.08
  • 5.10 a
  • 5.14
  • 5.15*
  • 5.17
  • 5.19
  • 5.31
  • 5.32
  • 5.34
  • 6.01
  • 6.02
  • 6.03
  • 6.04 b,c
  • 6.05 b
  • 6.06
  • 6.09
  • 6.10
  • 8.01
  • 8.02
  • 8.03
  • 8.04
  • 8.08
  • 8.09

*May not be applicable in certain circumstances. Refer to Transitioning from the National Safety and Quality Health Service Standards to the National Safety and Quality Primary and Community Healthcare Standards for more details.

Table B: Primary and Community Healthcare Standards actions to be assessed to convert from provisional accreditation to NSQHS Standards to accreditation to Primary and Community Healthcare Standards

Total number of assessable actions: 6

  • 1.12
  • 2.07
  • 1.24
  • 3.06
  • 3.20
  • 3.28