Short Notice Assessment

From 1 July 2023, all public and private hospitals and day procedure services undergoing assessment to the NSQHS Standards, will be assessed at short notice. Other health service organisations may voluntarily choose to be assessed at short notice, or it may be a requirement of licencing or funding contracts.

Health service organisations implementing the National Safety and Quality Primary and Community Healthcare Standards, or the National Safety and Quality Digital Mental Health Standards, are generally assessed with an announced visit, unless it is a requirement of licencing or funding contracts, or they choose to be assessed at short notice.

Where community services are part of a local health district or network and the contract with the approved accrediting agency is for a combined assessment, all services assessed under the contract will be subject to short notice assessment.

Community health services that implement the National Safety and Quality Primary and Community Healthcare Standards will be assessed via the announced pathway but may choose to be assessed at short notice voluntarily.

Where a clinical trials site is part of a local health district or network and the contract with the approved accrediting agency is for a combined assessment, all services assessed under the contract will be subject to short notice assessment.

Clinical trials sites that implement the National Clinical Trials Governance Framework but are not being assessed to the NSQHS Standards, will be assessed via the announced pathway but may choose to be assessed at short notice voluntarily.

Interim accreditation to the NSQHS Standards will be announced. The initial assessment must occur within 10 days of commencing operation. The final assessment will be announced and must be completed within 18 months of the initial assessment. All subsequent assessments will occur at short notice.

An assessment cycle may include a final assessment if actions are not met or met with recommendations at initial assessment. While the initial assessment occurs at short notice, a final assessment follows a period of remediation (60 business days) and is announced.

Organisations that meet the criteria for mandatory reassessment are required to have a second assessment within six months of achieving accreditation. Mandatory reassessment dates will be announced.

Organisations will generally have 24 hours-notice of their assessment commencing.  That means an assessment commencing on a Wednesday will be notified on Monday. Tuesday is considered the full 24-hour notice. If notice is given on a Friday, the assessment will commence on Tuesday as Monday is taken as the 24 hours-notice period. Weekends are not counted.

Some organisations will have 48 hours-notice. State and territory health departments that regulate health service organisations determine which hospitals are to be assessed at 48 hours or longer notice.  The Commission will work with state or territory regulators to identify organisations to be given 48 hours-notice. These organisations and their accrediting agency will be notified once this is confirmed.

The accrediting agency will contact the person designated by the health service organisation, 24 (or 48) hours before the assessment occurs by phone and email. It will be important for health service organisations to frequently communicate with their accrediting agency to ensure that key contact details are up to date.

The regulator will be copied into the email to health service organisations notifying them of the assessment date and details.

When notice is provided of the assessment, accrediting agencies will provide information about the assessment team, duration of the assessment and sites to be visited. The accrediting agency will be responsible for drafting up a schedule for the visit. Accrediting agencies will have greater responsibility for organising transport, catering, and logistics. 

Health service organisations will be required to implement processes to regularly inform the accrediting agency of any key changes within the organisation. This may include confirming not applicable actions, changes in the scope of services provided, facilities changes and changes in key governance arrangements and personnel.

An initial meeting will be required to allow the assessment to commence. It is not intended that this meeting be long or include any presentations.

The aim is to establish administrative and operational processes which may include confirmation of assessment team members, gathering authority statements and distributing IT access and security passes, and identifying whom the assessment team will liaise with and report to, during and after the assessment.

Assessors will not generally require chaperones during the assessment, but will need clear information about the layout, name and purpose of all the operational areas.

During the assessment, the assessor team may need to contact the person in charge (or their delegate) to verify evidence, seek additional information, or data, in order to triangulate and confirm findings.

Assessors will use an assessment framework called PICMoRS. For more information see Fact Sheet 12: Assessment framework for safety and quality systems.

The PICMoRS assessment method allows assessors to comprehensively evaluate each component of safety and quality systems in a health service organisation. This method provides a structure for conducting assessments based on evidence of actual performance from observations, interviews and records.

Assessors will spend at least 75% of the assessment time in clinical areas and gather evidence from a range of source including observation of clinical care, discussions with consumers and members of the workforce, and review of documents, such as policies, patient records, minutes of meetings and records of incidents. 

Assessors will require access to governance documents and systems. These documents should be prepared as part of usual business, not specifically for an assessment. This may include reports from incident management systems, reports from audit results, quality improvement programs and risk registers (or similar), credentialing documents and minutes of governance meetings.

Each hospital and day procedure facility is required to be assessed. Sampling can occur where multiple non-hospital and non-day procedure services operate under a single governance structure, such as community based, public dental, prisons and transport services, in line with Advisory AS18/13: Sampling for accreditation assessment.

The accreditation agency will determine the length of an assessment and number of assessors. This will depend upon the size and complexity of the health service, the time available for the assessment and the number of facilities to be assessed.