NSQHS Standards submissions, requests, extensions and appeals

Requests for hybrid assessments or accreditation extensions

To provide certainty for health service organisations, and facilitate accreditation assessments proceeding where possible, the Commission has developed a process for requests to conduct a hybrid or virtual assessment.

Where an assessment is unable to proceed via hybrid or virtual methods, the Commission, in collaboration with regulators, will make a decision regarding delaying on site assessment.

The following provisions for accreditation assessments apply:

On-site assessment is to proceed, whenever safe and feasible.
Hybrid assessment may occur where it is not possible for a full assessment team to be on site. This assessment involves part of the assessment team being on site and part of assessment team off site.
Off-site virtual assessment may be allowed in exceptional circumstances.
Accreditation can be maintained and the accreditation expiry date revised, where an assessment cannot proceed.

Submission form for health service organisations and accrediting agencies

Extensions will be considered where:

Risks have been identified that prevent a hybrid assessment from taking place
Natural disaster, fire, accident, or emergencies such as a pandemic has occurred that lead to damage, or restricted access to health care facilities
The health service organisation’s operational priorities have changed, clinical operations have temporarily ceased or relocated
There have been changes in governance structures, such as acquisition or transfer of operations
Recent personal hardship or tragedy has been experienced by key workforce personnel which has or is likely to significantly impact the operations over an extended period of time. This includes but is not limited to severe illness or death.

For more information, please contact the Safety and Quality Advice Centre email AdviceCentre@safetyandquality.gov.au or call 1800 304 056.

Apply for an exemption to Advisory AS24/01: Reprocessing of reusable medical devices in health service organisations

Where timelines for implementation exceed 3 years, health service organisations may apply to the Commission for an exemption to the rules of the AHSSQA Scheme, relating to the rating scale for assessment. See Fact Sheet 4: Rating scale for assessment.

An exemption supports Action 3.17 to be rated ‘met with recommendations’ across assessment cycles. Where the requirements of Advisory 24/01 have been met, the rating of MWR will not count towards a remediation period, nor mandatory reassessment.

Application form for extension related to Advisory AS24/01

Key Steps

Step 1	Complete an on-line application form providing the: Name and location of the facility Service type Category the extension request is for Approved implementation plan and timelines, stipulating the current systems and processes that are in place to ensure safety and quality is maintained. The application should include copies of the gap analysis, risk remediation and and a summary of the project plan indicating executive approval and allocated funding. Note: If submitting a request for multiple facilities, please email: AdviceCentre@safetyandquality.gov.au
Step 2	The application will be reviewed against the criteria to determine compliance. Applicants will be notified if the application is not complete. Submissions cannot proceed for formal approval until all documentation is provided.
Step 3	Advice will be sought from the relevant Regulator.
Step 4	Once an outcome has been determined, successful applications will be notified to the health service organisation, Regulator and accrediting agency.
Step 5	Unsuccessful applicants may appeal the Commission’s decision. An appeal will involve review of the application by an officer not involved in the initial determination. The appellant may provide further information or evidence. The regulator may also be invited to provide further input. If you have any questions, please contact the Safety and Quality Advice Centre email AdviceCentre@safetyandquality.gov.au

Apply for recognition of exemplar practice implementing the NSQHS Standards

Enrol in the NSQHS Standards Orientation Course

This course aims to provide an overview of the National Safety and Quality Health Service (NSQHS) Standards for assessors and health service organisations' workforce. It is self-paced and includes learning material such as case studies, videos and tips for implementing the NSQHS Standards. Read more about the NSQHS Standards orientation course.

Request for NSQHS Standards logo and icons

Request for NSQHS Standards commercial design files

The NSQHS Standards and resources to support implementation are available in PDF format. Hard copies are not available for distribution.

These are for organisations wanting to print several copies of these resources for distribution throughout their own organisation. The print-ready design files are intended for use on a commercial printer for the production of a large number of bound copies on behalf of a health service organisation.

Accreditation Assessment Outcome: Appeals Process

There is provision within the Australian Health Service Safety and Quality Accreditation (AHSSQA Scheme) for health service organisations to appeal the outcome of their accreditation assessment. Health service organisations may appeal to the Australian Commission on Safety and Quality in Healthcare (the Commission) where the process conducted by the accrediting agency has not complied with the AHSSQA Scheme.

An appeal to the Commission can follow an appeal to the accrediting agency or occur without a prior appeal to the accrediting agency.

Criteria for appeal

A health service organisation may only appeal to the Commission where their accrediting agency did not comply with:

The AHSSQA scheme as set out in the policy
Commission fact sheets or advisories
Where there is evidence that:
1. A conflict of interest has been identified in breach of the Policy – Approval under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme
2. A conflict of interest has been identified in breach of the Policy - Avoiding and managing conflicts of interest under the Australian Health Service Safety and Quality Accreditation Scheme
3. The accreditation assessment was not conducted within the time frames as stipulated in the Flow chart of an assessment to NSQHS Standards
4. The health service organisation was not afforded due process to appeal the outcome of the accreditation assessment with their accrediting agency.

Appeals to the Commission will not be considered for reasons such as:

The health service organisation did not allow sufficient time, or comply with the reasonable directions of the accrediting agency to finalise the administration of the assessment prior to the accreditation expiry date
The health service organisation is transferring between accrediting agencies
The health service organisation is disputing the ratings awarded at assessment to actions in a set of standards not part of a Commission accreditation scheme.

Process for reviewing health service organisations appeals against the NSQHS Standards accreditation assessment outcome

Step 1	The health service organisation (HSO) receives the final NSQHS Standards accreditation assessment outcome report and wishes to appeal. If the HSO wishes to appeal: to the accrediting agency, proceed to Step 2. directly to the Australian Commission on Safety and Quality in Health Care (the Commission), skip to Step 5.
Step 2	The HSO appeals to the accrediting agency. This must occur within 20 business days of the HSO receiving the final report.
Step 3	The accrediting agency reviews the appeal from the HSO and provides a determination. This must occur within 20 business days of the accrediting agency receiving the appeal submission.
Step 4	If the HSO is satisfied with outcome of the appeal, the appeals process ends here. However, if the HSO wishes to further appeal the decision of the accrediting agency, proceed to the next step.
Step 5	The HSO appeals to the Commission. Where an appeal is made directly to the Commission, it must be within 20 business days of the health service organisation receiving its final assessment report from its accrediting agency. Where an appeal is made following an appeal to its accrediting agency, it must be made within 20 business days of the accrediting agency ruling on its appeal.
Step 6	The Commission undertakes an initial compliance check of the appeals submission and contacts the accrediting agency and regulator for comment/response. This must occur within 20 business days of the Commission receiving the appeal.
Step 7	The accrediting agency and the regulator have 20 business days to provide a response.
Step 8	The Commission reviews the appeal and provides a determination. This must occur within 20 business days of the Commission receiving the accrediting agency and regulator response, or notification of nil response.
Step 9	The Commission notifies all relevant parties of the appeal outcome within 20 business days of the determination being made, including the HSO, accrediting agency and regulator. The appeals process ends here.

Submitting an appeal to the Commission

Where an appeal is made directly to the Commission, it must be within 20 business days of the health service organisation receiving its final assessment report from its accrediting agency. Where an appeal is made following an appeal to its accrediting agency, it must be made within 20 business days of the accrediting agency ruling on its appeal.

The Commission will have 80 business days to review the submission, establish an appeals panel and provide the health service organisation with a determination.

All appeals are to be in writing and include executive approval. Incomplete submissions will not be processed. Supporting evidence and documentation should accompany the appeal and include:

Name, title and contact details of the person (with delegated authority) submitting the appeal
Health service organisation name and address
Unique health service facility number (allocated by the Commission)
Name of accrediting agency
Accreditation expiry date for the health service organisation
Assessment date(s) relevant to the appeal
Reason for submitting an appeal
Evidence supporting the appeal

On receipt of an appeal the Commission will seek information from the accrediting agency and relevant regulator on the matter.

Appeals should be submitted to the Safety and Quality Advice Centre: AdviceCentre@safetyandquality.gov.au

National Standards