NSQHS Standards submissions, requests, extensions and appeals

The COVID-19 pandemic continues to create challenges for the health system. In some instances, this may impact the ability of hospitals and day procedure services to participate in on-site accreditation assessments to the NSQHS Standards.

To provide certainty for health service organisations, and to facilitate accreditation assessments proceeding where possible, the following provisions for accreditation assessments apply in 2022:

1. On-site assessment is to proceed, whenever safe and feasible.
2. 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.
3. Off-site virtual assessment may be allowed in exceptional circumstances. All virtual assessments must be followed up with an on-site assessment.
4. Accreditation can be maintained and the accreditation expiry date revised by up to six months. This option is available to health service organisations with assessments scheduled before 31 July 2022 that are experiencing COVID-19 related disruptions or unable to proceed due to public health orders imposing travel and border restrictions.

To find out how these arrangements apply to you, download the fact sheet:

Fact sheet 16: Accreditation assessments for health services in 2022

2022

Fact sheet or brochure

• Submission form for health service organisations and accrediting agencies

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

Applications for an extension related to Advisory AS18/07 can be made by completing the on-line application form:

• Application form for extension related to Advisory AS18/07

When an extension request is received, the Commission will follow the steps in the process outlined below.

Key Steps

Step 1:

Complete an on-line application form providing the:

• Name and location of the facility
• Note: a separate submission should be made for each facility
• Service type
• Category the extension request is for
  • Segregation of clean and dirty activities
  • Design of storage areas for sterile stock
  • Monitoring requirements for water quality.
• 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 the reasons for the submission and identify the specific requirements that will not be met.

Applicants will be notified if the application is incomplete. The application will not proceed until the submission is complete.

Step 2

The application will be reviewed against the criteria to determine compliance. Applicants will be notified if the application is not compliant. Submission will not proceed until the application is compliant.

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. For unsuccessful applications, only the applicant will be notified.

Step 5 (Appeals Process)

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.

Applicants for extensions will need to provide copies of the health service organisation approved implementation plan including time frames, evidence it is authorised by the governing body or relevant other executive officer and complete the application form.

• Application form for extension related to Advisory AS18/07

If you have any questions or concerns please contact the NSQHS Standards Advice Centre: accreditation@safetyandquality.gov.au

The awarding of exemplar practice is used to highlight examples of safe and good-quality practice in health services who are implementing the NSQHS Standards (second edition), to facilitate the sharing of information between organisations.

Read more about NSQHS Standards exemplar practice.

• Exemplar practice nomination form

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.

• Enrolment form for the course
• Course login page
• Enquiry form for course troubleshooting

Health service organisations may brand locally developed resources with the NSQHS Standards logo and icons.

• Application form to request NSQHS Standards logo and icons

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

These resources are currently being updated and print-ready design files are not available.

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.

There is provision within the Australian Health Service Safety and Quality Accreditation (AHSSQA Scheme) for health service organisations and general practices 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. 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.

All appeals are to be in writing. Supporting evidence and documentation should accompany the appeal.

Submissions should 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.

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.

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

Further information on the process flow for assessments and appeals are documented in the fact sheet: Flow chart of an assessment to NSQHS Standards.