National Accreditation Forum, Vic Health Ms Margaret Banks, A/Senior Operations Manager 25 July 2011

An Australian Health Services Safety and Quality Accreditation Scheme National Safety and Quality Health Service (NSQHS) Standards National coordination

Aim of the NSQHS Standards To drive the implementation and use of safety and quality systems; and To improve the quality of care in Australia.

Standard 7 Blood and Blood Products Standard 10 Preventing Falls and Harm from Falls The NSQHS Standards Standard 1 Governance for Safety and Quality in Health Service Organisations Standard 2 Partnering with Consumers Standard 4 Medication Safety Standard 3 Healthcare Associated Infections Standard 8 Preventing and Managing Pressure Injuries Standard 9 Recognising and Responding to Clinical Deterioration in Acute Health Care Standard 5 Patient Identification and Procedure Matching Standard 6 Clinical Handover

Services to be Accredited Determined by Regulators National agreement about: Hospitals Day Procedure Services Ongoing discussion about: Community services Dental services

Not Applicable Actions Two mechanisms: Declared when Standards released Application process via accreditation agency

Example: Not Applicable Actions

Core and Developmental

Rating Scale Assessment may be against a three point rating scale: Not Met - the actions required have not been achieved. Satisfactorily Met - the actions required have been achieved. Met with Merit – in addition to achieving the actions required, measures of good quality and a higher level of achievement are evident. This would mean a culture of safety, evaluation and improvement is evident throughout the organisation in relation to the action or standard under review.

Approved Accrediting Agencies Criteria: Hold current international accreditation eg: JASANZ, ISQua Providing data on accreditation outcomes for services they assess to the relevant regulators and to the national coordination program of the Commission. Having in place an appeals process that meets administrative law requirements. Working with the national coordination program to: Maximise inter-assessor and inter-agency reliability Ensure consistent messages during surveyor training Streamline reporting and data collection to regulators and the Commission Formalise relationships with regulators

Data Collection Options Data on all 256 action items: Pros:Regulators can review priority Standards or actions Over time can go back and see trends on any of the Standards Comprehensive while simple for accrediting agencies to extract Cons: Large data set therefore resource intensive to store, ensure quality and analysis data set Data extract Pros:Specific to regulator needs More efficient to store, ensure quality and undertake analysis Cons: Greater risk poor quality with extract from multiple data bases/systems Limited capacity to review issues as they emerge

Responsive Regulatory Approach A regulator may respond with any one or more of the following actions: Confirm the concerns raised are genuine by: identifying the scope, impact and spread of the issue reviewing strategies being implemented reviewing the timeframe to mitigate the issue Provide additional time for improvement in performance, so it is consistent with the issue and context Provide support to meet the NSQHS Standards Restrict specified practices in specific units or services Place conditions on an organisation’s licensing, funding, performance agreement Suspend services in an organisation for a period of time Withdraw the organisation’s licensing or funding

Appeals Two levels of appeals: Health Services can appeal decisions / processes of an accrediting agency - continuation of current system Accrediting Agencies can appeal the decisions of the national coordinator - new process

Timeframes Standards endorsed by Ministers – imminent Release of Guides for Health Services – Early August Consultation process – close October 2011 Pilot guides in health services - completed end October 2011 Interim approval of Accrediting Agencies – follows Standards endorsement Commencement of implementation phase – follows Standards endorsement Mandatory assessment against Standards – determined by regulators, currently 1 January 2013

Timeframes Review of core and developmental actions – completed by 2015 Review of guides – ongoing, comprehensive review by 2015 Review of Standards – completed by 2017

National coordination Inform the work of the Commission’s programs Support standards development Enable benchmarking across health services Engage Departments to reduce the intervention time when there is underperformance Create formal relationships

What next Release of the standards Pilot of Guides for health services Training Facts sheets Communication Strategy with a focus on – Health service practitioners – Consumers – Surveyors

For more information Commission’s website: For access to: NSQHS Standards Draft Guides for hospitals and day surgery centres List of Approved Accrediting Agencies Fact sheets on the NSQHS Standards Commission resources and tools to support the implementation of the Standards