National Accreditation Forum, Vic Health

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

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

3. 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.

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

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

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

7. Example: Not Applicable Actions

8. Core and Developmental

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. 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

17. 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

18. For more information • Commission’s website: • www.safetyandquality.gov.au. • 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