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ADHA 2015
Margaret Banks
Program Director
10 September 2015
NSQHS Standards and
Accreditation Scheme
The Australian health care system
1440 acute health services (in 2015)
• 22% (315) day procedure services
• 21% (298) private hospitals
• 53% (764) public hospitals
• 4% (63) other
Interim accreditation
2013 2014 2015 Total
Total number of interim
assessments18 22 10 50
DPS interim
assessments12 17 4 33 66%
Comparison of DPS assessments 2013-2015
2013 % 2014 % 2015* %
Total no. of assessments
(all health services)750 1072 397
Total no. of day procedure
assessments237 32% 259 24% 120 30%
Interim 12 5% 17 7% 4 3%
Mid cycle 139 59% 115 44% 61 51%
Organisation-wide 86 36% 127 49% 55 46%
*2015 - January to July
Implementation of the NSQHS Standards 2015
All assessments scheduled for 2015 and assessments completed by
jurisdiction for private DPS and hospitals for January to June 2015
0
10
20
30
40
50
60
70
80
ACT NSW NT QLD SA TAS VIC WA
DPS-scheduled DPS-Assessed Pvt hospital-scheduled Pvt hospital-assessed
Implementation of the NSQHS Standards 2015
Breakdown of assessments per type of service (January to June 2015)
Day
procedure
services
Hospitals Other Total
Private 120 72 4 196
Public 0 116 85 201
Total 120 188 89 397
Implementation of the NSQHS Standards 2015
Table 5: Rating at initial assessment for core actions only (interim, mid-
cycle and organisation-wide) for 2014 and January to June 2015 for
individual services and health service clusters
Jan to Dec 2014 Jan to Jul 2015
n=259 n=120
Day procedure services with
all actions met at initial
assessment
190 73% 99 83%
Day procedure services with
actions that need to be re-
assessed within 90 days
68 26% 20 17%
Day procedure services not
accredited1 0% 1 1%
Implementation of the NSQHS Standards 2015
Range, average, media and mode for not met core actions at
organisation wide assessments
Day procedure services Private hospitals
Jan-Dec 2014 Jan-Jul 2015 Jan-Dec 2014 Jan-Jul 2015
n=127 n=55 n=99 n=38
Range 0 to 126 0 to 125 0 to 32 0 to 4
Average 4 4 2 0
Median 0 0 0 0
Mode 0 0 0 0
Implementation of the NSQHS Standards 2015
Core actions not met at organisation-wide assessment as a percentage
of total number of actions in each Standard (cluster)
Implementation of the NSQHS Standards 2015
Developmental actions not met at organisation-wide assessment as a
percentage of total number of actions in each Standard (cluster)
Implementation of the NSQHS Standards 2015Top core NOT MET actions DPS and all services – Jan to July 2015
Action DetailsNo. of
PDS
No. of all
services
3.16.1Monitoring compliance with relevant standards for cleaning, disinfection and
sterilisation of reusable instruments4 7
1.10.2 Monitoring clinical workforce are working within agreed scope of practice 4 7
1.10.1 System is in place to define and review the scope of practice for the workforce 4 6
3.18.1Maximising coverage of workforce trained in decontaminating reusable medical
devices4 4
3.15.1 Policies are in place for environmental cleaning 3 5
3.10.2 Auditing of compliance to aseptic technique 3 3
6.2.1 Workforce has access to processes for clinical handover 3 3
1.5.1 Use and monitoring of an organisation-wide risk register 3 5
3.10.3 Action to Increase compliance to aseptic technique 3 3
10.1.1Policies for falls used that are consistent with best practice guidelines and
incorporate screening and assessment tools3 3
8.1.2 Use of pressure injury policies are monitored 3 4
2.7.1Information is provided to consumers on the organisation’s safety and quality
performance3 4
3.10.1 The Clinical workforce is trained in aseptic technique 3 3
8.1.1Policies for falls are used, are consistent with best practice guidelines and
incorporate screening and assessment tools3 4
Action DetailsNo. of
services
2.9.2Consumers participate in the implementation of quality activities relating to patient
feedback data37
2.9.1 Consumers participate in the evaluation of patient feedback data 37
2.3.1Consumers access orientation and ongoing training to enable them to fulfil their
partnership role36
2.5.1 Consumers participate in the design and redesign of health services 35
2.8.1Consumers participate in the analysis of organisational safety and quality
performance34
2.1.2Governance partnerships are reflective of the diverse range of backgrounds
accessing care in the health service organsiation33
2.6.2 Consumers are involved in training the clinical workforce 33
2.1.1 Consumers are involved in the governance of the health service organisation 32
2.2.1 Consumers are engaged in the strategic/operational planning for the organisation 31
2.8.2 Consumers are involved in planning and implementation of quality improvements 31
Implementation of the NSQHS Standards 2015
Top developmental NOT MET actions DPS only – Jan to July 2015
Action DetailsNo. of
services
1.6.2 Action is taken to maximise patient quality of care 17
1.6.1 Organisation-wide quality management system is used and monitored 15
1.2.2 Action is taken to improving the safety and quality of patient care 11
1.1.2The impact on patient safety and quality of care is considered in
business decision making9
1.1.1Organisation-wide management system is in place for development,
implementation and review of policies and protocols9
1.5.1 An organisation-wide risk register is used and monitored 8
1.2.1Executives monitor performance using safety and quality indicators and
other performance data8
1.5.2 Action is taken to minimising risks to patient safety and quality of care 7
1.12.1 Workforce have access to ongoing safety and quality training 7
Implementation of the NSQHS Standards 2015
Top core MET WITH MERIT actions DPS only – Jan to July 2015
Action DetailsNo. of
services
1.4.4Competency-based training is provided to the clinical workforce
to fulfil their safety and quality roles6
1.4.1Orientation and ongoing training is provided to the workforce to
fulfil their safety and quality roles and responsibilities6
1.4.2Organisation provides access to annual mandatory training
programs to meet the requirements of the Standards5
2.2.1Consumers are engage in the strategic and operational planning
for the organisation3
Implementation of the NSQHS Standards 2015
Top developmental MET WITH MERIT actions DPS only – Jan to July 2015
Review of the NSQHS Standards
• Commence 2015
• Information on version 1 evaluated
• Consulted
• Consumers
• technical experts
• nurses, doctors and allied health
• Considering current and emerging safety and
quality issues and evidence
Version 2 of the NSQHS Standards
Research included in version 2:
• Mental health
• Cognitive impairment
• End of life care
• Health literacy
• Aboriginal health
New concepts in version 2 of the NSQHS
Standards
• Leadership
• Safe clinical environment
• Integrated assessment
• Goal directed care planning
• Malnutrition and dehydration
• Organ and tissue donation
• Shared decision making
• Consumer e-health records
Standard GS: Governance for safety and quality
Standard PC: Partnering with consumers
Standard CC: Comprehensive care
Standard RH: Reducing harm
Standard CS: Communicating for safety
Standard IP: Preventing and controlling healthcare-associated infections
Standard MS: Medication safety
Standard BP: Blood product safety
Standard RR: Recognising and responding to acute deterioration
Version 2 of the NSQHS Standards
Jul - Dec 2014
Jan - Jun 2015
Jul - Dec 2015
Jan - Jun 2016
Jul - Dec 2016
Jan - Jun 2017
Jul - Dec 2017
Feedback from
stakeholders
Resources reviewed, updated, approved and distributed
Development and delivery of education and training
NSQHS Standards
Education and training
Resources
Drafting Piloting Endorsement
Finaliseand
publish
Review of the NSQHS Standards – key milestones and activities
Regulatory Impact Statement
Cost benefit assessment
Review and amend Australian Health Service Safety and Quality Accreditation scheme
Implementation requirements
Proposed deliverables from the review
process
1. NSQHS Standards, version 2
2. Revised Safety and Quality Improvement Guides
3. Accreditation workbooks tools
4. Translation of the NSQHS Standards for consumers
5. Identification of the training requirements of the NSQHS Standards
for education bodies and health service organisations
6. Associated safety and quality measures for each Standard
7. Train the trainer package for accrediting agencies and surveyor
and information packages for health services
