Implementation of the AHSSQA Scheme and NSQHS Standards in Western Australia

Applicable to: See below

Description: The implementation of the Australian Health Service Safety and Quality Accreditation Scheme and the National Safety and Quality Health Service Standards in public and private hospitals in Western Australia.

Implementation of the Australian Health Service Safety and Quality Accreditation Scheme and the National Safety and Quality Health Service Standards in Western Australia

Compliance with this Operational Directive is mandatory.

PURPOSE

This Operational Directive describes the implementation in Western Australia (WA) of the accreditation process for the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme.

INTRODUCTION

  • On 12 November 2010 Australian Health Ministers endorsed the AHSSQA Scheme as the national accreditation model for all jurisdictions. 
  • The AHSSQA Scheme incorporates accreditation to the National Safety and Quality Health Service (NSQHS) Standards. 
  • The NSQHS Standards were endorsed by Australian Health Ministers in September 2011.  

APPLICATION OF THE AHSSQA SCHEME IN WA

  • All public and private hospitals and private day hospitals (Class A) (as defined in the Hospitals and Health Services Act 1927  and associated Standards) (herein referred to as health services) in WA will be required to achieve accreditation to the NSQHS Standards. 
  • Accreditation to the NSQHS Standards will be in addition to health services’ existing requirements for accreditation to other standards. 

RESPONSIBILITIES RELATED TO ACCREDITATION

  • The Licensing and Accreditation Regulatory Unit (LARU), Department of Health, will be responsible for regulating the AHSSQA Scheme in WA. 
  • The Executive Director of the Performance, Activity and Quality Division will be the Executive Sponsor for the regulatory process. Further, the Executive Sponsor will approve any policy directly associated with the AHSSQA Scheme and the regulatory function. 
  • All health services are required to register their organisation for accreditation against the NSQHS Standards with the LARU by completing a LARU accreditation registration form. 
  • For existing health services, completed accreditation registration forms must be lodged before 31 March 2013. For new health services, registration with the LARU will occur within 3 months of commencement of the service. 
  • All health services must choose an accrediting agency that has approval from the Australian Commission on Safety and Quality in Health Care (ACSQHC), to assess their service against the NSQHS Standards. A list of approved accrediting agencies is located on the ACSQHC’s website at www.safetyandquality.gov.au . 
  • In the event of disagreements about the assessment process or outcome the health service will follow the dispute resolution mechanisms of the accrediting agency in the first instance. 

ACCREDITATION TO THE NSQHS STANDARDS

  • It is mandatory that all health services are assessed against and accredited to the NSQHS Standards. Health services may elect to be assessed against additional standards offered by accrediting agencies. 
  • In order to achieve satisfactory performance against the NSQHS Standards health services must meet 100 percent of core actions and be actively working towards the developmental actions  in the NSQHS Standards to be awarded accreditation. 

TIMELINES FOR IMPLEMENTING THE NSQHS STANDARDS

  • The implementation of accreditation to the NSQHS Standards will commence from 1 January 2013 for health services. 
  • All  health services will be assessed, in accordance with their current accreditation cycle, against: 
    • the ten NSQHS Standards at their first organisational wide accreditation survey scheduled after 1 January 2013 
    • Standards 1, 2 and 3 at all mid cycle assessments scheduled after 1 January 2013. In addition mid cycle assessments will also include review of recommendations from past assessment processes and the organisational quality improvement plan. 

REPORTING FOR HEALTH SERVICES

  • Following each organisational wide accreditation survey and mid-cycle assessment health services are required to provide a copy of their written report to the LARU, within 10 working days of its receipt, via email at LARUAccreditation@health.wa.gov.au or facsimile to (08) 9222 4077. 
  • Health services are required to notifiy the LARU within 10 working days of any change: 
    • in the accrediting agency nominated to undertake the organisation’s accreditation against the NSQHS Standards 
    • to the information provided in the application for registration for example change of contact details/persons, number of services covered in the application etc. 
  • Health services are required to provide any other information related to accreditation against the NSQHS Standards that may be requested by LARU and within specified timeframes. 

REPORTING FOR ACCREDITING AGENCIES

  • Where accrediting agencies assess performance against the NSQHS Standards, determine core actions to be ‘met’ and no major issues are identified, accreditation/certification is awarded as per the agreed contract. Accrediting agencies provide routine assessment data to the LARU as agreed with the ACSQHC. 
  • When performance against the NSQHS Standards results in any core action/s being determined as ‘not met’ the approved accrediting agency will make recommendations for risk mitigation/improvement. The accrediting agency will also provide a limited timeframe for improvement, 90 days (during first year of operation this will be 120 days from 1 January 2013 to 31 December 2013) before determining a final outcome of assessment process. 
  • Where the health service addresses all of the accrediting agency’s recommendations, to the accrediting agency’s satisfaction and within the given timeframe, accreditation/certification award is confirmed. Accrediting agencies provide routine assessment data to the LARU as agreed with the ACSQHC. 
  • If the health service does not address the accrediting agency’s recommendations, to the accrediting agency’s satisfaction and within the specified timeframe, the accrediting agency shall notify the LARU and a responsive regulatory process will be enacted. 
  • Where the accrediting agency identifies significant patient risk in areas covered by the NSQHS Standards it will refer the concerns to the health service’s system manager/Licence Holder representative. The accrediting agency and the health service system manager/Licence Holder representative will agree on an action plan which identifies the level of risk to patients and includes recommendations for risk mitigation/improvement within agreed timeframes. 
  • The accrediting agency will: 
    • notify the LARU at the time the significant risk is identified and provide a verbal report of the nature of the risk and the name of the accrediting agency officer responsible for identifying the risk 
    • forward a copy of the agreed action plan to the LARU, by the end of 48hrs of the initial identification. 
Note: Significant risk to patient safety is one that may result in a serious adverse incident, sentinel event, impairment, grossly sub-standard care or death of a patient or risk of harm that could impact on a large number of patients.

RESPONSIVE REGULATORY PROCESS

  • A responsive regulatory process is utilised in the following circumstances: 
    • where a significant patient risk/s in areas covered by the NSQHS Standards is identified by a certified accrediting agency during a mid cycle assessment or organisational wide accreditation survey against the NSQHS Standards 
    • where a health service has failed to address ‘not met’ core item/s of the NSQHS Standards within specified timeframes. 
  • An initial regulatory response will begin with a process of verifying the scope, scale and implications of the reported issues, review of documentation, and may include one or more site visits. 
  • The LARU will review the action plan agreed between the health service and the accrediting agency  using the regulatory process.  
  • Upon evidence of completion of mandatory items the LARU will advise the health service and the accrediting agency. 
  • The regulatory process for public hospitals may include one or a combination of the following actions: 
    • provide advice, information on options or strategies that could be used to address the non-met actions within a designated time frame 
    • connect the hospital to other hospitals that have addressed similar deficits or have exemplar practice in this area. 
  • In the case of serious or persistent non-compliance and where required action is not taken by the  health service, the response may be gradually escalated. The LARU, with approval from the Executive Director of the Performance, Activity and Quality Division, may undertake one or a combination of the following actions: 
    • restrict specified practices/activities in areas/units or services of the health service where the NSQHS Standards have not been met 
    • suspend particular services at the health service until the area/s of concern are resolved 
    • suspend all service delivery at a health service for a period of time 
    • place conditions on the organisation’s licence. 

APPEALS PROCESS

  • Appeals against decisions of the Regulator will be dealt with by an independent reviewer appointed by the Director General, Department of Health. 
    • Details of the appeal to be lodged with the Director General within fourteen working days of receipt of the Regulator’s decision.  
    • Appeal decisions will be available at twenty one working days from date of receipt. 

Kim Snowball
DIRECTOR GENERAL
DEPARTMENT OF HEALTH

Date of effect: 01 January 2013 to 01 January 2018

Policy Framework

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