ACSQHC Objectives

• Improve safety and quality for patients using the National Safety and Quality Health Services Standards

• Support implementation of the Australian Health Services Safety and Quality Accreditation Scheme

Standard 7Blood and Blood

Products

Standard 10Preventing Falls and

Harm from Falls

The NSQHS Standards

Standard 1Governance for Safety and

Quality in Health Service Organisations

Standard 2Partnering withConsumers

Standard 4Medication Safety

Standard 3Healthcare AssociatedInfections

Standard 8Preventing and

Managing Pressure Injuries

Standard 9Recognising and

Responding to ClinicalDeterioration in Acute

Health Care

Standard 5Patient Identificationand ProcedureMatching

Standard 6ClinicalHandover

Services to be Accredited

Determined by RegulatorsNational agreement about:

Hospitals

Day Procedure Services

Ongoing discussion about:

Community services

Dental services

Core vs developmental actions

A degree of flexibility is required in the application of the NSQHS Standards.

Actions are designated as: • Core, which are critical for safety and quality

and which must be met in order to meet the Standard, or

• Developmental, which are aspirational targets. Health services organisations will not be required to achieve developmental actions in order to meet the Standard

Not Applicable Items

Two mechanisms:

• Declared when Standards released

• Application process via accreditation agency

Responsive Regulatory Approach

A regulator may respond with any one or more of the following actions:

• Confirm the concerns raised are genuine by:

• verifying who has identified and rated the concerns being raised

• identifying the scope, impact and spread of the issue

• reviewing strategies being implemented

• reviewing the timeframe to mitigate the issue

The action that follows may then be either: • A regulatory response

• Departmental response

Responsive Regulatory Approach

Regulatory response may go on to:

• Restricting specified practices in areas/units or services of the organisation where Standards have not been met.

• Suspending particular services at the organisation until the areas of concern are resolved.

• Placing conditions on the organisation licensing/funding.

• Suspending an organisation’s services for a period of time.

• Withdrawing the organisation’s licensing/funding.

Responsive Regulatory Approach

Departmental / Ministry response may go on to:

• Provide advice, information on options or strategies to be used by the health service to address the concern

• Connect the health services with other health services that have addressed a similar concern or have exemplar practice in this area

• Providing support to the organisation to meet the NSQHS Standards.

Timeframes for implementation

• Standards endorsed by Ministers – September 2011

• Release of Guides for Health Services –

• Analysis of written responses to consultation underway

• Pilot guides in health services - completed December 2011• Interim approval of Accrediting Agencies

• Complete, available on ACSQHC website• Commencement of implementation phase – underway

• Focus - gap analysis by services to NSQHS Standards

• Mandatory assessment against Standards – determined by regulators from 1 January 2013

Evaluation of the NSQHS Standards

Internal evaluation will consider:• Acceptance of the NSQHS Standards

• Penetration of the NSQHS Standards

• Reliability of accreditation outcomes

• Compliance with the NSQHS Standards

• Reduced duplication between standards

• Accrediting Agencies experience

External evaluation through a collaborative research program being conducted by the University of NSW

What next

NSQHS Standards now available

Quick-start guides for implementing quality improvement to become available throughout 2012

Reference for health services providing information on evidence for the safety and quality accreditation process to be finalised by mid 2012

Facts sheets for consumers available

Projects to support implementation

• Support for small hospitals• Audit tools

For more information

Commission’s website: www.safetyandquality.gov.au.

For access to: • NSQHS Standards

• Workbook or Guide for Health Services

• List of Approved Accrediting Agencies

• Fact sheets on the NSQHS Standards

• Frequently Asked Questions

• Commission resources and tools to support the

implementation of the NSQHS Standards

Health service organisations to be accredited

State Hospitals Day Procedure ServicesDental

PracticesCommunity

ServicesOther

Public Private Public Private Public Public Private

ACT

NSW

NT

QLD

SA Std 1 to Ambulance Service via performance agreement

TAS

VIC by 2014

Public Mental Health

WA

Not all State and Territories have publicly articulated which, if any, additional health services are to be accredited to the NSQHS Standards.

Health service organisations to be accredited

State Hospitals Day Procedure ServicesDental

PracticesCommunity

ServicesOther

Public Private Public Private Public Public Private

ACT

NSW

NT

QLD

SA

TAS

VIC

WA

Not all State and Territories have publicly articulated which, if any, additional health services are to be accredited to the NSQHS Standards.

Standards to be mandated

State NSQHS Standards Other State based Standards

Organisational Standards Mandated

Health service notified

Hospital DPS Dental

ACT Nutrition

NSW

NT

QLD HQCC Stds

SA Nutrition

TAS

VIC Nutrition

WA

Standards to be mandated

State NSQHS Standards Other State based Standards

Organisational Standards Mandated

Health service notified

Hospital DPS Dental

ACT

NSW

NT

QLD

SA

TAS

VIC

WA