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Transitioning to the National Safety and Quality Health Service Standards Print E-mail
The Quarterly 2012


As many of you responsible for Quality activities at your health services are aware, from January 2013 all hospitals and Day Procedure Services (DPS) across Australia will be expected to meet the 10 National Safety and Quality Health Service (NSQHS) Standards in order to be accredited for 3-year periods.

The NSQHS Standards, released in June 2011 by the Australian Commission on Safety and Quality in Healthcare (ACSQHC), were developed following extensive public and stakeholder consultation and are designed to assist health services to deliver safe and high quality care1.

The 10 Standards are -

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



Standards 1 and 2, 'Governance for Safety and Quality in Health Service Organisations' and 'Partnering with Consumers', set the overarching requirements for effective implementation of the remaining 8 Standards1.

The Standards address areas in which there are risks because:

  • there are large numbers of patients involved;
  • there are known gaps between the current situation and best practice outcomes; and
  • there are existing improvement strategies that are evidence based and achievable 1.



Each Standard outlines a statement of intent, its context, criteria, items and actions. In all, there are 256 actions across the 10 Standards, of which 223 are core actions and must be met in order to achieve accreditation. The remaining 33 actions are developmental (i.e. aspirational) and do not need to be met to achieve accreditation at this stage. It is planned that the developmental actions will be reviewed in 2015 and the Standards as a whole will be reviewed in 2017.

The following Table demonstrates a breakdown of numbers of criteria, items and actions for each Standard.

Standard Criteria Items Actions (no. developmental actions)
Standard 1 - Governance for Safety and Quality in Health Service Organisations 5 20 53 (4)
Standard 2 - Partnering with Consumers 3 9 15 (9)
Standard 3 - Preventing and Controlling Healthcare Associated Infections 6 19 41 (3)
Standard 4 - Medication Safety 5 15 37 (2)
Standard 5 - Patient Identification and Procedure Matching 3 5 9 (0)
Standard 6 - Clinical Handover 3 5 11 (1)
Standard 7 - Blood and Blood Products 4 11 23 (0)
Standard 8 - Preventing and Managing Pressure Injuries 4 9 24 (4)
Standard 9 - Recognising and Responding to Clinical Deterioration in Acute Health Care 4 9 23 (8)
Standard 10 - Preventing Falls and Harm from Falls 4 10 20 (2)
Total Actions     256 (33)



The actions can be rated as 'Not Met', 'Satisfactorily Met' or 'Met with Merit'. All core actions must achieve 'Satisfactorily Met' or 'Met with Merit' for the service to be accredited. A 'Not Applicable' category can be used but it is expected that this would be an unusual occurrence.

Currently, most acute health services are accredited by the Australian Council on Healthcare Standards (ACHS) under EQuIP 5 (from July 2011). ACHS has mapped the Criteria of EQuIP 5 with the Actions in the National Standards and it is believed that 181 Actions match across both frameworks with 17 of the EQuIP Criteria matching with developmental Actions from the Standards2.

As an example, Standard 1 is a broad category and would match with aspects of 19 Criteria across all three EQuIP5 Functions including the clinical governance and quality frameworks, incident and complaints management, risk management, open disclosure, patient charter of rights, informed consent, clinical guidelines and pathways, use of an integrated clinical record, the role and scope of practice of the clinical workforce and performance development systems. (For those with specific interest, see Criteria 1.1.1, 1.1.2, 1.13, 1.1.7, 1.1.8, 1.3.1, 1.6.2, 1.6.3, 2.1.1, 2.1.2, 2.1.3, 2.1.4, 2.2.2, 2.2.3, 2.2.4, 2.3.1, 3.1.2, .3.1.3, and 3.1.5 under EQuIP5).

The Commission developed the NSQHS Standards to be applied across all areas of care. Hospitals and DPS will be expected to be accredited against the Standards from 1 January 2013 but the Commission expects that other types of health services would also choose to use the Standards as part of their internal quality systems3.

There will be a number of approved accrediting agencies for the Standards as long as the agencies are accredited themselves under thee Joint Accreditation System of Australia and New Zealand (JASANZ) or the International Society for Quality in Healthcare (ISQua).

Currently we are in a Transition Phase which commenced on 1 July 2011 and ends on 31 December 2012. Health services are still being accredited under EQuIP5 but many are also testing themselves for survey against the NSQHS Standards and many are busy preparing for full implementation of the Standards.

As an ACHS surveyor I am about to undertake a combined EQuIP5 survey and 'test' survey against the National Standards and there will be two different sets of documentation for me to complete with duplication of evidence checking. In future I expect that a significant number of health service organisations will choose to undertake EQuIPNational under ACHS which combines the NSQHS Standards with a further five Standards that cover Standards and Criteria currently included in EQuIP5 but not under the National Standards4.

We are now well into the Transition Phase and the next few months will be busy (and at times somewhat confusing) for health service staff and surveyors alike.

Dr Susan Sdrinis
RACMA Fellow

References
1 Australian Commission on Safety and Quality in Healthcare, National Safety and Quality Health Service Standards, June 2011
2 Presentation by the ACHS Executive Director - Customer Services at ACHS Surveyor Training Day held in Melbourne August 2011.
3 Australian Commission on Safety and Quality in Healthcare, National Safety and Quality Health Service Standards- Draft guide for use in hospitals, October 2011.
4 Australian Council on Healthcare Standards Communication December 2011.


Acknowledgment: This article is based on work undertaken by the author in 2011 while working at Peninsula Health in the role of Executive Director Medical Services, Quality and Clinical Governance. With thanks to the Chief Executive of Peninsula Health, Dr Sherene Devanesen.




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Last Updated on Friday, 17 July 2015 14:15