Australian Commission on Safety and Quality in Health Care

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 The NSQHS Standards Standard 1 Governance for Safety and Quality in Health Service Organisations

Standard 2 Partnering with Consumers Standard 3 Healthcare Associated Infections Standard 10 Preventing Falls and Harm from Falls Standard 4 Medication Safety

Standard 9 Recognising and esponding to Clinical eterioration 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 Services to be Accredited Determined by Regulators National 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 organisations services for a period of time. Withdrawing the organisations 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 Commissions 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