Key messages

  • Health Services will be assessed to eight standards.
  • Victorian clinical mental health services (including Forensicare) are accredited to the NSQHS Standards (second edition) as of 1 January 2019.
  • All standards will be assessed as either ‘met’ or ‘not met’.
  • Assessments must be scheduled 80 days prior to the health service organisation’s accreditation expiry date.
  • Health service organisations must be regularly assessed to the standards at an announced assessment, or short notice assessment.
  • Health service organisations are required to submit an attestation statement annually.
  • Health service organisations will no longer be able to apply for extensions to their accreditation expiry date as of 1 January 2020 (The Commission has made transition arrangements for health services for 2019).

There are eight standards and 148 actions in the NSQHS Standards (second edition), compared with 10 standards and 256 actions in the first edition.The second addition has been revised and simplified to encompass comprehensive care for all patients, health literacy, end of life care, care of Aboriginal and Torres Strait Islander people, and care for people with lived experience of mental illness and cognitive impairment. There are no developmental actions in the second edition of the NSQHS Standards, and all actions will be classified as ‘met’ or ‘not met’. Health service organisations may apply for actions to be classified ‘not applicable‘ if they are not relevant to the service they provide. All core actions must be met to achieve accreditation.

Health service organisations are required to schedule their assessment at least 80 business days before their accreditation expires. This allows a 60 day remediation period and 20 business days (80 days in total) for the accrediting agency to finalise the assessment report. The Commission has allowed a transitional period until 1 January 2020 that permits hospitals to apply for extensions to their accreditation expiry date during 2019. During this transition period, health services are given an 80 day remediation period and an additional 20 days for the accrediting agency to finalise the assessment report. This means health services are allowed a total of 100 days between their accreditation expiry date and assessment date.

While health service organisations may apply for extensions to their accreditation expiry date during the transition period, extensions will no longer be permitted from 1 January 2020.

From 1 January 2019, all health service organisations will move to being assessed against the NSQHS Standards (second edition), with two assessment pathways to accreditation. In the case of announced assessments, the health service is aware of their assessment date well in advance, with no mid-cycle assessments. Alternatively, health services may apply in writing to the Regulator to participate in the short notice pathway, where the health service will receive 48 hours’ notice prior to each assessment over the three year accreditation cycle.

Health service organisations are required to submit an attestation statement to their accrediting agency, signed by a member of the governing body of the health service each year. This will also be monitored by the Regulator.

What is assessed?

The NSQHS standards (second edition) cover all areas that are essential for ensuring the safety of patients and improving the quality of health service provision, namely: 

  1. Clinical Governance
  2. Partnering with consumers
  3. Health associated infection
  4. Medication safety
  5. Comprehensive Care
  6. Communicating for safety
  7. Blood management
  8. Recognising and responding to acute deterioration

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