Advisory AS18/06: Accreditation assessment requirements of health service organisations post significant clinical or governance review

Advisory details

Purpose

To describe the requirement for accrediting agencies to examine external and non-routine internal reports of reviews and investigations into significant safety and quality issues, clinical governance or safety breaches as part of a health service organisation’s accreditation assessment. 

Issue

The purpose of the Clinical Governance Framework is to ensure that patients and consumers receive safe and high-quality health care by describing the elements that are essential for acute health service organisations to achieve integrated corporate and clinical governance systems. Through these systems, organisations and individuals are accountable to patients and the community for continuously improving the safety and quality of their services. 

The Clinical Governance Framework:

• Defines clinical governance 
• Provides the context for clinical governance being an integrated component of corporate governance 
• Describes the key components of a clinical governance framework, based on the NSQHS Standards 
• Discusses the role of culture in supporting good clinical governance 
• Outlines the roles and responsibilities of, and essential partnership between, patients and consumers, clinicians, managers, and governing bodies (such as boards) in implementing effective clinical governance systems in health service organisations. 

Health service organisations are reviewed from time to time to meet regulatory, health department, audit or governanments. Reviews may also be undertaken by the health service organisation that are not scheduled or routinely conducted, into significant clinical governance or safety breaches. 

This advisory relates only to these external reports or reports from non-routine internal reviews into significant safety and quality issues, clinical governance or safety breaches. These are described as major safety and quality reports in this advisory. 

The major safety and quality reports, whether generated internally or externally, may lead to recommendations for improvement in safety and quality. The implementation of any recommendations from these processes is the responsibility of the health service organisation. 

This advisory does not require health service organisations or facilities to undertake any additional reviews, instead it is seeking to ensure when a review occurs, the safety and quality issues raised are considered at the next accreditation assessment and recommendations are thoroughly examined. 

External reports that apply across multiple organisations are to be considered where the recommendations apply directly to the health service organisation being assessed.

Requirements

Accrediting agencies are to: 

1. Formally request the health service organisation submit the following information on major safety and quality reports prior to assessment: terms of reference, scope of the review, completion date, recommendations from the review and/or executive summary 
2. Examine the full report during the accreditation assessment. It is not intended that major safety and quality reports be taken off site, or assess the safety and quality issues identified in the major safety and quality report(s) during the accreditation assessment, but not for the purpose of reprosecuting the review process. 
3. Formally request the terms of reference, scope of the review and expected completion date on any external reviews or non-routine internal reviews into significant safety and quality issues, clinical governance or safety breaches that are currently underway 
4. Seek an update at the commencement of the accreditation assessment on any review(s) in progress to determine if any safety and quality issues have been identified that warrant close inspection during the accreditation assessment 
5. Formally request the following information on major safety and quality report(s) that are prepared under qualified privilege and not available to accrediting agencies for review: the existence of any such report(s), the executive summary and/or recommendations, actions taken to implement the report recommendations
6. Assure themselves all safety and quality systems identified as underperforming or needing improvement in the major safety and quality reports are 
   • in place 
   • being used 
   • monitored by the organisation 
   • regularly evaluated for their effectiveness and 
   • reported on to the governing body 
7. Direct assessors to examine evidence that demonstrates action has been taken that will directly address recommendations in the safety and quality report and improve the safety and quality systems under review 
8. Seek an explanation from the health service organisation where action has not been taken 
9. Where action is planned, but not yet commenced, assessors should review the timetable and seek evidence that adequate resourcing has been allocated to implement the plan
10. Where action is planned, but not yet commenced, assessors should review all action plans to ensure the timetable for implementation does not place consumers at unnecessary or unreasonable additional risk 
11. Require the health service organisation to provide follow up reports on the improvement action taken as part of the normal cycle of reporting 
12. Ensure the data, or other forms of evidence provided, are contemporary and relevant to the performance of the safety and quality systems 
13. Reflect the evidence of performance of the safety and quality systems in the assessment ratings awarded to the health service organisation against the relevant actions in the NSQHS Standards 
14. Notify as soon as practical, the responsible jurisdiction and the Australian Commission on Safety and Quality in Health Care (the Commission) where the evidence provided is not of sufficient strength to indicate risk of harm to consumers has been reduced or effectively managed including where sufficient time has passed to ensure the corrective action is embedded 
15. Notify the responsible jurisdiction and the Commission if at subsequent assessments, or on review of follow up reports, improvement has not been implemented or there have been unexplained or unreasonable delays