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 that relate to the safety and quality of a health service before or at the commencement of a health service organisation’s assessment to the National Safety and Quality Health Service (NSQHS) Standards.

Issue

This advisory relates to external and internal reports into safety and quality issues, clinical governance or safety breaches which are described in this advisory as major safety and quality reports. 

In scope are reports on reviews, adverse events, failures in governance, coronial and sentinel event investigations, cluster reviews, Safe Work Reports, or reports from inspections, such as licensing, or Office of Chief Psychiatrist announced or unannounced inspections. Also included may be external reports that apply across multiple organisations where the recommendations apply directly to the health service organisation being assessed.

State or territory regulators may provide information to the relevant approved accrediting agency, or the Commission on external review(s) that have been conducted for consideration prior to assessment that may be in scope. 

Out of scope are routine safety and quality reviews such as internal root cause analysis or incident reports and reports that do not require health service organisations or facilities to undertake any additional reviews. These reports may be viewed as part of the assessment of Actions 1.07 – Risk Management and 1.11- Incident Management.

Requirements

1. Accrediting agencies must formally request information from the health service organisation on major safety and quality reports and licensing reports, which may include reports commissioned by the relevant state or territory health department, completed since the last assessment and/or any other relevant review currently underway. Requests may include: 
   • Terms of reference or scope of the review
   • Commencement and completion date
   • Recommendations from the review
   • Executive summary
   • Actions taken to implement report recommendations.
2. Where health service organisations provide accrediting agencies with information on external reports, accrediting agencies are to forward that information to its assessors and have that information considered at assessment. 
3. Where state or territory regulators provide accrediting agencies with information on external reports, accrediting agencies are to forward that information to its assessors and have that information considered at assessment.
4. Assessors are to seek an update at the commencement of the accreditation assessment of reviews in progress to determine if any safety and quality issues have been identified that warrant close inspection during the accreditation assessment.
5. Major safety and quality reports prepared under qualified privilege may be subject to privacy and confidentiality legislative obligations. 
6. Where reports are lawfully able to be provided, assessors are to examine the information provided during the accreditation assessment (including licensing reports from the State or Territory Regulator). Major safety and quality reports are to be reviewed on site and copies are not to be circulated, distributed, quoted or taken off site.
7. Assessors are not to re-prosecute the review process but must seek evidence that:
   • Recommendations from the report have been considered, and an action plan developed
   • The action plan has been endorsed and monitored by the appropriate level of governance
   • The actions are being progressed as per timeframes in the action plan
   • All safety and quality systems identified as underperforming or needing improvement in the major safety and quality reports are:
     • In place and being used or being developed
     • Monitored by the organisation
     • Regularly evaluated for their effectiveness
     • Reported to the governing body.
8. Assessors are to seek an explanation from the health service organisation where action has not been taken.
9. Assessors are to rate as ‘not met’ relevant actions in the NSQHS Standards where recommendations from major safety and quality reports are not being reasonably progressed, or there is no evidence the health service organisation has given due consideration to their implementation.
10. Upon review of a health service organisation’s final accreditation report, State or Territory Regulators should advise the Commission if they are aware that a major safety and quality review has been completed since the last assessment but was not provided to the accrediting agency or assessors at the time of the assessment.