Assessment to the NSQDMH Standards

Assessment methodologies used by accrediting agencies assessing the NSQDMH Standards are approved by the Commission including for desktop assessments.

The Commission may also issue guidance for conducting desktop assessments from time to time.

On-site and virtual assessments

PICMoRS is a mnemonic that was designed to help assessors to undertake assessment for accreditation under the AHSSQA Scheme. Originally developed for assessment to the National Safety and Quality Health Service Standards, the same process can be applied to the NSQDMH Standards. PICMoRS stands for:

• Process;
• Improvement;
• Consumer participation;
• Monitoring;
• Reporting and
• Systems.

When undertaking or participating in virtual assessments, accrediting agencies and digital mental health service providers must follow the guidance issued by the Commission relating to virtual assessments.

For further information on the application of PICMoRS, please see the fact sheet below.

NSQDMH Standards - Using PICMoRS for quality improvement and assessment preparation - Fact sheet

2022

Fact sheet or brochure

Assessors will assess evidence of compliance to relevant actions in the NSQDMH Standards and assign a rating for each action. Ratings that may be attributed to individual actions include:

Digital mental health service providers implementing the NSQDMH Standards should consider their individual circumstances in determining whether specific actions are not applicable. It is not intended that actions be implemented where they are beyond the scope of the clinical and technical practice of the service provider.

Where a service provider considers an action is not applicable, it must provide its accrediting agency with evidence demonstrating the action does not relate to the service being provided.

Applications should be submitted to the approved accrediting agency well in advance of the assessment. The accrediting agency will provide an initial determination of the service provider’s submission before undertaking the scheduled assessment, this assessment is based on guidance provided by the Commission. At assessment, the assessors must verify that the decision to award these actions not applicable status is justified.

Where an application for not applicable status is not consistent with the Commission’s advice, an application can be made by either the accrediting agency or service provider to the Commission for its review.

For further information please see the fact sheet below.

'Not applicable' actions in the NSQDMH Standards

2023

Fact sheet or brochure

During the course of conducting an accreditation assessment, assessors may identify a significant risk. A significant risk is one where there is a high probability of a substantial and demonstrable adverse impact for service users if it is not mitigated and is sufficiently serious to warrant an immediate response in order to reduce risks to service users. While the focus of reporting by assessors will be on significant risks of service user harm, it will not necessarily exclude other significant risks.

If one or more significant risks are identified during an accreditation assessment, assessors and/or approved accrediting agencies are to:

• immediately notify the service provider of the risk(s) identified
• discuss immediate action(s) to be taken by the service provider
• develop a plan of action to resolve or mitigate the risk
• notify the Commission within 48 hours of identifying the risk.

Mediation is the process of an intervention to resolve conflict. Accrediting agencies or service providers may request the Commission mediate where there is a difference of opinion regarding applications for not applicable actions, evidence required to assess an action and as a result assessment outcomes. Mediation can only occur during an assessment.

An Advisory is a formal communication issued by the Commission to accrediting agencies and service providers. Advisories provide guidance and direction on the interpretation and/or assessment of the NSQDMH Standards under the AHSSQA Scheme. Advisories will usually be issued when the Commission identifies that additional support is required to assist with the consistent implementation or assessment of a specific action or topic. An advisory may also be issued where the implementation of an action requires a stepwise process with long implementation timeframes.

Examples of topics where an advisory may be issued include:

• managing conflicts of interest
• informed financial consent
• viewing and providing clinical information to My Health Record.

The list of Advisories related to the NSQDMH is available on the NSQDMH Resources webpage. 

A service provider is accredited if all applicable actions in the NSQDMH Standards are rated as "Met" or "Met with recommendations".

Based on initial assessment, service providers will be issued with an exceptions report and receive one of two outcomes.

A final assessment may be conducted after the remediation period depending on the ratings of applicable actions.

If any of the actions are rated as “Not met” the service provider must address material concerns raised during the initial assessment and is required to have a final assessment by the end of the remediation period of 60 business days.

Within the remediation period the service provider has the opportunity to convert actions rated “Not met” or “Met with recommendations” to “Met” by addressing recommendations from the initial assessment.

Accrediting agencies are required to provide formal documentation to service providers as part of the accreditation assessment process. These include:

• an exceptions report, outlining the outcome of the initial assessment including actions that are rated "Met with recommendations" or "Not met"
• a final accreditation report.

For service providers that achieve the accreditation outcomes of Accredited or Working Towards Accreditation, accrediting agencies are required to provide additional formal documentation. These include:

• an accreditation certificate
• a testimonial, which includes the information from the accreditation certificate and further detail of the assessment process and outcome.

The accrediting agency must include the following information in a testimonial that is to accompany the certificate of accreditation:

• service provider name
• list of each digital mental health service provided by the service provider covered by the award
• the relevant standards to which the accreditation relates, and any parts of the relevant standards excluded from the assessment as not applicable or not assessed
• the category of accreditation awarded
• date accreditation is awarded and expiration of the relevant accreditation cycle.

The Commission will be responsible for issuing the digital accreditation badge to the service provider.

Exemplar practices are real-world examples of digital mental health service providers that demonstrate best practice in the implementation of the NSQDMH Standards. These service providers have safety and quality systems that are substantially higher than the general rating of ‘met’ for relevant standards or actions being assessed.

Approved accrediting agencies will be able to nominate service providers that have been awarded accreditation with all relevant actions rated as ‘met’ and are implementing an initiative that meets specified criteria. Initiatives considered as exemplars are:

• designed to address a significant safety and quality issue
• evidence-based or use best practice
• user-centred
• clearly communicated to all relevant parties
• embedded into day-to-day practice
• regularly measured
• sustainable
• being appropriately evaluated
• improving user outcomes in the safety and quality of care delivered.

Submissions will be reviewed by the industry-based accreditation coordinating committee against specified criteria. Service providers that are formally recognised as exemplars will be issued with a certificate and have their case study published on the Commission’s website. This is intended to facilitate the identification and sharing of information on safe and good quality practice.

If a service provider does not agree with their assessment outcome, an appeal may be submitted to their accrediting agency or directly to the Commission. It is strongly recommended that service providers exhaust all avenues of review or appeal with their accrediting agency before submitting an appeal to the Commission.

The Commission will only consider appeals where there is evidence that the relevant accrediting agency did not comply with Commission-specified policies, processes and/or directions relating to the assessment conducted.

An appeal, whether made to the accrediting agency or directly to the Commission, must be submitted within 20 business days of the service provider receiving its final assessment report from its accrediting agency. Where an appeal is made to the Commission following an appeal to its accrediting agency, it must be made within 20 business days of the accrediting agency ruling on its appeal.

All appeals are to be in writing and submitted to the Safety and Quality Advice Centre via AdviceCentre@safetyandquality.gov.au.

Supporting evidence and documentation should accompany the appeal.

Submissions should include:

• name, title and contact details of the person (with delegated authority) submitting the appeal
• service provider name and address
• name of accrediting agency
• accreditation expiry date, if relevant
• assessment date(s) relevant to the appeal
• reason for submitting an appeal
• evidence supporting the appeal.

On receipt of an appeal, the Commission will seek information from the relevant accrediting agency, and review the evidence provided by the appellant, accrediting agency and regulator (if relevant). The Commission will then establish a panel to review the appeal and make recommendations to the Commission’s Chief Operating Officer.

The outcome of an appeal may involve one or more of the following:

• find any or all matters reviewed not substantiated
• find any or all matters reviewed substantiated and make recommendations to the agency for corrective action
• find any or all matters reviewed substantiated and take further action
• find any or all matters reviewed substantiated but determine further action is not warranted under the specified circumstances.

The Commission will:

• notify the relevant service provider and accrediting agency in writing of the outcome of the appeal, within five business days of the panel being convened
• notify in writing the relevant service provider and accrediting agency of any action to be taken, together with the date of effect of that action.

Once the Commission has issued a determination, there is no further avenue of appeal within the Commission.

A service provider may wish to change the accrediting agency they have engaged to conduct accreditation assessments. Service providers should not be prevented from transferring between accreditation agencies.

In the instance of a service provider changing accrediting agency:

• the initial accrediting agency is the accrediting agency that currently provides accreditation services, and;
• the receiving accrediting agency is the accrediting agency that the service provider wishes to engage as their future accreditation service provider.

Service providers wishing to change their accrediting agency during their current accreditation cycle are able to do so, provided that they:

• have signed a contract with the receiving accrediting agency prior to or immediately following cancellation of their client agreement with the initial accrediting agency
• maintain the existing accreditation cycle and schedule of assessment
• have no outstanding obligations to the initial accrediting agency.

Any current accreditation certificates awarded by the initial accrediting agency will continue to be recognised by the Commission until the expiry date of the current accreditation award.

The receiving accrediting agency must not issue replacement accreditation certificates for the current accreditation award.

Accrediting agencies are required to advise the Commission of service providers that change accrediting agencies during an assessment or before an accreditation award is determined.

Appendix 3 in the AHSSQA Scheme sets out the responsibilities of accrediting agencies in relation to implementation of the NSQDMH Standards.

Policy - Approval under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme to conduct assessments

2024

Publication, report or update