Advisory D23/01: Sampling for Digital Mental Health Standards accreditation assessment

Advisory details

Item	Details
Advisory number	D23/01
Version number	1.0
Trim number	D23-15096 [v1]
Publication date	30 June 2023
Replaces	N/A
Compliance with this advisory	It is mandatory for accrediting agencies to comply with this advisory.
Information in this advisory applies to	Approved accrediting agencies Digital mental health service providers
Key relationship	Policy - Approval under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme to conduct assessments 2024 Publication, report or update
Attachment	N/A
Notes	N/A
Responsible officer	Margaret Banks Director, National Standards Phone: 1800 304 056 Email: AdviceCentre@safetyandquality.gov.au
To be reviewed	June 2025

Purpose

To describe the sampling methodology to be used by accrediting agencies when sampling multi-site digital mental health service providers at accreditation assessment.

Issue

The Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme requires digital mental health service providers to be assessed either onsite, virtually or using a hybrid method (e.g. a combination of both onsite and virtual assessment). Sampling is only permitted for providers where multiple digital mental health services operate under a single governance structure.

To ensure consistency, the Australian Commission on Safety and Quality in Health Care (the Commission) has developed a sampling methodology, to be applied by all accrediting agencies, to eligible digital mental health service providers seeking accreditation.

Multi-site service providers

For the purposes of this advisory, the definition of a multi-site service provider is an organisation with multiple services operating under the same governance, policy, and process arrangements. Multi-site service providers will have sites in separate geographical locations which provide the same type of services being assessed to the National Safety and Quality Digital Mental Health Standards.

Multi-site service providers are to be assessed at the level of the site, regardless of whether they provide a number of different service streams (e.g., telephone, SMS-based or online chat services).

Requirements

For digital mental health services providers with up to 30 separate services that are to be assessed and where sampling is approved, the following calculation will be used:

• Five (5) sites, plus one third of all remaining services are to be assessed, (rounded up to the nearest whole number).

For digital mental health services with more than 30 separate services that are to be assessed and where sampling is approved, the following calculation will be used:

• Ten (10) sites plus one quarter of all remaining health services are to be assessed, (rounded up to the nearest whole number).

View an example of sampling methodology calculation

Health service organisations with greater than 100 sites can apply to the Commission to have the number of sites that undergo onsite assessment capped at an upper limit.

The following rules will apply when selecting the assessment sites:

1. The corporate or main entity is always to be assessed.
2. 75 percent of sites assessed are to be selected based on a risk assessment by the accrediting agency. This assessment will take into consideration factors such as (but not limited to) previous assessment results and the last time the site was assessed (where relevant), information provided in a gap analysis such as incidents and complaints, information from external reports, and information gained in discussions with the service provider.
3. 25 percent of sites assessed are to be selected at random, ensuring a representative sample of the service is assessed.
4. Accrediting agencies are to notify the service provider of sample sites just prior to or at the commencement of the assessment, and for rural or regional sites no more than six weeks in advance.
5. Sample sites are to be selected by the accrediting agency, without taking into consideration the views of the service provider.
6. Exceptions to point 4 and 5 of these rules can be made for services where the availability of staff and patients is unpredictable and therefore requires some advance planning, or advanced notice is a requirement of entry to the service.
   
   
   Applications for exemption to point 4 and 5 will be considered on a case-by-case basis by the Commission. Where approval is granted, the approved accrediting agency can work in collaboration with the service provider implementing rules 1-3 to maximise the number of staff, service users (where relevant) and sites that can be interviewed and visited during an assessment.
7. Organisations seeking exemption from this sampling methodology are to make a submission in writing (which can be in the form of an email), to the Commission via their approved accrediting agency. The Commission will, in collaboration with accrediting agencies make a determination on these applications.

Example of sampling methodology calculation