Advisory AS18/13: Sampling for accreditation assessment

Advisory details

Purpose

To describe the sampling methodology to be used by accrediting agencies when sampling health service organisations at accreditation assessment.

Issue

The Australian Health Service Safety and Quality Accreditation Scheme requires all hospitals and day procedure services to be assessed by onsite assessment. Sampling is only permitted in those health service organisations where multiple non-hospital and non-day procedure services operate under a single governance structure, such as community based, public dental, prisons and transport services. 

To ensure consistency, the Australian Commission on Safety and Quality in Health Care has developed a sampling methodology, to be applied by all accrediting agencies, to eligible health service organisations.

Requirements

For a health service organisation with up to 20 separate health services that are to be assessed and where sampling is approved, the following calculation will be used: 

1. 5 sites plus one third of all remaining health services are to be assessed, (rounded up to the nearest whole number).

For health services with more than 20 health services that are to be assessed and where sampling is approved, the following calculation will be used: 

2. 10 sites plus one quarter of all remaining health services are to be assessed, (rounded up to the nearest whole number).

An example of this calculation is at Attachment 1. 

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 health service 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, the last time the site was assessed, information provided in a gap analysis such as incidents and complaints, information in external reports, information gained in discussions with the health service organisation. 
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 health service organisation 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 health service organisation
6. Exceptions to point 4 and 5 of these rules can be made for health service organisations 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. 

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 regulators make a determination on these applications. 

Where approval is granted, the approved accrediting agency can work in collaboration with the health service organisation implementing rules 1-3 to maximise the number of staff and patients that can be interviewed and operational sites and visited during an assessment.

Attachment 1 - Example of sampling methodology calculation