Accreditation Policy for ACT Public Health Care ...



ACT Health Policy Accreditation Policy for ACT Public Health Care Organisations and FacilitiesContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc522699339 \h 1Policy Statement PAGEREF _Toc522699340 \h 2Background PAGEREF _Toc522699341 \h 2The Accreditation framework PAGEREF _Toc522699342 \h 2The Public Health Act 1997 PAGEREF _Toc522699343 \h 2Purpose PAGEREF _Toc522699344 \h 3Scope PAGEREF _Toc522699345 \h 3Roles & Responsibilities PAGEREF _Toc522699346 \h 31.Scheduling accreditation assessments PAGEREF _Toc522699347 \h 42.Monitoring and response (between assessments) PAGEREF _Toc522699348 \h 53.Accreditation assessments PAGEREF _Toc522699349 \h 54.Significant risk identified at assessment PAGEREF _Toc522699350 \h 65.Accreditation outcome – core actions ‘met’ (at initial or final assessment) Accreditation awarded or maintained PAGEREF _Toc522699351 \h 66.Accreditation outcome – Core actions ‘not-met’, remediation required PAGEREF _Toc522699352 \h 77.Accreditation outcome – core actions ‘not-met’ following remediation, accreditation not awarded or withdrawn PAGEREF _Toc522699353 \h 8Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc522699354 \h 10Definition of Terms PAGEREF _Toc522699355 \h 11References PAGEREF _Toc522699356 \h 13Search Terms PAGEREF _Toc522699357 \h 14Attachments PAGEREF _Toc522699358 \h 14Attachment 1: Flow chart of Accreditation Process PAGEREF _Toc522699359 \h 15Policy StatementIn the ACT, the Health Directorate has responsibility for ensuring the accreditation status of public health facilities. The Director-General, ACT Health, or authorised delegate(s) of the Director-General, may direct relevant work units, staff or resources as appropriate to ensure that the Health Directorate achieves full compliance with the National Standards. Accreditation to the National Standards is a key performance indicator of the ACT Health Directorate.When this policy refers to the accreditation monitor, it refers to the Deputy Director-General (DDG), Health Systems, Policy and Research Group who has been delegated by the Director-General ACT Health to perform the functions and duties as outlined in this document. BackgroundThe Accreditation frameworkAccreditation is part of the regulatory framework that informs the government and community that systems are present in the healthcare organisation and facilities to protect the public from harm and improve the quality of health service delivered. The National Standards were developed by the Australian Commission on Safety and Quality in Health Care (the Commission) in consultation with the federal, state and territory health departments, health service organisations, consumers and the private sector. The primary aim of the National Standards is to protect the public from harm and improve the quality of health care. The National Standards provide direction for health service organisations to establish and maintain systems that ensure they can deliver a nationally consistent level of quality and safe health care.The Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme provides national coordination of the accreditation process. Under the AHSSQA scheme the Commission approves accrediting agencies to assess health service organisations against the National Standards. The ACT Health Directorate is the jurisdictional monitor for the ACT and is responsible for monitoring the accreditation of all public healthcare organisations and facilities in the ACT. The Public Health Act 1997The Public Health Act 1997 (the Act) provides that the Minister may, by instrument, determine Codes of Practice setting minimum standards or guidelines for the purpose of the Act. The ACT Health Care Facilities Code of Practice 2001 (the Code) is a Code of Practice for the purpose of the Act, and is enforceable through the Act. The Chief Health Officer (CHO) is nominated as the Minister’s delegate for specific actions under the Act. This includes ensuring the Act and associated Code is complied with.A?facility’s accreditation status may influence their obligations under the Act. All?facilities should be aware of their obligations under the Act and the Code (including any applicable licence conditions) in providing health care services. The Code stipulates specific actions which health facilities and the CHO or their delegate must take when a significant patient risk is identified. PurposeThe purpose of this document is to outline roles, responsibilities and requirements for public health care organisations and facilities in relation to the National Standards and associated accreditation in the ACT.ScopeThis document applies to all ACT public health care organisations and facilities.This document does not cover the accreditation requirements for private health care organisations and facilities. Nor does it extend to other accreditation requirements for specific specialities and units.Roles & ResponsibilitiesIn the ACT public healthcare organisations and facilities are responsible for:Ensuring that they are fully accredited to the National Standards at all timesEnsuring that assessments and reassessments are undertaken in accordance with the AHSSQA Scheme, and with the procedures and requirements outlined in this policyResponding to recommendations from assessments within timeframes specified under the AHSSQA SchemeCommunicating outcomes of accreditation assessments to the public and consumers of the healthcare organisation or facilityRaising safety and quality concerns with the monitor in a timely mannerAdhering to the reporting and notification requirements and time frames outlined in Section 3 of this policy, and as determined under the AHSSQA SchemeComplying with increased performance monitoring and intervention from the monitor in the event of any non-compliance with the National Standards, the AHSSQA Scheme, and-or this policyComplying with the Code, inclusive of specific actions required when a significant patient risk is identified. In the ACT accrediting agencies are responsible for:Assessing healthcare organisations and facilities against the National Standards and conferring accreditation awardsEnsuring the assessments and reassessments are undertaken in accordance with the AHSSQA Scheme and with the procedures and requirements outlined in this policyAdhering to the reporting and notification requirements and time frames outlined in Section 3 of this policy, and as determined under the AHSSQA Scheme.In the ACT the monitor is responsible for:Monitoring the accreditation status of ACT public healthcare organisations and facilities Responding to instances of non-compliance with the National Standards, the AHSSQA Scheme, and/or this policy, with increased performance monitoring and interventionLiaising with the Commission in relation to regulatory functions under the AHSSQA Scheme.In the ACT the CHO or their delegate is responsible for:Ensuring healthcare organisations and facilities comply with the CodeReceiving notification of a significant patient risk from healthcare organisations and facilities Verification of the scope, scale and implications of the risk and taking action (including escalation of the risk) as required Monitoring the status of the action plan and timeframes to address the risk. Section 1 – Accreditation ProcessThis process should be used in conjunction with the Commission’s Information for Health Service Organisations Undergoing Assessment to the NSQHS Standards: Steps for implementing the NSQHS Standards which are available on the Commission’s website at Scheduling accreditation assessmentsHealthcare organisations or facilities are required to:Select an accrediting agency and notify the monitor if they intend to change the accrediting agency with which they are enrolledEnsure the accreditation assessment dates for the next accreditation cycle are booked and confirmed with the accrediting agency at the completion of the previous cycle, or no less than 12 months before the required assessment periodEnsure the periodic mid-cycle assessment is scheduled to occur approximately halfway through the accreditation cycleEnsure the organisation wide assessment is scheduled to occur at least 90 days prior to the organisation or facilities accreditation expiry dateWhere the above in not possible, seek approval from the monitor to extend the organisation or facilities accreditation expiry date as soon as the issue has been identified. The request for extension is to be submitted in writing to the monitor. The organisation or facility may be required to accept a reduced remediation period where an extension is not sought and/or grantedWhen an application to extend accreditation expiry date, notify the accrediting agency of the monitors decision and, if approved, provide copy of the approval.Accrediting agencies are required to:Ensure the organisation wide assessments are scheduled at least 90 days prior to the organisation or facilities accreditation expiry dateOnly extend the date of an organisation or facilities accreditation expiry date upon confirmation from the monitor.The monitor will:Consider all requests for extension of accreditation expiry date and approve at its discretion. Requests for extensions to accreditation expiry dates after a healthcare organisation or facility has entered remediation will not be approved and may result in the organisation being unaccreditedNotify the healthcare organisation or facility requesting extension of the accreditation expiry date of the decision (in writing)Maintain a record of all scheduled assessments and expiry dates. Update the record of scheduled assessments and expiry dates with extension details Notify the Commission of all approved extension to expiry dates.Monitoring and response (between assessments)Healthcare organisations or facilities are required to:Develop, implement, maintain and improve safety and quality systems in line with the National StandardsUndertake self-assessment against the National Standards at regular intervalsRaise any emerging issues or concerns with the monitor as early as possibleThe monitor will:Support healthcare organisations or facilities to address relevant issues or concerns. Accreditation assessmentsPublic healthcare organisations and facilities are required to:Participate in a periodic mid-cycle assessment completed by an accrediting agency approximately halfway through the accreditation cycleParticipate in an organisation wide assessment completed by an accrediting agency at least 90 days prior to the organisation or facilities accreditation expiry date, or as approved by the monitor.Accrediting agencies are required to:Complete a periodic mid-cycle assessment of the healthcare organisation or facility approximately halfway through the accreditation cycleComplete an organisation wide assessment of the healthcare organisation or facility at least 90 days prior to the organisation or facilities accreditation expiry date, or as approved by the monitorThe monitor will:Monitor the occurrence and outcomes of accreditation assessments against the accreditation scheduleRespond to emerging issues.Significant risk identified at assessmentAccrediting agencies are required to:Notify the healthcare organisation or facility and the monitor immediately if a significant risk is identifiedNotify the Commission of the patient safety risk as per Advisory 16/01.Healthcare organisations and facilities are required to:Notify the CHO or their delegate by telephone within one business day of any incident taking place as described by Cl6.1 of the ACT Health Facilities Code of Practice 2001. Any incident notification should be followed up with written notification within three business days of the incident taking place Negotiate with the CHO or their delegate an action plan and timeframe to address the identified riskMeet with the CHO or their delegate within three working days of the risk being identifiedProvide the CHO or their delegate with a copy of the agreed action plan and timeframeImplement the agreed action plan within the agreed timeframe. The CHO or their delegate will: Meet with the healthcare organisation or facility within three working days of the risk being identifiedVerify the scope, scale and implications of the identified risk and take further action as requiredEscalate the identified risk to the Director-General and the Minister for action as required. Accreditation outcome – core actions ‘met’ (at initial or final assessment) Accreditation awarded or maintainedAccrediting agencies are required to:For a mid-cycle assessment, advise the healthcare organisation/facility that accreditation is maintainedFor an organisational assessment, advise the healthcare organisation/facility that accreditation is awardedProvide the healthcare organisation or facility with a final report and advice of accreditation outcome within 20 working days of the assessmentFor organisational assessment issue an accreditation certificate within 20 working daysReport on the outcome in routine monthly reporting to the Commission, as per the AHSSQA Scheme.Healthcare organisations and facilities are required to:Notify the monitor of the outcome of accreditation assessments within two working days of the notification from the accrediting agencyProvide the monitor with a copy of the accreditation report within five working days of receiving the report from the accrediting agencyFor organisational assessment provide the monitor with the organisation or facility’s new accreditation expiry dateNotify the monitor of any developmental actions ‘not-met’Provide the monitor with a copy of the accrediting agency’s reportCommunicating outcomes of accreditation assessments to the public and consumers of the healthcare organisation.Accreditation outcome – Core actions ‘not-met’, remediation requiredAccrediting agencies are required to:Provide the healthcare organisation or facility and the monitor with a report detailing any recommendations and the ‘not-met’ actions within five working days of the assessmentComplete a final assessment of the healthcare organisation or facility to reassess against previously ‘not-met’ actions within 90 days of providing the report to the healthcare organisation or facility.Healthcare organisation or facilities are required to:Notify the monitor immediately upon receipt of a ‘not-met’ ratingDevelop a remediation action plan to address the ‘not-met’ action/sMeet with the monitor and provide the monitor with a remediation action plan within ten working days of receiving the report from the accrediting agencyProvide the remediation action plan to the accreditation agencyImplement remediation action plan and provide the monitor with regular updates on progress Participate in a final assessment against the previously ‘not-met’ actions within 90 days of receiving the report from the accrediting agencyCommunicating outcomes of accreditation assessments to the public and consumers of the healthcare organisation.The monitor will:Verify the number, spread and nature of the ‘not-met’ actionsIdentify the potential safety and quality risks and respond with appropriate monitoring, action and/or escalation:Low risk: monthly progress updates and a progress update meeting half way through the remediation periodMedium risk: fortnightly progress updates (via phone/email) and monthly progress review meetingsHigh risk: Options of peer or external support, weekly progress updates (via phone/email) and monthly progress meetingsMeet with the healthcare organisation or facility and confirm monitor responseIdentify the potential risk of accreditation not being awarded following remediation and notify/escalate to the Minister accordingly.Accreditation outcome – core actions ‘not-met’ following remediation, accreditation not awarded or withdrawnAccrediting agencies are required to: Notify the healthcare organisation or facility and the monitor immediately following the final assessment if there is a potential risk of non-compliance (accreditation not awarded or withdrawn) Provide the healthcare organisation or facility and the monitor with a final report and advice of the accreditation outcome within 20 working days of the final assessmentReport on the outcome in routine monthly reporting to the Commission, as per the AHSSQA Scheme. Healthcare organisation or facilities are required to:Meet with the monitor within three working days of receiving the report from the accrediting agencyReview all safety and quality systems within the scope of the National Standards and identify required improvements within timelines agreed to by the monitor or participate in an external review against the National Standards as directed by the monitorDevelop a remediation action plan to address the ‘not-met’ actions and/or other areas identified for improvementProvide the monitor with the remediation action plan within five working days of receiving the report from the accrediting agency or the report from the external review (if applicable)Implement a remediation action plan within six weeks or other specified time period (no greater than 12 months) as determined by the monitor and in accordance with the ASSQA Scheme.Within twelve months, schedule accreditation assessment and participate in organisational wide assessment against all of the National Standards and actions at the completion of the specified remediation planCommunicating outcomes of accreditation assessments to the public and consumers of the healthcare organisation.The monitor will:Notify the Minister, Director-General and Deputy-Directors General of the potential risk that the healthcare organisation or facility could become unaccredited Meet with the healthcare organisation within three days of notice of non-complianceVerify the number, spread and nature of ‘not-met’ actionsDetermine the required remediation period in accordance to the AHSSQA SchemeUndertake a risk assessment to determine the required performance monitoring and interventionSupport the healthcare organisation or facility to implement the remediation plan and prepare for organisation wide assessment against the National Standards within the agreed timeframe.At the Minister’s discretion, the Minister may:Appoint an independent consultant to lead the remediation action plan Direct resources as appropriate to ensure the healthcare facility is fully compliant with the National Standards, Public Health Act 1997 and any licence conditions.Take other action under the Public Health Act 1997 such as suspend the at risk services.Section 2 – Accreditation Time Frames and ContactsNotificationWhen and howContactResponsibleSignificant patient riskNotify immediately upon identification of riskMonitor Notify the Chief Health Officer if required (see?1.4.2) Accrediting agencyNotify the proposed course of action within 24 hours of risk being identifiedSubmit action plan within three working days of risk being identifiedHealthcare organisation or facilityAssessment outcome – Core actions ‘met’Notify within two working days of receiving advice from accrediting agencyProvide accreditation report within five working days of receipt from the accrediting agencyMonitorHealthcare organisation or facilityAssessment outcome – core actions ‘not-met’Notify immediately upon receiving advice from the accrediting agencySubmit remediation action plan within ten working days of receiving the report from the accrediting agencyMonitorHealthcare organisation or facilityAssessment outcome (final assessment) – core actions ‘not-met’ – accreditation not awarded or withdrawnNotify immediately following the final assessment if there is a potential risk of non-complianceProvide formal advice and submit accreditation report within 20 working days of final assessmentMonitorAccrediting agencySubmit remediation action plan within five working days of receiving the report from the accrediting agency or the report of an external review (if applicable)Healthcare organisation or facilityRelated Policies, Procedures, Guidelines and LegislationPoliciesMedication Handling PolicyPatient Identification and Procedure Matching PolicyClinical Audit PolicyConsumer Handouts PolicyConsumer and Carer Participation PolicyConsumer Feedback Management in ACT Health PolicyProceduresNational Standard for User applied Labelling of Injectable Medicines, Fluids and LinesFalls Prevention and Management Procedure Nursing and Midwifery Continuing Competence ProcedureHealthcare Associated Infections ProcedurePatient Identification and Procedure Matching ProcedureClinical Audit ProcedureClinical Handover ProcedureClinical Handover – Mental Health, Justice Health and Alcohol and Drug Services(MHJHADS) ProcedureFresh Blood Product Administration ProcedurePressure Injury Prevention and Management ProcedureVital Signs and Early Warning Scores ProcedureConsumer Feedback Management in ACT Health ProcedureGuidelines ACT Health Quality Strategy 2018-2028Clinical Supervision for Allied Health Clinicians Credentialing and Defining Scope of Clinical Practice for Allied Health ProfessionalsCredentialing and Defining Scope of Clinical Practice for Senior Medical and Dental PractitionersLegislationPublic Health Act 1997ACT Health Care Facilities Code of Practice 2001Health Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Definition of Terms Accreditation Cycle – The time period that an accreditation award is valid and the sequence of assessments that take place during that time period. The cycle is three years and will generally involve a periodic mid-cycle assessment approximately half way through the accreditation cycle and an organisation wide assessment toward the end of the cycle.Accreditation outcome – The result of an accreditation assessment. There are three possible accreditation outcomes:Core actions ‘met’ – accreditation awarded or maintainedCore actions ‘not-met’ – remediation requiredCore actions ‘not-met’ – accreditation not awarded or withdrawn.Accreditation agency – An agency that has been approved under the AHSSQA Scheme to assess healthcare organisations and facilities against the National Standards.Assessment – An assessment of a healthcare organisation and/or facility against the National Standards by an assessor from an accrediting agency. Assessor – A person employed or contracted by an accreditation agency to assess a healthcare organisation or facility against the National Standards.Chief Health Officer – The Chief Health Officer appointed under the Public Health Act 1997.Code of Practice – the ACT Health Care Facilities Code of Practice 2001, enforceable under the Public Health Act 1997. Core actions – Actions under the National Standards that are mandatory. Healthcare organisations and facilities must meet all core actions to be awarded accreditation.Core actions ‘met’ – accreditation awarded or maintained – A healthcare organisation or facility has ‘met’ all core actions, accreditation is awarded (organisation-wide assessment) or maintained (mid-cycle assessment).Core actions ‘not-met’ – accreditation not awarded or withdrawn – If following a final assessment the healthcare organisation or facility continues to have a core action ‘not-met’ the accreditation is not awarded (organisation wide assessment) or withdrawn (mid cycle assessment).Core actions ‘not-met’ – remediation commenced – When a healthcare organisation or facility has core actions that are ‘not-met’ at the initial assessment the organisation or facility enters a remediation period of up to 90 days in which to address the ‘not-met’ core actions. A final assessment is completed at the end of the remediation period. If the core actions previously ‘not-met’ are ‘met’ accreditation is awarded. Developmental actions – Actions under the National Standards that are not mandatory. Healthcare organisations and facilities that do not meet all developmental actions may still be granted accreditation if all core actions are met. Under the second edition of the National Standards there are no developmental actions.Final assessment – The assessment to be undertaken following a remediation period.Healthcare organisation or facility – All organisations or facilities providing public healthcare in the ACT.Initial assessment – The first assessment to be undertaken in an assessment period (mid cycle or organisational wide) and is followed by a final assessment if remediation is required.Met – The result recorded against an action under the National Standards when a Healthcare organisation or facility is assessed as being fully compliant with that action.Monitor – The ACT Health appointed officer responsible for fulfilling the monitor roles and responsibilities outlined in this policy. The monitor collaborates with the Commission regarding regulatory functions under the AHSSQA scheme. This role has been delegated by the Director-General, ACT Health to the Deputy Director-General (DDG), Health Systems, Policy and Research Group.National Standards – The National Safety and Quality Health Service Standards. In the first edition there are ten standards that healthcare organisations or facilities are assessed against. Assessment against the second edition of the National Standards will commence 1 January 2019. The second edition will assess healthcare organisations or facilities against eight standards.Not-met – The result recorded against an action under the National Standards when a healthcare organisation or facility is assessed as not being fully compliant with that anisation wide assessment – An assessment that occurs toward the end of the accreditation cycle at which the healthcare organisation or facility is assessed against all actions and standards in the National Standards.Periodic mid-cycle assessment – An assessment that takes place half-way through the accreditation cycle at which the healthcare organisation or facility is assessed against Standards 1, 2 and 3 of the National Standards, as well as any recommendations from previous assessments. Private health care organisation and facilities – Health care organisations and facilities operating in the ACT operated and funded by private organisations.Public health care organisations and facilities – Health care organisations and facilities operating in the ACT to provide public health care. Public healthcare is operated and funded by the federal and state governments supported by the Medicare system. Recommendation/s – Recommendations provided by an accrediting agency in response to safety and quality concerns. Recommendations may relate to ‘not-met’ core actions or developmental actions under the National Standards, or other areas of concern as identified by the assessor.Remediation – A period of 90 days in which healthcare organisations and facilities respond to recommendations from the accrediting agency and address ‘not-met’ actions prior to the final assessment and the accreditation outcome being determined. Significant Patient Risk – where there is a high probability of a substantial and demonstrable adverse impact for patients. A significant risk is sufficiently serious to warrant an immediate response to reduce the risks to patients. Further information can be found at Advisory-A13_01-Notification-of-significant-risk. ReferencesAustralian Commission on Safety and Quality in Health Care, (2017) Assessment to the NSQHS Standards. Available at: accessed on 03 May 2018.Australian Commission on Safety and Quality in Health Care, (2017) Advisory no: A13/01 Notification of significant risk. Available at: accessed on 01 June 2018.Public Health Act 1997, ACT Government. Available at: ACT Health Care Facilities Code of Practice 2001, ACT Government. Available at: Public Health Act 1997, ACT Government, Explanatory Memorandum for the ACT Health Care Facilities Code of Practice 2001 declared under the Public Health Act 1997. Available at: State of Victoria, Department of Health and Human Services (2018) Accreditation policy for Victorian public health service organisations. Available at: Search TermsAccreditation, met, not met, remediation, assessment, national assessment, national standards, the commissionAttachmentsAttachment 1: Flow chart of Accreditation ProcessDisclaimer: This document has been developed by ACT Health specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval This document supersedes the following: Document NumberDocument NameAttachment 1: Flow chart of Accreditation Process ................
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