Day Procedure Services
Accreditation
Workbook
October 2012
ISBN:
Print: 978-1-921983-25-2
Electronic: 978-1-921983-26-9
Suggested citation: Australian Commission on Safety and Quality in Health Care. Day Procedure Services
Accreditation Workbook (October 2012). Sydney. ACSQHC, 2012.
© Commonwealth of Australia 2012
This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the
inclusion of an acknowledgement of the source. Requests and inquiries concerning reproduction and rights
for purposes other than those indicated above requires the written permission of the Australian Commission
on Safety and Quality in Health Care:
Australian Commission on Safety and Quality in Health Care
GPO Box 5480
Sydney NSW 2001
Email:
Acknowledgements
This document was prepared by the Australian Commission on Safety and Quality in Health Care in
collaboration with numerous expert working groups, members of the Commission’s standing committees
and individuals who generously gave of their time and expertise.
The Commission wishes to acknowledge the work of its staff in the development of this document.
Table of Contents: Day Procedure Services Accreditation Workbook
Table of Contents: Day Procedure Services Accreditation Workbook 3
Introduction 5
Accreditation 6
Timeframe 8
Enrolling in an accreditation program 8
Approved accrediting agencies 8
Core and developmental actions 9
Non-applicable criteria or actions 13
Assessment and rating scale 18
Met with merit: 22
Actions which are not met 23
Appeals process 23
Accreditation award 23
Data and reporting 24
How to use this Workbook 25
Examples of evidence 28
Workbook resources 29
Additional resources 51
Terms and definitions 52
Standard 1: Governance for Safety and QualityinHealthService Organisations 60
Governance and quality improvement systems 61
Clinical practice 69
Performance and skills management 72
Incident and complaints management 77
Patient rights and engagement 82
Standard 2: Partnering with Consumers 87
Consumer partnership in service planning 88
Consumer partnership in designing care 92
Consumer partnership in service measurement and evaluation 94
Standard 3: Preventing and Controlling Healthcare Associated Infections 97
Governance and systems for infection prevention, control and surveillance 98
Infection prevention and control strategies 105
Managing patients with infections or colonisations 112
Antimicrobial stewardship 116
Cleaning, disinfection and sterilisation 119
Communicating with patients and carers 122
Standard 4: Medication Safety 124
Governance and systems for medication safety 125
Documentation of patient information 134
Medication management processes 137
Continuity of medication management 143
Communicating with patients and carers 145
Standard 5: Patient Identification andProcedureMatching 148
Identification of individual patients 149
Process to transfer care 152
Processes to match patients and their care 153
Standard 6: Clinical Handover 155
Governance and leadership for effective clinical handover 156
Clinical handover processes 158
Patient and carer involvement in clinical handover 162
Standard 7: Blood and Blood Products 163
Governance and systems for blood and blood product prescribing and clinical use 164
Documenting patient information 169
Managing blood and blood product safety 172
Communicating with patients and carers 174
Standard 8: Preventing and ManagingPressureInjuries 176
Governance and systems for the prevention and management of pressure injuries 177
Preventing pressure injuries 181
Managing pressure injuries 185
Communicating with patients and carers 187
Standard 9: Recognising and Responding to ClinicalDeterioration in Acute Health Care 188
Establishing recognition and response systems 189
Recognising clinical deterioration and escalating care 193
Responding to clinical deterioration 197
Communicating with patients and carers 199
Standard 10: Preventing Falls and Harm from Falls 203
Governance and systems for preventing falls 204
Screening and assessing risks of falls and harm from falling 208
Preventing falls and harm from falling 210
Communicating with patients and carers 212
References 214
Introduction
The Australian Commission on Safety and Quality in Health Care (the Commission) hasdeveloped this Accreditation Workbook to assist day procedure services to determine if they meet the requirements of the National Safety and Quality Health Service (NSQHS) Standards.1
The NSQHS Standards were endorsed by Australian Health Ministers in 2011 andprovide a clear statement about the level of care consumers can expect from health service organisations. They also play an essential part in new accreditation arrangements under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme.
This Workbook focuses on the process of accreditation, and:
· outlines the key steps in an accreditation process
· provides examples of evidence that could be used to demonstrate the NSQHSStandards have been met.
The Workbook has been developed for individuals within health service organisationswho are responsible for coordinating accreditation processes. Thismayinclude practice managers or quality managers who are responsible forsupporting improvementactivities in a day procedure service and collating the outcomesof improvement processes to provide evidence for day procedureserviceaccreditation.
Accreditation
Under the new accreditation model, state and territory health departments have agreed that hospitals, day procedure services and public dental clinics are required to be accredited to the NSQHS Standards. Further, some states and territories have determined that additional health service organisations will be required to be accreditedto the NSQHS Standards. Contact the relevant state or territory healthdepartments for more information.
Accreditation is one tool, in a range of strategies, which can be used to improve safetyand quality in a day procedure service. It is a way of verifying:
· actions are being taken
· system data is being used to inform activity
· improvements are made in safety and quality.
To be eligible for an accreditation award, a health service organisation may undergo:
· periods of self-assessment
· comprehensive assessment against the NSQHS Standards
· interim or mid cycle assessment against some NSQHS Standards.
You can find further details in Figure 1.
Figure 1: The accreditation process
Timeframe
Accreditation to the NSQHS Standards commences on 1 January 2013. This means that after 1 January 2013, the next scheduled recertification audit or organisation-wide accreditation visit will involve assessment against all 10 NSQHS Standards.
For a mid-cycle assessment, periodic review or surveillance audit scheduled any time after 1 January 2013, day procedure services will not need to be assessed against all 10 NSQHS Standards. Any mid-cycle assessment will, at a minimum, involve:
1. Standards 1, 2 and 3
2. the organisational quality improvement plan
3. recommendations from previous accreditation assessments.
Health services or accrediting agencies may agree to additional assessment requirements for the mid-cycle assessment.
Enrolling in an accreditation program
By selecting an approved accrediting agency, a day procedure service will be selecting the style and timing of assessment against the NSQHS Standards. Not all accrediting agencies will take the same approach. The accreditation cycle ranges from 3 to 4 years, and the frequency and style of the mid-cycle assessment, periodic review or surveillance audit may vary between agencies.
Approved accrediting agencies
The Commission approves accrediting agencies to assess health service organisations against the NSQHS Standards. In order to be able to accredit to the NSQHS Standards, the Commission requires accrediting agencies to:
· be accredited by an internationally recognised body
· work with the Commission to ensure the consistent application of the NSQHSStandards
· provide data on accreditation outcomes to state and territory health departmentsand the Commission.
A list of all approved accrediting agencies is available on the Commission’s web site atwww.safetyandquality.gov.au2
Core and developmental actions
The NSQHS Standards apply to a wide variety of health service organisations. Becauseof the variation in size, structure and complexity of health service delivery models a degree of flexibility is required in the application of the NSQHS Standards.
To achieve this flexibility, each action within a Standard is designated as either:
· Core, which are critical for safety and quality. All core actions must be met beforea day procedure service can achieve an accreditation award to the NSQHSStandards; or
· Developmental, which are areas where day procedure services should focus theirfuture efforts and resources to improve patient safety and quality. Activityinthese areas is still required, but the actions do not need to be fully metinordertoachieve accreditation.
Commonwealth, state and territory health departments (referred to as Regulators) require day procedure services to meet all core actions listed in Table 1 in order toachieve accreditation to the NSQHS Standards.Please note that in July 2012, a number of actions were re-classified. For day procedureservices, 48 actions have been classified as developmental and these are listed at Table 1. In addition, Actions 3.12.1 and 3.16.1 in Standard 3 have been re-classified as core. The Commission will carry out the next formal review of all core and developmental items in 2015.
Table 1: Core and developmental actions for day procedure services
/Standard / Core Actions / Developmental Actions /
Standard 1
Governance for Safety and Quality inHealthService Organisations / 1.1.1
1.1.2
1.2.1
1.2.2
1.3.1
1.3.2
1.3.3
1.5.1
1.5.2
1.6.1
1.6.2 / 1.7.1
1.7.2
1.8.1
1.8.2
1.8.3
1.9.1
1.9.2
1.10.1
1.10.2
1.10.3
1.10.4 / 1.10.5
1.11.1
1.11.2
1.12.1
1.13.1
1.13.2
1.14.1
1.14.2
1.14.3
1.14.4
1.14.5 / 1.15.1
1.15.2
1.15.3
1.15.4
1.17.1
1.17.2
1.18.1
1.18.2
1.19.1
1.19.2
1.20.1 / 1.4.1
1.4.2
1.4.3
1.4.4
1.16.1
1.16.2
1.17.3
1.18.3
1.18.4
Subtotal / 44 / 9
Standard 2
Partnering with Consumers / 2.4.1 / 2.4.2 / 2.6.1 / 2.7.1 / 2.1.1
2.1.2
2.2.1 / 2.2.2
2.3.1
2.5.1 / 2.6.2
2.8.1
2.8.2 / 2.9.1
2.9.2
Subtotal / 4 / 11
Standard 3
Preventing and Controlling HealthcareAssociated Infections / 3.1.1
3.1.2
3.1.3
3.2.1
3.2.2
3.3.1
3.3.2
3.4.1
3.4.2
3.5.1 / 3.5.2
3.5.3
3.6.1
3.7.1
3.8.1
3.9.1
3.10.1
3.10.2
3.10.3
3.11.1 / 3.11.2
3.11.3
3.11.4
3.11.5
3.12.1
3.13.1
3.13.2
3.14.1
3.14.2
3.14.3 / 3.14.4
3.15.1
3.15.2
3.15.3
3.16.1
3.17.1
3.18.1
3.19.1 / 3.1.4
3.4.3
3.19.2
Subtotal / 38 / 3
Standard 4
Medication Safety / 4.1.1
4.1.2
4.2.1
4.2.2
4.3.1
4.3.2
4.3.3
4.4.1 / 4.4.2
4.5.1
4.5.2
4.6.1
4.6.2
4.7.1
4.7.2
4.7.3 / 4.9.1
4.9.2
4.9.3
4.10.1
4.10.2
4.10.3
4.10.4
4.10.5 / 4.10.6
4.11.1
4.11.2
4.12.1
4.12.2
4.12.3
4.12.4 / 4.8.1
4.13.1
4.13.2
4.14.1
4.15.1
4.15.2
Subtotal / 31 / 6
Standard 5
Patient Identification and ProcedureMatching / 5.1.1
5.1.2
5.2.1 / 5.2.2
5.3.1 / 5.4.1
5.5.1 / 5.5.2
5.5.3 / Nil
Subtotal / 9 / 0
Standard 6
Clinical Handover / 6.1.1
6.1.2
6.1.3 / 6.2.1
6.3.1 / 6.3.3
6.3.4 / 6.4.1
6.4.2 / 6.3.2
6.5.1
Subtotal / 9 / 2
Standard 7
Blood and Blood Products / 7.1.1
7.1.2
7.1.3
7.2.1
7.2.2 / 7.3.1
7.3.2
7.3.3
7.4.1
7.5.1 / 7.5.2
7.5.3
7.6.1
7.6.2
7.6.3 / 7.7.1
7.7.2
7.8.1
7.8.2
7.9.1 / 7.9.2
7.10.1
7.11.1
Subtotal / 20 / 3
Standard 8
Preventing and Managing
Pressure Injuries / 8.1.1
8.1.2
8.2.1
8.2.2
8.2.3 / 8.2.4
8.3.1
8.4.1
8.5.1
8.5.2 / 8.5.3
8.6.1
8.6.2
8.6.3
8.7.1 / 8.7.2
8.8.1
8.8.2
8.8.3
8.8.4 / 8.7.3
8.7.4
8.9.1
8.10.1
Subtotal / 20 / 4
Standard 9
Recognising and Responding toClinical Deterioration in Acute HealthCare / 9.1.1
9.1.2
9.2.1
9.2.2 / 9.2.3
9.2.4
9.3.2
9.3.3 / 9.4.1
9.4.2
9.4.3
9.5.1 / 9.5.2
9.6.1
9.6.2 / 9.3.1
9.7.1
9.8.1
9.8.2 / 9.9.1
9.9.2
9.9.3
9.9.4
Subtotal / 15 / 8
Standard 10
Preventing Falls
and Harmfrom Falls / 10.1.1
10.1.2
10.2.1
10.2.2
10.2.3 / 10.2.4
10.3.1
10.4.1
10.5.1
10.5.2 / 10.5.3
10.6.1
10.6.2
10.6.3
10.7.1 / 10.7.2
10.7.3
10.8.1 / 10.9.1
10.10.1
Subtotal / 18 / 2
TOTAL / 208 / 48
Non-applicable criteria or actions
In some circumstances a Standard, criterion or action may be considered non-applicable. Non-applicable actions are those which are inappropriate in aspecificservice context or for which assessment would be meaningless.
There are two ways in which a criterion or action can be classified as non-applicable:
1. The Commission has designated non-applicable actions for a health service bycategory. Table 2 summarises non-applicable actions by service type.
2. During the accreditation process, there may be instances where an individual dayprocedure service decides that a criterion or action is non-applicable.
A day procedure service can apply to their accrediting agency to have either coreordevelopmental actions considered non-applicable. The process for applyingfor non-applicable actions is outlined in Table 3.
Table 2: Non-applicable actions for day procedure services
/Type of Health service organisation / Definition / NSQHS Standards /
1 / 2 / 3 /
4
/ 5 / 6 / 7 / 8 / 9 / 10 /Day procedure services or independent stand-alone units funded by a private enterprise
Day surgery hospitals / Health service organisations providing general and specialist surgical procedures performed under general anaesthesia, spinal anaesthesia, or sedation. / All actions applicable / All actions applicable / Action 3.14.3 may not be applicable / All actions applicable / All actions applicable / All actions applicable / May not be applicable if blood not in use / Actions 8.5–8.8 may not be applicable / Actions
9.7–9.9
may not be applicable / Actions
10.5–10.8
may not be
applicable
Gynaecology / Specialist gynaecological health service organisations providing surgical procedures performed under general anaesthesia, spinal anaesthesia, or sedation. / All actions applicable / All actions applicable / Action 3.14.3 may not be applicable / All actions applicable / All actions applicable / All actions applicable / May not be applicable if blood not in use / Actions 8.5–8.5 may not be applicable / Actions
9.7–9.9
may not be
applicable / Actions
10.5–10.8
may not be
applicable
Endoscopy / Specialist health service organisations providing procedures performed primarily under sedation. / All actions applicable / All actions applicable / Action 3.14.3 may not be applicable / All actions applicable / Action 5.3 may not be applicable / All actions applicable / Not
applicable / Actions 8.5– 8.8 may not be applicable / Actions
9.7–9.9
may not be
applicable / Actions
10.5–10.8
may not be
applicable
Haemotology / oncology / Specialist health service organisations providing care and treatment for cancer and blood disorders including: chemotherapy, radiotherapy, pain management, bone marrow biopsies and blood/blood products transfusion. / All actions applicable / All actions applicable / Action 3.14.3 may not be applicable / All actions applicable / Action 5.3 may not be applicable / All actions applicable / All actions applicable / Actions 8.5– 8.8 may not be applicable / Actions