Accreditation Workbook
for Mental Health Services
March 2014
Accreditation Workbook for Mental Health Services, 2014
ISBN Print: 978-1-921983-66-5
ISBN Online: 978-1-921983-60-3
© Commonwealth of Australia 2014
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 Commissionon Safety and Quality in Health Care:
Australian Commission on Safety and Quality in Health Care
GPO Box 5480
Sydney NSW 2001
Email:
Suggested citation
Australian Commission on Safety and Quality in Health Care (2014) Accreditation Workbook for Mental Health Services, Sydney, ACSQHC.
Acknowledgements
This workbook was prepared by the Australian Commission on Safety and Quality in Health Care, in collaboration with the Department of Health and the Safety and Quality Partnership Standing Committee ofthe Mental Health and Drug and Alcohol Principal Committee of the Australian Health Ministers’ Advisory Council. The Commission wishes to acknowledge thework of its staff in the development of this document.
This document can be downloaded from the ACSQHC website: www.safetyandquality.gov.au
Foreword
The Australian Commission on Safety and Quality in Health Care (the Commission) ispleased to provide health services with the Accreditation Workbook for Mental HealthServices.
This workbook has been developed through collaborative work between the Commission, the Department of Health, and the Safety and Quality Partnership Standing Committee. This workbook contributes to the ongoing processes of collaboration which aim to ensure the provision of safe, high quality health care topeople with mental health conditions.
In 2010, Health Ministers endorsed the National Standards for Mental Health Services (NSMHS). The NSMHS present safety standards and best practice guidelines forservice delivery to be applied across the broad range of mental health services.
In September 2011, Health Ministers took a significant step towards improving Australia’s health system by mandating the National Safety and Quality Health Service (NSQHS) Standards and the national accreditation scheme. The new system will, for the first time, create a nationally coordinated safety and quality accreditation schemeforhealth service organisations.
Accreditation to the NSQHS Standards commenced on 1 January 2013. This workbook is intended as a tool for health services implementing and being accredited to both the NSQHS Standards and the NSMHS.
The workbook maps both sets of standards. The mapping work has shown that there is a significant overlap on the safety aspects of the two standards. It has also provided valuable lessons that have highlighted a number of important aspects of safety in mental health, including advocacy, consent, collaborative care planning to reduce self-harm, and the use of restraint and seclusion. There is a need to continue to work toward embedding these safety and quality aspects into the future revisions of the NSQHS Standards.
Professor Debora Picone AM
Chief Executive Officer
Australian Commission on Safety and Quality in Health Care
Table of Contents: Accreditation Workbook for Mental Health Services
Foreword 3
Introduction 7
Mapping the two sets of standards 7
Purpose of this Workbook 7
Accreditation to the National Safety and QualityHealthService Standards 9
Figure 1: The NSQHS Standards accreditation process 10
Enrolling in an accreditation program 11
Approved accrediting agencies 11
Timeframe 11
Core and developmental actions forNSQHSStandards 11
Non-applicable criteria or actions 12
Assessment and rating scale 17
Actions that are not met 21
Appeals process 21
Accreditation award 21
Data and reporting 21
Accreditation to the National Standards forMentalHealthServices 23
Timeframe 23
Enrolling in an accreditation program/Approvedaccreditation agencies 23
Core and developmental actions for NSMHS 23
NSMHS Non-applicable criteria or actions 24
Assessment and rating scale 28
Actions that are not met 28
Appeals process 28
Accreditation award 28
How to use this Workbook 29
National Safety and Quality Health ServiceStandards 29
National Standards for Mental Health Services 30
Figure 2: How the NSQHS Standards with matched NSMHS are presented in this Workbook 31
Figure 2: How the NSQHS Standards with matched NSMHS are presented in this Workbook (continued) 32
Examples of evidence 33
Workbook resources 33
Additional resources 35
Table 5: Map of NSQHS Standards with matching NSMHS 36
Table 6: Map of NSMHS with matching NSQHS Standards 37
Terms and definitions 38
Table of Contents: Accreditation Workbook for Mental Health Services
Section A: National Safety and Quality Health Service Standards with matchingNational Standards for Mental Health ServicesStandard 1: Governance for Safety and Quality in Health Service Organisations
Standard 2: Partnering with Consumers
Standard 3: Preventing and Controlling Healthcare AssociatedInfections
Standard 4: Medication Safety
Standard 5: Patient Identification and Procedure Matching
Standard 6: Clinical Handover
Standard 7: Blood and Blood Products
Standard 8: Preventing and Managing Pressure Injuries
Standard 9: Recognising and Responding to Clinical DeteriorationinAcute Health Care
Standard 10: Preventing Falls and Harm from Falls / Section B: National Standards for Mental Health Services for which there is no match with the National Safety and Quality Health Service Standards
Standard 1: Rights and Responsibilities
Standard 2: Safety
Standard 3: Consumer and Carer
Standard 4: Diversity Responsiveness
Standard 5: Promotion and Prevention
Standard 6: Consumers
Standard 7: Carers
Standard 8: Governance, Leadership and Management
Standard 9: Integration
Standard 10: Delivery of Care
References
Introduction
The Australian Commission on Safety and Quality in Health Care (the Commission) has developed this Accreditation Workbook to assist mental health services to understand and determine if they meet the requirements of the National Safety and Quality Health Service (NSQHS) Standards1 and the National Standards for Mental Health Services (NSMHS)2. This work was done in collaboration with the Department of Health and the Safety and Quality Partnership Standing Committee (SQPSC) of the Mental Health, Drug and Alcohol Principal Committee of the Australian Health Ministers’ AdvisoryCouncil.
The NSQHS Standards were mandated by Australian Health Ministers in 2011 and provide a clear statement about the level of care consumers can expect from health service organisations. The primary aims of the NSQHS Standards are to protect the public from harm and to improve the quality of health service provision. They provide a quality assurance mechanism that tests whether relevant systems are in place to ensure minimum standards of safety and quality are met, and a quality improvement mechanism that allows health services to realise aspirational or developmentalgoals. All Australian public and private hospitals are required to be accredited to the NSQHSStandards commencing 2013.
The National Standards for Mental Health Services (NSMHS) were endorsed by Australian Health Ministers in 2010. They have been developed to be applied across the broad range of mental health services. They are designed to represent one component of the environment of different quality, safety and performance frameworks that influence service delivery2.
This Workbook focuses on the process of accreditation, and:
· outlines the key steps in an accreditation process for the NSQHS Standards
· provides information about the areas of match and no match between the NSQHSStandards and the NSMHS
· provides examples of evidence that could be used to demonstrate that the NSQHSStandards and the NSMHS have been met.
Mapping the two sets of standards
The Commission worked with the Department of Health and the Safety and Quality Partnership Standing Committee to map the NSQHS Standards and the NSMHS. Theaim was to identify areas where a substantial match, in terms of scope and intent, exists between the two sets of standards. The exercise also highlighted differences between the two standards and areas where separate evidence is needed to meet both sets ofstandards.
Purpose of this Workbook
This Workbook is designed to guide services through the accreditation process for the NSQHS Standards, and highlight areas where mental health services will also have substantively achieved relevant NSMHS criteria. Our intention is to assist mental health services to ensure efforts to establish evidence to meet either set of standards are notduplicated.
In addition to using criteria to guide accreditation requirements, the NSQHS Standards specify actions that should be taken to ensure that criteria are met.
Tables are provided to demonstrate where the standards overlap. Table 5: Map of NSQHS against NSMHS Standards highlights the overlap of the NSQHS Standards to the NSMHS. Table 6: Map of NSMHS against NSQHS Standards is a reverse map, from the NSMHS to the NSQHS Standards.
Across the two sets of standards there are some areas in which no match or overlap exists. Additional evidence may be required to meet the NSHMS criteria. Section B of this workbook outlines criteria in the NSHMS where no overlap or matching action occurs in the NSQHS Standards. This section contains reflective questions and examples of evidence drawn from the Implementation Guidelines for Public Mental Health Services and Private Hospitals.3
It is important that each mental health service check with their accrediting agency and regulatory authority to confirm the requirements for meeting the NSMHS.
Accreditation to the National Safety and QualityHealthService Standards
The following section describes the process of accreditation to the NSQHS Standards. The NSQHS Standards were developed to establish a common set of standards for hospitals, day procedure centres and dental services. This means that, for the first time, the same standards for safety and quality are being used in these different settings across Australia. The NSQHS Standards focus on the areas of care where we know that too many people are harmed from their health care, and where there is good evidence about how to provide better care.
They also play an essential part in new accreditation arrangement under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme. The AHSSQA builds on the strengths of the current accreditation arrangements and provides for thenation coordination of accreditation processes.
Under this 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. Other health service organisations may also be required to be accredited to the NSQHS Standards. Health services should contact relevant state or territory health departments for information applicable to them.
Accreditation is one tool, in a range of strategies, which can be used to improve safety and quality. 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 mental health service may undergo:
· periods of self-assessment
· comprehensive assessment to the NSQHS Standards
· interim or mid-cycle assessment to some NSQHS Standards.
You can find further details in Figure 1.
Figure 1: The NSQHS Standards accreditation process
Enrol with accrediting agency: Enrolled health service organisations can access information on processes, timing and resources available from their accrediting agency and ACSQHC. An accreditation process involves self-assessment and external assessments (organisation-wide assessment and mid-cycle assessment).Self-assessment: An assessment conducted by the health service organisation to review their processes and practices and determine the extent to which they meet the NSQHS Standards. Timing: Specified by accrediting agency.
Assessment: Assessment can be organisation-wide or mid-cycle. Organisation-wide assessment is undertaken as an external visit. Mid-cycle is generally an external visitbut may be a desktop assessment. The collated evidence is reviewed to determine if the actions required in the NSQHS Standards have been met.
Timing: Period of on-site assessment agreed between accrediting agency and health service.
Notify regulators: Health service organisations and regulators are advised by the accrediting agency ifasignificant risk has been identified.
Response: Health service organisation implements improvements. Regulators take action appropriate totheissue.
Report on assessment: Following assessment, the accrediting agency will provide a written report of their assessment. The report specifies not met actions,
and provides detail of why the action is not met. Timing: Within 7 days from external assessment visit.
Core actions met: Routine reporting by accrediting agencies to regulators and ACSQHC. Mid-cycle, accreditation maintained. Full assessment to all Standards, accreditation awarded. / Core actions NOT met: Health service organisations have 90 days to implement quality improvement strategies to address not met actions. Timing: 90 days from written notification.
Re-assessment: Evidence of improvement provided by health service organisation to accrediting agency anddetermination made on not met items.
Actions NOT met: Accreditation not awarded or accreditation not retained for mid-cycle assessment. Quality improvement and self-assessment process recommenced. Regulator informed in writing by accrediting agency.
Remediation: Health service organisation to implement improvements, address any action not met from accreditation process. Action will be consistent with timing and processes specified by jurisdiction.
Enrolling in an accreditation program
By selecting an approved accrediting agency, a mental health service will be selecting the style and timing of assessment to the NSQHS Standards. Not all accrediting agencies will take the same approach. The accreditation cycle ranges from 3-4years, 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 to the NSQHS Standards. In order to be able to accredit to the NSQHS Standards, theCommission 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 departments and the Commission.
A list of all approved accrediting agencies is available on the Commission’s website4 atwww.safetyandquality.gov.au .
Timeframe
Accreditation to the NSQHS Standards commenced in January 2013. This means that the next scheduled recertification audit or organisational-wide accreditation visit will involve assessment to all 10 NSQHS Standards.
For a mid-cycle assessment, periodic review or surveillance audit, hospitals 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 may agree to additional assessment requirements for the mid-cycleassessment.