Accreditation Workbook for Mental Health Services

246 Pages·2014·7.22 MB·English

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
Commission on Safety and Quality in Health Care:
Australian Commission on Safety and Quality in Health Care
GPO Box 5480
Sydney NSW 2001
Email:
Foreword
The Australian Commission on Safety and Quality in Health Care (the Commission)
is pleased to provide health services with the Accreditation Workbook for Mental
Health Services.
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
to people 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
for service delivery to be applied across the broad range of mental health services.
In September 2011, Health Ministers took a signifcant 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 frst time, create a nationally coordinated safety and quality accreditation
scheme for health 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 signifcant 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 Offcer
Australian Commission on Safety and Quality in Health Care
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Table of Contents: Accreditation Workbook for Mental Health Services
Introduction 4 Accreditation to the National Standards for Mental Health Services 20
Maping the two sets of Standards 4 Timeframe 20
Purpose of this Workbook 4 Enrolling in an accreditation program/Approved accreditation agencies 20
Core and developmental actions for NSMHS 20
Accreditation to the National Safety and Quality Health Service Standards 5
NSMHS Non-applicable criteria or actions 20
Figure 1: The NSQHS Standards accreditation process 6
Table 4: Applicable NSMHS criteria for mental health services 21
Enrolling in an accreditation program 7
Assessment and rating scale 25
Approved accrediting agencies 7
Actions which are not met 25
Timeframe 7
Appeals process 25
Core and developmental actions for NSQHS Standards 7
Accreditation award 25
Non-applicable criteria or actions 8
Table 1: Applicable NSQHS Standard actions for mental health services 9 How to use this Workbook 26
Table 2: Steps in applying for NSQHS Standards Non-applicable actions 13 Figure 2: How the NSQHS Standards with matched NSMHS are presented
in this Workbook 27
Assessment and rating scale 14
Examples of evidence 29
Table 3: Decision support tool for determining the level of performance
to meet the NSQHS Standards 15 Workbook resources 29
Actions which are not met 19 Additional resources 30
Appeals proces 19 Table 5: Map of NSQHS Standards with matching NSMHS 31
Acreditation award 19 Table 6: Map of NSMHS with matching NSQHS Standards 32
Data and reporting 19
Terms and defnitions 33
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Table of Contents: Accreditation Workbook for Mental Health Services
Section B:
Section A:
National Standards for Mental Health Services for
National Safety and Quality Health Service Standards with 42
which there is no match with the National Safety 214
matching National Standards for Mental Health Services
and Quality Health Service Standards
Standard 1:  Governance for Safety and Quality Standard 1: Rights and Responsibilities 215
43
in Health Service Organisations
Standard 2: Safety 216
Standard 2: Partnering with Consumers 80 Standard 3: Consumer and Carer Participation 217
Standard 3: P reventing and Controlling Healthcare Standard 4: Diversity Responsiveness 217
92
Associated Infections
Standard 5: Promotion and Prevention 219
Standard 4: Medication Safety 121
Standard 6: Consumers 221
Standard 7: Carers 221
Standard 5: Patient Identifcation and Procedure Matching 149
Standard 8: Governance, Leadership and Management 223
Standard 6: Clinical Handover 156
Standard 9: Integration 224
Standard 7: Blood and Blood Products 164 Standard 10: Delivery of Care 225
Standard 8: Preventing and Managing Presure Injuries 176 References 239
Standard 9:  Recognising and Responding to Clinical
188
Deterioration in Acute Health Care
Standard 10: Preventing Falls and Harm from Falls 203
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Introduction
The Australian Commission on Safety and Quality in Health Care (the Commission)
Mapping the two sets of standards
has developed this Accreditation Workbook to assist mental health services to
understand and determine if they meet the requirements of the National Safety and The Commission worked with the Department of Health and the Safety and Quality
Quality Health Service (NSQHS) Standards1 and the National Standards for Mental Partnership Standing Committee to map the NSQHS Standards and the NSMHS.
Health Services (NSMHS)2. This work was done in collaboration with the Department The aim was to identify areas where a substantial match, in terms of scope and intent,
of Health and the Safety and Quality Partnership Standing Committee (SQPSC) of the exists between the two sets of standards. The exercise also highlighted differences
Mental Health, Drug and Alcohol Principal Committee of the Australian Health Ministers’ between the two standards and areas where separate evidence is needed to meet both
Advisory Council. sets of standards.
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 Purpose of this Workbook
service organisations. The primary aims of the NSQHS Standards are to protect the
This Workbook is designed to guide services through the accreditation process for
public from harm and to improve the quality of health service provision. They provide
the NSQHS Standards, and highlight areas where mental health services will also have
a quality assurance mechanism that tests whether relevant systems are in place to
substantively achieved relevant NSMHS criteria. Our intention is to assist mental health
ensure minimum standards of safety and quality are met, and a quality improvement
services to ensure efforts to establish evidence to meet either set of standards are
mechanism that allows health services to realise aspirational or developmental goals.
not duplicated.
All Australian public and private hospitals are required to be accredited to the
NSQHS Standards commencing 2013. In addition to using criteria to guide accreditation requirements, the NSQHS Standards
specify actions that should be taken to ensure that criteria are met.
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 Tables are provided to demonstrate where the standards overlap. Table 5: Map of
broad range of mental health services. They are designed to represent one component NSQHS against NSMHS Standards highlights the overlap of the NSQHS Standards to
of the environment of different quality, safety and performance frameworks that the NSMHS. Table 6: Map of NSMHS against NSQHS Standards is a reverse map, from
infuence service delivery2. the NSMHS to the NSQHS Standards.
This Workbook focuses on the process of accreditation, and: Across the two sets of standards there are some areas in which no match or overlap
• outlines the key steps in an accreditation process for the NSQHS Standards 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
• provides information about the areas of match and no match between the
occurs in the NSQHS Standards. This section contains refective questions and
NSQHS Standards and the NSMHS
examples of evidence drawn from the Implementation Guidelines for Public Mental
• provides examples of evidence that could be used to demonstrate that the
Health Services and Private Hospitals.3
NSQHS Standards and the NSMHS have been met.
It is important that each mental health service check with their accrediting agency and
regulatory authority to confrm the requirements for meeting the NSMHS.
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Accreditation to the National Safety and
Quality Health Service 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 frst 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
the nation 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 fnd further details in Figure 1.
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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: Specifed 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
visit but 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
if a signifcant risk has been identifed.
Response: Health service organisation implements improvements. Regulators take action appropriate
to the issue.
Report on assessment: Following assessment, the accrediting agency will provide a written report of their assessment. The report specifes 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 Core actions NOT met: Health service organisations have 90 days to implement quality improvement
agencies to regulators and ACSQHC. Mid-cycle, strategies to address not met actions. Timing: 90 days from written notifcation.
accreditation maintained. Full assessment to all
Standards, accreditation awarded.
Re-assessment: Evidence of improvement provided by health service organisation to accrediting agency
and determination 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 specifed by jurisdiction.
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Accreditation to the National Safety and
Quality Health Service Standards (continued)
Enrolling in an accreditation program Timeframe
By selecting an approved accrediting agency, a mental health service will be selecting Accreditation to the NSQHS Standards commenced in January 2013. This means that
the style and timing of assessment to the NSQHS Standards. Not all accrediting the next scheduled recertifcation audit or organisational-wide accreditation visit will
agencies will take the same approach. The accreditation cycle ranges from 3-4 years, involve assessment to all 10 NSQHS Standards.
and the frequency and style of the mid-cycle assessment, periodic review or
surveillance audit may vary between agencies. 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:
Approved accrediting agencies
1 Standards 1, 2 and 3
The Commission approves accrediting agencies to assess health service organisations
2 the organisational quality improvement plan
to the NSQHS Standards. In order to be able to accredit to the NSQHS Standards,
the Commission requires accrediting agencies to: 3 recommendations from previous accreditation assessments.
• be accredited by an internationally recognised body
Health services may agree to additional assessment requirements for the
• work with the Commission to ensure the consistent application of the
mid-cycle assessment.
NSQHS Standards
• provide data on accreditation outcomes to state and territory health departments
and the Commission. Core and developmental actions
A list of al approved accrediting agencies is available on the Commission’s website4 for NSQHS Standards
at www.safetyandquality.gov.au . The NSQHS Standards apply in a wide variety of health settings. Because of the
variation in size, structure and complexity of health service delivery models a degree
of fexibility is required in the application of the NSQHS Standards.
To achieve this fexibility, each action within a Standard is designated as either:
• Core – actions must be met before a mental health service can achieve an
accreditation award to the NSQHS Standards. All core actions are critical
for safety and quality; or
• Developmental – activity in these areas is still required, but the actions do not
need to be fully met in order to achieve accreditation. Developmental actions are
in areas where services should focus their future efforts and resources to improve
patient safety and quality.
A list of core and developmental actions for different types of health settings can be
found on the Commission’s website at www.safetyandquality.gov.au . The Commission
will review the classifcation of core and developmental actions in 2015.
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Accreditation to the National Safety and
Quality Health Service Standards (continued)
Non-applicable criteria or actions
In some circumstances a Standard, criterion or action may be considered
non-applicable. Non-applicable actions are those that are inappropriate in a
specifc service context or for which assessment would be meaningless.
There are two ways in which a criterion or action can be classifed as non-applicable:
1 T he Commission has designated non-applicable actions for various mental health
services by category. Table 1 summarises non-applicable actions by service type.
2 D uring the accreditation process, there may be instances where an individual
mental health service decides that a criterion or action is non-applicable. A service
can apply to their accrediting agency to have either core or developmental actions
considered non-applicable. The process for applying for non-applicable actions
is outlined in Table 2.
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