Accreditation guideline

Guideline number: QH-HSDGDL-032-5:2022

Effective date: 31 January 2024

Review date: 31 January 2027

Supersedes: Version 1.0

On this page:

1. Purpose
2. Scope
3. Accreditation requirements
4. Responsive regulatory process
5. Supporting and related documents
6. Definitions of terms
7. Approval and implementation
8. Version control

1. Purpose

This guideline describes the mandatory accreditation requirements outlined within the Patient Safety Health Service Directive.

2. Scope

This guideline applies to all Hospital and Health Services (HHSs).

3. Accreditation requirements

3.1 Hospitals, day procedure services and health care centres

• All Queensland public hospitals, day procedure services and health care centres (howsoever titled) managed within the framework of HHSs are to maintain accreditation under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme.
• Accreditation will be assessed against the National Safety and Quality Health Service (NSQHS) Standards, with the option that HHSs may choose to be assessed against the National Safety and Quality Primary and Community Healthcare Standards for primary and community facilities/services.
• The HHS will select their accrediting agency from among the approved accrediting agencies. The Australian Commission on Safety and Quality in Health Care (ACSQHC) provide a list of approved accrediting agencies which is published on their website.
• If the HHS does not meet the standards accreditation requirements, the HHS has 60 business days from the initial assessment, to address any actions requiring remediation.
• Following assessment, the HHS must provide to the Executive Director, Patient Safety and Quality, Clinical Excellence Queensland:
  1. immediate advice if a significant patient risk (one where there is a high probability of a substantial and demonstrable adverse impact for patients) is identified during an onsite visit, also identifying the plan of action and timeframe to remedy the issue, as negotiated between the assessors and/or the respective accrediting agency and the HHS.
  2. a copy of any initial assessment report within two days of receipt by the HHS,
  3. notification if mandatory reassessment is required.
  4. a copy of the final assessment report within seven days of receipt by the HHS
  5. immediate advice should any action be rated ‘not-met’ by the accrediting agency following the final assessment of an accreditation event, resulting in the facility or service not being accredited. In this instance a responsive regulatory process may be enacted under section 4.
• The following ACSQHC Standards/Module are optional for Queensland public hospitals, day procedure services and health care centres (howsoever titled):
  • Environmental Sustainability and Climate Resilience Healthcare Module
  • National Safety and Quality Digital Mental Health Standards
• The following ACSQHC Standards are not applicable to Queensland public hospitals, day procedure service and health care centres (howsoever titled):
  • National Safety and Quality Cosmetic Surgery Standards
  • National Safety and Quality Mental Health Standards for Community Managed Organisations

3.2 Newly established Satellite Hospitals and newly established off-campus, sub-acute or low care services

• If a service is an extension of an existing service and is operating under the same governance structure, same model of care and uses the same policies, procedures and safety and quality systems, the service can either be assessed along with its hub at the next accreditation assessment or can undergo the below approach.
• Prior to a facility/service opening and accepting patients, a self-assessment against the National Safety and Quality Health Service (NSQHS) Standards or the National Safety and Quality Primary and Community Healthcare (NSQPCH) Standards must be completed; and the choice of standards and self-assessment endorsed/approved by the peak HHS Clinical Governance Executive Committee and HHS Board.

  Note: HHSs may choose to have the newly established service assessed against the National Safety and Quality Primary and Community Healthcare Standards where services are predominately General Practitioner (GP) lead.

• If assessed against the NSQHS Standards
  • An interim assessment using standards described in the Australian Commission on Safety and Quality in Health Care’s (ACSQHC) Advisory AS18/02 is required to be conducted within three (3) months of the start of clinical services. Note: the assessment will be finalised within 4 months of the initial assessment, i.e., allows for the remediation period and 30 days for finalisation of the report.
  • Full assessment is to be finalised within 18 months from the commencement of services.
  • Subsequent assessments may occur at short notice and can be aligned with other services in the HHS.
• If assessed against the NSQPCH Standards
  • Full assessment is required to be conducted within three (3) months of the start of clinical services. Note: the assessment will be finalised within 4 months of the initial assessment, i.e., allows for the remediation period and 30 days for finalisation of the report.
  • Subsequent assessments may occur at short notice and can be aligned with other services in the HHS.
• Following assessment, the HHS must provide to the Executive Director, Patient Safety and Quality, Clinical Excellence Queensland:
  1. immediate advice if a significant patient risk (one where there is a high probability of a substantial and demonstrable adverse impact for patients) is identified during an onsite visit, also identifying the plan of action and timeframe to remedy the issue, as negotiated between the assessors and/or the respective accrediting agency and the HHS,
  2. a copy of any assessment report within seven days of receipt by the HHS; and
  3. immediate advice should any action be rated ‘not-met’ by the accrediting agency, that may result in the facility or service not being accredited. In this instance a responsive regulatory process may be enacted under section 4 below.

3.3 General practices

• General practices owned or managed by the HHS must maintain accreditation against the Royal Australian College of General Practitioners (RACGP) Standards; under the National General Practice Accreditation (NGPA) Scheme.
• The HHS is required to select their accrediting agency from the list of approved providers published by the ACSQHC.
• Following assessment, the HHS must provide to the Executive Director, Patient Safety and Quality, Clinical Excellence Queensland:
  1. immediate advice if a significant patient risk (one where there is a high probability of a substantial and demonstrable adverse impact for patients) is identified during an onsite visit, also identifying the plan of action and timeframe to remedy the issue as negotiated between the assessors and/or the respective accrediting agency and the HHS,
  2. copy of any ‘not-met’ assessment report within two days of receipt by the HHS,a copy of the final assessment report within seven days of receipt by the HHS; and
  3. immediate advice should any action be rated ‘not-met’ by the accrediting agency following the final assessment of an accreditation event, resulting in the facility or service not being accredited. In this instance a responsive regulatory process may be enacted under section 4 (see below).

3.4 Residential aged care facilities

• Residential aged care facilities, owned and managed by the HHS, must maintain accreditation against the Aged Care Quality Standards in accordance with the requirements of the Aged Care Quality and Safety Commission (ACQSC).
• Following assessment against the Aged Care Quality Standards, the HHS must provide to the Executive Director, Strategic Policy and Legislation Branch.
  1. a copy of any ‘not-met’ report within two days of receipt of the report by the HHS, including reports against the Aged Care Module of the NSQHS Standards.
  2. the accreditation report within seven days of receipt of the report by the HHS, including reports against the Aged Care Module of the NSQHS; and
  3. immediate advice should any action be rated ‘not met’ by the accrediting agency following the final assessment of an accreditation event, resulting in the facility or service not being accredited.

3.5 Breast screen

• BreastScreen Queensland managed by the HHS must maintain accreditation and deliver screening and assessment services in accordance with the BreastScreen Australia National Accreditation Standards.

3.6 Non-government organisations (NGO) funded by Queensland Health for delivery of specified service types

• HHSs contracting a NGO vendor to provide healthcare, must ensure the vendor has progressed accreditation according to the requirements of the QH Patient Safety Health Service Directive and Accreditation Guideline.

  For contracted mental health services:

  • Mental health (psychosocial) – assessment under the National Standards for Mental Health Services or Human Services Quality Standards (inclusive of mental health services) or National Safety and Quality Health Service Standards
  • Mental health (clinical and psychosocial) – National Safety and Quality Health Service Standards, and
  • Youth mental health services – National Standards for Mental Health Services or National Safety and Quality Health Service Standards.

  The NGO vendor must provide the outcomes of the accreditation assessments to the HHS for consideration as specified in the contract for healthcare services.

4. Responsive regulatory process

• A responsive regulatory process is utilised in the following circumstances:
  1. where a significant patient risk is identified by a certified accrediting agency during an accreditation process; and/or
  2. where an HHS has failed to address ‘not met’ actions of the specified standards within required timeframes.
• An initial regulatory response will begin with a process of verifying the scope, scale and implications of the reported issues, a review of documentation, and may include one or more site visits by nominated specialty experts.
• The regulatory process may include one or a combination of the following actions:
  1. Seek further information from the HHS.
  2. Request a progress report for the implementation of an action plan.
  3. Escalate non-compliance and/or risk to the Performance Review Meeting.
  4. Provide advice, information on options or strategies that could be used to address the non-met actions within a designated time frame.
  5. Connect the hospital to other hospitals that have addressed similar deficits or have exemplar practice in this area.
• In the case of serious or persistent non-compliance and where required action is not taken by the HHS the response may be escalated. The Department may undertake one or a combination of the following actions:
  1. Restrict specified practices/activities in areas/units or services of the HHS where the specified standards have not been met.
  2. Suspend particular services at the HHS until the area/s of concern are resolved.
  3. Suspend all service delivery at a facility within an HHS for a period of time.

5. Supporting and related documents

• Hospital and Health Boards Act 2011 (Qld)
• Hospital and Health Boards Regulation 2012 (Qld)
• Australian Health Service Safety and Quality Accreditation Scheme
• Australian Commission on Safety and Quality in Health Care
• Aged Care Quality and Safety Commission
• National Safety and Quality Health Service Standards
• NSQHS Standards Aged care module
• RACGP Standards 5th edition
• Aged Care Quality Standards
• BreastScreen Australia National Accreditation Standards

6. Definition of terms

7. Approval and implementation

Guideline custodian
Executive Director, Patient Safety and Quality, Clinical Excellence Queensland.

Approving officer
Deputy Director General, Clinical Excellence Queensland, Department of Health.
Approval date: 31 January 2024
Effective from: 31 January 2024

8. Version control