Advisory No: A15/05
TITLE
Accreditation assessment requirements of health service
organisations post significant clinical or governance review
VERSION
Version 1.0
DATE OF
PUBLICATION
17 December 2015
REPLACES
Not applicable
STATUS
Active
COMPLIANCE
Mandatory
APPROVED FOR
DISTRIBUTION BY
CEO
REVIEW DUE
DATE
November 2017
INFORMATION IN
THIS ADVISORY
APPLIES TO:
All approved accrediting agencies
KEY
RELATIONSHIP
Standard 1 – Governance for safety and quality in health service
organisations
RESPONSIBLE
OFFICER
Margaret Banks
CONTACT
DETAILS
Phone: 1800 304 056
TRIM NO.
D15-41690
All health service organisations
Senior Program Director
Email: accreditation@safetyandquality.gov.au
LINKAGES TO
OTHER
ADVISORIES
and/or
DOCUMENTATION
ATTACHMENTS
n/a
NOTES
(if applicable)
1
Advisory No: A15/05
Accreditation assessment requirements of health service
organisations post significant clinical or governance review
PURPOSE:
To describe the requirement for accrediting agencies to examine reports of reviews and
investigations into serious incidents as part of a health service organisation’s accreditation
assessment.
ISSUE:
Standard 1: Governance for safety and quality in health service organisations sets out the
requirements for health service organisations to implement safety and quality systems
including developing policies and procedures, identifying risk, monitoring performance,
analysing clinical incidents, implementing quality improvement processes and reporting to
the highest level of governance on the performance of these systems and outcomes of
care.
Health service organisations are reviewed from time to time to meet regulatory,
departmental, audit or governance requirements. Reports are also produced following the
investigation of significant clinical governance or safety breaches; or as a result of
significant clinical governance or safety breaches identified during the course of other
review processes.
These reports, whether generated internally or externally, may lead to recommendations
for improvement. The implementation of any recommendations is the responsibility of the
health service organisation.
These reviews will in future form part of the information submitted to accrediting agencies
by health service organisations prior to assessment. Further, the issues covered in these
reviews and recommendations should be thoroughly examined during the accreditation
assessment.
REQUIREMENTS:
Accrediting agencies are to:

formally request the health service organisation to submit to them copies of reports
following regulatory, departmental, audit or governance reviews; or reports
following investigation of significant clinical governance or safety breaches; or
reports resulting from other review process that have been conducted since the last
accreditation assessment and that identify significant clinical governance or safety
breaches.

formally request information on any review currently underway, including the terms
of reference, scope of the review and expected completion date

during the accreditation assessment thoroughly examine the safety and quality
issues raised by such review(s)
Advisory No: A15/05
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Version 1.0 December 2015

a health service organisation is not required to release a report to an accrediting
agency if the report is produced by a committee or individual with qualified
privilege. Qualified privilege safeguards those who engage in effective quality
assurance activities under a legislative or policy framework. In this case the health
service organisation should notify the accrediting agency of the existence of the
report and the recommendations and actions from the report should be reviewed
by the accrediting assessor during the assessment visit

assure themselves all relevant safety and quality systems identified through the
review are in place, being used, monitored, regularly evaluated and reports are
being provided to the highest level of governance

direct assessors to examine evidence that demonstrates action has been taken
that will directly address the recommendations in the report or evaluate and
improve the safety and quality systems under review

seek an explanation from the health service organisation where action has not
been taken

where action is planned, but not yet commenced, assessors should review the
timetable and seek evidence that adequate resourcing has been allocated to
implement the plan

where action is planned, but not yet commenced, assessors should review all
plans for action to ensure the timetable for implementation does not place
consumers at unnecessary or unreasonable additional risk

require the health service organisation to provide follow up reports on the
improvement action taken as part of the normal cycle of reporting and follow up by
the accrediting agency

seek data or other forms of evidence that could indicate current performance of the
relevant safety and quality systems

reflect the evidence of performance of the safety and quality systems in the
assessment ratings awarded to the health service organisation against the relevant
actions in the NSQHS Standards

notify as soon as practical, the responsible jurisdiction and the Australian
Commission on Safety and Quality in Health Care where the evidence provided is
not of sufficient strength to indicate risk of harm to consumers has been reduced or
effectively managed

notify the responsible jurisdiction and the Commission if at subsequent
assessments, or on review of follow up reports, improvement has not been
implemented or there have been unexplained or unreasonable delays.
Advisory No: A15/05
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