Advisory No: A14/01 (Amended)
TITLE
Assessment of developmental actions in the
National Safety and Quality Health Service
Standards
VERSION
Version 2.0
DATE OF
PUBLICATION
8 September 2015
REPLACES
Version 1.0 issued 28 March 2014
STATUS
Active
COMPLIANCE
Mandatory
APPROVED FOR
DISTRIBUTION BY
COO
REVIEW DUE
DATE
September 2017
INFORMATION IN
THIS ADVISORY
APPLIES TO:
Health Service Organisations and all approved Accrediting
Agencies
KEY
RELATIONSHIP
All developmental action in the NSQHS Standards
RESPONSIBLE
OFFICER
Margaret Banks
Senior Program Director
CONTACT
DETAILS
Phone: 1800 304 056
Email: accreditation@safetyandquality.gov.au
TRIM NO.
D15-16000
LINKAGES TO
OTHER
ADVISORIES
and/or
DOCUMENTATION
ATTACHMENTS
n/a
NOTES
(if applicable)
Amended July 2015
Advisory No: A14/01
1
Version 2.0 September 2015
Advisory No: A14/01 (Amended)
Assessment of developmental actions in the
National Safety and Quality Health Service Standards
PURPOSE:
To clarify the assessment requirements for developmental actions from the National Safety
and Quality Health Service (NSQHS) Standards.
ISSUE:
Health service organisations and accrediting agencies have requested written clarification
from the Commission in relation to the assessment and rating of developmental actions.
The introduction of mandatory accreditation to the NSQHS Standards required accrediting
agencies to assess both core and developmental actions in the NSQHS Standards.
Core actions are considered to be critical safety and quality requirements and 100 percent of
core actions must be met for a health service organisation to achieve accreditation.
Developmental actions are important and health service organisations should be working
towards implementing these actions. However, health service organisations do not need to
have satisfactorily met the requirements to be awarded accreditation. Developmental actions
will be reviewed as part of the development of version 2 of the NSQHS Standards.
There are 47 developmental actions in the NSQHS Standards for hospitals and 48 for day
procedure services. These are detailed on the Commission’s website at
www.safetyandquality.gov.au.
REQUIREMENTS:
Approved accrediting agencies are to assess all actions (core and developmental) and
provide health service organisations with a rating using the agreed 3-point rating scale of not
met, met satisfactorily and met with merit. Health service organisations are required to
provide evidence of planning, analysis and/or focus of effort for all developmental actions.
Accrediting agencies may provide health service organisations with recommendations for all
‘not met’ actions, including developmental actions.
Accrediting agencies should not take the ratings of developmental actions into consideration
when determining accreditation status of a health service organisation.
Health service organisations should take the recommendations of not met actions into
consideration when developing their improvement plans.
Advisory No: A14/01
2
Version 2.0 September 2015