Advisory No: A13/04 (Amended)
TITLE
Collection and reporting of accreditation evidence by
accrediting agencies
VERSION
Version 3.0
DATE OF PUBLICATION
8 September 2015
REPLACES
Version 2.0 issued 23 September 2013
STATUS
Active
COMPLIANCE
Mandatory
APPROVED FOR
DISTRIBUTION BY
COO
REVIEW DUE DATE
September 2017
INFORMATION IN THIS
ADVISORY APPLIES TO:
All approved accrediting agencies
All health service organisations
KEY RELATIONSHIP
All NSQHS Standards
RESPONSIBLE
OFFICER
Margaret Banks
Senior Program Director
CONTACT DETAILS
Phone: 1800 304 056
Email: accreditation@safetyandquality.gov.au
TRIM NO.
D15-15053
LINKAGES TO OTHER
ADVISORIES and/or
DOCUMENTATION
ATTACHMENTS
Attachment 1: Evidence of Implementation
NOTES
(if applicable)
Amended August 2015
Advisory No: A13/04
1
Version 3.0 September 2015
Advisory No: A13/04 (Amended)
Collection and reporting of accreditation evidence by
accrediting agencies
PURPOSE:
To advise health service organisations and approved accrediting agencies that
sighting and collecting data described as evidence of implementation of the NSQHS
Standards is no longer required as part of the AHSSQA Scheme.
ISSUE:
The National Health Reform Act 2011 describes the Commission’s functions relating
to health care safety and quality matters. These functions include:
i. formulating safety and quality standards
ii. formulating model national accreditation schemes
iii. to advise Ministers about safety and quality
iv. to report on safety and quality
Health service organisations were asked to collect and report on accreditation
outcomes and evidence of implementation of the NSQHS Standards from January
2013. This data was to be collected to understand the extent and effectiveness of
implementation of the NSQHS Standards.
Approved accrediting agencies were required to collect information at each health
service assessment and report routinely through the Commission’s information
submission mechanism.
Multiple issues became evident in the collection, storage, transmission and reporting
of this data.
REQUIREMENTS:

Health service organisations should continue to collect and monitor relevant
indicators associated with action in the NSQHS Standards and report these to the
highest appropriate level of governance within an organisation.

Accrediting agencies should verify, during their assessment survey, that health
service organisations are collecting, monitoring and reporting relevant indicators
for the NSQHS Standards.

Health service organisations and approved accrediting agencies are no longer
required to specifically collect or review items described in the Accreditation
evidence of implementation of the National Safety and Quality Health Service
(NSQHS) Standards.
Advisory No: A13/04
2
Version 3.0 September 2015
Attachment 1
Evidence of implementation
The following items are no longer specifically required by the Commission to be collected by
health service organisations or reviewed and reported by accrediting agencies. However,
health service organisations may continue to collect, report and monitor these measures
where they are a jurisdictional or local requirement.
NSQHS
Standard
Measure
#
Action Required
Additional action required if
submitting data
Reference
1 Governance
for safety and
quality in
health service
organisations
Measurement of
patient experience
– admitted
overnight patients
1a
Evidence is sighted that the
health service organisation has
mechanisms (such as surveys,
interviews or focus groups) to
obtain feedback about
experiences from admitted
overnight inpatients, which is
monitored within the
organisation.
List of mechanisms (such as
surveys, interviews or focus
groups) used to seek feedback
about experiences from
admitted overnight inpatients
where feedback is monitored
within the organisation’s
governance system.
Performance
and
Accountability
Framework
(PAF)
6.2.2.1
NSQHS
Standards
(NSQHSS)
1.20.1
Measurement of
patient experience
– same day
admitted patients
1b
Evidence is sighted that the
health service organisation has
mechanisms (such as surveys,
interviews or focus groups) to
obtain feedback about
experiences from same day
admitted patients, which is
monitored within the
organisation’s governance
system
List of mechanisms (such as
surveys, interviews or focus
groups) used to seek feedback
about experiences from same
day admitted patients where
feedback is monitored within
the organisation’s governance
system.
PAF 6.2.2.1
NSQHSS
1.20.1
Use of agreed
clinical guidelines
2
Evidence is sighted that the
health service organisation has
a list of agreed clinical
guidelines in use in the health
service, which are used by the
clinical workforce in the health
service and monitored.
List of agreed clinical
guidelines where use by the
clinical workforce is monitored.
NSQHSS 1.7.1,
1.7.2
Advisory No: A13/04
3
Version 3.0 September 2015
NSQHS
Standard
Measure
#
Action Required
Additional action required if
submitting data
Reference
Monitoring of core,
hospital-based
outcome indicators
3
Evidence is sighted that the
health service organisation has
identified which of the following
core, hospital-based outcome
indicators are relevant to its
service provision and regularly
reported to the executive level
of governance:
List of the Core, HospitalBased Outcome Indicators
(CHBOI), which are relevant to
service provision and regularly
reported to the executive level
of governance, is submitted for:
PAF
CHBOI 1 Hospital standardised
mortality ratio (HSMR)
NSQHSS 1.2.1
CHBOI 1 Hospital standardised
mortality ratio (HSMR)
CHBOI 2 Death in low-mortality
Diagnosis Related Groups
(DRGs)
CHBOI 3 In-hospital mortality
for:
a. acute myocardial
infarction (AMI)
b. stroke
c. fractured neck of femur
d. pneumonia
Unplanned/unexpected samehospital readmission rate for
patients discharged following
management of:
a. acute myocardial
infarction (AMI)
b. knee replacements
c. hip replacements
6.2.1.1
6.2.1.2
6.2.1.3
6.2.1.4
CHBOI 2 Death in low-mortality
Diagnosis Related Groups
(DRGs)
CHBOI 3 In-hospital mortality
for:
a. acute myocardial
infarction (AMI)
b. stroke
c. fractured neck of femur
d. pneumonia
Unplanned/unexpected samehospital readmission rate for
patients discharged following
management of:
a. acute myocardial
infarction (AMI)
b. knee replacements
c. hip replacements
d. paediatric tonsillectomy
and adenoidectomy
d. paediatric tonsillectomy
and adenoidectomy
3 Preventing
and
controlling
healthcare
associated
infections
Reporting of
sentinel events
4
Compliance with
the National Hand
Hygiene Initiative
5
Advisory No: A13/04
Evidence is sighted that the
health service organisation
undertakes reporting and
review of sentinel events at the
highest level of governance
and at the point of clinical care.
Information about sentinel
events reported to the highest
level of governance, by type
and number and review
protocol.
ROGS
Evidence is sighted that the
health service organisation
undertakes reporting and
review at the highest level of
governance of the percentage
of observations compliant with
the National Hand Hygiene
Initiative, by Moment (1-5) and
type of healthcare worker
(nurse, medical doctor,
personal care staff, allied
health, domestic staff,
administrative and clerical staff,
invasive technician, students,
other).
The percentage of
observations compliant with the
National Hand Hygiene
Initiative, by Moment (1-5) and
type of healthcare worker
(nurse, medical doctor,
personal care staff, allied
health, domestic staff,
administrative and clerical staff,
invasive technician, students,
other).
MyHospitals
4
NSQHSS
1.14.2
NSQHSS 3.5.1,
3.5.2
Version 3.0 September 2015
NSQHS
Standard
Measure
#
Action Required
Additional action required if
submitting data
Reference
Completion of
hand hygiene
training
6
Evidence is sighted that the
health service organisation
undertakes reporting and
review at the highest
appropriate level of
governance of the percentage
of the clinical workforce who
have completed online
modules in hand hygiene
delivered by Hand Hygiene
Australia, by staff category
(medical, nursing/midwifery,
allied health, non-clinical staff).
The percentage of the clinical
workforce who have completed
online modules in hand
hygiene delivered by Hand
Hygiene Australia, by staff
category (medical,
nursing/midwifery, allied health,
non-clinical staff).
NSQHSS 1.4.1,
1.4.2, 3.5.1,
3.5.2
Rate of healthcare
associated
Staphylococcus
aureus
bacteraemia
7
Evidence is sighted that the
health service organisation
undertakes reporting and
review at the highest
appropriate level of
governance of patient episodes
of healthcare associated
Staphylococcus aureus
bacteraemia per 10,000 patient
days.
The rate of patient episodes of
healthcare associated
Staphylococcus aureus
bacteraemia per 10,000 patient
days.
PAF 6.2.1.5
Monitoring of
hospital-identified
Clostridium difficile
infection (CDI)
8
Evidence is sighted that the
health service organisation
undertakes reporting and
review at the highest
appropriate level of
governance of the number of
cases of hospital-identified
Clostridium difficile infection
(CDI).
The number of cases of
hospital-identified Clostridium
difficile infection (CDI).
PAF 6.2.1.6
4 Medication
safety
Medication
reconciliation
9
Evidence is sighted that the
health service organisation
undertakes routine audits of a
sample of current patients, to
ascertain the proportion of
patients for whom current
medications are documented
and reconciled at admission.
Based on a routine audit
sample, the percentage of
patients whose current
medications are documented
and reconciled at admission.
NSQHSS 4.8.1
5 Patient
identification
and
procedure
matching
Patient
identification and
procedure
matching
10
Evidence is sighted that the
health service organisation
undertakes routine audits of a
sample of current patients, to
ascertain the proportion of
patients that have identification
bands that are compliant with
the national specifications
Based on a routine audit
sample, the percentage of
patients that have identification
bands that are compliant with
the national specifications.
NSQHSS
6 Clinical
handover
Clinical handover
– discharge
summary
11
Evidence is sighted that the
health service organisation
undertakes routine audits of a
sample of patients, to ascertain
the proportion of patients
whose discharge summary has
been sent to their ongoing
clinical provider and/or general
practitioner within 48 hours of
discharge.
Based on a routine audit
sample, the percentage of
patients whose discharge
summary has been sent to
their ongoing clinical provider
and/or general practitioner
within 48 hours of discharge.
NSQHSS 6.1.2,
6.3.1
Advisory No: A13/04
5
NHA PI 39
ROGS
NSQHSS 3.2.1
NSQHSS 3.2.1
AHMC 2008
5.1.2, 5.3.1
Version 3.0 September 2015
NSQHS
Standard
Measure
#
Action Required
Additional action required if
submitting data
Reference
7 Blood and
blood
products
Wastage of blood
and blood
products
12
Evidence is sighted that the
health service organisation
undertakes reporting and
review at the highest
appropriate level of
governance of the percentage
of units of red blood cells
discarded.
The percentage of blood
products discarded - red cells.
NSQHSS
8 Preventing
and managing
pressure
injuries
Assessment of risk
of pressure
injuries
13a
Evidence is sighted that the
health service organisation
undertakes routine audits of a
sample of current patients, to
ascertain the proportion of
patients with documented
pressure injury risk
assessment undertaken within
eight hours of admission.
Based on a routine audit
sample, the percentage of
patients with documented
pressure injury risk
assessment undertaken within
eight hours of admission.
NSQHSS 8.3.1,
8.5.1, 8.5.2,
8.5.3, 8.6.2
Pressure injuries
acquired during
admission.
13b
Evidence is sighted that the
health service organisation
undertakes routine audits of a
sample of current patients, to
ascertain the rate of pressure
injuries acquired during
admission, reported by Grade
(I-IV), unstaged pressure injury
and suspected deep tissue
injury.
Based on a routine audit
sample, the rate of pressure
injuries acquired during
admission, reported by Grade
(I-IV), unstaged pressure injury
and suspected deep tissue
injury.
NSQHSS 8.2.1,
8.2.2, 8.2.3,
8.6.1, 8.8.3
Staff training in
basic life support
14
Evidence is sighted that the
health service organisation
monitors the percentage of
clinicians who have achieved
certification, or received
refresher training in basic life
support, by category (medical,
nursing/midwifery, allied
health).
The percentage of clinicians
who have achieved
certification, or received
refresher training in basic life
support, by category (medical,
nursing/midwifery, allied
health).
NSQHSS 1.4.1,
1.4.2, 9.6.1
Completeness of
documentation of
core physiological
observations
15
Evidence is sighted that the
health service organisation
undertakes routine audits of a
sample of patients, to ascertain
the proportion of patient charts
where the last set of recorded
observations is compliant with
their monitoring plan.
Based on a routine audit
sample, the percentage of
patient charts where a
complete set of observations is
part of the last set of recorded
observations, in agreement
with their monitoring plan.
NSQHSS 1.9.1,
1.9.2, 9.3.2,
9.3.3
Falls resulting in
injury for admitted
hospital patients
16
Evidence is sighted that the
health service organisation
monitors the rate of falls
resulting in injury for admitted
hospital patients.
The rate of falls resulting in
injury for admitted hospital
patients.
NSQHSS
10.2.1, 10.2.2,
10.2.3
9 Recognising
and
responding to
clinical
deterioration
in acute
health care
10 Preventing
falls and harm
from falls
Advisory No: A13/04
6
7.8.1, 7.8.2
Version 3.0 September 2015