The National Safety and Quality Health Service (NSQHS) Standards 2nd Edition commenced from January 2019. As part of the 2nd Edition health service organisations can elect to undertake either the announced assessment program or short notice assessment program.
The short notice assessment consists of one or two on site assessments each year. The health service organisation receives 48 hours notice that the assessments are going to take place with three or four standards being assessed during the on site visit.
“Previously we undertook a three yearly announced assessment, being assessed against the 10 national standards. When the Australian Commission on Safety and Quality in Health Care released the second edition of the national standards, organisations could elect to do undergo short notice survey. This meant that across the 3 year cycle the organisation would be assessed against all of the 8 national standards, but the assessment wouldn’t occur in one pre planned visit, there would several unannounced visits. The hospital wouldn’t know which standards were going to be assessed until 48 hours prior to the visit.” – Jennifer McNamara, Director of Clinical Services, Gosford Private Health.
As Jennifer mentioned participation in the short notice assessment is voluntary for health service organisations unless a relevant regulator has asked for the organisation to undertake the survey.
The short notice assessment process requires healthcare organisations to fully comply with the requirements of the NSQHS Standards and have processes in place to demonstrate compliance at any time.
Gosford Private Hospital has assigned team leaders to each of the national standards. They have undertaken gap analysis of the standards and are currently working to address any gaps to ensure compliance with the standards. They are providing evidence support how the organisation meets each of the actions within the standards.
Jennifer says “We have a committee for each of the standards, due to the size and additional actions within standard 5 it has been broken down into smaller sub committees. Our gap analysis documents are working documents that have the teams intentions on what evidence is appropriate to address each action within the standard.”
Organisations contemplating short notice assessments should ensure their safety and quality systems are well embedded, and routine processes are in place to monitor safety and quality performance against the NSQHS Standards and conduct regular self-assessments and gap analysis.
Gosford Private Hospital has elected to undergo the short notice assessment program to ensure an organisational wide culture with safety and quality at it’s core.
On asking Jennifer her thoughts on why they chose to implement the survey, here is what she had to say:
“The reason we have elected to do this at Gosford Private is because we believe this will assist in embedding safety and quality in the culture of our organisation. Traditionally when you would go through the accreditation process, staff would be reluctant to be involved in the process. It is important for all staff to understand that the systems and processes within the organisation are safe and encourage them to communicate this confidently, we believe the short notice assessment provides this opportunity.
The short notice survey encourages our team to communicate in a way that promotes the wonderful work we do and the safe manner in which we practice everyday. It is about embedding safety and quality in the culture of your organisation.”
Don’t miss Jeniffer McNamara’s (Director of Clinical Services, Gosford Private Health) case study presentation on “Utilising short notice surveys as a catalyst to culture change” at the Applying the 2nd Edition of the NSQHS Standards Conference on the 19th & 20th June 2019 in Melbourne.