Conference Report Community Health: Making Accreditation Work for You By Sue Schreiner

Community Health: Making Accreditation Work for You  July-December 2014

Workshop held 26 September at Canberra Hospital

The workshop went from 9am-4pm with half hour lunch break.

There were 16 participants - all from Community Health (except me).

The presenter was Sue Gilham whose background is in nursing but who now is a Surveyor with The Australian Council on Healthcare Standards(ACHS).  She trains other Surveyors and has been involved in training hospitals in India, Asia the Middle East and Ireland in how to reach accreditation standards.

ACHS is one of 13 bodies whose  business is accrediting health entities’ compliance with National Safety and Quality Health Service Standards(NSQHS) and accreditation. It has a number of Surveyors, including a Surveyor who is a consumer. This organisation is the one chosen by ACT Health. Services to be accredited can choose whoever they wish and significantly, the accrediting bodies do not operate in the same way- so that what one finds acceptable another may not.

The purpose of the workshop was to explain what the Surveyors employed by ACHS expected and would be looking for when deciding accreditation of Community Services provided by Community Health - in particular looking at how Community Health could and should  comply with the Standards. Safety and quality of care for the patient is paramount. The standards and principles which apply to Acute health services also apply to Community health. The measures are the same. There is close scrutiny of claims about how the standards are met - “we look at the clinical content of the record and its quality”.

NSQHS standards consist of 10 Standards and 41 Criteria (209 Core actions and 47 developmental actions)   

Basically what the Surveyors are looking for is how the Standards are met by the organisation (ACT Health) as a whole and by each of the services. The Standards will be surveyed “by discussions with all groups. Reviews of policy and related documents,committee and departmental minutes,mandatory audits and reviews, active use of the findings, communication to senior level and to clinical teams, review complaints,clinical handovers and feedback both positive and negative; visits to community sites, talk to managers and staff members about their outcomes of care, review the clinical indicator reports; review client records for the use of screening and assessment tools. documentation of care plans and intervention, evidence of the engagement of clients in planning care.”

We went through in small groups what 3 of the Standards required. Services are required to prove how they comply with each Standard.  There was much discussion as to what constitutes proof. e.g. policies and procedures,clinical performance indicators, copies of internal and external audits contracts, department and committee quality activities staff training records, feedback and communication,keeping minutes, written records of activity, patient satisfaction surveys.

In greater detail for example against" NSQHS 1 (Governance for safety and quality in health service organisations was : “Measure of patient experience of admitted overnight patients - there could be a list of mechanisms such as surveys,interviews or focus groups used to seek feedback about experiences from admitted overnight patients where feedback is monitored within the organisation’s governance system”.

“Other Performance Measures” were complaints,incidents, near misses, safety assessments, patient satisfaction surveys.”

“Surveyor Verification” consists of; 

1. examining evidence demonstrating how the service has achieved the standards and how they have been incorporated into everyday practice
2. Interviews-staff, client focus groups, service providers, consumers, stakeholders
3. observation
4. review documentation

This is an attempt to summarise the workshop, some of it taken from powerpoint slides. Written material was given to participants and is available if you would like it.

The main points from my perspective are that Community care is judged in the same way as Acute care and that there is close scrutiny of each stage of the accreditation.It is all spelled out and available and gives Community Health clear guidelines as to what is expected. If these guidelines are followed the consumer will be well cared for.

Sue Schreiner