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 In 2018 following review of the accreditation arrangements for the National Safety and Quality Health Service (NSQHS) Standards it was agreed mandatory short notice accreditation assessments (SNAA) would be implemented. These assessments will commence from 1st July 2023.The main benefits of SNAAs are enhanced support for continuous compliance with the NSQHS Standards of care, transfer of the focus from preparation for on-site assessment to assessment of day-to-day practice, removal of administration burden of preparation for accreditation and change in perception of a not met action from a system and services failure to an opportunity for improvement.

What we know so far:

SNAA will commence on 1st July 2023

SNAA will occur once in a three year cycle, with all 8 Standards assessed including the Clinical Trials Governance Framework. Excluded in current cycle are the National Safety and Quality Digital Mental Health Standard and the National Safety and Quality Primary Community Healthcare Standard.

The organisation will be given 24 hours’ notice (1 full business day) of an assessment. There will be 6 assessors on-site for 5 days.

Assessment methodology- PICMoRS- Process, Improvement, Consumer Participation, Monitoring Reporting and Systems will include interviews with consumers and their nominated representatives, members of the workforce, volunteers and contractors, observation of workforce practice, review of documents and records and examination of how the health service’s quality improvement systems are used to reduce risk

Assessors must spend 75% of their time in operational areas

Post SNAA a report is provide within 5 days and there is then a 60 day remediation period for the organisation to address any not met recommendations. These actions are subject to review (announced visit) at the end of the remediation period and the final report notifying the health service if it has retained accreditation is received.

What we need to do:

Establish governance, capacity-building and communications systems for transition to SNAA including:

Implement mechanisms to keep AWH self-assessment documentation and evidence up to date and reviewed at least quarterly- including links between Standard Governance Groups, Operational Divisions and Support Directorates (SNAA Governance Model- 30th March 2023)

Develop a communication plan related to changes to keep all key stakeholders (Consumers, Board, Executive, Directors, Managers and Workforce) informed (Communication Plan -28th February 2023)

Develop a capacity-building plan for consumers and workforce with the aim of enhancing the understanding of the requirements of the NSQHS Standards of Care including terminology assessors may use during a SNAA. (Capacity-building Plan- 28th February 2023)

Develop a system to inform consumers and workforce an assessment is occurring and assessors may be observing and talking to them about the care they will receive (AWH SNNA procedure- 30th April 2023)

Implement a standardised AWH National Standards Toolkit for Managers/Senior Leads to allow expansion of workforce understanding of National Standards of Care, this will include tools to assist discussions with teams at huddles, preparation checklists, examples of what to display on Improvement and innovation boards (Resource toolkit- 31st March 2023)

What can I do now:

Start the conversation with your teams and colleagues around transitioning to Short Notice Accreditation Assessments (SNAA) and the positive impact this will have on embedding the National Standards of Care.

Where can I get help:

Additional information on Short Notice Accreditation Assessments can be located at: https://www.safetyandquality.gov.au/standards/nsqhs-standards

Information on Implementation of the NSQHS Standards can be located at: https://www.safetyandquality.gov.au/standards/nsqhs-standards/implementation-nsqhs-standards

For any additional questions related to AWH”s Transition to Short Notice Accreditation Assessment please contact the Clinical Safety and Quality team

And always remember: