ACHS Position Statements

To provide more information on the direction and principles which underpin the work of the ACHS, we have published position statements on the following topics:

1.   THE PURPOSE OF AN ACCREDITATION PROGRAM

Position Statement

The purpose of the ACHS accreditation program is to guide the performance of organisations to deliver safe, high quality health care.

This ACHS program is based on standards and processes developed by health care professionals for health services[1]. 

The granting of accreditation status is the result of an independent, peer-based assessment of performance against those standards.

Rationale

·          Participating in an accreditation program or achieving accreditation status is not an absolute guarantee of safety as there are too many variables.

·          Accreditation should be and can be a very positive indication that a culture of safety exists in an organisation.

·          Accreditation supports and facilitates the minimisation of risk.

·          Accreditation results may be used by those responsible for operational management to assist in monitoring and improving performance.

How does the ACHS program operate?

ACHS Accreditation is a complete framework for measurement and improvement rather than a specific compliance audit.

2.   ACCREDITATION AND REGULATION – DIFFERENT BUT LINKED

Position Statement

The influence of the accreditation program should extend to all parts of an organisation and provide an overarching framework to improve care. Government regulation tends to have a more limited and specific focus.

Rationale

·          A quality framework incorporates governance, service delivery, financial, and administrative functions.

·          Accreditation programs can adapt to changing expectations very quickly.  Whereas regulation may be slow to adapt to new developments.

·          While regulation tends to set minimum standards, accreditation provides an adaptable framework which outlines structures and processes to meet both regulatory requirements and local needs

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3.   ACCREDITATION AGENCIES – THE CASE FOR INDEPENDENCE

Position Statement

To realise the benefits of ‘third-party’ review, accreditation agencies should be independent (from service providers) and transparent in their operations.

Accreditation agencies should also be accountable for their performance especially in relation to the rigour and reliability of their programs.

Rationale

·          Independence ensures freedom from influence on the results of performance assessments.

·          Independence of the accrediting body (from the service provider) can enhance consumer respect for accreditation.

·          The industry is arguably more responsive to an independent accreditation program that transcends jurisdictional boundaries.

·          An independent national body is also able to bring perspectives from beyond jurisdictional boundaries.

Is the ACHS independent?

The ACHS is an independent not-for-profit organisation.

Standards for evaluation, assessment and accreditation are determined by a committee drawn from peak bodies in health, representatives of government and consumers.

ACHS is governed by a Board of directors elected by Council members and supported by a corporate management structure.

The ACHS surveyors (professionals with recent health care experience) provide a recommendation on accreditation status to the ACHS Council. Normally three ACHS Council members vote on a survey report in order to determine an organisation’s accreditation status.

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4.   STANDARDS AND THEIR DEVELOPMENT

Position Statement

The most important issue is how standards are developed (as opposed to who develops standards).  For standards to be useful[1] they must:

1.       Address a recognised need

2.       Be evidence based (as far as practicable)

3.       Be developed through a transparent and consultative process

4.       Be outcome focused

5.       Achievable

6.       Measurable

Rationale

·          The current discussion as to whether control of the development of standards should be placed in the hands of government is a distraction.  There is no evidence base for this position.

·          However the ACHS recognises and supports that governments, as major funders and/or providers of services, should have a key role in the development of standards.

5.   STANDARDS FOR CLINICAL SERVICES

Position Statement

Standards for clinical services should be developed:

·          when there is a demonstrable need (such as to ensure best practice),

·          when evidence exists to support its adoption (where possible), and

·          with thorough clinical, consumer and industry consultation.

Rationale

·          Standards for specific clinical care models need to integrate into a broader organisation wide quality framework.

·          Clinician input must be integral to the development of any clinical service standards.

·          All standards need to be regularly reviewed and revised to reflect growth in knowledge and expectations.  The costs and logistical requirements need to be taken into account.

·          For clinical service standards to be effective resources to meet those standards must be provided.

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6.   PUBLICLY ACCESSIBLE STANDARDS

Position Statement

Standards should be readily available at no cost to any interested party.

Rationale

·          Free access to standards is important in demonstrating the transparency of an accreditation program.

How does the ACHS program operate?

ACHS standards are freely available

Click here to view the standards

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7.   DISCLOSURE OF PERFORMANCE INFORMATION

Position Statement

Appropriate information resulting from accreditation surveys should be publicly available.

Rationale

Accreditation programs were originally designed for use within a health care organisation.  However, over time consumers, health funders and corporate owners have sought increasing levels of performance related information.

How does the ACHS program operate?

In the interests of transparency the ACHS has increased the focus on providing information on accreditation performance through two main methods:

§          the introduction from, July 2007, of a requirement to publish an agreed Accreditation Performance Statement; and

§          the biannual publication of a National Report on Health Services Accreditation Performance.

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8.   CORRECTING POOR PERFORMANCE

Position Statement

It is the role of the health care organisation to have a structure in place to monitor and correct poor performance. Accreditation programs provide information that facilitates the identification and/or correction of poor performance.

Rationale

·          Accreditation agencies can play a part in correcting poor performance if requested, although this is not part of an accreditation process.

·          It is important that the provision of consultancy services is clearly and transparently separated from assessing performance.

·          Correction of poor performance, whilst usually simple, can be complex and have significant cost, service delivery and political implications.  It is not appropriate for an accreditation agency, which has no power to act, to carry this responsibility.

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