The Australian Council on Healthcare Standards

A set of Frequently Asked Questions regarding the introduction of the new National Safety and Quality Health Service Standards and the EQuIPNational program have been created to assist ACHS members, and those interested in changing to ACHS programs.

For further information regarding the Australian Commission on Safety and Quality in Health Care and resources to assist you with implementing the NSQHS Standards, visit their website at www.safetyandquality.gov.au.

The following two brochures provide additional information on EQuIPNational and NSQHS Standards.

  • 1. What is Accreditation?

    Accreditation is the status obtained by an organisation after a successful third party external evaluation by a recognised body to assess whether an organisation meets applicable pre-determined and published standards.

  • 2. Is the ACHS accreditation process similar to an audit?

    No. The focus of ACHS accreditation programs is to provide a framework for continuous improvement. ACHS accreditation is not quality assurance, or ticking the boxes and staying at the same level of performance. It is about establishing a structure and processes that allow quality and safety to consistently improve over time.

  • 3. Is accreditation compulsory in Australia?

    Internationally and nationally, governments and funders are increasingly seeking objective evidence of continuous improvement, responsiveness to patients and quality health outcomes in a nation's health facilities. Globally there is an increased reliance by the public sector on the results of voluntary and regulated accreditation activities. While in the private sector many insurance funds are designating selected service providers on the basis of accreditation status. There is also an increasing demand for accountability of health services for the quality of care they provide.

  • 4. Is it compulsory to collect clinical indicators?

    Not from the perspective of the ACHS. The ACHS clinical indicator program is voluntary. However, to meet the standards of the ACHS accreditation program (EQuIP) an organisation is required to collect and evaluate relevant clinical indicators. This may be done through sets of indicators other than those established by the ACHS. For example some individual state health departments mandate the collection and submission of specific indicators. The benefit of collecting ACHS indicators is the ability to compare with peers and the national rate through six-monthly reporting arrangements.

  • 5. How is the ACHS funded?

    The ACHS is an independent, not-for-profit organisation. The vast majority of our funding is from our membership base. We also sometimes receive funding from government organisations and other industry bodies, linked to individual projects.

  • 1. Why did ACHS develop EQuIPNational if a national set of standards was being developed?

    The additional five standards that make up EQuIPNational (along with the mandatory 10 NSQHS Standards) have been created for those organisations seeking a comprehensive, organisation-wide level of accreditation. ACHS has a long history of being an Australian leader in healthcare accreditation. With the requirements of the new NSQHS Standards in 2013 our intention was to continue to provide leading accreditation services – not only for those who wish to meet the NSQHS Standards, but also for those who seek to retain some of the comprehensive quality and safety elements from EQuIP5. The five additional standards in EQuIPNational have been adapted to build on and complement the NSQHS Standards.

  • 2. What should I do if I want to take up EQuIPNational?

    Unless advised otherwise by you, ACHS will transfer your EQuIP membership over automatically to the EQuIPNational program if you are required to be accredited to the Commission’s NSQHS Standards. Your next event after 1 January 2013 will be under EQuIPNational.

  • 3. How does the rating scale with EQuIPNational work?

    EQuIPNational uses the same rating system as the NSQHS Standards (that is: ‘Satisfactorily Met’ and ‘Not Met’). This is to avoid confusion and duplication and ensure that the transition to the new program is seamless.

  • 4. How long is the EQuIPNational cycle?

    The cycle is a four year cycle. The requirements of the Organisational Wide Survey (OWS) will include all 15 EQuIPNational Standards and progress towards addressing recommendations from previous surveys; while the requirements of the Periodic Review (PR) are NSQHS Standards 1, 2 and 3 and the mandatory actions of Standards 11 to 15 and progress towards addressing recommendations from the previous survey.

  • 5. How can I access the EQuIPNational guides?

    The EQuIPNational guides have been available since December 2012 and are available to all ACHS members. ACHS members can also download them as a pdf from the ACHS website.

  • 6. Are there any mandatory actions in the EQuIP component (Standards 11 to 15) of EQuIPNational? i.e, emergency management, safety management?

    Within the five EQuIP-derived Standards, certain actions have been designated as mandatory. These actions, if not met, could risk the quality of care or the safety of people within the organisation. There are 24 mandatory EQuIPNational actions.

  • 7. What does an organisation need to do to achieve accreditation?

    In order to achieve full EQuIPNational accreditation, an organisation must be rated at least ‘Satisfactorily Met’ against all mandatory actions in Standards 11-15, in addition to the core actions within the ten NSQHS Standards.

  • 8. How does an EQuIPNational survey work, is it similar to an EQuIP5 survey?

    It is very similar to an EQuIP5 survey; however the surveyors are looking for evidence against the EQuIPNational Standards. The organisation for the survey itself is very similar to EQuIP5 with an agreed number of surveyors conducting an OWS. Our surveyors will endeavour to make the survey a positive, constructive and helpful dialogue and will offer advice and suggestions.

  • 9. What does the Self-Assessment look like in EQuIPNational?

    The self-assessment in EQuIPNational is designed to minimise the need for documentation to be submitted by the member organisation. What is required is for the member to update their member details section, provide an update of their progress against their recommendations from the previous survey, and submit a copy of the Quality Improvement Plan. Member organisations may also elect to submit a copy of the Risk Register.

  • 10. What does the Pre-survey Self-Assessment (PSA) look like in EQuIPNational?

    Before a survey the member is required to submit a Pre-survey Self-Assessment (PSA). The PSA should include updated member details section (including sites for survey), action taken towards addressing recommendations from the previous survey, self-ratings for each action and an action plan for any actions self-rated as ‘not met’ and a summary of key pieces of evidence for each of the 15 standards. The two rating scales for members to use since 1st of July, 2014 are 'Satisfactorily Met' and 'Not Met'. For each standard the member should provide at least one key piece of evidence for each criterion in that standard. The Quality Improvement Plan and Risk Register do not need to be submitted with the PSA, as these documents are reviewed onsite during the survey.

  • 11. Is it necessary for me to do a Pre-survey document prior to the OWS and PR?

    As mentioned above (Question 10.) before a survey the member is required to submit a Pre-survey self-assessment which will cover the above details and also requires members to submit a summary of key pieces of evidence for each of the 15 standards (OWS) or NSQHS Standards 1, 2 and 3 and mandatory actions for PR .

  • 12. How will the Advanced Completion (AC) process be applied in practice? For example, if my organisation has 23 hospitals as part of the membership, if some of the hospitals do not meet some of the core standards, will each hospital within the membership be given an AC?

    In the event that there are core or mandatory actions which are “not met” at the survey, the ACHS will offer members the option of an Advanced Completion (AC) survey. This will allow members a period of up to 90 days to address any ‘not met’ core or mandatory actions before a final determination on accreditation is made. In the example given there will only be one AC survey for the membership, but the surveyors would need to review those areas or services which were rated “not met” in the original survey.

  • 13. Will I be getting recommendations in EQuIPNational, even if we have met the Standard?

    Recommendations will only be given in the EQuIPNational and NSQHS Standards program if there are “not met” actions. The surveyors will also be given opportunities to provide suggestions for improvement to the standard if they feel that there are areas that the member could improve in.

  • 1. Is my organisation required to be assessed against the NSQHS Standards?

    Two key factors must be considered when answering this question. 1.The Australian Commission on Safety and Quality in Health Care (the Commission) has stated that “The National Safety and Quality Health Service (NSQHS) Standards are considered essential to improving the safety and quality of care for patients.” Under the new arrangements, health services such as hospitals, day procedure services and public dental clinics will be required to be accredited to the NSQHS Standards. Other health services may choose to use the NSQHS Standards as part of their internal quality systems. Accreditation to the NSQHS Standards commenced 1 January 2013 in line with individual health organisation’s current accreditation cycles. (reference: http://www.safetyandquality.gov.au/our-work/accreditation/ 2. Accreditation requirements rest with the Health Departments that regulate health services in various jurisdictions. It has been agreed that all (public and private) hospitals and day procedure services and public dental clinics will need to be accredited to the NSQHS Standards. However, some States and Territories have determined that additional services will also be required to be assessed to the NSQHS Standards. You should contact your relevant Health Department if you have any queries on specific health service accreditation requirements.

  • 2. Do dental practices have to be assessed to the NSQHS Standards?

    Public dental clinics are required to be accredited to the NSQHS Standards. Other dental practices will be encouraged to participate in accreditation to the NSQHS Standards on a voluntary basis for the first time. For private practitioners, the process will be established as a self-regulated scheme driven by the industry through the Australian Dental Association Inc (ADA). Dental practices participating in accreditation will need to work with an approved accrediting agency of their choice to demonstrate that they met the NSQHS Standards. The Commission is developing a range of resources to assist dental practices with implementing the NSQHS Standards and these can be accessed at the following link: http://www.safetyandquality.gov.au

  • 3. My organisation is required to be accredited to the NSQHS Standards – what are my options?

    Organisations that are required to be accredited to the NSQHS Standards can choose from two ACHS products: 1. The ACHS National Safety and Quality Health Services (NSQHS) Standards program, 2. The ACHS EQuIPNational program (EQuIP5 + National Standards) which addresses the additional areas of EQuIP5 but has had all the existing duplication between EQuIP5 and the National Standards removed. More details on these programs are contained below in the relevant sections.

  • 4. What program does the ACHS recommend I do?

    The ACHS is proud to recommend our EQuIPNational product as this comprehensive program covers both the NSQHS Standards and other areas that are of key importance in the delivery of health care services and addressing the risks associated with the management of health care services. The EQuIPNational program complements the NSQHS Standards by reviewing the “support” and “corporate” aspects of healthcare delivery in addition to the NSQHS Standards. An organisation which undertakes the EQuIPNational program will have a wide ranging program that will stand them in good stead and will cover additional jurisdictional/regulatory requirements. ACHS can give advice on all its program options through its Customer Services Managers (CSMs), and will pass on any knowledge regarding State and Territory requirements, as that is declared. As ACHS is not a regulatory body, ACHS recommends that member organisations contact their relevant State or Territory regulatory bodies to confirm exact accreditation requirements.

  • 5. Can ACHS accredit health services to the NSQHS Standards?

    Yes, the ACHS is an approved accrediting agency. This means the Commission has approved ACHS to assess health services to the NSQHS Standards. The ACHS offers two ways to become accredited to the NSQHS Standards – either through the ACHS NSQHS Standards program, or through the EQuIPNational program. Both of these programs offer an organisation accreditation to the NSQHS Standards.

  • 6. What is the length of each program membership?

    The ACHS NSQHS Standards program is a three year membership program. EQuIPNational is a four year membership program.

  • 7. What happens to recommendations from previous EQuIP surveys?

    ACHS will transfer those recommendations that map to the NSQHS Standards to be reviewed at the NSQHS Standards survey.

  • 8. Where can I get a copy of the Commission’s NSQHS Standards?

    Copies of the National Safety and Quality Health Service (NSQHS) Standards are available from the Commission’s website and can be downloaded from: http://www.safetyandquality.gov.au/publications/national-safety-and-quality-health-service-standards/

  • 9. Is there a guide for the Commission’s NSQHS Standards?

    The Commission has developed a range of resources to assist health services implement the NSQHS Standards. These include: Safety & Quality Improvement Guides for each NSQHS Standard and Accreditation Workbooks. These are available from the Commission’s website at http://www.safetyandquality.gov.au

  • 10. Is the ACHS producing a mapping document between the NSQHS Standards and EQuIP?

    No, the Commission requires that the NSQHS Standards must be used in their original format and must not be adapted or replicated in any other format.

  • 11. Do I need to complete a self-assessment to the NSQHS Standards?

    The ACHS NSQHS Standards program requires that organisations undertake a self-assessment and provide evidence of their achievement to the Standard level. In addition the organisation will complete an action plan against any ‘not met’ actions.

  • 12. Can I still get help from my ACHS Customer Services Manager?

    Yes. All ACHS member organisations are entitled to assistance from a dedicated Customer Services Manager (CSM) who can support you.

  • 13. What would the ACHS recommend I do now to start the first steps towards meeting the new NSQHS Standards?

    The ACHS recommends that you become familiar with the NSQHS Standards and utilise the Safety & Quality Improvement Guides and Accreditation Workbooks to conduct a gap analysis for your organisation. The more familiar you are with the NSQHS Standards the easier you will find it is to understand and demonstrate evidence against them. We would also recommend that you become familiar with the Commission’s website at www.safetyandquality.gov.au as they not only produce the NSQHS Standards but have an extensive range of other resources and tools to assist you. You can contact your CSM if there is further, specific information you require, if it has not already been covered here.

  • 14. Does ACHS plan to have an online tool for both EQuIPNational and the new NSQHS Standards?

    Yes. The ACHS has developed a new online tool for our members, the Assessment Recording Tool (ART).

  • 1. What is the EQuIPNational Day Procedure Centres Program?

    EQuIPNational Day Procedure Centres is a three year accreditation program that ensures a continuing focus on quality across the whole organisation, for those organisations required to be accredited to the new National Safety and Quality Health Service (NSQHS) Standards. Developed in response to the Australian Commission on Safety and Quality in Health Care (ACSQHC’s) mandatory NSQHS Standards, these new Standards ensure organisations can meet the necessary requirements of the NSQHS Standards in 2013.

  • 2. Why has ACHS developed EQuIPNational Day Procedure Centres if a national set of standards has already been developed?

    As well as the ten NSQHS Standards, EQuIPNational Day Procedure Centres Offers a further five Standards, EQuIPNational Day Procedure Centres includes: Service and Care Delivery, Workforce Planning and Management, Information Management, Organisational Systems and Systems for Safety. The extra five Standards cover the holistic performance of service delivery processes, provision of care as well as non-clinical systems.

  • 3. How can I access the EQuIPNational Day Procedure Centres Program?

    ACHS is pleased to advise its day procedure centre members that the new EQuIPNational Day Procedure Centres program for day hospitals, day surgeries and day procedure services is now published and is available to download as a pdf from the ACHS website, under ‘Publications and Resources”.

Expertise Professional Good customer service.

ACHS member response to survey