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Our New Suite of Cognitive Impairment Resources

Posted on by Aaron Banick

Cognitive impairment is a broad term referring to difficulties that a person has with memory, thinking, their ability to learn new things, concentrate and communicate with other people. Cognitive impairment can be associated with a range of conditions, including dementia, delirium, an acquired brain injury, intellectual disability, and others.

People with cognitive impairment face greater barriers to receiving safe, high-quality care, and increased risks of preventable harm during care. The recent Royal Commissions into Aged Care Quality and Safety, and Violence, Abuse, Neglect and Exploitation of People with Disability have concluded that people with cognitive impairment are vulnerable to harm when systems are not implemented which meet their needs and protect their human rights.

Dementia and the Care Reform Agenda

This is particularly true for people who live with dementia, who routinely face challenges in receiving safe, accessible care which meets their needs and respects their human rights. The Australian Institute of Health and Welfare estimated that:

  • in 2021-2022, more than half of individuals living in residential aged care facilities had dementia;
  • Australia’s ageing population will contribute to an increased in the number of people living with dementia, which is predicted to more than double by 2058; and
  • in 2022 dementia was the second leading cause of death.

In late 2024, the Australian Government published its first National Dementia Action Plan which outlined a whole-of-government response to improve the quality of life and protect the rights of people with dementia. The Action Plan reiterated the reform agenda which has been ongoing across the health system, in aged care, and disability support services to better support people with cognitive impairment.

Actions and requirements relating to the care and support for people with cognitive impairment have been integrated into a number of practice standards, including the:

National Safety and Quality Health Service (NSQHS) Standards

  • Actions 5.29 and 5.30 under the Comprehensive Care Standard
  • Relevant to other actions including 1.15, 1.30, 4.10, 5.09, 5.33, 5.34, 5.35, and 8.05

NDIS Practice Standards

  • Considerations for people with intellectual disability and others who may have cognitive impairment are at the core of the NDIS Practice Standards and Supplementary modules for specialist behaviour support service providers.

Strengthened Aged care Quality Standards

  • Improving the quality, safety and accessibility of services for individuals with dementia was a key objective of strengthening the Aged Care Quality Standards.
  • Actions under Outcome 5.6: Cognitive Impairment
  • Actions under Outcomes 1.1, 2.2b, 2.9, 3.1, 3.2, 4.1b, 5.3, 5.4, 5.5 and 7.2
  • The Commission has indicated in their recent draft Audit Evidence Collection tools, that they expect organisations to have a current Cognitive Impairment Policy.

Our New Cognitive Impairment Resources

To help providers address this important issue and implement appropriate procedures, we’ve put a lot of work into developing resources which incorporate a range of rights-based considerations for supporting people cognitive impairment.

Our New Cognitive Impairment Policy Template:

Our new policy template addresses key considerations including:

  • Partnering with people with cognitive impairment, and safeguarding their rights to safe and effective care;
  • Supported decision-making and advance care planning;
  • Considerations for effective behaviour support planning and minimisation of the use of restrictive practices;
  • Considerations for managing medications, including reducing the use of psychotropic medications; and
  • Considerations for comprehensive care, including:
    • Nutrition, eating and hydration
    • Pain management
    • Falls prevention
    • Preventing and managing delirium

Updated Policy Templates:

We’ve added new sections to a number policy templates to incorporate additional considerations for supporting people with cognitive impairment, as well as linked them to relevant standards, including these ones:

  • Info: Intimacy and Sexuality (Aged Care)
  • Info: Nutrition, Meals and Hydration
  • Policy: Advance Care Planning
  • Policy: Clinical Deterioration
  • Policy: Diversity and Cultural Inclusion
  • Policy: Elder Financial Abuse
  • Policy: Intake and Referral
  • Policy: Intimacy and Sexuality (Aged Care)
  • Policy: Key Elements of Client Safety and Wellbeing
  • Policy: Managing Violence and Aggression
  • Policy: Medication Management
  • Policy: Nutrition, Meals and Hydration (Aged Care)
  • Policy: Pain Management (Aged Care)
  • Policy: Partnering with Consumers
  • Policy: Safety and Security in Residential Aged Care Facilities
  • Policy: Supported Decision-Making and Dignity of Risk
  • Policy: Use of Restrictive Practices (Aged Care)
  • Policy: Use of Surveillance Devices in Residential Aged Care Facilities

Our self-assessments supporting safe care for people with cognitive impairment

We have a number of self-assessments which support safe and accessible care for people with cognitive impairment including the specific requirements of the Delirium Clinical Care Standard and Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard.

We are continuously reviewing our resources to ensure that they incorporate best practice and especially based on input from our members. We have taken care to ensure that the updated resources are linked to relevant actions in key standards self-assessments as suggested evidence, to support ease of use. 

You can access these resources by logging into your SPP account and searching for them in the Reading Room or with a relevant keyword like “cognitive impairment”, “dementia”, or “delirium”. 

Interested in our cognitive impairment resources?

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Spotlight on 2024

Posted on by Tanya Haywood

With 2024 coming to an end, it’s a great time to look back at some of the biggest changes and developments of the year in the community and health services sector. 

Aged Care

Following the release of the final draft Strengthened Aged Care Quality Standards in December 2024, this year the focus was on preparing for implementation, which will commence in July 2025.  We worked hard over the 2024 Christmas break and then released an updated self-assessment for those Standards in early January, to help providers understand and prepare for expected changes and new requirements. 

Throughout the year, we’ve been reviewing our suite of resources against the draft requirements to ensure they’ll be ready to support providers’ compliance when the new Framework comes into effect. From revising 19 resources to cover new evidence-based care requirements, to updating our safeguarding resources in light of SIRS changes, to releasing a new policy template on Personal Property, and using Aged Care Quality and Safety Commission Clinical Alerts to guide the development of a new Extreme Heat policy template, we’ve been working to ensure we’re ready to support your organisation.  We’ve also just recently updated and added to our Medication Management resources.

Disability

The findings and themes of the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability have continued to inform changes in the disability sector (and beyond) throughout 2024. Following on from our work in 2023 to revise and update our safeguarding resources to reflect the recommendations of the Disability Royal Commission, this year we worked to create new resources and review our existing resources to reflect other recommendations. Some highlights include our new Policy: Human Rights and Policy: Disability Access and Inclusion. 

We also updated our NDIS Code of Conduct self-assessment to reflect changes to the legislation, and built a new self-assessment designed for Disability Employment Service (DES) providers to help them comply with the DES Quality Framework. 

More recently, we published a blog post on the NDIS regulatory reforms and some of the changes in the Disability sector, summarising the themes of focus, the changes already made and expectations for changes yet to come. 

We will be closely monitoring the release of the consultation draft of the new NDIS Practice Standards and Rules in early 2025.

Healthcare

This year we’ve had an increased focus on building self-assessments under the National Safety and Quality Health Service (NSQHS) Standards umbrella. We worked in collaboration with some of our members to develop self-assessments for three of the Clinical Care Standards, to help healthcare providers meet their NSQHS obligations when delivering specific care supports in the following areas: 

  • Antimicrobial Stewardship; 
  • Delirium; and 
  • Psychotropic Medicines in Cognitive Disability or Impairment. 

Following their launch in late 2023, we also released new self-assessments this year for the National Consensus Statement for End-of-Life Care and National Safety and Quality Cosmetic Surgery Standards. 

State and Territory Self-assessments

The States and Territories have also been busy in 2024. Updates to major social services standards in Victoria (Victorian Social Services Standards replacing the Human Services Standards) and Queensland (Human Services Quality Standards) have resulted in changes to our self-assessments, while we’ve also been building self-assessments for more specialised state and territory Standards, such as the: 

  • ACT Children and Young People (Care and Protection Organisation) Standards, 
  • NSW Point to Point Safety Audit Tool, and the  
  • SA Injury Management Standards for Self-Insured Employers.  

Many of our specialised state and territory self-assessments have been built in consultation with, or following requests from, our members, directly supporting their compliance. If there’s a self-assessment for a particular set of Standards you’d like to see in SPP, let us know! 

A key area of focus for the States and Territories this year has been child safety and protection, with both Tasmania and Queensland introducing their Child Safe Standards to join the National Principles for Child Safe Organisations, and the Victorian and New South Wales Child Safe Standards in the platform. We’ve built self-assessments for all of those jurisdictions, and will be watching closely for the release of child safe standards in other jurisdictions in the year to come! 

Workplace Reforms

Another priority this year relates to working conditions for staff. Updates to the Fair Work Act 2009 have changed the way organisations assess a person’s status as a contractor or casual employee, and work to protect work-life balance through new right to disconnect provisions. We’ve updated our Policy: Contractor Management in response to these changes, and will be working on resources about the right to disconnect in the new year. 

In addition, we’ve continued work on expanding and improving our suite of Workplace Health and Safety resources, including a new Manual Handling Policy, reviewed Whistleblower Management resources for added requirements in the new Aged Care Act 2024, and a helpful spotlight on workplace safety covering key areas in WHS. 

Extra Features in SPP

We also made some exciting changes to the SPP platform during the year. In addition to our Board Governance Toolkit which launched late last year, we’ve now added an in-platform Risk Register tool, with an integrated Heat Map, to help providers manage risks across their organisation. 

We’ve also made improvements to our document search system, allowing members to search for resources in the Reading Room that match particular Standards, and in many cases individual requirements within those Standards, to streamline the search process and help providers match resources that are going to be of most assistance to the requirements they need to meet. 

Looking Forward to 2025

2024 was a busy year in the community and health services sector, and 2025 is already shaping up to be the same. Major legislative developments in both the Disability and Aged Care sectors have recently passed, heralding significant changes to these areas in the new year- and we will be here to help you navigate all the changes you need to know about in 2025.  

We’ll be taking some time to celebrate the holidays and the New Year, so our last day in the office for the year will be Friday, December 20 and we’ll be back on Monday, January 6, but if you need urgent assistance over that time, we’ll still be monitoring our inbox and we’ll get back to you as soon as we can! 

All of our best wishes over the holiday season!

Spotlight on Antimicrobial Use in Aged Care

Posted on by Aaron Banick

A recent report on the use of antimicrobials in the community published by the Australian Commission on Safety and Quality in Health Care found that, while the overall use of antimicrobials in the Australian community has reduced over time, the dispensing of antimicrobials for residents of aged care homes and people over 65 is actually trending up.

What are antimicrobials?

Antimicrobials are medicines that are used to treat, prevent, and control a broad range of infections and infectious diseases, by inhibiting or destroying the bacteria, viruses or fungi that cause the infection.

The risk with over-use of antimicrobials is that antimicrobial resistance can occur. This happens when bacteria, viruses, fungi and parasites no longer respond to the antimicrobial medicines, lessening their effectiveness at fighting infections and therefore increasing the risk of severe illness, disability and death.

Antimicrobial resistance is accelerated when antimicrobials are unnecessarily or improperly used. This can result in negative effects across the entire health system, by increasing the likelihood of resistant infections and increasing the risk of other important health procedures including organ transplantation, major surgeries, and chemotherapy.

Enhanced risk for older people in care homes

Older people residing in care homes are at advanced risk off microbial infections, due to a few factors including:

  • They may have more than one medical condition affecting them (i.e. comorbidity);
  • Compromised immunity; and
  • The increased risk of exposure to infections due to frequent contact with staff, visitors and other residents.

Because older people are more at risk of infection, there is an enhanced risk that they may be prescribed antimicrobials inappropriately or unnecessarily. 

The Report

The Commission’s report, Antimicrobial use in the Community: 2023, draws from national prescription records between 2015 and 2023. The report found that the number of antimicrobial prescriptions in the general community between 2022-2023 remained roughly steady, at about 24% of the amount in 2015. However, this general downwards trend has not been reflected among older people, particularly residents of aged care homes.

Between 2022-2023, there was an 11.1% increase in overall antimicrobial prescriptions among residents of aged care homes. Nearly three quarters of residents received at least one antimicrobial prescriptions, which is well above the average of one-third for the general community. Older people living in care homes were also much more likely to be given broad-spectrum antimicrobials, even when they were not recommended for common infections.

Antimicrobial Stewardship

The report notes the critical importance of curbing the unnecessary or inappropriate use of antimicrobials through a dual strategy — preventing infections through minimising risk of transmission, and through promoting antimicrobial stewardship (AMS). 

AMS represents an ongoing effort by a provider to implement policies and processes which optimise and minimise the use of antimicrobials, to reduce the risks associated with increasing antimicrobial resistance.

AMS in the context of standards

Instituting best-practice AMS policies and procedures is a requirement of several sets of standards within the health and aged care sectors:

  • Health Services:
The Australian Commission on Safety and Quality in Health Care has included antimicrobial stewardship provisions within Standard 3 (Preventing and Controlling Infections) of the National Safety and Quality Health Services Standards, as well as within the related Antimicrobial Stewardship and Sepsis Clinical Care Standards.
 
AMS is also a requirement within the National Safety and Quality Mental Health Standards for Community Managed Organisations (Action 3.35), and the National Safety and Quality Primary and Community Healthcare Standards (Action 3.14). 
 
And AMS policies are relevant to compliance with the Royal Australian College of General Practitioners’ Standards for General Practice (Criterion GP4.1), which includes RACGP guidance for general practitioners on reducing risk of infections. 
  • Aged Care:

 The Aged Care Quality and Safety Commission has included antimicrobial stewardship within Standard 3(g) – (Minimisation of infection-related risks) of the Aged Care Quality Standards, and AMS also features prominently in the new Strengthened Aged Care Quality Standards under outcome 5.2 (Preventing and Controlling Infections).

The Commission advises aged care providers to implement best-practice processes and systems for monitoring antimicrobial use, to identify when prescriptions fall outside of recommended guidelines, and ensure that staff are educated on antimicrobials, including their responsibilities regarding antimicrobial stewardship. Additional information and resources can be found on the Aged Care Quality and Safety Commission’s website, including their antimicrobial stewardship self-assessment tool.

SPP Resources

Self-assessment modules to track compliance 

SPP provides a range of self-assessments for the standards mentioned above, to help you understand and track your compliance with their particular indicators or requirements regarding antimicrobial stewardship.

Policy templates to help implement procedures 

In addition, in SPP’s Reading Room you can find our Policy: Antimicrobial Stewardship, which is a valuable introductory resource for developing effective antimicrobial stewardship procedures. Antimicrobial stewardship should be developed alongside strong medication governance procedures. Our Policy: Medication Management will assist in outlining some key considerations.

These resources are complemented by our information and policy documents regarding Clinical Governance, and our self-assessment based on the Aged Care Quality and Safety Commission’s guidance for Clinical Governance.

We are also hard at work preparing for the upcoming changes in the Strengthened Aged Care Quality Standards so we can continue to support your efforts to deliver high quality aged care.

How is your organisation supporting AMS?

Sign up to SPP and let our antimicrobial stewardship resources guide you towards compliant processes!

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The Cosmetic Surgery Standards are now in place

Posted on by Quentin bngonline

As part of the national reform of the cosmetic surgery sector in Australia, the Australian Commission on Safety and Quality in Health Care (the Commission) developed and released the National Safety and Quality Cosmetic Surgery (NSQCS) Standards in December 2023. These aim to protect the public from harm and improve the quality of cosmetic surgery in Australia by mitigating risks relating to the delivery of clinical care within cosmetic surgery services.  

Who will the Standards affect?

These standards must be implemented by every service in Australia where cosmetic surgery is performed. The Commission has defined Cosmetic Surgery as an invasive surgical procedure that involves cutting beneath the skin (not injectables) for the purpose of achieving what a person perceives to be a more desirable appearance.

All services that offer these procedures, from small day procedure clinics to large health organisations, will be equally monitored against these standards. This does not include:

  • Non-surgical procedures that do not involve cutting beneath the skin (e.g. mole removal);  
  • Gender affirmation surgery; 
  • Surgery and procedures which may also lead to improvement in appearance; and 
  • Reconstructive surgery. 

The standards are aligned to the National Safety and Quality Health and Safety (NSQHS) Standards, which all hospitals and day procedure services (including services offering the above procedures) are required to follow. In addition to the NSQHS-aligned actions, there are also 20 actions specific to the delivery of cosmetic surgery that must be followed as part of the Cosmetic Surgery Standards. 

Organisations who already follow the NSQHS Standards may find it useful to use the Commission’s map of the NSQHS to NSQCS to guide their understanding of how the new requirements fit with their existing compliance.

What are the standards?

There are seven individual standards:  

  1. Clinical governance
  2. Partnering with consumers
  3. Preventing and controlling infection
  4. Medication safety
  5. Comprehensive care
  6. Communicating for safety
  7. Recognising and responding to acute deterioration

The first two standards, clinical governance and partnering with consumers, incorporate the clinical governance framework to establish the underlying requirements for services to effectively fulfill the subsequent standards. Each standard includes a consumer outcome statement, a statement of intent and then several items which are broken down into more detailed actions.  

Additional changes and reforms:

The standards have been curated to complement other reforms to the cosmetic surgery sector, including:  

  • legislative amendments to the requisite training required to acquire the title “surgeon”; 
  • changes to the national licensing framework for cosmetic surgery by the Commission; 
  • new guidelines enforced by the Medical Board of Australia (MBA) for conducting and advertising cosmetic surgery; and  
  • the introduction of a cosmetic surgery area of practice enforcement by the MBA.

For more information outlining these complementary reforms look here.

The Cosmetic Surgery Standards in SPP

To help you understand all these requirements and intended outcomes, we’ve built a new self-assessment in SPP for the Cosmetic Surgery Standards.  

This is in addition to our existing NSQHS self-assessments.

Need to comply with the Cosmetic Surgery Standards?

Sign up to SPP to ensure your organisation is meeting their new requirements!

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An Introduction to the Clinical Care Standards

Posted on by Quentin bngonline

What are the Clinical Care Standards?

The Clinical Care Standards are a group of 17 evidence-based quality statements that address the expected level of care and outcomes when managing specific health conditions.

They include guidance for both clinicians and health service organisations, and also include expectations for consumers receiving the relevant type of care. Each Standard includes a set of indicators that can be used by health service organisations to support implementation, monitoring and identify areas for improvement.

The aim of the Standards is to set out a baseline standard of care for the delivery of clinical care wherever this care is being provided, and to reduce variation in care outcomes. Broad implementation of the Standards should ensure that:

  • Patients understand the care they’ll be receiving in order for them to make informed decisions;
  • Clinicians and healthcare professionals understand current best practice, and use this to inform their care delivery; and
  • Health service organisations understand how to best support their clinicians and monitor the level of care their patients are receiving.

The National Safety and Quality Health Service (NSQHS) Standards, which must be followed by all public and private hospitals, day procedure services and public dental practices, include actions that support or require the implementation of the Clinical Care Standards.

Who should follow the Standards?

Two of the Clinical Care Standards, Antimicrobial Stewardship and Delirium, are explicitly referenced under Action 3.18 and Action 5.29 respectively of the NSQHS Standards. Compliance with the requirements of these Standards therefore forms a part of mandatory NQSHS compliance for health service organisations.

Advisory AS18/12 also mandates the Colonoscopy Clinical Care Standard for any health service organisation that provides colonoscopy services under Actions 1.23, 1.24, 1.27b, and 1.28a of the NSQHS Standards.

Following the Clinical Care Standards that are relevant to your service is strongly encouraged as best practice, as it supports improved outcomes for patients.  An evaluation report of the impact of the Clinical Care Standards on patient outcomes revealed that 92% of health organisations surveyed who had implemented one of the Standards reported that it improved the quality of care delivered to patients in that care area. Secondary health data sources relating to the Antimicrobial Stewardship, Delirium and Hip Fracture Standards demonstrate a correlation between the release of each Standard and improved outcomes in the respective areas.

Implementation of relevant Clinical Care Standards can help organisations meet their obligations under the NSQHS Standards, in particular Actions 1.01c, 1.27b, and 1.28.

Which clinical care areas are covered?

The following areas have a specific clinical care standard:

  • Acute Anaphylaxis;
  • Acute Coronary Syndromes;
  • Acute Stroke;
  • Antimicrobial Stewardship;
  • Cataract;
  • Colonoscopy;
  • Delirium;
  • Heavy Menstrual Bleeding;
  • Hip Fracture Care;
  • Low Back Pain;
  • Management of Peripheral Intravenous Catheters;
  • Opioid Analgesic Stewardship in acute pain;
  • Osteoarthritis of the Knee;
  • Sepsis;
  • Stillbirth;
  • Third and Fourth Degree Perineal Tears; and
  • Venous Thromboembolism Prevention.

In addition, the Australian Commission on Safety and Quality in Health Care is developing two new Clinical Care Standards, covering Chronic Obstructive Pulmonary Disease and Psychotropic Medicines in Cognitive Disability or Impairment. The Acute Stroke, Heavy Menstrual Bleeding, Osteoarthritis of the Knee, and Colonoscopy Standards are under review.

The Clinical Care Standards in SPP

A number of our health service clients asked us to look at developing self-assessments to implement some of the Clinical Care Standards. So we’ve worked with them to build one for the Antimicrobial Stewardship Clinical Care Standard, which is now available in SPP.

A self-assessment for the Delirium Clinical Care Standard is on the way next, so make sure to keep an eye out for it!

Organisations can use the results from completing each Clinical Care Standard as evidence to support their compliance against their NSQHS requirements.

If there’s a particular Clinical Care Standard you’d be interested in accessing as a self-assessment, we’d be keen to hear from you – just let us know!

Are you up to date with your NSQHS compliance?

Sign up to SPP to check how your organisation performs against the NSQHS Framework.

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How an effective call bell system can improve service provision 

Posted on by Quentin bngonline

An effective call bell system is a key part of safe and quality care delivery in facilities providing services to care recipients. It can play an important role in risk mitigation, staff management and ongoing continuous improvement processes, and also helps demonstrate to your care recipients your organisation’s commitment to safe and high quality services.  

Promptly responding to call bell requests from care recipients can aid in risk management and the prevention of issues such as falls or pressure injuries. Long or delayed response times for call bells can be a sign of policy or procedure issues relating to the staff model or communication. Monitoring call bell response times and the reasons for the calls can contribute to identifying opportunities to improve service delivery.

It’s therefore vital for organisations to have processes and procedures in place to provide this assistance for their care recipients.  

1. Staff management

One of the most important aspects of a call bell system is the provider’s ability to respond to requests in a timely way. To achieve this, facilities must manage their staffing and rostering to support their staff’s ability to respond to call bells. Failure to roster enough staff, overburdening staff with too many responsibilities, and a lack of communication around expected responsibilities, priorities and processes are all common explanations for high call bell response times. 

2. Standards compliance

While you won’t find call bells specifically mentioned in standards requirements, there’s a lot of indicators that can be supported by good call bell response practices. For example, in a number of Provider Performance Reports, the Aged Care Quality and Safety Commission has referred to call bell response times and reporting as relevant to its assessment of compliance by providers with: 

  • Standard 3(3)(b) – Effective management of high-impact or high-prevalence risks associated with the care of each consumer; 
  • Standard 7(3)(a) – The workforce is planned to enable, and the number and mix of members of the workforce deployed enables, the delivery and management of safe and quality care and services; and 
  • Standard 8(3)(d) – Effective risk management systems and practices.  

As another example, for care facilities following NSQHS, call bell system management and reporting is relevant in relation to the Clinical Governance Standard and the Comprehensive Care Standard.  

3. Quality improvement

Reviewing call bell response records can form an important part of an organisation’s continuous quality improvement processes. Accurate records of the reasons for each call bell use, as well as response times, are useful for verifying care recipient and staff feedback and/or complaints and highlighting where improvements can be made in service procedures. Commonly listed reasons for response times outside the target window indicate opportunities for organisations to review current processes and how they impact safe and quality service delivery. 

How SPP can help

We’ve developed a new policy template for providers with call bell systems to optimise their call bell procedures. The template will help providers set response time KPIs, clarify staff responsibilities, and put in place regular reporting and analysis.  

In addition, our SPP self-assessment platform allows providers to link their call bell records as evidence against relevant Standards. 

We're here to help.

Need help with your call bell procedures? Ask us about a free trial of SPP.

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NSQHS Accreditation Assessments for HSOs: What’s Changing? 

Posted on by Quentin bngonline

From July 2023, the National Safety and Quality Health Service (NSQHS) Standards assessment procedure for accreditation of hospitals or day procedure services (Health Service Organisations, or HSOs) will be changing, with mandatory short notice accreditation assessments replacing the existing announced and voluntary assessments.  

Why the change?

The move to short notice assessments is intended by the Australian Commission on Safety and Quality in Health Care (the Commission) to “support the continuous implementation of the NSQHS Standards and reduce the administrative burden of preparing for accreditation assessment”.

The new process is designed to move the focus of assessments from preparation for assessment, to assessment of day-to-day practice. It is intended to support and emphasise continuous self-assessment by HSOs of their compliance with the NSQHS Standards, as well as their implementation of continuous quality improvement strategies.

The Commission requires that HSOs have systems and processes in place to keep their self-assessment documentation up to date, and conduct reviews of their self-assessment and their compliance status at least every three months.  

When will we be assessed?

Short notice accreditation assessments will occur: 

  • at least once within each three-year accreditation cycle;  
  • at least 4 months before the HSO’s accreditation expires;   
  • no sooner than 6 months after the previous assessment; and 
  • within 4 years of the previous assessment. 

HSOs therefore need to be ready for an accreditation assessment at any time. HSOs may request up to 20 business days per accreditation cycle to be excluded from assessment. These are days where a short notice assessment would either directly impact the provision of the service to consumers or the consumers of the service would be unavailable.

When will we be given notice of an upcoming assessment?

The notice period for an upcoming assessment will differ depending on the HSO’s location and/or the specific services provided. 

  • If you are an HSO in a metropolitan, rural or regional area with public transport options, you will be given 24 hours’ notice of assessment. 
  • If you are an HSO in a rural or remote area with either no or restricted public transport options, you will be given 48 hours’ notice of assessment.  

For some HSOs where special permissions must be sought to conduct assessment, such as services in some Aboriginal communities, fly-in fly-out services or services operating in prisons, your assessment notice may be up to 4 weeks to accommodate these requirements. 

For more information, see the Commission’s fact sheet, or feel free to contact us if you have any questions about the new assessment changes.

The importance of active, continuous self-assessment

Regular self-assessment of your compliance with the NSQHS Standards will maintain a focus on identifying opportunities to improve your service delivery. It forms an important step in the cycle of active, continuous quality improvement. As well as tracking compliance with each standard, your self-assessment process should also incorporate improvement opportunities that you identify through consumers’ feedback and complaints, and also from any incidents or near misses that occur. 

Ideally, your streamlined self-assessment system should include: 

  • A chronological record of all the compliance gaps and improvement opportunities you identify, and when you’ve addressed them; 
  • The ability to collaborate on and track improvements, including by assigning responsibility for certain tasks to team members;  
  • A compliance status report that you can generate at any point in time; and 
  • The ability to store and link documentary evidence of your compliance with each standard (for example, relevant policies and procedures that are implemented across your organisation).

How SPP can help

Our NSQHS self-assessment modules allow providers to understand the requirements of the Standards in detail, collate all identified improvement opportunities through an individually curated action plan, and review and report on their compliance status at any time.   

They also provide a helpful way to link relevant evidence against each standard, streamlining the self-assessment process and ensuring that your evidence of compliance is kept up to date. 

SPP also has self-assessments for other standards within the National Safety and Quality family, including for: 

  • Digital Mental Health,  
  • Mental Health for Community Managed Organisations, and  
  • Primary and Community Healthcare. 

In addition, SPP provides a deep pool of resources in our Reading Room (such as policy templates and info sheets) covering all aspects of organisational good governance to help HSOs work towards best practice.  

You can find our NSQHS Standards self-assessments in SPP by searching for ‘NSQHS’ in the Standards tab or under the ‘Australian National Standards’ subheading in that same tab. 

Looking for NSQHS resources?

Sign up for a free trial of SPP.

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The new Digital Mental Health Standards

Posted on by Quentin bngonline

Accreditation to the National Safety and Quality Digital Mental Health Standards (NSQDMHS) became available for all organisations on November 1 2022. Digital mental health services provide valuable support to clients, as they can be easier to access for most clients, and they can also offer clients the opportunity to discuss issues anonymously.

Launched in November of 2020, the Standards are not mandatory, however they do provide an opportunity for providers to give greater confidence to users of their services.

Who are the NSQDMHS for?

The Digital Mental Health Standards are available to a variety of mental health support providers. These include providers of:

  • Peer to peer support;
  • Services that provide information about accessing mental health services;
  • Digital counselling; and
  • Treatment services (assessment, triage and referral).

Digital mental health services may be provided via telephone, video conference, online (including web chat), SMS, and mobile applications.

What is in the standards?

There are three standards, and a total of 59 actions within the Digital Mental Health Standards. The three standards are:

  • Clinical and Technical Governance Standard;
  • Partnering with Consumers Standard; and
  • Model of Care Standard.

The standards map directly to the National Safety and Quality Healthcare Standards (NSQHS), however they contain fewer requirements than the NSQHS.

For more information about the content within the National Safety and Quality Digital Mental Health Standards, see our previous blog post on the topic.

Should we consider accreditation to the NSQDMHS?

Accreditation to the Digital Mental Health Standards provides clients with the assurance that their service provider is meeting the expected standards for safety and quality. The standards will also help to refine a provider’s processes, and provide better outcomes for users.

Feedback from organisations who participated in the pilot program for the Digital Mental Health Standards was that the standards helped them to document the processes they already had in place, and helped them to identify if they had any issues or areas for improvement in their processes. Organisations highlighted the data collection and management requirements within the Standards, saying that these assisted in mapping patient care journeys and change management processes.

What is the accreditation process?

Accreditation is provided by independent accrediting agencies who have been approved by the AHSSQA Scheme. The Australian Commission on Safety and Quality in Health Care (the Commission) has a list of accreditors on their website.

The process for accreditation to the National Safety and Quality Digital Mental Health Standards is as follows:

Application and engagement

  • Application – apply to an approved accrediting agency
  • Preparation – implement the NSQDMH Standards and clarify arrangements for an assessment
  • Application for not applicable actions – not all of the actions within the NSQDMH Standards are applicable to all providers, here you will specify which actions are irrelevant

Assessment and remediation

  • Interim assessment – the approved accreditor conducts an interim assessment which includes:
    • Desktop review – a review of evidence submitted by the provider to demonstrate compliance with the NSQDMH Standards
    • Verification – an assessment to verify the safety and quality systems described by the provider
  • Remediation period – a period of 60 business days is allowed in order to address any areas where the service provider does not comply with the requirements of the Standards
  • Final assessment – this assessment is for the actions that were either ‘not met’ or ‘met with recommendations’ during the interim assessment

Outcome, reporting and monitoring

  • Outcome – the provider receives an outcome based on the final assessment
  • Final report – the accrediting agency delivers a final assessment report
  • Submission of data – the Commission is notified of assessment outcomes by the accrediting agency
  • Registration – the Commission adds the provider to their register of accredited digital mental health service providers
  • Ongoing monitoring – the service provider continues their monitoring and continuous improvement responsibilities

Further reading and how we can help

Since April 2021 we have had a module available to help providers self-assess against the NSQDMH Standards and ensure that their documented processes are in line with the requirements of the Standards. The module is intended to help to conduct a gap analysis before beginning accreditation, and with ongoing monitoring.

The Commission has developed a resource pack for the Digital Mental Health Standards, which can be found on their website.   

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Lessons from the pandemic: how Standards have evolved

Posted on by Quentin bngonline

We’re now two years into the pandemic, and the care and support sector has had to make some major adjustments to their service delivery in response to the COVID-19 crisis.

A number of standards have been amended or updated with significant new changes, to provide guidance on improving and standardising infection control processes, as well as ensuring that there are processes to manage workforce capacity and disaster readiness.

We’ve updated our self-assessments in SPP to reflect these changes, and thought it would be helpful to summarise the core themes that have emerged across the different major standards.  

Core infection control and disaster response themes

The core themes that have appeared consistently in standards updates include:

  • ensuring the workforce has the capacity, skills, training and equipment to implement infection prevention and control systems,
  • planning for and sourcing an alternative workforce in the event of disruptions,
  • developing, testing and reviewing an emergency and disaster management plan,
  • reporting to the governing body on infection control processes and implementation/testing of the emergency and disaster management plan,
  • testing, fitting and training in the use of PPE,
  • training in hand hygiene, respiratory hygiene and cough etiquette,
  • implementing stringent processes for communicating relevant information to family, patients and carers,
  • undertaking routine environmental cleaning,
  • ensuring workplace policies and procedures are in line with the relevant state or territory public health requirements,
  • managing movement of staff between areas and supporting staff required to isolate, and
  • procedures for waste management including safe storage and disposal of clinical waste.

These are some key areas that service providers should be addressing to ensure they are on top of their compliance requirements. Providers should check that they are familiar with any updates to standards that apply to their organisation. SPP can assist you with this, as we always update the modules on our platform in response to changes to standards.

Here are the main standards that have been updated to incorporate infection control requirements so far:

The updated Standards

National Safety and Quality Health Service Standards (NSQHS)

Changes to the NSQHS were introduced in May 2021 and include requirements to:

  • plan for public health and pandemic risks,
  • ensure the workforce has the capacity, skills, training and equipment to implement infection prevention and control systems,
  • test, fit, train workers and use PPE, and
  • ensure policies and procedures are in line with the relevant state or territory public health requirements.

NDIS Practice Standards

In November 2021 the NDIS Commission released a number of changes to these standards, to address:

  • planning for alternative workforce arrangements in the event of disruptions,
  • developing, testing, and reviewing emergency and disaster management plans,
  • implementing infection prevention and control precautions throughout all settings,
  • ongoing training on and supplies of PPE for workers, and
  • waste management including safe disposal of clinical waste.

QIC Health and Community Service Standards

In February this year, an updated version of the QIC Standards was released, with updates addressing infection control requirements including:

  • staff training in hand hygiene,
  • infection prevention management program aligning with state and territory guidelines,
  • regular cleaning of the environment, and
  • waste management.

Australian Community Industry Standard

The Australian Community Industry Standard was also updated towards the end of last year to include the following infection prevention and control requirements:

  • workplace preparation for pandemic,
  • workforce response to pandemic consistent with advice from health authorities, and
  • implementing and documenting an outbreak management plan.

RACGP Standards for General Practitioners

The RACGP Standards have seen a number of updates throughout 2021 and more recently in 2022, with the most recent update being in February 2022. The updated requirements address:

  • increased requirements around telehealth consultations (e.g. ensuring privacy etc.),
  • managing the risk of cross infection during a home visit,
  • updated processes for isolating patients and traceability processes for identifying patients who have used instruments,
  • establishing protocols for managing outbreaks of infectious disease in line with local, state and national guidance, and
  • environmental cleaning.

Aged Care Quality Standards

While the Aged Care Quality Standards haven’t been updated with new infection control requirements, the Aged Care Quality and Safety Commission has released a number of resources to guide providers in their implementation of infection control requirements. 

Resources to help you

We’ve developed and updated a number of resources in our platform to assist providers to manage infection control requirements under the standards that apply to them, as well as implement best practice processes. Here are some examples of how we can help:

  • a module for the “First 24 hours – managing COVID-19 in a residential aged care facility”,
  • a module to guide organisations to implement COVID-safe operations based on recommendations from Safe Work Australia,
  • a module to guide organisations through the components they should address in developing infection control / respiratory outbreak plan based on recommendations from various sources including the Department of Health, the Aged Care Quality and Safety Commission, and the NDIS Quality and Safeguards Commission,
  • resource templates including:
    • an outbreak management plan checklist,
    • an information sheet for employers on staff vaccination against COVID-19,
    • first 24 hours – managing COVID-19 in a Residential Aged Care facility checklist,
    • an emergency and disaster management plan,
    • emergency and disaster management procedures,
    • working from home policy,
    • working from home agreement,
    • client risk assessment.

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