National Safety and Quality Health Service Standards: Governance, partnering with consumers and healthcare associated infection

As of January 1 this year, all Australian hospitals and day procedure services began accreditation against ten new National Safety and Quality Health Service (NSQHS) Standards, writes the Australian Commission on Safety and Quality in Health Care’s Amy Winter.
The NSQHS Standards, mandated by Health Ministers as a key priority for safety and quality in health care, focus on areas that are essential to improving patient safety and quality of care.
They were developed by the Australian Commission on Safety and Quality in Health Care (the Commission) to drive the implementation and use of safety and quality systems, and provide a nationally consistent statement of the level of care, consumers should be able to expect.
Through the implementation of the NSQHS Standards, hospitals and day procedure services will be able to provide a measured approach to improve the quality of health care services provided to all Australians.
There are ten NSQHS Standards. Eight focus on good clinical practice in areas that present the greatest risk to patients when they access care, like infections, medication errors, gaps in information exchange when they move between carers, falls, pressure injuries and errors from transfusion of blood. There are also two overarching standards, one that sets the governance framework to ensure accountabilities and clear responsibilities for keeping patients safe, and a Standard that requires the engagement of consumers in the processes of developing and reviewing health services.
The Standards are evidence based and supported by extensive programs undertaken largely by the Commission in collaboration with technical experts, health services, clinicians, consumers and other organisations. By making them the centre of a mandatory accreditation program there is a consistent external verification process in place.
Accreditation to the NSQHS Standards came into effect on 1 January 2013, with flexible transition arrangements in place for the first year. This article outlines the purpose and benefits of the first three Standards:

1. Governance for Safety and Quality in Health Service Organisations


2. Partnering with Consumers


3. Preventing and Controlling Healthcare Associated Infections.

Standard 1 Governance for Safety and Quality in Health Service Organisations.
Standard 2 Partnering with Consumers.
Standard 3 Preventing and Controlling Healthcare Associated Infections.
Standard 1
Governance for Safety and Quality in Health Service Organisations
Although most health care in Australia is associated with good clinical outcomes, patients still do not always receive all the care that is recommended to them, and preventable adverse events continue to occur across the Australian healthcare system.¹
The intention of the Standard 1: Governance for Safety and Quality in Health Service Organisations is to create integrated governance systems that maintain and improve the reliability and quality of patient care, as well as improve patient outcomes. Through this Standard, health service organisation leaders will implement governance systems to set, monitor and improve the performance of the organisation and communicate the importance of the patient experience and quality management to all members of their workforce. Clinicians and other members of the workforce will use the governance systems that are put in place.
The Governance for Safety and Quality in Health Service Organisations Standard provides a safety and quality framework by outlining the expected structures and processes of a safe organisation. The framework provided in the Standard will enable organisations to develop and implement their own comprehensive governance systems, taking into account local needs and values.
This Standard will ensure:

• that there is an integrated system of governance that actively manages patient safety and quality risks


• the clinical workforce is guided by current best practice and uses clinical guidelines that are supported by the best available evidence


• managers and the clinical workforce have the right qualifications, skills and approach to provide safe, highquality health care and


• patient safety and quality incidents are recognised, reported and analysed, and the information is used to improve safety systems

Standard 1: Governance for Safety and Quality in Health Service Organisations is one of the overarching requirements for effective implementation of the other NSQHS Standards.
Standard 2
Partnering with Consumers
In 1978, the Declaration of Alma Ata stated that ‘The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.’² Since then, there has been an emergence of policies promoting the rights and responsibilities of consumers and carers within the healthcare system, and an increasing focus on consumer and carer participation and collaboration in the planning, design, delivery and evaluation of health care. There has been a slow but steady shift towards the recognition that healthcare providers, healthcare organisations, consumers and carers are all partners in the healthcare system.
Evidence is now emerging about the benefits that partnerships with consumers can bring.³ Involvement of consumers in service planning, delivery, monitoring and evaluation is more likely to result in services that are more accessible and appropriate for users.^4-5 Feedback on consumers’ experience of healthcare organisations has been shown to strongly correlate with measures of clinical quality, such as mortality and infection rates.^6-8
Standard 2: Partnering with Consumers requires the engagement of consumers in the processes of developing and reviewing health services.
Effective partnerships with consumers and carers exist when they are treated with dignity and respect, when information is shared with them and when participation and collaboration in healthcare processes are encouraged and supported to the extent that consumers and carers choose.
Involving consumers in the governance of healthcare organisations is an important aspect of establishing these partnerships. Consumers have a unique position and perspective which can help to identify opportunities for improvement at an individual and organisational level, which otherwise might not have been identified.^9-10 For example, research has shown that consumers can readily identify adverse events and incidents which occur in hospitals.^11-12
Partnering with consumers in governance is about listening to and using consumer knowledge, skills and experience in a systematic way to make the health care that is delivered better. These partnerships can be demonstrated in a variety of ways. They can involve including consumers on boards, establishing consumer advisory committees, working with consumers to shape safety and quality initiatives, and coopting consumers into the planning and design of health services. Strategies for obtaining feedback from consumers include the use of surveys, focus groups, committees, incident reviews, compliments and complaints processes.
There has also been an increasing interest and research into partnering with consumers through co-design or experienced-based design. There is now evidence that involving consumers in the planning and design of healthcare environments and services can have significant benefits in terms of strengthening relationships and empowerment of both staff and consumers,13-14 as well as contributing to the reorientation of services to the needs and preferences of consumers.¹⁴
The health experiences of Australians compare well to other countries,¹⁵ and it is often assumed that partnerships with consumers are well-established and operating effectively. However, anecdotal feedback received by the Commission suggests that many healthcare professionals and organisations are unsure about what partnerships in governance might mean. They are also equally uncertain about how to go about implementing strategies to support partnerships in governance, and engaging and involving consumers in their organisation’s safety and quality processes in a systematic and organised way.
Together with Standard 1: Governance for Safety and Quality in Health Service Organisations, Standard 2: Partnering with Consumers is one of the overarching Standards that apply across the clinical areas of the other eight Standards.
The Commission has established a mailing list for people interested in this area, and provides regular updates and newsletters. To subscribe to this list, email mail@safetyandquality.gov.au, and ask to join the mailing list for partnering with consumers.
Standard 3
Preventing and Controlling Healthcare Associated Infections
Healthcare associated infections (HAI) are the most common complication affecting patients in hospital. Infections increase morbidity, mortality, pain and suffering to patients, and are associated with significant resource costs, as they prolong hospital stays and create more work for hospital staff.
One of the most significant recent changes in relation to combating healthcare associated infections is the development of Standard 3: Preventing and Controlling Healthcare Associated Infections. The intention of this Standard is to prevent patients from acquiring preventable healthcare associated infections and effectively manage infections when they occur by using evidence-based strategies. Standard 3: Preventing and Controlling Healthcare Associated Infections ensures that health care services undertake to improve their systems and processes for reducing and addressing HAI. It has been developed in accord with the recommendations and evidence found in the Australian Guidelines for the Prevention and Control of Infections in Health Care (NHMRC, 2010).
At least half of all HAI are thought to be preventable and Australian and overseas studies have shown that mechanisms exist to reduce the rate of infections caused by health care.
Infection prevention and control practice aims to reduce the development of resistant infectious agents and minimise risk of transmission. However, just as there is no single cause of infection, there is no single solution to preventing infections. Successful infection prevention and control practice requires collaboration between executive leaders and clinicians, and implementation of a range of strategies across the healthcare system.
The criterion within Standard 3: Preventing and Controlling Healthcare Associated Infections require health services to demonstrate that:

• effective governance and management systems for healthcare associated infections are implemented and maintained


• strategies for the prevention and control of healthcare associated infections are developed and implemented


• patients presenting with, or acquiring an infection or colonisation during their care are identified promptly and receive the necessary management and treatment


• safe and appropriate antimicrobial prescribing is a strategic goal of the clinical governance system


• healthcare facilities and the associated environment are clean and hygienic. Reprocessing of equipment and instrumentation meets current best practice guidelines.


• information on healthcare associated infections is provided to patients, carers, consumers and service providers.

There are some key areas that were new for accreditation from January 2013, and are priorities in relation to infection prevention and control. These are:

• having an effective governance framework


• identifying what is working well and what needs to be changed or improved


• understanding risks in relation to infection prevention and control and having a plan to address and respond to identified risks


• having systems to gather, review and report evidence to demonstrate progress and improvement


• engaging with others in the organisation to meet the criteria

For more information about Standard 3: Preventing and Controlling Healthcare Associated Infections, email HAI@safetyandquality.gov.au.
Implementation Support
The Commission is supporting  health services implement the NSQHS Standards. Accreditation Workbooks have been developed for hospitals and day procedure services that provide useful information on the process, checklists and tools needed for self-assessment, and possible examples of evidence. The Commission has also developed Safety and Quality Improvement Guides. There is one Guide for each Standard. The Guides will help health services focus their quality and improvement activities within the framework set by the NSQHS Standards.
An Advice Centre has also been established to provide information and support. If required mediation between health services and surveyors during surveys is available. This service can be accessed by telephone within Australia on 1800 304 056, via email on accreditation@safetyandquality.gov.au.
References
1. Australian Commission on Safety and Quality in Health Care. Windows into Safety and Quality in Health Care 2010. Sydney: ACSQHC, 2010.
2. Declaration of Alma-Ata; 1978. World Health Organization.
3. Australian Commission on Safety and Quality in Health Care. Patient-Centred Care: Improving Quality and Safety through Partnerships with Patients and Consumers. Sydney: ACSQHC, 2011.
4. Crawford MJ, Rutter D, Manley C, Weaver T, Bhui K, Fulop N, et al. Systematic review of involving patients in the planning and development of health care. British Medical Journal 2002;325(7375):1263.
5. Consumer Focus Collaboration. The evidence supporting consumer participation in health. Canberra: Consumer Focus Collaboration, 2001.
6. Edgcumbe D. Patients’ perceptions of hospital cleanliness are correlated with rates of methicillinresistant Staphylococcus aureus bacteraemia. Journal of Hospital Infection 2009;71(1):99-101.
7. Greaves F, Pape UJ, King D, Darzi A, Majeed A, Wachter RM, et al. Associations between web-based patient ratings and objective measures of hospital quality. Archives of Internal Medicine 2012;172(5):435-36.
8. Meterko M, Wright S, Lin H, Lowy E, Cleary PD. Mortality among patients with acute myocardial infarction: The influences of patient-centered care and evidence-based medicine. Health Services Research 2010;45(5p1):1188- 204.
9. Donaldson LJ. Put the patient in the room, always. Quality and Safety In Health Care 2008;17(2):82-83.
10. Iedema R, Allen S, Britton K, Gallagher TH. What do patients and relatives know about problems and failures in care? BMJ Quality & Safety 2012;21(3):198-205.
11. Conway J, Federico F, Stewart K, Campbell M. Management of Serious Clinical Adverse Events. IHI Innovation Series white paper. Cambridge: Institute for Healthcare Improvement, 2010.
12. Watt I. A review of strategies to promote patient involvement, a study to explore patient’s views and attitudes and a pilot study to evaluate the acceptability of selected patient involvement strategies. York: Patient Safety Research Group, University of York, 2009.
13. Iedema R, Merrick E, Piper D, Britton K, Gray J, Verma R, et al. Codesigning as a discursive practice in emergency health services: The architecture of deliberation. The Journal of Applied Behavioral Science 2010;46(1):73-91.
14. Tsianakas V, Robert G, Maben J, Richardson A, Dale C, Wiseman T. Implementing patient-centred cancer care: using experience-based co-design to improve patient experience in breast and lung cancer services. Supportive Care in Cancer:1-9.
15. Davis K, Schoen C, Stremikis K. Mirror, Mirror on the Wall: how the performance of the US health care system compares internationally. 2010 Update.: The Commonwealth Fund, 2010:1-21.
More information
More information and resources to support implementation of the NSQHS Standards are available on the Commission’s web site at www.safetyandquality.gov.au or by contacting the Commission’s Advice Centre on 1800 304 056 or accreditation@safetyandquality.gov.au.