This page contains answers to frequently asked questions about Western Health Accreditation against the National Safety and Quality Health Service (NSQHS) Standards.

On the right hand side of the page are resources to support areas to be ‘accreditation ready’.

Frequently Asked Questions

  • What are the NSQHS Standards?

    The Australian Commission on Safety and Quality in Health Care developed National, Safety and Quality Health Service (NSQHS) Standards to drive the implementation of safety and quality systems and to improve the quality of health care in Australia. The NSQHS Standards provide a nationally consistent statement about the level of care consumers can expect from health services.

    Health Services are required to be independently assessed for compliance against the NSQHS Standards.

    There are eight NSQHS Standards covering the following:

    1. Clinical Governance
    2. Partnering with Consumers
    3. Preventing and Controlling Healthcare-Associated Infection
    4. Medication Safety
    5. Comprehensive Care
    6. Communicating for Safety
    7. Blood Management
    8. Recognising and Responding to Acute Deterioration
  • When was our last Accreditation Survey and how did we go?

    Western Health had an incredibly successful survey in December 2023 against the eight NSQHS Standards.

    There was high praise from the Surveyors about the standard of care, commitment to being person-centred, our culture of respect and teamwork and involvement and empowerment of consumers in their care.

    There is one part of the Accreditation process though that we are still to complete.

    On 14 March 2024, two ACHS Surveyors will visit us to review a couple of areas identified in December as requiring some improvement; namely medical credentialing processes and the reporting of training data.

    We have undertaken considerable work to fully review and rectify/improve these areas. This work will be formally assessed by Surveyors on 14 March, with a final Survey Report issued after this visit and shared with staff.

  • When are we due to have our next Accreditation Survey?

    We will only have a NSQHS Accreditation Survey once in every 3 year accreditation cycle.

    Our current accreditation cycle came to an end when we had a survey in December 2023.

    We then start a new 3 year accreditation cycle in 2024

    We will only have one accreditation survey in 2024 – 2026 but it could be at any time in that period.

  • What happens when accreditation survey is announced?

    We have developed a plan to activate when we are given our 24 hour notice that Accreditation Surveyors will be visiting Western Health. Note: We will be given notice on a Thursday, with a Survey commencing on the Monday and concluding on the Friday.

    This plan includes a number of ways to notify staff, services and patients, including emails, PA announcements and screen savers.

    All staff communication will tell staff to access the home page of the Live Best Care site. A big banner with a link to Accreditation Survey roles for staff, FAQs and tools will be visible to support you through the Accreditation Survey.

    The link will take you to the following page which will be updated whenever survey is announced: NSQHS Accreditation Survey FAQs and Tools – Live Best Care (wh.org.au)

     

  • Will all Western Health campuses and services be visited during accreditation survey?

    Yes, all Western Health campuses will be visited during accreditation survey.

    Accreditation Surveyors will now spend much more time on our clinical wards and departments, with a target of 75 per cent of their time as compared to 60 per cent in 2020.

    All clinical areas in all Western Health campuses will be visited during Accreditation Survey.

    Non-clinical / Corporate Areas may still be visited by Surveyors and they are likely to ask questions of staff they see in public areas of our campuses.

  • What is the best way I can be prepared for accreditation survey?

    The best way you can be prepared for accreditation survey is to focus on living best care everyday, everywhere, every time.

    Every single staff member at Western Health — either directly or indirectly, whether clinical staff, non-clinical staff or volunteers — makes a contribution every day to supporting the provision of Best Care and the best experience for our patients.

    Best Care is care that is person-centred, co-ordinated, safe and right for each patient’s needs.

    Click here to learn more about our Best Care Framework and your role in living best care.

  • How will my service be supported to be 'accreditation ready' for survey against the NSQHS Standards?

    As part of a ‘business as usual’ approach to NSQHS Standard Accreditation Readiness, the following programs are in place:

    • A new NSQHS Standard of the Month Program
    • Executive Walkarounds
    • Guided use of Top Tips/Readiness Tools
    • The use of accreditation readiness standard agenda items and readiness messaging in established meetings/committees
    • The continued use of the WH Live Best Care site to communicate and provide access to accreditation related information
  • Are there resources my area can access to be ready for accreditation survey?

    The Are You Ready page on our Live Best Care site has a number of resources to assist with accreditation readiness.