Published on 24 January 2023

We are due to undertake health-service-wide accreditation against the National Safety and Quality Health Service (NSQHS) Standards in the second half of 2023. We last underwent accreditation at Western Health in 2020 – in fact it was the week before COVID was declared a pandemic. There have been a number of changes to the accreditation process since then, which include:

  • Accreditation now being a short-notice assessment rather than a scheduled event. For Western Health, this means we will get 24 hours’ notice any time from 1 July 2023 – 30 November 2023 that surveyors will be arriving for a week of survey. Although quite different to what we are used to, this is positive as it means surveyors will get to see us how we really are when undertaking our ‘business as usual’.
  • The surveyors will 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.
  • Our new mental health services will be included in the assessment.
  • Our evidence of compliance needs to be more evident and accessible than previously required.

Fortunately, we were already working on a business as usual approach to compliance against the NSQHS Standards before the above changes were announced on 16 January 2023. New multi-disciplinary (‘Fab 5’) teams for each standard commenced in October last year and are working in conjunction with key Western Health committees to ensure our Best Care quality systems are being used to continually monitor, review and improve compliance against the NSQHS Standard requirements.

At the start of November last year, there was great staff engagement in the Advancing Best Care week that included the launch of improved quality systems supporting compliance with NSQHS Standards such as PROMPT (policy & procedure platform) and the refreshed ABC (Audit Best Care) process and changes to the Riskman system.

The new Live Best Care site was also launched which will be a central hub for communications, information and links to business as usual evidence supporting NSQHS Standard compliance. With accreditation surveyors spending so much time in clinical wards and departments, this site will also be great resource for front-line staff to easily access information on our approach to Best Care to share with surveyors.

We passed accreditation with sterling results in 2020 and we have continued to improve! The really positive message from this survey was when surveyors were out talking to our staff and our patients and our volunteers, they all talked the language of Best Care – care that is person-centred, co-ordinated, right to meet the needs of patients, and safe. The short-notice accreditation survey in 2023 will be another opportunity for us to show Best Care in action and what great work we do. I have every confidence we will shine.

Information will start coming out over the coming weeks and months on things you can do to ensure you feel ready for our short-notice accreditation survey.

Regards,

Adjunct Professor Shane Crowe
Executive Director Nursing & Midwifery