‘Quality Care Everyday’ - Embedding continual quality improvement into business as usual

Overview

Initiative type

System Improvement

Status

Deliver

Published

14 May 2018

Summary

The Short Notice Accreditation Assessment Pilot (SNAAP) embeds a state of continual readiness and continual quality improvement rather than accreditation process that is ‘event management’ approach.

A review of the SNAAP model found that most staff found it better than the standard notice model, the FTE requirements for accreditation preparation were significantly reduced and the results of accreditation more accurately reflected day-to-day level of quality and safety of the organisation.

Key dates

Jan 2018 - Dec 2019

Implementation sites

Metro South Hospital and Health Service (Logan and Beaudesert Hospital)

Partnerships

The Australian Council on Healthcare Standards (ACHS), Queensland Health, Australian Commission on Safety and Quality in Health Care (ACSQHC)

Aim


To be in a state of continual readiness for accreditation rather than an accreditation process that reflects an ‘event management’ approach. 

Benefits


  • Consistently high level of compliance with the National Safety and Quality Health Service (NSQHS) standards.
  • Organisational continuous readiness for accreditation.
  • Reduced cost in preparation for accreditation.
  • Improved staff engagement in quality and safety initiatives.

Background


In Australia, independent peer assessment generally occurs within a four-year cycle, with an announced pre-determined survey of a defined set of standards. A criticism of the scheduled accreditation survey is the emphasis within the organisation to preparation and improvement in the months leading to the planned accreditation date. This altered focus results in the redirection of activity from continuous quality improvement 1 and primary patient care goals 2. Furthermore, evidence demonstrates that hospital staff in managerial roles suffer elevated stress during the preparation period related to increased workload, negatively impacting physical and emotional health and reducing job satisfaction 3.

Performance improvements often prove challenging to sustain, although evidence shows the return of performance to ‘business as usual’ following the accreditation review 4,5.

A short-notice survey (SNS) accreditation process offers a solution to the limitations of the current accreditation process, while maintaining the benefits.

Solutions implemented


The trial was conducted using version 1 of National Standards. Under the short-notice survey accreditation process, each organisation is assessed on the ten mandatory NSQHS standards and five Evaluation and Quality Improvement Program (EQuIP) standards, with two on-site assessment visits held per year. National Standards 1, 2 and 3 and the mandatory criteria for EQuIP standards 11-15 will be assessed twice in the 4 year accreditation cycle. All other standards will be assessed once in a four year cycle.

The organisation is contacted 48 hours prior to the accreditation body arriving onsite and the list of standards to be assessed during this survey is also given at this time.

Under the pilot process, the hospital has up to 30 days following the survey to provide additional information to the survey team in response to the queries made during the assessment.

The process for serious clinical risk identified during the survey did not change under the pilot. The accreditation agency has the obligation for additional visits or escalation of issue if serious concerns are identified.

Evaluation and results


A midway review has found that 94 per cent of staff found Short Notice Survey better than the standard notice model. SNAAP has shown to be significantly more cost and time efficient in the 6 months leading up to accreditation and 82 per cent of staff believe Short Notice Survey is a better reflection of the true level of quality and safety in the organisation.

Lessons learnt


Employees feel more confident of the results from the short notice model.


References


  1. Ehlers LH, Simonsen KB, Jensen MB, Rasmussen GS, Olesen AV: Unannounced versus announced hospital surveys: a nationwide cluster-randomized controlled trial. International Journal for Quality in Health Care 2017, 29(3):406-411.
  2. Brubakk K, Vist GE, Bukholm G, Barach P, Tjomsland O: A systematic review of hospital accreditation: the challenges of measuring complex intervention effects. BMC Health Services Research 2015, 15:280.
  3. Elkins G, Cook T, Dove J, Markova D, Marcus JD, Meyer T, Rajab MH, Perfect M: Perceived Stress Among Nursing and Administration Staff Related to Accreditation. Clinical Nursing Research 2010, 19(4):376-386.
  4. Greenfield D, Braithwaite J: Health sector accreditation research: a systematic review. International Journal for Quality in Health Care 2008, 20(3):172-183.
  5. Devkaran S, O’Farrell PN: The impact of hospital accreditation on quality measures: an interrupted time series analysis. BMC Health Services Research 2015, 15:137.

Further Reading


Evaluation and Quality Improvement Program

Key contact

Branko Vidakovic

Director of Clinical Governance

Metro South Hospital and Health Service

Email:  Branko.Vidakovic@health.qld.gov.au

Last updated: April 2025

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