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Quality System Assessment Program

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What is Quality Systems Assessment (QSA)

The Quality Systems Assessment (QSA) program is a new initiative for the NSW health system and a key component of the NSW Patient Safety and Clinical Quality Program. The QSA program will be developed for most organisations within the public health system including the eight Area Health Services (AHS), the NSW Ambulance Service, Justice Health and the Children’s Hospital at Westmead.

As set out in the NSW Clinical Excellence Commission Directions Statement 2004 (page 7-8) QSA is described:

7.3 PHO assessment
In accordance with its statutory responsibilities, the NSW Health Department will define the standards t be evaluated in the quality systems assessments. The Clinical Excellence Commission (CEC) will assess Public Health Organisations (PHOs) using these criteria to identify whether they have effectively implemented the NSW Patient Safety and Clinical Quality Program.
The role of the CEC is to support PHOs to facilitate ongoing improvements in the delivery of health care.
The CEC will provide an assessment report to a PHO on conclusion of the quality system assessment, which may, where appropriate, also include recommendations for improvement. PHOs will be responsible for the implementation of recommendations.
7.4 Notification of the Department
The Department carries ultimate regulatory responsibility for patient safety. The Department will require and support PHOs to address risks that are identified by the CEC, or through its own sources of information and advice.
The CEC will provide the quality system assessment report to the CEO of the PHO and a copy to the Department. The PHO will notify the Department of the actions taken to address safety and quality issues contained within the report and work with the Department to ensure appropriate implementation.
The CEC will also be required to identify key system issues and work with the PHO and the Department, where appropriate, to implement agreed recommendations.

How it will work

The main objectives of the QSA program are to provide evidence of the following:

Assurance of compliance with
- Policies
- Standards
- Guidelines
Assessment of the level of development of
- A patient safety system
- Clinical quality improvement
The level of improvement at a local, facility and systems level
The identification of future risks to patient safety

The QSA program will focus on the systems for quality and safety in organisations within the NSW Health System and not on individual performance.
Due the complex nature of the NSW Health System there will be three levels of organisational focus for the QSA program. Each level is a key accountability point in the system and has responsibility and governance of patient safety and quality systems.
The three levels are:

Area Health Services
Facilities and / or Clinical Streams
Department / Clinical Units

The QSA will co-exist with current accreditation activities, not replace or duplicate them.

Anticipated benefits of the QSA program

The QSA program will identify areas for improvement and areas of exemplary practice in relation to quality and safety arrangements in the NSW health system. In addition the QSA program will be able to provide assurance about the quality of health services and compliance with standards and policy requirements developed by NSW Department of Health.

Work to date

In early 2006, the Clinical Excellence Commission working closely with expert consultants developed the methodology, conceptual framework and a model assessment tool for the QSA program. The consultant, KPMG, undertook a review of the literature and consultation with stakeholders and experts to help formulate a methodology and assessment framework. The major outcomes of this work include:

Identification of the most suitable approach for the QSA program to review the patient safety and clinical quality system with external verification of the internal audit process supported by an improvement framework ;
Development of a set of criteria to underpin the Safety and Clinical Quality Program Standards and to inform the development of the assessment tools;
Development of tools suitable for assessing the clinical quality and patient safety systems at Area Health Service (AHS) level.

The draft Area Health Service level Quality System Activity Statement was piloted in three AHSs during September- October 2006. The results from the pilot have provided useful information which will be used to refine the activity statement prior to roll out to other AHS.

Proposed model for the QSA

The QSA aims to evaluate the systems and processes that organisations have in place to control risks to patient safety. To minimise the burden of the QSA the assessment will focus on those systems to manage those risks that are widely acknowledged to have a significant impact on patient safety and the quality of care. Examples of risk controls include robust protocols for patient identification throughout the patient journey and management oversight through audit or observation to ensure these protocols are followed.

The preferred framework for the QSA has an improvement focus. It is anticipated that each year an identified area of high risk will be subject to in-depth assessment supported by opportunities to collaborate in improvement initiatives.

The QSA is based on the assumption that the systems will develop and mature so that those areas which show good performance are not assessed every year. It also recognises that different care settings will manage their risks in different ways and that there needs to be a degree of flexibility in how systems and processes work across the huge diversity which exists within the NSW Health system. This model will allow frontline clinicians and managers to modify their risk controls to suit the local context.

Further development of the QSA program

The CEC is further developing the QSA program to a stage that will enable roll-out of the Program across the eight AHSs, Children’s Hospital at Westmead, Justice Health and the NSW Ambulance Service. Work on this project will commence in January 2007.
Activities planned as part of this work include, but are not limited to:

Further development of the QSA program methodology, through additional literature reviews, consultation with experts, and review of the findings of the pilot of the AHS level Quality System Activity Statement;
A proof of concept exercise, in order to test the validity and practicality of the proposed QSA approach. This exercise will involve a ‘biopsy’ test of one element of a QSA standard at each of the three levels of the PHO – the AHS level, the facility/stream level, and the clinical unit level;
Development of a costing model for roll-out of the program;
Identification of relevant criteria and development of activity statements for facility/stream and clinical unit level.
Detailed mapping of accreditation standards and assessment criteria with that of the QSA to identify any areas of overlap in the scope of the QSA program with major accreditation agencies;
Piloting of the activity statement and validation methodology in AHSs at facility/clinical stream and clinical unit/department level and in the Ambulance service and Justice Health; and

Development of a database, analysis and reporting tools to support and facilitate benchmarking, networking and improvement of clinical quality and patient safety systems.

How the methodology will involve public health organisations and other experts

Taking in to account the views and feedback from experts and practitioners will be crucial to developing a QSA program which is both practical and effective. As such, a number of activities will be undertaken which involve organisations with the NSW Health System to elicit constructive feedback on the program.
These include:

Use of an expert reference group to provide critical advice throughout all stages of the project;
Consultation with staff involved at the AHS pilot site to understand the strengths and weakness of the existing program methodology;
Consultation workshops with stakeholder groups (including rural sites) to test the practicality and acceptability of the emerging QSA methodology;
Targeted interviews with subject matter experts; and
Piloting of facility/stream and clinical unit level activity statements at major health service sites (e.g. tertiary referral, major metropolitan, regional based hospital and multipurpose health centres), including a comprehensive evaluation of the pilot program.

The CEC will contact organisations within the NSW Health System and expert advisors directly for their input. State-wide stakeholder workshops will commence in February 2007.

Resources

For further information contact:
Ms Bernie Harrison
Director, Quality Systems Assessment (QSA)
qsa@cec.health.nsw.gov.au
Tel: (02) 9382 7614
Fax: (02) 9382 7615

Ms Bernadette King
Project Officer Quality Systems Assessment Program
qsa@cec.health.nsw.gov.au
Tel: (02) 9382 7829
Fax: (02) 9382 7615

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