Section A - Policy
16. Specific Programs & Technical Details
Appendix 3-Accreditation Outcomes Program
Accreditation is an important baseline indicator of quality for all providers of public acute care services. All networks and hospitals are required to achieve and maintain their accreditation status as from 1 January 2000. Hospitals which are not in a position to achieve accreditation/certification by 1 January 2000 should submit a quality plan to the Department for assessment by 30 September 1999, detailing arrangements in place for future external survey and accreditation/certification.
In 1999-2000 accreditation bonuses will be linked to the provision of information to the Department about accreditation/certification survey outcomes.
- All networks/hospitals accredited as of 31 December 1999 should provide to the Department, by this date, a report detailing the outcomes of their most recent accreditation/certification survey. The Accreditation Outcomes Report (AOR) should specify:
- the level of accreditation achieved and expiry date;
- recommendations made by surveyors for improvement;
- high priority recommendations for action;
- commendations noted for outstanding achievement; and
- intended response by the network/hospital to address recommendations made, including timeframes.
- Those hospitals undergoing their first survey in late 1999 and who have not received the results of their survey by 31 December 1999 should provide an AOR to the Department as soon as possible following receipt of their survey report, in order to be eligible for bonus funding.
- Hospitals which are not accredited or have not undergone a first survey by 31 December 1999 will not be eligible for an accreditation bonus payment in 1999/2000.
- Upon receipt of the AOR, all A1, A2 and B group hospitals will be eligible for an additional specified payment of $30,000. All other hospitals will receive $15,000. Thereafter, annual funding will be conditional upon the provision of AORs to the Department for the duration of the accreditation period.
- AORs should be provided within 60 days of receipt of an accreditation/certification survey report or following finalisation of any appeals process, from the accrediting/certifying body and again following the periodic (external) review process at the midway point of an accreditation cycle. For example, for those hospitals seeking accreditation through the ACHS EQuIP and awarded full 4 year accreditation, an AOR should be provided at 2 points in an accreditation cycle approximately 2 years apart; following the organisation wide survey and following a periodic review.
- All AORs should be forwarded directly to the Quality Branch of Acute Health which will administer the accreditation outcomes program in conjunction with Regional Offices.
- Where high priority recommendations have been made (clinical or safety issues) the Department will follow up with the network/hospital to ensure their timely resolution.