Once the NSQHS Standards have been implemented and evidence has been collected to demonstrate that each action has been met, an accreditation survey can be conducted by an approved accrediting agency.
The steps involved in this process will be determined by your accrediting agency. The process is likely to include a self assessment followed by an external survey. You will receive a report on the findings and the agency will then confirm an accreditation award to the National Safety and Quality Health Service Standards.
Assessment and rating scale
Accrediting agencies may use their own rating scales when assessing public dental clinics, but will be required to use the following 3 point rating scale to report accreditation outcomes to both regulators and the Commission:
- Not Met – the actions required have not been achieved
- Satisfactorily Met – the actions required have been achieved
- Met with Merit – in addition to achieving the actions required, measures of good quality and a higher level of achievement are evident. This would mean a culture of safety, evaluation and improvement is evident throughout the public dental clinic in relation to the action or standard under review.
This rating system can be used to rate individual actions within a Standard and to rate the Standard overall.
When an action is not met
When an accrediting agency finds a public dental clinic is unable to comply with the requirements of the NSQHS Standards, the agency will initially inform the clinic to provide the opportunity for remedial action.
Public dental clinics will have 90 days (and 120 days for the introductory year of 2013) from the receipt of their survey report to rectify any ‘not met’ actions before a final determination is made on an accreditation award.
Where improvements are not implemented or patient risks not addressed, accrediting agencies will notify regulators. The exception to this may be where an accrediting agency identifies a significant or serious risk to patient safety. In these circumstances, regulators will be informed by the accrediting agency promptly. The notification will include information about the action the public dental clinic and accrediting agency have agreed will occur. An initial regulatory response may begin with a process of verifying the scope, scale and implications of the reported non-compliance and gradually increases in urgency and scope if the public dental clinic does not rectify the patient safety risk. States and territories have translated these requirements into their local regulatory context.
Appeals process
All accrediting agencies have a well established appeals process by which public dental clinics can appeal assessment decisions. Information on these processes should be accessed via your approved accrediting agency.