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Accreditation of cancer services — a discussion paper

A core strategy for cancer care:

COVER Accreditation of Cancer Services.indd 1 8/03/2005 12:02:20 PM

A core strategy for cancer care:

Accreditation of cancer services – A discussion paper

February 2005

Prepared by the National Breast Cancer Centre

on behalf of the Australian Cancer Network

Funded by the Australian Government Department of Health and Ageing

Accreditation of cancer services ii

This report was prepared by the National Breast Cancer Centre for the Australian Cancer Network: National Breast Cancer Centre

92 Parramatta Road Camperdown, Sydney, Australia

Locked Bag 16 Camperdown NSW 1450

Telephone: +612 9036 3030

Facsimile: +612 9036 3077

Website: www.nbcc.org.au © The Cancer Council Australia, Australian Cancer Network and the National Breast Cancer Centre 2005 ISBN Print: 1 74127 103 7 Online: 1 74127 109 6

CIP: 616.9940994 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced without prior written permission from the National Breast Cancer Centre. Requests and enquiries concerning reproduction and rights should be addressed to the Communications Manager, National Breast Cancer Centre, Locked Bag 16 Camperdown NSW 1450 Australia.

Website: www.nbcc.org.au

Email: [email protected] Recommended citation:

The Cancer Council Australia, Australian Cancer Network and National Breast Cancer Centre. A core strategy for cancer care: accreditation of cancer services – a discussion paper. 2005 National Breast Cancer Centre, Camperdown, NSW.

Disclaimer The Cancer Council Australia, Australian Cancer Network and the National Breast Cancer Centre do not accept any liability for any injury, loss or damage incurred by use of or reliance on the information. The Cancer Council Australia, Australian Cancer Network and the National Breast Cancer Centre develop material based on the best available evidence, however they cannot guarantee and assume no legal liability or responsibility for the currency or completeness of the information.

Copies of this report can be downloaded from The Cancer Council Australia, Australian Cancer Network and the National Breast Cancer Centre websites:

www.cancer.org.au

www.cancer.org.au/ACN

www.nbcc.org.au

Accreditation of cancer services iii

C O N T E N T S

LIST OF TABLES vi

LIST OF FIGURES vi

ACKNOWLEDGEMENTS vii

EXECUTIVE SUMMARY 1

Standards development 2

An Australian model for cancer services accreditation 3

Conduct of accreditation 4

Linkage to existing accreditation agencies 5

Compliance 5

Issues 6

Concluding remarks 7

1. INTRODUCTION 9

Impact of cancer in Australia 9

The importance of evaluating quality in health care 12

Delivery of cancer services in Australia 18

References 24

2. CANCER STANDARDS 29

Defining standards 29

Accreditation of cancer services iv

International models for the development of cancer standards 31

Principles for the development of cancer standards in Australia 41

A framework for cancer services standards in Australia 42

Current activity in cancer services standards development in Australia 45

Key issues to be considered in the development of a national set of standards for

Australian cancer services 46

References 49

3. ACCREDITATION MODELS 53

Background 53

Lessons from the non-health sector 54

International health services accreditation models 54

Australian health services accreditation models 63

The relationship between standards development and accreditation processes 65

International cancer accreditation models 80

Cancer accreditation models in Australia 93

References 112

4. OUTCOMES OF THE SCOPING STUDY 119

Setting standards 119

An Australian model for cancer services accreditation 121

Conduct of accreditation 122

Accreditation of cancer services v

Linkage to existing accreditation agencies 123

Compliance 123

Issues 123

Concluding remarks 124

APPENDICES 125

Appendix I: scoping study methodology 125

Appendix II: organisations studied and stakeholders consulted 131

Appendix III: ISQua’s international principles for healthcare standards 2004 –

second edition 141

Appendix IV: description of cancer standards – international 145

Appendix V: description of standards in Australia – cancer and other relevant

standards 151

Appendix VI: approaches to cancer standards in Australia – State and Territory

activity 165

Appendix VII: Cancer Services Standards Framework 171

Appendix VIII: mapping current cancer standards and related activity against key

cancer focus areas 183

Appendix IX: comparison of approaches to accreditation in health in four

countries 195

Appendix X: comparison of approaches to accreditation in Australia – across health

care 201

Appendix XI: comparison of approaches to accreditation in Australia – specialist

areas of health care 205

Accreditation of cancer services vi

Appendix XII: comparison of approaches to cancer services accreditation –

international 223

L I S T O F T A B L E S

Table 1: Approval award matrix 84

Table 2: Standards achieved at different levels of accreditation 98

L I S T O F F I G U R E S

Figure 1: Organisational strategies to improve quality of care 13

Figure 2: Common processes in an accreditation approach 58

Figure 3: Statutory framework for licensing of private hospitals 69

Figure 4: Basic services provided by every CoC-approved cancer program 82

Accreditation of cancer services vii

A C K N O W L E D G E M E N T S

The National Breast Cancer Centre gratefully acknowledges the support of individuals

and organisations who contributed to the conduct of this study, in particular those who

participated in the stakeholder consultation process (see Appendix II).

Australian Cancer Network Accreditation Development Committee for Cancer Services

Professor Bruce Barraclough, Medical Director, Australian Cancer Network (Chair)

Associate Professor Michael Barton, Research Director, Collaboration for Cancer

Outcomes Research and Evaluation

Professor Jim Bishop, Chief Executive Officer, Cancer Institute NSW

Dr Fran Boyle, Medical Oncologist, Department of Clinical Oncology, Royal North Shore

Hospital, NSW

Ms Elise Davies, Manager, Cancer Coordination Unit, Department of Human Services,

VIC

Ms Diane Flecknoe-Brown (to Oct 04), Program Manager for Health, SAI Global

Associate Professor Paul Harnett, Director of Medical Oncology, Westmead Hospital,

NSW

Mr Brian Johnston, Chief Executive, Australian Council on Healthcare Standards

Dr Lizbeth Kenny, Radiation Oncologist, Division of Oncology, Royal Brisbane Hospital,

QLD

Dr Karen Luxford, Deputy Director, National Breast Cancer Centre

Mr Russell McGowan, Chair, Cancer Alliance Network

Accreditation of cancer services viii

Emeritus Professor Tom Reeve, Senior Medical Advisor, Australian Cancer Network

Mr Robert Schonberger (from Oct 04), Corporate Governance and Health Manager,

SAI Global

Professor Robert Thomas, Surgeon, Department of Surgical Oncology, Peter

MacCallum Cancer Centre, VIC

Dr Mary Turner, Medical Advisor, Metropolitan Health and Aged Care Services,

Department of Human Services, VIC

Funding

Funding for this Project was provided by the Australian Government Department of

Health and Ageing.

National Breast Cancer Centre Staff

Over the course of the Accreditation Scoping Study the following people were involved

as staff members in the conduct of the Project and/or the preparation of this report:

Dr Karen Luxford

Dr Alison Evans

Ms Elizabeth Metelovski

Ms Jane Francis

Ms Caroline Nehill

Ms Kath Vaughan

Ms Thea Kremser

Accreditation of cancer services 1

E X E C U T I V E S U M M A R Y

In 2004, the Australian Cancer Network (ACN) commissioned the National Breast

Cancer Centre to undertake a scoping study of current International and Australian

cancer service accreditation systems and processes, with a view to developing a

discussion paper identifying common themes, principles, criteria and processes that

may inform an Australian model of accreditation for cancer services. The study was

funded by the Australian Government Department of Health and Ageing. The study

involved a review of national and international literature regarding standards

development and accreditation processes, and consultations with key national and

international stakeholders. The study incorporated both healthcare accreditation

models and more specific cancer services accreditation. International models of

accreditation studied included those used in the USA, Canada, UK (including England,

Wales and Scotland) and New Zealand. Within Australia, relevant national and

State/Territory activity has been considered.

Development of an accreditation system for cancer services in Australia is complex.

Australia has a mixed model of care for patients with cancer involving both public and

private health sectors. In addition Australia’s unique geography presents the challenge

of ensuring equity across rural and remote areas. This is further complicated by the mix

of Federal and State/Territory governance. Moreover, cancer service delivery is an

evolving process in all States and Territories with cancer frameworks and plans at

differing stages of development.

The scoping study critically examined international and Australian cancer service

accreditation systems and standards with a view to identifying models that may be

applicable to the Australian health care system. In doing so, the study has identified

key principles, criteria and common themes that could be applied to the Australian

context and has highlighted relevant issues that should be considered when

implementing an accreditation system for cancer services.

Key questions addressed by the scoping study included identification of:

• relevant key accreditation bodies and their governance structures

2 Accreditation of cancer services

• standards development and measurement processes

• assessment processes/approaches used

• levels of accreditation and criteria for accreditation decisions

• sanctions and disincentives used where there is non-compliance

• feedback processes

• public reporting of accreditation results.

This report does not seek to define one model for cancer services accreditation in

Australia. Instead, it focuses on key elements that should be considered when

developing standards and implementing an accreditation system.

S t a n d a r d s d e v e l o p m e n t

Key outcomes from the scoping study have highlighted the need for:

• standards to be set at a national level to ensure consistency

• flexibility to take account of Australia’s mix of public and private systems and to

ensure appropriate linkages exist between public and private sector services

• consideration of service provision, referral and network arrangements in both rural

and urban contexts

• multidisciplinary input into the standards development process, including consumer

representation

• avoidance of duplication of existing standards

• numbers of standards to be kept to a minimum


• a staged approach whereby minimum standards that focus on process are initially

agreed

• appropriate standards review and revision processes with feedback from a range of

key stakeholders.

It is recommended that standards are based on the Cancer Services Standards

Framework (see Appendix VII), incorporating areas of:

• safety, quality and outcomes

• patient focus

• accessibility

• facility requirements

• elements in the patient pathway

• multidisciplinary care

• professional and staff development

• data management and cancer database operations

• research.

A number of quality criteria have been developed for the private health care sector.

The Private Health Industry Quality and Safety Committee (PHIQS) has endorsed that

private health care facilities should be accredited by industry-recognised and approved

accreditation agencies and that the quality criteria be included as a component of

standard accreditation requirements.


A n A u s t r a l i a n m o d e l f o r c a n c e r s e r v i c e s a c c r e d i t a t i o n

It is recommended that an Australian model for cancer services accreditation should:

• focus on quality improvement, with compliance rewarded and support provided to

encourage improvement

• be voluntary, with efforts made to gain support and buy in from key stakeholders to

increase participation

• be clinician-led, incorporating both self-assessment and peer review, with a written

report produced by assessors and presented to the accrediting body to inform an

accreditation decision

• involve consumer participation throughout.

The number of levels of accreditation awarded will need to be agreed and could be

used to indicate compliance, provisional compliance and non-compliance.

It is recommended that the accreditation process should:

• follow a three-year cycle, incorporating the development of action plans that are

monitored on an annual basis, with feedback provided to facilities as necessary

• ensure that the burden on health services and facilities is minimised

• be transparent with outcomes made publicly available

• be supportive with education provided to services following accreditation to rectify

problem areas and improve service on an ongoing basis

• take into consideration the demands of existing accreditation cycles on the

availability of assessors

• incorporate a transparent and accessible appeals and mediation process


• be reviewed at intervals, for example at the end of each accreditation cycle, to drive

improvement in the accreditation system.

C o n d u c t o f a c c r e d i t a t i o n

It is recommended that a peer-review process is followed and that the accrediting team

should:

• include oncology health professionals, technical experts and consumers

• receive training and support, with an external and independent quality assurance

system in place

• make a recommendation to the relevant accrediting body about whether

accreditation should be awarded.

Ultimately the accreditation decision will rest with the accrediting body.

A question remains about whether there should be one national accrediting body or

multiple agencies, either at a national or State and Territory level. While multiple

agencies may raise the issue of consistency and comparability, the existence of

defined and agreed standards, assessed by trained assessors, will facilitate

consistency of approach over a range of accreditation agencies.

Regardless of whether there is one or more accrediting body it is important that a

degree of autonomy from Government control is maintained.

L i n k a g e t o e x i s t i n g a c c r e d i t a t i o n a g e n c i e s

It is recommended that:

• the use of existing accrediting bodies within Australia is considered


• if multiple agencies are used, links between them should be established and

maintained from the outset

• the timing of accreditation cycles should be coordinated to streamline the process

for services.

C o m p l i a n c e

The success of an accreditation system will depend on the ability to embed it into the

organisational culture of each health service and facility. To this end, it is

recommended that:

• the accreditation process focuses on continuous quality improvement rather than

enforced regulation

• buy-in is gained from all relevant stakeholders at both a facility level and a health

service level from the outset through demonstration of the benefits of compliance

with standards and continuous quality improvement

• ongoing feedback and support are provided to demonstrate the benefits of the

process

• the number of standards and the administrative effort required to undertake an

accreditation process is minimised as far as possible.

Consideration should also be given to appropriate levers for accreditation. Possible

examples include:

• public reporting of accreditation results and promotion of accreditation services

• rewarding compliance with additional funding.


I s s u e s

There are a number of issues that will need to be considered in developing an

accreditation system for Australia. These include issues of:

• workforce, both in terms of the resources needed to undertake the accreditation

process and difficulties of workforce shortages in speciality areas that could

potentially preclude a service from meeting key standards

• leadership of the accreditation process, with champions identified at a national and

local level to drive the process and engender support from peers

• cost, with cost implications of accreditation considered and incorporated into health

service funding structures

• data collection processes and management.

C o n c l u d i n g r e m a r k s

Development of a national accreditation system for cancer services in Australia is

achievable. There are many lessons that can be learned from existing national and

international models. Key to the success of the process will be wide stakeholder

involvement, a focus on quality improvement and provision of adequate feedback and

support to encourage participation. Australia already has a number of activities and

accreditation systems in place that can be built on or adapted to focus specifically on

cancer services. The outcomes of this scoping study will be crucial in informing a

nationally consistent approach to cancer services accreditation.


1 . I N T R O D U C T I O N

I m p a c t o f c a n c e r i n A u s t r a l i a

Nature of cancer

Cancer is not a single disease, but a range of diseases with some common features

and some distinct characteristics that vary according to the site of origin and the cell

types involved. Common features of malignant cancers include uncontrolled growth

and the ability to invade and spread to other tissues (metastasis). Each cancer has its

own distinct pattern of growth and metastasis, which influences effects on morbidity

and mortality.

Known risk factors for cancer include lifestyle factors such as smoking and diet, age,

genetic mutations and exposure to common malignancies such as radiation or

infectious agents. However, for many cancers, the causes remain unknown. Early

detection and appropriate treatment are key to the successful management of many

cancers. The aim of treatment is to remove the cancer, destroy any remaining cancer

cells and prevent the cancer from recurring. Supportive care as an integrated

component of care, during, between and after periods of active treatment is an

important part of the management process. In cases where curative treatment is not

possible, services for palliative and end-of-life care must be in place. Thus, the people

and services involved in the management of cancer cover the full spectrum of care

including screening, diagnosis, treatment (surgery, oncology, and radiotherapy),

rehabilitation, supportive care, and palliative and end-of-life care. While cancer care is

highly specialised, involving hospitalisation and specialist treatment, a large part of a

cancer patient’s journey takes place in the community, managed by general

practitioners and community nurses. Each service involved can therefore not be viewed

in isolation, emphasising the need for care co-ordination and a multidisciplinary

approach.


Burden of disease

In Australia, one in three men and one in four women will be affected by cancer by the

time they are 75 years of age.1 Each year around 350,000 people are newly diagnosed

with cancer. Excluding non-melanocytic skin cancers, over 85,000 new cases of cancer

were diagnosed in 2000, with over 35,000 deaths from the disease.1 The most common

cancers in 2000, together accounting for 60% of all registrable cancers, were:

• colorectal cancer (12,405 cases)

• breast cancer (11,314 cases in women, 86 cases in men)

• prostate cancer in men (10,512 cases)

• melanoma (8531 cases)

• lung cancer (8060 cases).

In 2000, 27% of all potential life years lost were due to cancers (257,800 years).2

Mortality was highest in men for lung cancer, prostate cancer and colorectal cancer

and in women for breast cancer, lung cancer and colorectal cancer. Five-year survival

for all cancers was higher for women (63%) than for men (57%).3

In 2000–01, annual health expenditure due to cancer in Australia was $2.76 billion.4

This represented around 5.5% of the annual healthcare budget for Australia and meant

that cancer ranked as the ninth most expensive disease area for health expenditure.

However, these costs are not an estimate of the total economic impact of cancer to the

community in Australia as they do not take account of the social costs to carers and

family members, travel costs for patients, the cost of pain and suffering and the cost of

loss of quality and quantity of life.

Management of cancer in Australia involves both the public and private sectors. In

1993–94, 45% of the total health system costs for cancer were expended for public

hospital inpatients compared with 18% for private hospital inpatients, 7% for public

hospital non-inpatients, 14% for medical services, 4% for public health, 4% for research

and 10% for ‘other’.5 However, for health service delivery in general there has been an


increase in the proportion of private hospital admissions over recent years, which is

likely to be reflected in an increase in cancer-specific hospital admissions. In 1991–98,

38% of the total 264,372 hospital separations for cancer were in the private sector

compared with 45% of the total 316,853 separations in 2001–02.1

National Health Priority Areas

In 1996 the Australian Government identified seven National Health Priority Areas

(NHPAs). These are chronic conditions judged to pose a significant burden of disease

and to have the potential for significant health gains and improved outcomes for

patients.6 Cancer is included as one of the NHPAs in recognition of the burden it places

on the community.

The aim of the NHPA initiative is to:

• monitor health outcomes and progress in the NHPAs

• identify the most appropriate and cost-effective points of intervention

• identify the most appropriate role for government and non-government

organisations in fostering the adoption of best practice

• identify and discourage inappropriate practice

• address some of the underlying determinants of health such as education,

employment, and socioeconomic status.

Eight 'priority' cancers are currently targeted under this initiative: lung cancer;

melanoma skin cancer; non-melanocytic skin cancer; cancer of the cervix; breast

cancer; colorectal cancer; prostate cancer; and non-Hodgkins lymphoma.


T h e i m p o r t a n c e o f e v a l u a t i n g q u a l i t y i n h e a l t h c a r e

In discussions of quality of healthcare, the distinction must be made between quality

improvement – an ongoing process of continually improving service quality – and

quality assurance – an assessment of compliance against a set of standards at a given

time point. Within any service, it is important that both processes are operating

effectively.

Interest in processes and models for evaluating health care has increased since the

mid-1990s, driven in part by the need for countries to know more about resource use

and its impact in health care delivery.7 The need for risk reduction is another key driver

for quality improvement on the basis that compliance with standards based on best

available evidence should lead to improved patient safety and reduced medical errors.

The need for processes to evaluate quality in health and in other industries has led to

the development of a number of different quality improvement and assurance systems.

In 1996 the European Commission funded the 3-year ExPeRT project (the European

Research Project on External Peer Review Mechanisms), which identified four

common models of external quality systems in use by the European Union.8 The

models focused on:

• a process of peer review of health service delivery based around published

standards (accreditation)

• technical standards around processes and systems (the International Organisation

for Standardisation)

• business standards and customer and employee satisfaction (European

Foundation for Quality Management)

• a quality monitoring program around professional and clinical performance in terms

of knowledge, skills and attitudes (commonly referred to as ‘visitatie’ – the Dutch for

‘visitation’ or reciprocal visiting; this may be informal or in relation to the

assessment of clinical training).


Within the healthcare system, accreditation is the most widely used process for quality

evaluation. However, this is only one factor in the quality improvement process. Figure

1 illustrates the organisational strategies that contribute to improvements in quality of

health care.

What is accreditation?

There are number of definitions of accreditation. This scoping study focuses on the

accreditation of health services. Definitions of accreditation in this context vary in their

detail but have key common elements, such that accreditation can be defined as: ‘a

process of external peer review of an organisation’s processes and performance using

defined standards with the aim of quality improvement’. Accreditation generally

Leadership At Multiple Levels

• vision and ability to promote and manage change

• advocacy for public policy change • research commitment • accreditation • performance standards, fostering of

practice/norms • collaborative/coordination philosophy • quality control/improvement philosophy

prepared, proactive practice team

productive interactions and

encounters

informed, activated patients

{

OUTCOMES

Delivery System Design

• service arrangements/contracts • task delegation/teams • case/demand management • centralised/decentralised

services • appointing and other

procedures • quality control/improvements

processes • coordination with community

Clinical Decision Support

• guideline development, updating, dissemination and education

• continuing education • protocols/critical

pathways/prompts • access to specialists

Clinical Information Systems

• encounter reminders, flowcharts • risk lists of screenings or other

care due • tracking of patients not adhering to

screening, follow-up other recommendations

Patient self-management support

• education about health issues • information about service

arrangements • risk assessment surveys • reminders of specific service

needs • reminders to bring needs to the

attention of clinicians (proactivity) • tracking and follow-up of

incomplete adherence • patient held records

Figure 1: Organisational strategies to improve quality of care (reproduced with permission from Zapka et al 9)


includes both quality assurance and quality improvement processes and may

incorporate issues of patient safety and risk reduction.

A number of different health accreditation processes are in place both internationally

and within Australia. These have been described in detail in previous publications

produced by the Australian Council for Safety and Quality in Health Care,10 the Safety

and Quality Council8 and the Quality Improvement Council.11 Activities in the area of

cancer services accreditation are variable and are based on a range of cancer

frameworks, plans, organisations and process and standards. Many of these cancer

services accreditation activities are based on more general health services

accreditation models. The aim of this scoping study is to review current International

and Australian cancer service accreditation systems and processes, with a view to

identifying common themes, principles, criteria and processes that may inform an

Australian model of accreditation for cancer services. This will also require a

description of general health services accreditation. Later chapters of this report

provide details of different models for accreditation and standards development in

health services and specifically in cancer services.

Does accreditation work?

Despite rapid growth in the area of accreditation, there is as yet little evidence about its

impact or about the costs and benefits of accreditation processes. Several factors

make accreditation a difficult process to evaluate:12

• the endpoints of accreditation are hard to define and vary according to expectations

of users and observers

• individual programs vary around a common model

• accreditation is not a single process but a number of activities that interact to

produce organisational change

• few countries offer a background in which case-control studies of accreditation can

be satisfactorily performed without contaminating effects from other factors.


Despite these issues, there is consensus that accreditation processes and standards

development have played an important role in improving safety and quality in the

Australian health care system.10 At an international level, organisations that provide

accreditation, both in health care and other sectors, list numerous benefits of the

process. Many of these benefits are related to the perception that accreditation offers

an objective indication that an organisation, facility or service operates to a consistently

high standard.

Within the healthcare industry, accreditation is promoted on the basis of encouraging

consumer confidence,13–16 lending credibility to performance reports,14 helping

organisations attract a high standard of staff,13–15 and increasing opportunities to gain

funding.15 Formal benefits extend to the recognition given to accreditation by insurers

and other third parties13,14,16 and by referring professionals.14 Potential internal benefits

to healthcare organisations for accreditation include an increase in staff morale and

teamwork through involvement in the accreditation process13,14,17 while enhancing staff

education and providing professional consultation,13,14,16 all of which stimulate quality

improvement within the organisation.13 Accreditation providers promote ongoing

benefits after accreditation has been achieved due to continuing support provided

through information and education resources.14,16,18 Accreditation is also believed to

enhance an organisation’s system of risk management.18

Ultimately the aim of accreditation is to improve the quality of healthcare.14,16–18

Controlled studies of the effects of accreditation are few, but generally suggest that

healthcare organisations improve their compliance with standards when these are

made explicit.19 A randomised control trial of 20 South African hospitals found that

accreditation encouraged more efficient internal management functions and

considerably increased communication between various service areas.17 After two

years there were significant increases in standard compliance and in nurse perceptions

of clinical quality.20

The Agenda for Leadership in Programs for Healthcare Accreditation (ALPHA) program

was established in 1999 through the International Society for Quality in Healthcare

(ISQua) with the aim of demonstrating at an international level that accreditation is a

credible evaluation process and that national accrediting bodies can themselves be

evaluated objectively.21 The program also aims to provide a forum for sharing

information and experience about accreditation on an international level.


Importance of accreditation of cancer services

Cancer has a very significant impact on the Australian population. In recent years,

many improvements have been made in technologies and treatments for the

management of cancer. Mechanisms could be implemented through cancer services

accreditation to ensure the ongoing quality of cancer services in the domains of safety,

clinical effectiveness, governance and patient focus while recognising the importance

of coordination of care between services throughout the patient journey and

maintaining a cost-effective model. Relevant services include diagnosis, treatment

(surgery, oncology, and radiotherapy), rehabilitation, supportive care, and palliative and

end-of-life care. There is some debate around whether population-based screening

should be included within this model.

Role of standards in the accreditation process

The development of appropriate standards is integral to the accreditation process,

providing a benchmark against which service quality can be measured. It is important

to differentiate between standards and performance indicators. A standard describes

the minimum performance expectations, processes or structures that should be in

place to ensure safe, high-quality services, whereas a performance indicator is a

numerical threshold used to measure performance in a given area.11,22 Performance

indicators may be used to determine whether a service is meeting a given standard or

as an additional quality improvement mechanism to complement a set of standards.

However, it is the former definition that is most relevant in the context of providing a

structure for quality improvement through accreditation.

Standards can measure structure, process and outcomes. ‘Structure’ can be defined as

the physical and organisational characteristics of an organisation (e.g. staff,

equipment); ‘process’ as what is done in caring for the patient (what the provider does,

including the sequence of care delivery and the interactions that occur between the

patient and the health care provider); and ‘outcome’ as what is achieved in terms of

improvement in health, attitudes, behaviour or knowledge.23 Outcomes are more

difficult to evaluate due either to difficulties in defining the outcome or to delays


between implementing change and seeing measurable outcomes. Measurement of

process can act as a proxy for outcome as long as there is evidence to link the two.24

Key principles for accreditation and standards development processes

The Australian Cancer Network (ACN) has identified the following key principles that

could inform the development of accreditation and standards for cancer services in

Australia.

These principles highlight the need for processes to:

• be clinician-led

• include support services

• centre on patients and be designed to answer patient needs

• have the ability to demonstrate benefit for patients

• include a framework to prioritise safety

• use a whole-team approach

• be service based, rather than specific to a single cancer type or tumour stream

• involve all sectors that provide cancer care, including public and private services,

using a ’distributed’ service model.

The ACN also recognises the need to ensure that all the elements considered to be

important for a cancer service are in place and that the service meets patient needs

including:

• timely access eg to treatment and information



• co-ordinated care across hospital and community services

• psychosocial support

• safety

• compassionate and effective communication

• information

• education

• clinical trials access and through trials to new treatments.

While it is recognised that these needs may be serviced in varying ways in different

settings, the ACN has emphasised the importance for them to be reflected in an

identifiable and publicly known mission statement for each service.

D e l i v e r y o f c a n c e r s e r v i c e s i n A u s t r a l i a

Definition of a cancer service

Accreditation of a cancer service requires an adequate definition of what constitutes a

‘cancer service’. Management of cancer is a complex process that follows a continuum

from the point of screening and/or diagnosis through treatment and supportive care to

follow-up and in some cases palliative and end-of-life care in both hospital-based and

community settings. This continuum requires input from both primary care and a range

of speciality services including, but not limited to, screening, diagnostic imaging,

pathology, surgery, radiation and medical oncology, oncology nursing. familial cancer

clinics, psychiatric services, and a range of allied health and palliative care services.

There is some debate over whether population screening and end-of-life care should

be included within a definition of a cancer service. This already complex process is

further complicated in Australia by issues of geography and the mix of public and

private health service delivery. In some large urban multidisciplinary units, many of


these services may be provided at one site. However, in regional and rural areas,

services are likely to be located over a wider area or may not exist, requiring adequate

referral and outreach systems. Furthermore, a large part of a cancer patient’s journey

takes place in the community, managed by general practitioners and community

nurses. Thus a ‘cancer service’ may comprise of a number of distinct entities and

professionals that are not necessarily within the same location but are linked by a well-

coordinated system of referral.

Within Australia and internationally, various methods for categorising cancer services

have been proposed. For example, the Cancer Services Framework for Victoria25

proposes a five-tier model for cancer services based on the level and types of services

provided. The levels range from basic provision of chemotherapy using pre-ordered

materials with no dose adjustment possible, and access to rehabilitation services,

palliative care services and an on-call registered medical practitioner, but not

necessarily on site ( Level 1) to services with a full range of services including

diagnostic imaging, pathology and specialist oncology services (Level 5). This model

assumes that lower level services will be linked with higher-level services to meet other

requirements in the continuum of cancer care and stresses the importance of

incorporating at all levels strategies to address psychosocial and supportive care

needs, provision of information and care coordination.

A cancer care model for NSW was developed as part of the Optimising Cancer

Management (OCM) initiative in NSW.26 Prior to the development of the model, cancer

care in NSW followed a tiered approach to the definition of hospitals with district

hospitals classed as level 2/3, major metropolitan and non-metropolitan hospitals

classed as level 4/5 and principal referral hospitals classed as level 5/6. The OCM

initiative proposed a reconfiguration of existing services into the following three

organisational delivery components:

• Population Health Services encompassing prevention, screening and diagnostic

services on both an individual and population basis

• Cancer Units comprising Role Delineation Level 4 medical oncology, radiation

oncology and general surgical services, supported by nursing and allied health

personnel and located at a district metropolitan or major non-metropolitan referral

hospital (Base Hospital)


• Comprehensive Cancer Care Centres comprising Role Delineation Level 5 and

Level 6 medical oncology, radiation oncology and specialist surgical services,

supported by specialist nursing and allied health personnel and located within a

major metropolitan referral or principal referral hospital.

This model is similar to the model developed in England and Wales in response to the

Calman-Hine report in 1995,27 which made recommendations about the structure and

organisation of local cancer services. In this model, cancer units with sufficient

expertise and facilities to manage common cancers are present in many district

hospitals, while larger cancer centres provide expertise in the management of all

cancers and include specialist diagnostic and therapeutic services. These services are

linked by a system of networks that bring together all cancer services in an area. There

are currently 34 such networks in England.

The Calman-Hine report also developed a set of principles for cancer services:

• high quality care, available to all, as close to home as possible

• public and professional education to assist the early recognition of cancer

symptoms, together with national screening programmes

• clear information and assistance to patients and their families about options and

outcomes

• patient-centred services, taking account of patients’ views and preferences

• primary care involvement and good communication between different service

providers at all stages

• attention to psychosocial aspects of care at all stages

• cancer registration and careful monitoring of treatment and outcomes.

The role of networks in linking cancer services is also highlighted in the USA’s

Commission on Cancer (CoC)28 which again stratifies services according to the

services they provide into one of nine Cancer Program categories including Teaching


Hospitals, Community Hospitals and Network Cancer Programs (an entity comprising

at least one hospital that provides integrated cancer care).

Australian National and State/Territory cancer plans

Cancer services accreditation models need to exist within the broader context of

cancer frameworks and plans that have or are being developed at National and State

and Territory levels. These are described below.

National Service Improvement Framework for Cancer

A key initiative for the Australian Government in 2003–2005 is the development and

implementation of a series of National Service Improvement Frameworks (NSIF) for

cancer and other NHPA chronic conditions with the aim of streamlining the patient

journey and pathways of care.29 Development and implementation of the NSIFs is the

responsibility of the National Health Priority Action Council (NHPAC), a subcommittee

of the Australian Health Ministers Advisory Council. The NSIFs provide a framework for

driving improvement in health service delivery for the NHPA chronic conditions,

including cancer, identifying areas of need throughout the continuum of care for

patients with a particular disease or condition. Attention is focused on a set of 19

critical intervention points considered to offer the greatest potential for improving health

outcomes and ensuring that all Australians have access to the best evidence-based

care. The NSIF recognises that management of cancer is complex and that each

patient’s journey is different.

Throughout the NSIF for cancer, there is an emphasis on the importance of quality

assurance and quality improvement in all aspects of cancer management including

prevention, screening, diagnosis, treatment and supportive care.29 Not all of the critical

intervention points will be relevant under the definition of a cancer service for the

purposes of an accreditation system.


State-based cancer plans and frameworks

In addition to national initiatives, each State and Territory of Australia is undertaking

strategies to drive quality improvement in cancer care. Specific activities that may

contribute to accreditation in each State and Territory is discussed in Chapter 3.

The Cancer Institute NSW was established in 2003 through the Cancer Institute (NSW)

Act 2003 with the aim of improving cancer care in NSW. The NSW Cancer Plan (2004–

2006) defines strategic principles, goals and programs to accelerate cancer control in

NSW within a Clinical Service Framework for Optimising Cancer Care in NSW.30 The

NSW Cancer Plan takes a patient-centred approach and identifies the need for ‘a

commitment to excellence linked to appropriate evaluation and accreditation’ within

cancer control.

The report A Cancer Services Framework for Victoria, produced in 2003, outlines what

an optimal cancer service should look like and identifies gaps in the current system in

Victoria.25 The Cancer Services Framework outlines an integrated service model for

metropolitan and rural cancer services which focuses on delivering the right treatment

and support to patients as early as possible in their cancer journey. Hospitals, primary

and community health services will develop integrated care and defined referral

pathways delivered for the populations they serve. The reforms will be delivered

through two mechanisms: establishment of Integrated Cancer Services (ICS) to

support improvements in the integration and coordination of services within a

geographic area and the delivery of clinical treatment and care through 10 major

tumour streams that focus on reducing variations of care across the State and

promoting best practice through the development and implementation of evidence-

based practice and standards of care for each of the tumour streams.

Initiatives are also underway in other States and Territories. For example, In

Queensland a framework is being developed that attempts to outline what should be

involved in the delivery of cancer services and a Cancer Institute is being established in

Western Australia, through funding provided to the Charles Gairdner Hospital.


Role of the private sector

The Australian Bureau of Statistics (ABS) has reported that in 2002–2003, there were

536 private hospitals (comprising 271 acute hospitals, 25 psychiatric hospitals and 240

free standing day hospital facilities) in Australia.31 In addition, an ABS survey in 2001–

2002 indicated that as of the end of June 2002, there were 19,464 private medical

practices (including general practices and specialist medical practices) and 50

pathology laboratory businesses in Australia.32 These private services contribute

significantly to the management of cancer within Australia, through provision of a range

of services including surgery, oncology, radiology and pathology, and should be taken

into account when developing a cancer services accreditation model for Australia.

Licensing and accreditation of private medical services and hospitals by State-

/Territory-based agencies is a requirement of the health insurers that fund them.


R e f e r e n c e s

1. Australian Institute of Health and Welfare and the Australasian Association of

Cancer Registries. Cancer in Australia 2000. AIHW Cat No CAN 18; Canberra:

AIHW, 2003.

2. Australian Bureau of Statistics. Deaths, Australia, 2000. Cat No 3302.0;

Canberra: ABS, 2000.

3. Australian Bureau of Statistics. Year Book Australia 2004. Cat No 1301.0;

Canberra: ABS, 2004.

4. Australian Institute of Health and Welfare. Australia’s Health 2004. Cat No AUS-

44. Canberra, AIHW, 2004.

5. Clinical Oncological Society of Australia, The Cancer Council Australia and the

National Cancer Control Initiative. Optimising Cancer Care in Australia.

Melbourne: National Cancer Control Initiative, 2003.

6. Australian Institute of Health and Welfare and Commonwealth Department of

Health and Family Services. First Report on National Health Priority Areas. Cat

No PHE 1, 1996.

7. Heidemann EG. Moving to global standards for accreditation processes: the

ExPeRT Project in a larger context. International Journal for Quality in Health

Care. 2000;3:227–230.

8. Safety and Quality Council. Standards setting and accreditation literature review

and report. Canberra: Department of Health and Ageing, 2003.

9. Zapka JG, Taplin SH, Solberg LI, Manos MM. Commentary: a framework for

improving the quality of cancer care: the case of breast and cervical cancer

screening. Cancer Epidemiol Biomarkers Prev. 2003; 12:4-13.


10. Australian Council for Safety and Quality in Health Care. Standards setting and

accreditation systems in health: a consultation paper. Canberra: Safety and

Quality Council, 2003.

11. Skok A, Swerissen H, Macmillan J. Standards and quality improvement

processes in health and community services: a review of the literature.

Canberra: Commonwealth of Australia, 2000.

12. Shaw CD. Evaluating accreditation. International Journal for Quality in Health

Care. 2003;15: 455–456.

13. Millennium Behavioral Health Care (MBHC). Health care accreditation for the

21st century: benefits (webpage). Accessed 4/11/2004;

http://www.mbhc.com/benefits.htm.

14. Joint Commission on Accreditation of Healthcare organizations. Behavioral

healthcare, benefits of accreditation (webpage). Accessed 4/11/2004;

http://www.jcaho.org/htba/behavioral+health+care/benefits+of+accreditation.ht

m.

15. Bureau of Primary Health Care. JCAHO Accreditation (webpage). Accessed

4/11/2004; http://bphc.hrsa.gov/osnp/JCAHOAccreditation.htm.

16. Popovich ML. Joint Commission on Accreditation of Healthcare Organisations:

why become accredited? Benefits and values of Joint Commission

accreditation. Home Care Provider 1998; 3:173-175.

17. Quality Health New Zealand. Benefits of accreditation (webpage). Accessed

4/11/2004; http://www.qualityhealth.org.nz/show.asp?Pageid=13.

18. Whittaker S, Green-Thompson RW, McCusker I, Nyembezi B. Status of a

health care quality review programme in South Africa. Int J Qual Health Care

2000; 12:247-250.

19. Shaw C. External assessment of health care. BMJ 2001; 322:851-854.


20. Salmon JW, Heavens J, Lombard C, Tavrow P. The impact of accreditation on

the quality of hospital care: KwaZulu-Natal province, Republic of South Africa.

Bethesda. Quality Assurance Project, 2003.

21. Heidemann EG. The ALPHA program. International Journal for Quality in Health

Care. 1999;11:275–77.

22. Joint Commission on Accreditation of Healthcare Organisations. About

accreditation.

http://www.jcaho.com/general+public/who+jc/about+accreditation.htm Accessed

11/04.

23. Donabedian A. The quality of care – how can it be assessed? Journal of the

American Medical Association. 1988; 260: 1743–48.

24. Shaw C. Measuring against clinical standards. Clinica Chimica Acta 2003; 333:

115–24.

25. Barton M, Frommer M, Olver I, et al. A cancer services framework for Victoria

and future directions for the Peter MacCallum Institute. State Government of

Victoria, Australia, Department of Human Services, 2003.

26. NSW Health. Optimising Cancer Management. A Cancer Care Model for NSW.

Sydney, NSW Health Department, 1999.

27. The Expert Advisory Group on Cancer to the Chief Medical Officers of England

and Wales. A Policy Framework for Commissioning Cancer Services: a report

by the Expert Advisory Group on Cancer to the Chief Medical Officers of

England and Wales. Guidance for providers and purchasers of cancer services.

Department of Health, 1995.

28. Commission on Cancer. Categories of Approval.

http://www.facs.org/cancer/coc/categories.html Accessed 11/04.

29. National Health Priority Action Council. National Service Improvement

Framework for Cancer. 2004.


30. NSW Cancer Plan 2004-2006. Sydney. The Cancer Institute NSW, 2004.

31. Australian Bureau of Statistics. Private hospitals. 2002-2003. Cat No: 4390.0.

32. Australian Bureau of Statistics. Private medical practices 2001-2003. Cat No:

8685.0.


2 . C A N C E R S T A N D A R D S

This chapter examines:

• International models for the development of cancer standards

• Issues for consideration-International models for development of cancer standards

• Principles for the development of cancer standards in Australia

• Further Australian issues impacting on the development of cancer standards in

Australia

• A framework for cancer services standards in Australia

• Current activity in cancer services standards development in Australia

• Key issues to be considered in the development of a national set of standards for

Australian cancer services.

Information relating to standards in this chapter comes from literature reviews

undertaken by BreastScreen Victoria,1 Matthews Pegg Consulting,2 and Quality

Improvement Council (QIC)3 together with stakeholder consultations conducted by the

National Breast Cancer Centre (NBCC).

D e f i n i n g s t a n d a r d s

Standards are an integral component of any accreditation process. For the purpose of

this report, a standard is defined as:

‘a statement that defines the performance expectations and/or structures or processes

that must be in place in order for an organisation to provide safe, high quality care,

treatment and services’ (p.4).1


A set of principles for the development of standards were developed by ISQua as part

of its Agenda for Leadership in Programs for Healthcare Accreditation.4 These were

revised in March 2004 to encompass a broader range of health services standards

accreditation. The ISQua international principles for healthcare standards – second

edition5 provide a generic guide to the development of health care standards for

accreditation and are summarised below.

• Standards should contribute to improvements in quality and performance, both in

the health organisation and the wider health system. This includes defining and

monitoring systems of accountability and responsibility as well as systems of

continuous quality improvement. Standards should recognise and, where

appropriate, integrate legal requirements and health policy.

• The scope of the standards should be patient/client focused and encompass the

whole organisation, including its management and support infrastructure.

Standards should reflect the patient continuum of care. The responsibilities of

governance and of the client services should be defined and their performance

evaluated.

• The content of the standards should be comprehensive and reflect nine dimensions

of quality: accessibility, appropriateness, capacity, continuity, effectiveness,

efficiency, responsiveness, safety and sustainability. The dimensions of quality are

comprehensive, covering such aspects as the cultural sensitivity of Services, the

review of resource utilisation, consumer participation in Service delivery planning,

and staff recruitment and training.

• Standards should be planned, formulated and evaluated through a defined,

evidence-based process that involves professional, provider and consumer groups

and other stakeholders. This includes the use of a defined process to develop,

introduce, evaluate and revise standards, with the provision of information and

education to users and assessors within an appropriate timeframe.

• Standards should enable consistent measurement, with an unambiguous rating

system to assess performance against the standards, individually and as a set.

The results of users’ evaluation of the measurement system should be used to

make improvements.


(For full details on ISQua’s International Principles for Standards 2004 – Second

Edition see Appendix III).

I n t e r n a t i o n a l m o d e l s f o r t h e d e v e l o p m e n t o f c a n c e r s t a n d a r d s

Appendix IV provides an overview of the cancer standards that have been developed

by the CoC in the USA, the National Health Service (NHS) in England and Wales and

National Health Service Quality Improvement Scotland (NHS QIS) in Scotland.

Broadly, the development of cancer standards in these countries can be summarised

under three models.

Model 1: Standards development within a comprehensive cancer service with standards development led by health professionals (CoC in the USA)

In the USA, Commission of Cancer standards are developed with strong input from

clinicians and associated members of CoC. There are currently 100 individuals, who

are either surgeons representing the American College of Surgeons, or representatives

from 39 professional organisations affiliated with the CoC. These groups include the

Society of Surgical Oncology, American Society of Clinical Oncology, American

College of Radiology, and Oncology Nursing Society.6 Each of the 100 representatives

serve on one standing committee or disease site team of the CoC. CoC programs are

also supported by a network of more than 1,500 volunteer physicians representatives

who provide local support to a range of CoC services and cancer control initiatives.7 In

total, there are over 1,400 CoC approved cancer programs in the USA and Puerto

Rico, and representing almost one quarter of the hospitals that treat approximately

80% of newly diagnosed cancer patients.7

The principles that underpin the cancer standards of the CoC focus on five elements:

• provision of high quality clinical services that cover the cancer care continuum

• establishment of a multidisciplinary cancer committee


• establishment of cancer conferences

• evaluating outcomes and implementing improvements to care

• establishing a high-quality cancer registry and database to monitor quality of care.7

There are 36 standards, which mainly focus on processes and outcomes rather than

structure. For example, rather than detail the size, roles and responsibilities of key

staff and structures within a clinical service, such as chemotherapy or radiotherapy, the

standards aim to define the minimum key processes that should be established within

clinical services to provide high quality cancer care, based on the adoption of relevant

clinical management guidelines.

Aspects of the CoC model for consideration

• Standards are developed with strong input from clinicians and associated members

of CoC.

• ‘Cancer leadership’ is a strong feature of the standards many of which relate to how

a cancer committee operates, its key role in promoting quality care and ongoing

education and training opportunities of staff members.

• Many of the standards focus on the establishment of a high-quality cancer registry

and database. Information gathered from the accreditation process is used to

ensure that cancer services, care and outcomes are monitored and evaluated and

that improvements to care are implemented.

• Originally there were 151 standards that were required under the CoC Approvals

Program; now there are only 36 standards in total. This illustrates the importance

of regularly reviewing standards to ensure that they are not overly burdensome for

reporting purposes and that they target key areas of importance.

• It is unclear as to whether consumers provide any input to the standards

development process.


Model 2: Standards development led by government (NHS cancer standards – England and Wales)

In the UK, standards development is co-ordinated at a national government level, with

responsibility for implementing and measuring compliance against standards devolved

to regions within the NHS (For more information about the accreditation process in the

NHS see Chapter 3). Regional offices of the NHS were asked to co-ordinate input from

their cancer networks. Draft standards were also placed on the Internet during their

development and community consultations were undertaken with key professional

bodies and the voluntary sector.

The cancer standards developed by the NHS cover ten topics that span the patient

care pathway (from diagnostic and oncology services through to palliative care) and the

organisations of cancer services.8 Many of the standards focus on ‘structures’ and

‘processes’. For example, standards define the roles and responsibilities of staff within

a service such as radiotherapy and chemotherapy. They state the need for policies

and procedures associated with the establishment and operation of multidisciplinary

teams. Some of the process standards also cover issues such as communication and

co-ordination of care between primary, secondary and tertiary sectors of care, cancer

units or centres through processes such as appropriate and timely referrals.

In total there are 426 standards, although there is some repetition. For example,

standards that relate to the establishment of multidisciplinary teams for breast,

colorectal, lung and gynaecological cancer are the same. Standards are grouped into

Level 1 and Level 2 to identify their relative priority of compliance. Level 1 standards

are those standards that need to be met as a first priority. Services failing to meet the

standards, agree to develop an action plan to remedy the faults (see Chapter 3). The

large number of standards and the capacity required to achieve, administer and

monitor them has been questioned, given the availability and current levels of staff

trained in the area of cancer.9


Aspects of the UK NHS model for consideration

• Standards have been developed with strong input from the clinicians, other health

professionals and consumers to help ensure that they are relevant to health

professionals and patients.

• Many of the standards provide detailed information on the organisation, structure,

processes and resources required to establish a cancer service.

• Implementation of the standards by health care services is supported by funding

provided by the government.

• The standards can be used as a quality improvement tool and as a performance

assessment tool for NHS services.

• The large number of standards (426 in total) and the capacity of services to achieve

them has been raised as an issue.

Model 3: Tumour-specific standards, based on evidence-based guidelines (Scotland)

The NHS QIS, an independent Special Health Board, has responsibility for the

development of cancer standards in Scotland, a role previously undertaken by the

Clinical Standards Board for Scotland (CSBS). The CSBS had developed standards

for a range of cancers including breast,10 colorectal,11 gynaecological (ovarian)12 and

lung cancer.13 Much of the evidence supporting these standards was drawn from

guidelines developed by the Scottish Intercollegiate Guidelines Network (SIGN).10 Each

standard is supported by a ‘rationale’ section that outlines the importance of the

standard and references relevant guidelines or evidence.

The standards focus on care provided in an acute hospital setting and cover the patient

journey, from the point of diagnosis to palliative care. Many of the standards relate to

processes rather than structure. There is one specific standard relating to outcomes

that defines targets for recurrence and cancer survival rates.10


Underlying the development of these standards is the principle that they are should be

‘achievable but stretching’.10 The standards outline the essential and desirable

elements that should apply to a service. Essential criteria are expected to be met by all

services, whereas desirable criteria only need to be met in some parts of the service.10

The tumour-specific standards are also supported by generic standards, which focus

on the dimensions of care specifically relating to ‘patient focus’ and ‘safe and effective

clinical care’ and can be applied to clinical services.14 The generic standards have

recently been incorporated into draft standards focusing on Healthcare Governance,15

which cover facility, organisational, resourcing and risk management issues (see

Appendix IV).

Aspects of the Scottish model for consideration

• The standards development process is highly transparent due to the involvement of

health professionals, cancer services, research bodies, cancer organisations and

consumers.

• Standards are based on evidence and recommendations outlined in guidelines

produced by SIGN.

• Standards are based on the patient’s journey covering areas such as referral, time

to diagnosis of cancer, multidisciplinary and supportive care, staff education and

training, and communication and information sharing between care providers and

patients.

• The NHS QIS has recognised that it may be more useful to develop standards that

can be used to accredit clinical cancer networks, rather than developing individual

cancer service or tumour-specific standards.

• It is unclear how often these standards are reviewed.


Issues for consideration - International models of standards development

In examining the development processes for international cancer standards, a number

of issues surrounding the development of standards have been highlighted and these

are discussed in the following sections.

Role of evidence-based guidelines

It is internationally recognised that the development of cancer standards should be

underpinned by evidence-based guidelines. Organisations such as the National

Institute of Clinical Excellence (NICE) in the UK play an important role in providing

health professionals with advice on how to provide their patients with high-quality

clinical care. NICE does this through its three main programs:16

• appraisals program: assesses the clinical effectiveness and cost-effectiveness of

drugs, devices, and diagnostics and provides advice on how these should be used

in the NHS

• guidelines program: develops advice based on assessments of clinical and cost-

effectiveness, about the management of individual medical conditions

• interventional procedures program: undertakes a regulatory role in assessing the

safety and efficacy of drugs and devices, much like the Food and Drug

Administration in the USA.

While standards development and accreditation programs provide an opportunity to

promote best practice, it must be acknowledged that there is a cost implication

associated with implementing recommendations outlined in evidence-based

guidelines.16 In recognition of this issue, the NHS provided additional funding to

services to assist them in making the necessary structural and staffing changes

required to meet cancer standards.9


Level of consumer participation

In England, Wales and Scotland, standards are developed in partnership with members

of the public through their participation in workshops and consultation processes. In

Scotland, consumers can also be part of the review team that visits the services to

undertaking accreditation (see Appendix XII).

It is unclear whether consumers participate in the standards development program in

the CoC. The American Cancer Society is a member of the CoC, however, there does

not seem to be any formal consumer representation on the standards development

working group which is strongly represented by clinicians.7 The American College of

Surgeons focuses its activity on supporting and educating consumers about surgical

issues through its public education program. This program provides information to

consumers on how to assess a surgeon’s credentials, on questions consumers should

ask before providing consent to an operation, and producing procedure-specific

information resources.17

Despite the varying levels of consumer participation in the standards development

process, it should be noted that the principles underpinning all the standards have a

strong focus on the patient’s journey through the care continuum, on the importance of

providing high-quality, safe and effective care, and on providing information to patients

about their treatment options (see Appendix IV).

Workforce

The literature search and NBCC consultations indicate that workforce availability can

greatly impact on the ability of services to achieve compliance with some standards

under an accreditation process. For example, during the development of the NHS

accreditation standards for cancer services, community consultations revealed possible

difficulties in meeting standards for the establishment of multidisciplinary teams.

Although many services were committed to the establishment of multidisciplinary

teams, there was a lack of workforce actually available to participate in multidisciplinary

teams, especially for professionals such as histopathologists and radiologists.8


Under the UK system, cancer networks are required to develop workforce strategies as

part of their delivery plans in an effort to address these issues. Additional resources

have also been made available under the NHS Cancer Plan to develop and implement

targeted initiatives to try and address this issue.8

Monitoring of standards and data collection

The effectiveness of any quality improvement process is dependent on the quality of

data collected by a service.18,19 Data collection and reporting processes can be time

consuming and resource intensive. Many services do not want to duplicate effort with

existing data collections. The literature searches and NBCC consultations suggest that

the effectiveness of data feedback depends not only on the quality and timeliness of

the data, but also the organisational context in which such processes are

implemented.19 For example, data feedback could be more effective if clinicians are

involved in the presentation of data and an organisation promotes non-punitive

discussion of practices and quality improvement strategies.19

Many of elements have been incorporated into the CoC model. Each year the cancer

committee is required to analyse patient outcomes and disseminate results of the

analysis, which includes data regarding:

• diagnostic evaluation

• treatment modalities

• prognostic factors

• survival data by stage of disease

• comparison with benchmarks and other comparative data.7

The CoC standards also require the establishment of cancer databases and registries,

recognising that services need to invest in information technology and appropriate staff

training to provide high-quality, meaningful data to support performance reporting and

improvements to patient care (see Chapter 3).


Regular review and update of standards

It is widely agreed that standards should be dynamic and reviewed at regular intervals

to ensure that they reflect changes in practice.2,20 The NHS plans to review its ‘Manual

of Cancer Standards’ annually 8 however, tumour-specific guidance will be reviewed

every two years. The CoC recently undertook a major review of its cancer standards

produced in 1995. These originally included 151 standards of which 47 were

mandatory. The new Cancer Program Standards, published in 2004, contain only 36

standards, all of which are mandatory.

Further Australian issues impacting on the development of cancer standards in Australia

Evidence-based guidelines

Within Australia a number of organisations have produced evidence-based guidelines

and information on the management of cancer. These include the National Health and

Medical Research Council (NHMRC), the NBCC and the Australian Cancer Network

(ACN).

Workforce issues

Workforce availability is also an issue that has offered accreditation systems within

Australia. It is not only relevant to diagnostic services, for example, where the

accreditation of some BreastScreen Services has been affected by a lack of availability

of radiologists, but also effects the provision of specialist oncology services in rural and

remote areas.

Within Australia, the newly established Quality Assurance and Workforce Working

Group of the Australian Screening Advisory Committee will examine issues

surrounding workforce recruitment strategies specifically affecting the delivery of

screening services within Australia (see Chapter 3).


Professional standards

While accreditation generally refers to health care services, facilities or programs, the

review and maintenance of the clinical skills and competencies of health professionals

treating patients within those facilities or programs is typically undertaken by

Professional Colleges.

The Colleges provide credentialing, where the educational background, training,

qualifications, clinical competence, licences and references are reviewed for those

clinicians seeking appointment to a facility. In The Royal Australasian College of

Surgeons (RACS), for example, this is provided through the Credentials Committee.

Such committees also have a role in the maintenance of standards at healthcare

facilities. While the Australian Council on Healthcare Standards (ACHS) can provide

independent assessors who accredit facilities against a set of standards, those

hospitals complying with RACS requirements for the conduct of surgical services can

be designated as ‘Approved hospitals’. The Royal Australian and New Zealand College

of Radiologists is currently developing standards for radiologists and radiation

oncologists in areas such as training, teaching, back-up services and staffing levels.

The Australian Council for Safety and Quality in Health Care has also developed a

framework, with a formal peer-review process that can be used by health care services

and facilities to establish an appropriate process for the initial granting and on-going

validation and review of clinical privileges for all health care professionals. Reviews

may be undertaken at the end of a specified probation period, periodically on request

or as the result of a complaint.21

Through Boards of Practice Standards or Departments of Professional Standards, the

Colleges provide Continuing Medical Education (CME) or Professional Development

Programs (CPD) to advance the knowledge and skills of doctors for the benefit of the

patient and to provide tangible evidence of participation.22 Colleges, such as RACS,

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists,

The Royal Australian and New Zealand College of Psychiatrists, The Royal Australian

College of Physicians, and The Royal Australian and New Zealand College of

Radiologists, provide programs for Fellows. These programs cover participation in


activities such as: educational programs; presentations at scientific meetings; teaching;

participation in audits of clinical practice; and peer review.

To address issues of quality in undergraduate training, The Australian Medical Council

(AMC) has set up a Medical School Accreditation Committee designed to encourage

improvements in undergraduate medical education in Australia and New Zealand in

response to health needs, practices and educational and scientific developments. The

Committee has an oversight and guideline development role and will develop policy on

standards in medical education.23

P r i n c i p l e s f o r t h e d e v e l o p m e n t o f c a n c e r s t a n d a r d s i n A u s t r a l i a

The ACN has identified a number of principles that could inform the development of

accreditation and standards for cancer services in Australia. Under these principles

standards should:

• be clinician-led

• include support services

• centre on patients and be designed to answer patient needs

• have the ability to demonstrate benefit for patients

• include a framework to prioritise safety

• use a whole-team approach

• be service based, rather than specific to a single cancer type or tumour stream

• involve all sectors that provide cancer care, including public and private services,

using a ’distributed’ service model.


While there are common elements in these principles and those currently guiding the

development of cancer standards internationally (as outlined in Appendix IV), an

important differentiation is that the ACN principles recognise the important role that the

private sector plays in the delivery cancer service in Australia and that patients move

between the public and private sector during their cancer journey.

A f r a m e w o r k f o r c a n c e r s e r v i c e s s t a n d a r d s i n A u s t r a l i a

Using the ACN principles, and following an examination of the range of cancer

standards that have been developed internationally (Appendix IV) and within Australia

(Appendices VI and VII), and through the consultations undertaken by the NBCC, a

Framework for Cancer Services Standards has been developed. The Framework

could be used to guide the development of cancer standards in Australia.

The Framework, presented in detail in Appendix VII, includes the following domains:


• patient focus

• accessibility

• facility requirements (including those of both the public and private sectors)

• elements in patient pathway (including a range of clinical services, as well as the

co-ordination and communication between elements in the patient pathway)




• research.


Aspects of the Framework

The Framework for Cancer Services Standards focuses on processes rather than

structures and outcomes. Recognising the variable structure of cancer services across

Australia, due to factors such as jurisdictional differences in funding and management

arrangements, and the different sizes and geographic location of services, it is

proposed that a generic set of ‘process’ standards for cancer services be developed

and adopted as part of an appropriate accreditation process in Australia.

To reduce duplication of effort and reporting, standards development in the key

domains of the Framework should incorporate existing national cancer data definitions

as outlined in the NCCI Clinical Cancer Core Data Set and Data Dictionary Version 5

(2004),24 and be informed by statistical collection activities for cancer of the Australian

Institute of Health and Welfare, Australian Bureau of Statistics, and State/Territory

governments.

Standards within the Framework relate to care predominately provided within an acute

care setting, including the management and support of patients and their families

during active treatment. However, the Framework also includes the transition of

patients from one intervention point to another, through referral or discharge

processes. Such standards are particularly relevant for smaller cancer services that

may need to operate within a larger referral network in an effort to provide a full range

of care options to a patient.

In developing the Framework, critical intervention points within the National Service

Improvement Framework25 were also considered. However, the Framework for Cancer

Services Standards excludes ‘risk reduction’, defining a cancer service from the point

of diagnosis onwards. General practice falls outside the definition of a cancer service

but features at every step of the cancer patient’s pathway. The important role played

by general practitioners has been reflected in the Framework in areas such as referral

and discharge, and communication between specialist services and the general

practitioner. An accreditation process for general practice has been established

through Australian General Practice Accreditation Limited (AGPAL), and elements of

this process will impact on cancer-related service activity (see Appendix V).


The literature review and consultations undertaken by the NBCC had indicated that

there was some debate as to whether palliative care should be included within a cancer

service. The Clinical Standards Board of Scotland included generalist palliative care

standards as part of the patient’s journey in its tumour- specific standards; however

standards for specialist palliative care standards were planned to be developed

separately.10 In the NHS model, standards relating to palliative care are included in

the Manual of Cancer Service Standards and were due to be further refined after the

development of evidence-based guidelines on supportive and palliative care by NICE.8

The CoC does not have any specific standards that relate to palliative care within focus

areas that relate to clinical management or community outreach. The European

School of Oncology recently stated that all major cancer centres should include a

specialist palliative care service.26

In Australia, there is also some debate about the delivery of palliative care as a

separate service, outside the scope of a cancer service. This is somewhat complicated

by the fact that palliative care services can be provided in a range of settings including

a person’s home or other community-based environment such as residential aged care

facilities, as well as in inpatient palliative care and acute hospital facilities.26,27 It is

recognised that people who are dying need to be able to move freely between these

settings, in response to their changing clinical care or support needs.17 Goal 19 of the

NSW Cancer Plan states that patients should be provided with early and appropriate

access to palliative care services and that appropriate links should be established.28

The Victorian Cancer Service Framework recommends that Level 1 cancer services

(the most comprehensive) should provide patients with access to palliative care

services, but not necessarily on-site.29 For the purpose of this report, and as these

services are increasingly being recognised as integral, standards relating to palliative

care services have been incorporated into the Framework.

The inclusion of specific standards that relate to data management and cancer

database operations illustrates the importance of developing high-quality datasets to

assist in monitoring and improving the outcomes of patient care as discussed in the

previous section of this chapter.


C u r r e n t a c t i v i t y i n c a n c e r s e r v i c e s s t a n d a r d s d e v e l o p m e n t i n A u s t r a l i a

A mapping exercise was undertaken to identify gaps in Australian cancer standards

activity against the key domains of the Framework. Key outcomes from the mapping

exercise (see Appendix VIII) are outlined below.

• Cancer service standards have been developed or are currently being developed in

some States and Territories, such as New South Wales and Victoria.

• Facility-level standards are covered, to some extent, by health care accreditation

processes currently undertaken by organisations such as ACHS, SAI Global and

the Quality Improvement Council (QIC), although there may be some cancer-

specific governance standards that need to be developed. Standards that relate

specifically to the essential components of cancer safety, quality and outcomes

could also be developed further.

• Evidence-based guidelines and best-practice recommendations have been

produced for the treatment and management of many cancers, including breast,

ovarian and lung cancer (see Appendix VIII). These guidelines will play an

important role in underpinning the development of cancer service standards.

• While no standards are currently available, or in development for areas such as

genetic counselling, medical oncology, surgery, and oncology nursing, there are

certainly a number of related activities that will contribute to the development of

cancer standards.

• The importance of a multidisciplinary approach to cancer care has been recognised

and highlighted in a number of national reports and guidelines.30,31,32,33,34 In

particular, the NBCC used national and international evidence on multidisciplinary

care to develop the Principles of Multidisciplinary Care,35 as part of its National

Multidisciplinary Care Demonstration Project.34 The Principles emphasise the

importance of the team, communication, access to the full therapeutic range,


standards of care and the involvement of the patient. While developed specifically

for breast cancer, the Principles have broader application to all cancers.

• Specific standards referred to as the Private Sector Quality Criteria,36 have been

developed by Private Health Industry Quality and Safety Committee (PHIQS),

which has endorsed their inclusion as a component of the accreditation process

undertaken by external agencies such as ACHS and SAI Global. The standards

cover: the operational management of the hospital; clinical practices; safety and

quality of medication; personnel; and consumer rights.

• Gaps were identified in the areas of rehabilitation, community outreach services,

referral processes and cancer committee leadership.

• For standards related to staffing, there are a range of activities currently taking

place through the development of professional competencies (especially in the

areas of breast and lung cancer).

K e y i s s u e s t o b e c o n s i d e r e d i n t h e d e v e l o p m e n t o f a n a t i o n a l s e t o f s t a n d a r d s f o r A u s t r a l i a n c a n c e r s e r v i c e s

Appropriate input from a multidisciplinary team

• Standards development needs professional buy-in. Input should be sought from a

multidisciplinary team, with appropriate clinical knowledge and technical expertise

in standards development.

• Consumer involvement should be sought as part of the development process to

ensure that all aspects of the patient cancer journey are addressed.


Format of standards

• Standards should be service-based, rather than tumour-specific.

• Standards should be achievable and measurable and not too many in number.

• The initial focus for standards may focus on processes on rather than outcomes.

• Generic standards that cover aspects such as facilities or human resource issues

can be adapted to avoid duplication.

• Evidence-based guidelines should underpin the development of cancer standards.

Workforce issues

• Workforce issues can impact on the capacity of a cancer service to deliver on the

standards and this should be considered in the development process.

• Support for professional/staff development should be provided to encourage

compliance with the standards and to imbed the quality improvement approach.

Monitoring and data collection

• Efforts should be made to avoid duplication of data collection and where possible

incorporate existing national cancer datasets.

• Adequate data collection and monitoring may require the establishment of cancer

databases and registries or appropriate data linkages.


Review process

• Standards should be reviewed on a regular basis. The frequency of review can be

determined by the relevant standards development agency, but should take

account of factors such as changes to evidence-based practice, regulatory changes

and changes to Professional Standards.


R e f e r e n c e s

1. BreastScreen Victoria. The development of performance indicators for hospital

breast services in Victoria. Melbourne. Victorian Government Department of

Human Services, 2004.

2. Matthews Pegg Consulting. Standards Setting and Accreditation Literature

Review and Report. Canberra. Safety and Quality Council (Australian Council for

Safety and Quality in Health Care), 2003.

3. Skok A, Swerrissen H, Macmillan J. Standards and quality improvement

processes in health and community services: a review of the literature. Bundoora.

Quality Improvement Council Limited, 2000.

4. Heidemann EG. Editorial: the ALPHA program. Int J Qual Health Care 1999;

11:275-277.

5. ISQua. International principles for healthcare standards: second edition.

Melbourne. The International Society for Quality in Health Care, 2004.

6. Commission on Cancer. What is the Commission on Cancer?

www.facs.org/cancer/coc/cocar.html (accessed 30/10/2004).

7. Commission on Cancer. Cancer Program Standards 2004. Chicago. American

College of Surgeons. 2003.

8. Department of Health. Manual of Cancer Services Standards. London. National

Health Service Executive, 2000.

9. Mayor S. English government sets out first national cancer standards. News

roundup BMJ 2001; 322:192.

10. Clinical standards: breast cancer. Edinburgh. Clinical Standards Board for

Scotland, 2001.


11. Clinical standards: colorectal cancer. Edinburgh. Clinical Standards Board for

Scotland, 2001.

12. Clinical standards: gynaecological (ovarian) cancer. Edinburgh. Clinical

Standards Board for Scotland, 2001.

13. Clinical standards: lung cancer. Edinburgh. Clinical Standards Board for Scotland.

2001.

14. Clinical standards: generic. Edinburgh. Clinical Standards Board for Scotland.

2001.

15. Draft Standards for Healthcare Governance. NHS Quality Improvement Scotland.

2004.

16. Rawlins M. NICE work – providing guidance to the British National Health

Service. N Engl J Med 2004; 351:1383-1385.

17. Statement of the American College of Surgeons. Quality and consumer

information: physicians to the Federal Trade Commission and Department of

Justice. American College of Surgeons Testimony. Washington DC. Presented

by La Mar McGinnis. May 30 2003.

18. Bradley EH, Holmboe ES, Mattera JA, et al. Data feedback efforts in quality

improvements: lessons learned from US hospitals. Qual Saf Health Care 2004;

13:26-31.

19. Mannion R, Goddard M. Impact of published clinical outcomes data: case study in

NHS hospital trusts. BMJ 2001; 323:260-263.

20. Heidemann EG. The contemporary use of standards in health care. Geneva.

World Health Organisation, 1993.

21. National guidelines for credentials and clinical privileges. Attachment to Safety

through action – improving patient safety in Australia. Third report to the

Australian Health Ministers’ Conference. Australian Council for Safety and Quality

in Health Care, 2002.


22. Professional standards and professional development. Royal Australasian

College of Surgeons. http://www.racs.edu.au/edu/ (accessed 23/11/04).

23. Australian Medical Council web site. www.amc.org.au/accredit.asp.

24. NCCI clinical cancer core data set and data dictionary. Version 5. Carlton.

National Cancer Control Initiative, 2004.

25. National Health Priority Action Council. National Service Improvement Framework

for Cancer, 2004.

26. Ahmedzai SH, Costa A, Blengini C, et al. A new international framework for

palliative care. Eur J Cancer 2004; 40:2192-2200.

27. New South Wales palliative care framework: a guide for the provision of palliative

care in NSW. NSW Health Department, 2001.


29. Barton M, Frommer M, Olver I, et al. A cancer services framework for Victoria and

future directions for the Peter MacCallum Institute. State Government of Victoria,

Australia, Department of Human Services, 2003.

30. Cancer Strategies Group. Priorities for action in cancer control 2001-2003.

Canberra. National Health Priority Action Council, 2001.

31. Clinical Oncology Society of Australia, The Cancer Council of Australia and the

National Cancer Control Initiative. Optimising cancer care in Australia. Melbourne.

National Cancer Control Initiative, 2003.

32. House of Representatives Standing Committee on Community Affairs. Report on

the management and treatment of breast cancer in Australia. Canberra.

Australian Government Publishing Service, 1995.

33. NHMRC National Breast Cancer Centre. Clinical practice guidelines for the

management of early breast cancer. 1st Edition. Canberra. National Health and

Medical Research Council, 1995.


34. Multidisciplinary care in Australia: a national demonstration project in breast

cancer. Full report. Camperdown. National Breast Cancer Centre, 2003.

35. Zorbas H, Barraclough B, Rainbird K, et al. Multidisciplinary care for women with

early breast cancer in the Australian context: what does it mean? MJA

2003;179:528-531.

36. PHIQSC. Private Sector Quality Criteria accessed at

www.phiqs.org.au/stratplan.htm.


3 . A C C R E D I T A T I O N M O D E L S

This chapter examines:

• International models of health services accreditation

• Issues for consideration – International models of accreditation

• Australian models of health services accreditation

• Issues for consideration – Australian models of accreditation

• International cancer services accreditation models

• Australian cancer services accreditation.

B a c k g r o u n d

Although the focus of this scoping study is accreditation models for cancer services, an

overview of general health services accreditation models provides useful background.

The lessons learnt over many years of operation can be applied to an accreditation

model for cancer services, to avoid duplicating effort or reinventing processes. An

examination of current accreditation models for health services also provides an

opportunity to identify where existing accreditation processes may impact on, or

overlap with, the accreditation of cancer services. This is particularly relevant for

Australia, where a number of specialty health areas, such as general practice, and

pathology, relate to the cancer care continuum but are not exclusively involved in

cancer care. Much of the information regarding healthcare accreditation models is

sourced from a range of literature reviews that have examined standards and

accreditation processes in the health care sector.1,2,3


L e s s o n s f r o m t h e n o n - h e a l t h s e c t o r

Accreditation has an important role in a number of non-health sectors, including the

food and beverage industry, law, the child care industry, air safety, market research,

engineering and others. Many of the accreditation models used follow similar principles

to those described in this chapter with a focus on continuous quality improvement. It is

not possible to outline all processes used here. However, points of specific interest

include the system for air safety in Australia, in which two processes for external review

are followed: one for breaches that pose an immediate risk to safety and one for cases

with no immediate safety risk. For immediate safety risks, there is an option to withdraw

certification. For less serious breaches, a system of demerit points is used similar to

that used for motor vehicle drivers’ licences.

Within the law industry, two levels of standards exist: a minimum set of standards that

all practices must achieve and a second level of standards that take a broader, more

holistic approach.

I n t e r n a t i o n a l h e a l t h s e r v i c e s a c c r e d i t a t i o n m o d e l s

Appendix IX summaries international approaches to health care accreditation by the

following agencies:

• Joint Commission on Accreditation of Healthcare Organisations (JCHAO) in the

USA

• Healthcare Accreditation Programme (HAP) in the UK

• Canadian Council on Health Services Accreditation (CCHSA)

• Quality Health New Zealand (QHNZ).

These accreditation agencies have been chosen because they operate in English-

speaking countries and have been in operation for many years. Each country may have

more than one agency undertaking accreditation or external reviews. Rather than


summarising all systems currently operating, this report focuses on one main example

for each country. It should also be noted that Matthews Pegg Consulting has reported

much of the detail for each of these accreditation systems.2

As noted in Chapter 1, many standard setting systems and external review models in

health care are currently operating internationally. These include the European

Foundation for Quality Management (EFMQ), International Organisation for

Standardization (ISO), visitatie and accreditation. All of the organisations listed above

focus on the accreditation model described by Shaw,4 ie a process of peer review of

health service delivery based around published standards.

Differences between international health systems

While international approaches to accreditation of health services share some common

elements, it should be noted that differences between the health care systems can

impact on how accreditation works in practice.

The USA has a decentralised health system made up of variable State and Federal

regulations. The system is mostly funded by private, largely employer-based

organisations. Numerous heath care plans and networks have been established in the

private sector and these operate in a competitive market environment where patients

and health care purchasers make their selection based on performance information

(quality) and economic grounds (or cost).5

In the UK, the NHS was established in 1948, to publicly fund and provide universal

access to health services. In 1997, responsibility was devolved to regional authorities

and Trusts as part of a modernisation agenda.5

The Canadian health care system is mostly funded publicly though the Medicare

system. Under the Federal scheme, all costs associated with physician and hospital

services are covered. Other supplementary health services such as drugs, dental care,

physiotherapy and home care are financed through a mix of public and private

insurance and out-of-pocket payments made by consumers. Since the 1990s,

legislated health regions created by provincial and territorial governments have

overseen the daily operation of the health system.5


In New Zealand, health care services are provided by both public and private sectors.

Funding of health is through general taxation by the national government. Twenty one

District Health Boards are responsible for assessing the health and disability of

communities in their regions and for managing the resources and delivery of health

services.6

Components of international health services accreditation models

JCAHO is the longest-running health care accreditation agency. It was established in

1952, although its history dates back to 1917 when the American College of Surgeons

created a hospital certification program.7 Many of the health services accreditation

systems that have since been initiated around the world have modelled their approach

and standards development process on that used by JCAHO. For example the JCAHO

model was exported via Canada to Australia in the 1970s and to Europe in the 1980s,

including countries such as the UK, Spain, Portugal, the Netherlands, Finland, Italy,

France, Switzerland and Germany.4 JCAHO currently accredits approximately 17,000

health care organisations and programs in the USA, including 4,500 hospitals (80%),

and forms the basis for accreditation activities in approximately 80 countries around the

world.7

Given that many of the world’s accreditation systems are based on the JCAHO model,

it is not surprising to find a number of commonalties between their accreditation

approaches.

Governance structures

All the international health services accreditation agencies examined have similar

governance structures (see Appendix IX). These agencies are independent, not-for-

profit organisations, governed by a Board of Directors that typically comprises

stakeholders from the heath care industry and professional groups. Most agencies also

have consumer representation on their governing Boards. This broad representation of

stakeholders reflects the importance that users place on the value of accreditation in

assuring the safety and quality of care provided to patients.


Assessment process

All of the international health care accreditation agencies examined undertake a similar

assessment process, based on a three-yearly accreditation cycle (see Figure 2).

The accreditation process commonly starts with voluntary initiation by a health care

organisation. A self-assessment is undertaken in an effort to identify areas that require

improvement or attention prior to a site visit. The site visit is conducted by a trained

team of surveyors from the accrediting agency to examine practice against agreed

standards. These surveyors are usually experienced in the health care sector and

commonly include professionals such as doctors, nurses, administrators or chief

executives.8 All surveyors undergo some form of theoretical and/or practical training

that is usually provided by the accrediting agency.

The duration of site visits varies according to the size, nature and complexity of the

health service being surveyed. For example, a site visit can last one day for a small

health centre or up to 10 days for a large regional health organisation with multiple

sites.8 The surveyors take the opportunity to review certain documentation and a

sample of medical records, undertake interviews with key staff and record observations

during the site visits. Some seek input to the survey process from consumers.

Following the site visit a written evaluation report is prepared and an assessment

committee or Board of the accreditation agency makes an accreditation decision. A

service can choose to appeal if a decision is considered to be unfair. The final

accreditation results are commonly publicised and some form of recognition, such as a

certificate, is provided to those services that have successfully completed an

accreditation process. If a service is found to be non-compliant, an Action Plan to

address issues of concern is usually developed and follow-up visits can be scheduled

to monitor progress in meeting required standards.

This assessment process is commonly cited in the literature and is an internationally

proven method for making accreditation decisions.4,8 Accreditation agencies

themselves can undertake some form of external peer-reviewed process; they can

choose to participate in the international accreditation programs of ISQua and the Joint

Accreditation System of Australia and New Zealand (JASANZ).


Appendix IX shows the organisations that are externally accredited.

STEP 1: A service initiates a voluntary self-assessment Agency contact may guide a service through the process

STEP 2: External assessment and site visit: By trained surveyor or team (usually experienced in the health sector/peer, can be paid or volunteer)

Site visit includes a review of documentation and a sample of medical records, staff meetings, consumer input, site observations and an exit meeting

STEP 3: Assessment report prepared

Demonstrates compliance or non-compliance against explicit standards

Based on text and numerical grading

Non-compliance:

A service develops an Action Plan to address deficiencies

Follow-up or review visit initiated

Sanctions can be applied

STEP 4: Accreditation decision awarded

Decision considered by Board/Committee of the accreditation agency

A certificate or award granted

Service can choose to appeal a decision if in disagreement Ongoing monitoring applied Results published (eg websites)

Figure 2: Common processes in an accreditation approach


Compliance

All international accreditation systems are essentially voluntary and none of the

international systems have a legislated mandate for health organisations to undertake

accreditation. Certain government and financial levers are however used to encourage

organisations to participate in accreditation processes. For example, hospitals in the

USA are required to undergo JCAHO accreditation if they wish to be eligible for

Medicare funding. Accreditation by JCHAO also means that services have met State

licensing requirements. Health insurers and other payers have also made it a

requirement to undertake JCAHO accreditation for reimbursement of funding.2,7

In England and Wales, health care services are required to undertake a number of

internal and external assessments of their performance by the newly formed

Healthcare Commission (HCC). The HCC was established in April 2004 and has taken

over functions previously provided by the National Care Standards Commission (a

national system of registration and inspections for private and independent health care

services), and the Commission for Health Improvement (previously responsible for

undertaking clinical governance review for all NHS organisations in England and

Wales).9 Health services in the UK can also choose to undertake a voluntary external

accreditation process by organisations such as HAP, whose accreditation standards for

independent healthcare organisations include the minimum standards used by the

HCC for its inspections. A four-category star rating system, where three stars indicate

the highest level of performance and zero stars indicates the poorest level of

performance, is used to indicate how well an NHS organisation is performing against a

set of Performance Indicators (PIs) set by the HCC.

In Canada, the CCHSA is the sole Canadian provider of voluntary accreditation

services for health care organisations. The system is truly voluntary, as there is no

statutory enforcement for accreditation and accreditation is not linked to public funds

for Medicare.2

New Zealand has recently moved to a more regulated approach to its accreditation

process. The Health and Disability Services (Safety) Act 2001 requires providers of all

licensed or registered facilities, including hospitals, aged care homes and disabled

community welfare homes, to be certified against standards by a designated auditing

agency. As QHNZ is one of the designated auditing agencies, it has incorporated the


relevant standards for certification within its own accreditation standards, meaning that

any service subject to certification requirements can meet these obligations and

achieve QHNZ accreditation within a single assessment process.2

Consumer involvement

The level of consumer participation in each of the international health care

accreditation systems varies. A consumer is represented on each of the boards of

JCAHO, CCHSA and QHNZ. This is not the case for HAP in the UK, which is strongly

based on professional representation.

The JCAHO system has the strongest level of consumer involvement, reflecting the

competitive nature of the privately funded health system in the USA and the demand

from consumers and their families to be involved in decisions about their care.

Consumers find information sourced from accreditation processes of value reflecting an

increasing demand for information about the safety and quality of care provided to

them.11

In recognition of these issues, consumers are members of the JCAHO Board and are

represented on every professional and technical advisory committee. In 1999, a Public

Advisory Group on Healthcare Quality was formed to advise the board on quality

issues.11 Any organisation undergoing a JCAHO survey is also required to inform the

public of the survey so that patients and other members of the public can provide

information to the surveyors for use in the assessment process.2,12 An Office of Quality

Monitoring has also now been established within JCAHO to allow consumers and staff

to raise concerns about quality-of-care issues related to an accredited service. JCAHO

is required to follow complaints through correspondence or a site visit with an

organisation.2,11

Due to increased consumer concern about safety of care and the frequency of serious

adverse events, JCAHO has developed a Sentinel Events Policy. This policy requires

accredited services to report and undertake a root cause analysis of any sentinel

events. A national database on sentinel events has also been developed as a way of

sharing this information with other organisations in an effort to reduce the risk of further

occurrences.2,11


Public reporting of accreditation results

The level of public reporting of accreditation results for health care organisations also

varies between the accreditation agencies. Under the JCAHO system, performance

reports on each organisation are made available free of charge on the JCAHO website.

This report includes the organisation’s accreditation status and its performance in each

major area, any recommendations for improvement and a national comparison to

similar organisations.11

In Canada an annual list of sites accredited by CCHSA is available via the CCHSA

website for a fee. CCSHA also publishes annual aggregate findings from accreditation

surveys undertaken over a 12-month period.13

In New Zealand, a list of all organisations accredited by QHNZ is available on QHNZ

website. Similarly in the UK, a list of sites accredited under HAP and the date of

accreditation expiry is included on its website.

Accreditation decisions

All the international health care accreditation systems use a numerical grading system

to assess whether an organisation has successfully met the criteria required for each

standard. This varies from a five-point scale used by JCAHO to a seven-point system

utilised by CCHSA and QHNZ. However, two different approaches are taken to

awarding a final accreditation decision:

• JCAHO and CCHSA award accreditation on a series of accreditation levels.

JCAHO can award on six different levels: accreditation with full compliance;

accreditation with requirements for improvement; provisional accreditation;

conditional accreditation; preliminary denial of accreditation; and accreditation

denied. CCHSA awards decisions based on four levels: accreditation; accreditation

with report; accreditation with focused visit; and non-accreditation (refer to

Appendix IX).

• HAP and QHNZ decide whether to award or not award accreditation to an

organisation, but have the option to defer an accreditation award if a service can


show that it can meet recommendations. For example, HAP accreditation may be

deferred or awarded for one, two or three years depending on the level of

compliance with the standards. It is important to note that HAP is located within

Clinical Accountability, Service Planning and Evaluation (CASPE). This is an

independent research unit established in 1979 to develop better managerial

systems for clinicians and managers within health care settings.2,14 Given this base,

there is a strong focus on encouraging improvement and learning opportunities

within an organisation. QHNZ can award accreditation for three years; however,

non-compliance is significant and there are significant improvements to be made by

a service, then accreditation can be deferred until improvements are made.2

Issues for consideration – international approaches to accreditation for health services

• All international models foster an ‘arms-length’ approach through the use of an

external accreditation agency rather than an internal assessment process. This

helps to ensure that objective decisions and recommendations for improvement can

be made and removes the potential for a conflict of interest.

• Key stakeholders are represented on the Boards of international accreditation

agencies to ensure transparency and credibility.

• The level of consumer input varies. JCAHO has implemented a number of

consumer-focused initiatives, eg membership on boards and advisory committees,

the establishment of a complaints mechanism, and sentinel events register. Such

mechanisms help to ensure input and support from consumers. They can also be

used to add value to the accreditation process, which cannot be guaranteed to

identify all issues that may be of concern within a service. Consumer participation

and representation on some agencies could be increased.

• Many services being accredited view the process as an onerous task rather than an

opportunity to improve the safety and quality of their service. Some services

consider it an expensive and time-consuming exercise and suggest that resources

would be better spent directly improving the quality of services.15


• Despite the detailed assessment processes undertaken by JCAHO, some consider

that it does not adequately identify faults in a health service and suggest that

government should take a lead role in accreditation.16

• If accreditation is not linked to levers, this may reduce the incentive to implement

improvements.

• Accreditation systems that focus on a point-scoring approach to the assessment of

compliance against the standards do not take account of valuable information that

could be collected from qualitative approaches

• Agencies other than JCAHO have a poor level of public reporting. There are no

detailed reports published on the performance of individual services.

A u s t r a l i a n h e a l t h s e r v i c e s a c c r e d i t a t i o n m o d e l s

In Australia, there are three major national providers of health care services

accreditation:

• ACHS, which provides quality and accreditation programs for a range of health care

services including: hospitals, aged care facilities, day procedure centres, and

corporate offices with governance responsibility for delivery services

• QIC, which is the main provider in the non-medical primary health and community

sector, covering organisations where the main business is service provision,

advocacy, communication, social marketing, policy development, service

development, coordination, member services or administration

• ISO, represented in Australia by SAI Global, which certifies public and private

hospitals, area health services, defence health facilities, day surgeries, medical

practices and allied health services.

Accreditation processes also operate in specialist areas of health care, including

mental health, general practice, aged care, pathology and radiology. Appendices X and

XI compare approaches to accreditation in a range of Australian health care sectors.


Components of health services accreditation in Australia

In 2003, Matthews Pegg Consulting produced a report examining the various

international and Australian accreditation systems in detail2 and found a number of

commonalties, particularly in the areas of governance structures and assessment

processes. This could be attributed to the fact that the JCAHO accreditation system

was used as a basis for the creation of accreditation systems in Australia.

Governance

As is the case internationally, most of the accrediting bodies within Australia are not-

for-profit, member-based groups, formed because of a strong commitment by their

members to improving safety and quality.2 Exceptions, include the Aged Care

Standards and Accreditation Agency, which is an independent statutory agency.

Most accreditation processes are initiated on a voluntary basis and have been

designed around peer review, knowledge sharing and professional support. They

operate on a continuous quality improvement model, rather than on a basis of

inspection and strict enforcement of compliance.17

Assessment process

Most accreditation agencies in Australia follow a common assessment approach as

discussed in detail in the first part of this chapter. That is, a service is initially

encouraged to undertake a self-assessment against published standards. This is

followed by an external review by qualified peer reviewers who conduct an on-site visit

and prepare a formal report that outlines the outcomes of the review. This report is

considered by a committee of the accreditation agency for an accreditation decision.2

Differences between health services accreditation processes in Australia

Some of the key differences between the various health services accreditation

processes in Australia appear to be:


• the level of government involvement in mandating accreditation

• the extent to which clinical indicators are utilised as part of the accreditation

process; many focus on administrative and management issues (as discussed in

Chapter 2)

• the extent to which accrediting bodies ensure ongoing compliance with standards

between accreditation visits2

• the extent to which accreditation results are made available to the public

• the level of consumer participation in standards development and accreditation

processes.

Many of these issues are discussed throughout the remaining part of this chapter.

T h e r e l a t i o n s h i p b e t w e e n s t a n d a r d s d e v e l o p m e n t a n d a c c r e d i t a t i o n p r o c e s s e s

Appendix X provides a summary of the accreditation systems currently operating within

Australia. An examination of the international accreditation agencies in the first part of

this chapter illustrated that the accreditation agencies are also responsible for

developing standards with input from key stakeholders. Within Australia, this is not the

case for all accreditation systems and the variations are summarised in the following

three models, together with a summary of the key issues for each model (see also

Appendix XI). Aspects that should be considered when evaluating the possible

applicability of each model on a national level are also noted.

MODEL 1 – Dual role of standards development and assessment

Some accreditation agencies take on the dual role of standards development and

surveying services against these standards. For example, the Evaluation and Quality

Improvement Program (EQuIP) of the ACHS uses a standards and assessment

process to identify opportunities for improvement in the quality and safety of services.18


The ACHS standards are developed in consultation with the health industry and are

subject to pilot testing.19 The ACHS also undertakes organisation-wide surveys against

these standards with a team of trained, independent surveyors.19

Aspects of Model 1 for consideration

• Standards development and review includes a broad consultative and endorsement

process.

• The accreditation agency acquires a depth of knowledge and experience in the field

of standards development and assessment of organisations against these

standards.

• Standards for particular specialities can be developed based on the established

framework.

• The objectivity of the accreditation process may be questioned, as the developer of

the standards is also the accrediting agency.

MODEL 2 – Professional and government-led standards, accredited by external accrediting agency

Under the second model, Professional Colleges, State/Territory or Australian

Government departments set standards that are then used by an external established

accreditation agency. For example, the National Standards for Mental Health Services

were endorsed by Australian Health Ministers in 1996 and supported by State and

Territory Health Ministers under the National Mental Health Plan (1992). Current

requirements under the Australian Health Care Agreements make it mandatory that all

government-funded mental health services undertake an assessment against the

standards. ACHS and QIC are the only endorsed organisations that can undertake an

external assessment of mental health services.2 ACHS undertakes assessment of

mental health services using the National Standards, which are incorporated within the

EQuIP standards framework.2 The normal EQuIP survey team is also supplemented by

one or more mental health surveyors and a consumer surveyor.2



• Standards development includes strong professional and consumer involvement.

• Assessment process includes consumer involvement.

• A legislative process can be time consuming when changes are required to the

accreditation process.

• Important to ensure that the policy role is kept separate from the regulatory and

enforcement roles.20,21 By mandating a certain approach this may reduce the level

of competition and reduce possible innovation.

MODEL 3 – Agencies specifically established to accredit against specialised standards

In some cases, accreditation agencies are newly created to undertake surveys against

specialised standards developed or endorsed by independent bodies or government.

For example, in Australia, pathology organisations are accredited by the National

Association of Testing Authorities (NATA) against standards developed by the National

Pathology Accreditation Advisory Council (NPAAC). General practices can be

accredited by one of two major providers of accreditation services (Quality Practice

Accreditation Pty Ltd and AGPAL) against standards developed by the Royal

Australian College of General Practitioners.17 All aged care residential services seeking

Australian Government residential care subsidies are accredited by the Aged Care

Standards and Accreditation Agency against standards developed by the Australian

Government in consultation with key stakeholders.


• Not all agencies are externally accredited by ISQua or JASANZ.


• Due to the small size of some specialised health markets, it may be difficult to

sustain the operation of more than one accreditation agency in a competitive

market.

Private health sector issues

Third-party purchasers, such as health insurance funds, place considerable reliance on

the accredited status of private health facilities. Safety and quality are essential issues

of concern to Private Health Insurers as their customers seek access to treatment that

is safe and effective.

All health insurers require that private health facilities are accredited by an external

agency such as ACHS or SAI Global. Specific quality criteria for private health facilities

(Private Sector Quality Criteria) were developed in June 2003 by PHIQS.22 PHIQS has

endorsed the incorporation of the Private Sector Quality Criteria (see Chapter 2) into

standard accreditation requirements that are applicable across all private health care

facilities, although this is a self-regulatory and not a regulatory measure. PHIQS has

also endorsed that private health care facilities should be accredited/certified by

industry-recognised and approved accreditation processes.

Private health care facilities not only have to meet accreditation requirements but are

also required to be licensed. Licensing of private health care facilities by the States and

Territories enables Australian Government provider numbers to be granted, which in

turn enables the payment of private health insurance benefits for procedures

undertaken within the facility. In some States and Territories, licensing attempts to

integrate quality measures into legislative requirements and thus ensure an

enforceable standard of care and level of service provision.23 Licensing usually relates

to three issues: structural (premises design, construction standards), operational

(management, staffing) and service quality (clinical standards).

There is currently no nationally consistent approach to the registration and licensing of

public, private and day hospital facilities. State and Territory governments have each

developed their own requirements, processes and standards.2


Figure 3 attempts to summarise the statutory framework in operation in each State and

Territory for the licensing of private hospitals.

Figure 3. Statutory framework for licensing of private hospitals

The regulatory framework for licensing of private hospitals and day procedure

centres is underpinned by legislation. Each State and Territory has developed

statutes and regulations.

ACT Australian Capital Territory governs private hospitals and day procedure

centres through the Public Health Act (Private Hospitals) 1997 and Public

Health Risk (Health Care Facilities) Declaration 2001.

NSW Private Hospitals and Day Procedure Centres Act 1988 regulates private

hospitals and day procedures in New South Wales. This is supported by Private

Hospitals Regulation 1996 and Day Procedure Centres Regulations 1996.

NT In the Northern Territory, the Private Hospitals and Nursing Homes Act

1997 is responsible for private hospitals.

QLD Private Health Facilities Act 1999 regulates private hospitals and day

hospitals in Queensland.

SA Day hospital facilities are unregulated in South Australia. The private

acute health care sector is governed by the South Australian Health

Commission Act 1975 and the South Australian Health Commission (Private

Hospitals) Regulations 1985.

TAS Regulation of private hospitals is under review in Tasmania and the final

report is available (Review of the Regulation of the Hospitals Act 1918 as it

relates to the regulation of Private Hospitals). The aforementioned Act

regulates private hospitals.

VIC In Victoria, regulation occurs through the Health Services Act 1988 and

the Health Services (Private Hospitals and Day Procedure Centres) Regulations

2002.

WA Hospitals and Health Services Act 1927 in conjunction with Hospitals

(Licensing and Conduct of Private Hospitals) Regulations 1987, the Hospitals


(licensing and Conduct of Private Hospitals) Amendment Regulations 1997, and

the Hospitals (licensing and Conduct of Private Psychiatric hostels) Regulations

1997 regulates the private health sector in Western Australia.

(source: ref.22)

Consultations undertaken by the NBCC indicate that:

• private hospitals undertake a number of accreditation and quality audits (for

government, accreditation bodies and private health insurers) and these are often

expensive exercises and can lead to a duplication of effort

• variations exist between State and Territory licensing agreement, ie there is a lack

of consistency

• variations exist in the standards against which private health facilities are assessed,

so facilities may seek accreditation with a number of agencies if not initially

successful

• variations exist in standards reporting, as required by the many different health

insurers

• there are concerns about how the results of an accreditation process will used,

especially in negotiations with the health insurers

• private hospitals are usually well equipped to collect data and use established

networks to share IT resources and expertise.

Issues relating to Australian health services accreditation arising from literature review and NBCC consultation

A range of issues surrounding health services accreditation have been highlighted from

the literature and NBCC consultations as being important to consider when thinking

about the applicability to a cancer accreditation process and are outlined below.

Although most issues relate to Australian systems, relevant international examples are

referred to as appropriate.


External validation and review of accrediting bodies

Ensuring robustness in all accreditation systems is an important requirement for

external validation of standards setting and accreditation processes. A process for the

external validation of standards development and accreditation service providers

already exists through organisations such ISQua and JASANZ.17 Currently

organisations such as ACHS, QIC and SAI Global are externally validated. AGPAL is

currently seeking accreditation from ISQua. However, agencies such as NATA and the

Aged Care Standards and Accreditation Agency are not externally validated.

Due to the rapidly changing nature of health care, it is also important that accreditation

agencies also undertake ongoing reviews of their policies and accrediting

procedures.2,24

Public reporting of accreditation results

The need for transparency in the accreditation process is advocated by consumers,

who indicate a preference for access to detailed levels of information about

accreditation results and for involvement in decisions about how outcomes of

accreditation should be reported. These issues have been recognised in a review of

the Aged Care Standards and Accreditation Agency, where the main recommendation

was:

“that more simple information on the accreditation process needs to be made available

for consumers, that the Agency needs to encourage service providers to better inform

consumers about continuous improvement and that plain-English accreditation reports

on residential facilities need to be widely accessible by consumers”.2,24

Most agencies make accreditation results available to the public on their websites,

although the level of detail provided varies. For example, health services that are

accredited by ACHS are listed on its website along with the date that accreditation

expires. Any high-priority recommendations are highlighted but not detailed.2 Under

the Aged Care Accreditation Agency systems, detailed accreditation reports on each

residential facility are listed on the Agency’s website. Public notification of any service

that has had sanctions applied to it is listed on the Australian Government Department


of Health and Ageing website.2,25 In contrast, while AGPAL publishes the number of

general practices accredited in each region of Australia, it does not publish the names

of accredited practices.2 The NATA website lists the date the date when a facility was

last accredited and when the next accreditation survey is due. It also states if

accreditation has been withdrawn. The Minister for Health can disclose accreditation

status, on the advice of the Manager of Pathology Services, Health Insurance

Commission.

Liability and privacy

The need for transparency in accreditation processes presents a conflict between the

need to access detailed, often personal patient information, with the rights to personal

privacy and confidentiality, eg qualified privilege. Some health services may be less

willing to disclose such information to peer reviewers if it is to be made publicly

available; therefore services need to understand the nature and usefulness of the

information that is reported to accreditation agencies.2

Disclosure of information may be of concern for some health service providers. Private

hospitals may be concerned that full disclosure can be used against them as a ‘stick’

by health insurers, rather than as an improvement tool. A national set of standards for

the disclosure of performance would ensure that ratings are considered in the

appropriate context, for example, a health care facility with a high volume of patients

could be distinguished from a low volume facility or and differing clinical mixes of

services and risk profiles could be noted.

Consumer views and involvement in the accreditation and standards development process

Feedback from the stakeholder consultations has highlighted the importance of

involving consumers in the standards development and accreditation process. A key

aim of accreditation is to ensure a patient’s care journey is safe and of high quality.

Some of the suggestions regarding consumer input are outlined below.


• Consumers should participate in the governance structures of accreditation

agencies, as is the case for JCAHO and CCHSA, where consumers are

represented at Board level.

• Consumers can actively contribute to standards development and assessment

processes, not only by being involved in surveys or interviews as part of the

assessment process, but also by being part of the assessment team. It is

acknowledged that this would require well-educated and trained consumer

representatives. The Commonwealth Consumer Affairs Advisory Council (CCAAC)

has recently defined the way that government and industry bodies should relate to

and appoint consumer representatives.26 ACHS is also considering how consumer

involvement can be enhanced.

• Consumer engagement should include patients, community members, carers,

patient advocates and consumer organisations.17

• Consumer organisations could play an important role in educating the public about

the accreditation processes, by working in collaboration with government, health

services and accreditation agencies.

• Consumer feedback or complaints mechanisms can play a valuable role in

identifying important consumer concerns with a service, as these may not be picked

up by an accreditation process. It is often difficult for site visits to pick up all

individual issues about care. Such a consumer complaints mechanism is currently

operating for aged care residential facilities.

Compliance/sanctions

The application of remedial actions or sanctions varies amongst health care

accreditation systems in Australia. Most accreditation processes are voluntary, so the

only real sanction that can be applied is the withdrawal or alteration of an accreditation

status. Australian accreditation systems have a strong focus on peer support, so any

recommendations following an assessment process are usually designed to rectify

problems through the application of remedial actions. Services that do not achieve the

required level often receive a conditional award ranking, rather than simply removing


an accreditation status.2 For example, under the ACHS accreditation model, when

recommendations for improvement are made to an organisation following a site visit,

organisations are required to complete a quality action plan to address these

recommendations. This plan forms the basis of an agreement between the organisation

and the ACHS for future quality improvement activities, including a timeframe for

achieving these activities.2 A periodic review is also undertaken by the ACHS two years

after the service has undergone its initial service-wide survey. Some accrediting bodies

require regular reviews (six-monthly to two-yearly), others require regular progress

reports and some only write to an organisation if there are concerns about the level of

compliance (see further detail provided in Appendices X and XI).

Compliance with an accreditation program can be encouraged by incentives such as

recognition as a participant in a national program, as is the case with BreastScreen

Australia.

A ‘pyramid of responsive regulation’, with elements ranging from persuasion to comply

with regulations or standards, through to punitive measures such as the revocation of

licences, has been proposed to encourage compliance. The least interventionist

strategies would be used first; with other more interventionist methods being used

when these fail. Such an approach would see reform and compliance rewarded and

‘recalcitrant refusal’ ultimately punished. Responsiveness to the conduct of those

being regulated would be used to determine the appropriate response to a lack of

compliance.27

For accreditation systems in areas such as aged care and pathology, there are clear

protocols for responding to serious non-compliance, which often attract significant

financial and operational sanctions. For example, pathology services must be

accredited by NATA in line with the standards for Pathology Laboratories in order to

access Medicare funding (see Appendix XI). The Australian Government also requires

residential aged care facilities to comply with aged care standards in order to be

eligible for Australian Government residential care subsidies, as legislated in the Aged

Care Act 1997. The aged care accreditation agency also has a ‘support contact’ for

accredited services to ensure ongoing compliance, assist with continuous

improvement, identify the need for a review audit and provide any additional

information or training that may be required.2


Consultations by the NBCC also indicate the importance of ensuring that ongoing

support for services is available outside the review process. This may include funding

to address the in-built disincentive in which those facilities not performing well miss out

on additional funding and hence are unable to undertake necessary improvements in

areas identified by the accreditation process.

Consumers have advocated that remedial action should be undertaken to protect

public health and safety for non-complying services, especially if there is a significant

risk to public health and safety.17 For those accreditation models involving government

regulation, such as mental health, pathology and aged care, sanctions for non-

complying services could involve closing down the service; however this would need to

be balanced against the possible loss of access to services.

Levers

Incentives to comply with accreditation processes and sanctions for those

organisations that do not comply could form part of an accreditation process. Such

levers may come from Federal, State or Territory level and may take the form of:

• linking compliance with accreditation to additional funding, eg through Health

Program Grants

• provision of policy leadership and education processes at Federal/ State and

Territory level

• support from Federal/State/Territory government level for data development

processes

• use of State/Territory legislative powers through their licensing system, both in the

public and private sector, varies between States and Territories

• direct funding opportunities through State-based and Territory-based Area Heath

Service funding frameworks

• public listing of accredited services


• consumer pressure for reform.

While external levers may be applied to encourage compliance, internal levers may

also arise from the structure, functions and culture of organisations that make up

cancer services.27

Workforce implications

Consultations by the NBCC indicate that workforce issues have an impact on

accreditation processes, such as the shortages noted in the area of radiology. Some of

the implications for workforce shortages are:

• inability of health care services to undertake the necessary accreditation processes

due to lack of resources

• shortages of staff in particular specialist areas, eg radiology, may make it difficult to

meet accreditation criteria

• improvements based on the accrediting agency’s report may be difficult to achieve

without appropriate resources

• provisional accreditation status only may be granted to facilities that do not have

sufficient staffing levels and this may impact on appointment of the trainees

necessary to help address the workforce shortages.

Cost of accreditation

Although this report will not consider in detail the costs of an accreditation process, the

cost implications need to be taken into consideration. The cost often varies depending

on the size of the health service being accredited. Components include an annual

membership fee, plus the cost of undertaking an accreditation process over a regular

cycle. For example, the cost to undertake ACHS accreditation can range from about

$2,900 for a day surgery centre to $14,000 for a 400 bed hospital, plus GST (see

Appendix XI). Aged care facilities pay about $12,000 per year to undertake


accreditation. While there is currently no cost incurred for reviews and monitoring, if a

charge was introduced for support visits to the facility, as is under consideration by the

Australian Government, then the cost of accreditation could be as much as $30,000.

Good governance requires prioritisation of quality as a fundamental part of the service.

However, for many services, the cost of undertaking an accreditation process is

burdensome, involving not only the expense of the accreditation process itself, but the

costs associated with staff time and facility improvement. Health care organisations

may be committed to quality improvement, but achieving accreditation may be made

difficult due to lack of funds, and may only be achievable at the expense of other

services within the organisation.3,28 Stakeholder consultations have highlighted that

often those services that fail accreditation may actually require funding assistance to

achieve a satisfactory level of assessment. No financial support is currently made

available by government or private health insurers to health facilities who undertake

accreditation processes.3,28

Where facilities are required to meet the requirements of several quality programs

resources can be an issue. This is especially the case for private health facilities with

their funding requirements with private health insurers. Health care organisations and

health care professionals are seeking more streamlined accreditation processes, with a

reduction in current requirements for multiple accreditation surveys based on

duplicated standards.29

Assessors

Current accreditation processes in some sectors of the Australian health care system

are viewed by some stakeholders as lacking validity because of variation in the

training, skills and approaches of surveyors.17 Currently, under most accreditation

models, the surveyors are industry peers who have undertaken relevant courses to

become accredited assessors for agencies such as AGPAL, ACHS and SAI Global.

Some assessors work on staff at an accreditation agency; others can be contracted on

demand, as is the case with the Aged Standards and Accreditation Agency. In some

models, such as NATA, assessors work on a voluntary basis.


NBCC consultations indicate that there can be shortages in the availability of qualified

assessors at certain times of the accreditation cycle. For example, AGPAL and NATA

draw on a limited pool of expert assessors due to the specialised nature of

assessments. If there is a requirement that services are accredited every three years,

assessment processes need to be staggered to ensure that services are undertaking

accreditation at different times.

It is also important to recognise that different standards require different expertise from

the assessors. For example, some standards have a clinical focus, while others may

focus around financial, management or systems issues. It is unlikely that one person

will have all the skills required to complete a review in these different areas, particularly

in a one-day visit. It has been suggested that it might be appropriate in some cases to

establish a team of experts that could include a combination of professional surveyors,

industry peers and consumers.17 These groups could either visit on the same day or on

separate days.

Furthermore, the complex nature of some assessment processes requires a level of

judgment and interpretation of the standards, and this can vary among assessors.

Many agencies implement their own training models to ensure consistency of

assessments. This issue was identified in a review of the Aged Care Standards and

Accreditation Agency by Gray.30 The review found that the evaluation process under

the accreditation system had subjective components, which could result in inconsistent

assessments across nursing homes. A key recommendation was that:

“… the Agency examine its assessment protocol to ensure its consistency between

assessments”.30

Data collection and monitoring

Consultations held by the NBCC found that data collection and monitoring were key

issues. All those consulted noted the importance of appropriate and accurate data to

inform improvements within health care services. Groups from both the public and

private sector want to see the benefits of data reports and be able to use them as a

feedback tool to improve health care services. This may be facilitated by starting with a

set of basic reporting requirements so that staff can see the benefits. It was


acknowledged however, that health care services may lack the processes to facilitate

data collection and monitoring, that trained data managers are required, that data

collection and monitoring can be time consuming and resource intensive and that there

is a need to avoid duplication with existing data collection and reporting requirements.

While electronic collection of data is the ideal situation, much of the data collection is

still paper-based.

Principles for Australian accreditation systems

The Australian Council for Safety and Quality in Health Care has identified a number of

principles for health care accreditation.17

These principles provide a useful summary of the key issues highlighted in the

examination of models of accreditation systems currently operating in Australia and

overseas and are useful to inform the development of a cancer service accreditation

process.

• Stakeholder confidence in the rigour of accreditation systems and the reliability of

responses to significant non-compliance is enhanced.

• Accreditation of health care services is supported. Varying regulatory and funding

options for achieving greater national consistency are utilised to encourage

accreditation of health care services.

• Effective consumer engagement occurs throughout the accreditation system.

• The administration of accreditation is efficient.

• Standards against which compliance is assessed are capable of adaptation to

varying health environments – but are firm and credible.

• Surveying against standards is credible, robust and consistent.

• Accreditation processes encompass both assessment of compliance with minimum

standards and encouragement of continuous improvement.


• Standards setting and accreditation processes are externally validated.

• Assessment options are flexible.

• Responsibility for taking action on accreditation outcomes is clearly defined.

• Accreditation processes and outcomes are transparent.

• Information learned from accreditation is used for system-wide improvement.

• The direct and indirect relationship between accreditation and safety and quality in

health care is evaluated through research.

These principles also highlight the need to avoid duplication of effort in any cancer

services accreditation process.

I n t e r n a t i o n a l c a n c e r a c c r e d i t a t i o n m o d e l s

The USA, England and Wales, and Scottish health systems have all developed cancer

standards and accreditation models. A brief summary of the processes used for each

health system is outlined below. More detailed information on the standards

development process is discussed in Chapter 2. New Zealand and Canada have also

undertaken significant steps to support the development of future cancer accreditation

activities and a brief summary is outlined later in this chapter.

Commission on Cancer (USA)

The accreditation of cancer services in the USA is led by the CoC, which was

established in 1922 by the American College of Surgeons. The CoC is a consortium of

professional organisations involved in the care of patients. It has a membership of

more than 100 individuals who are either surgeons from the College or representatives

from 39 national, professional organisations affiliated with the CoC. These

organisations include the American Cancer Society, Society of Surgical Oncology,


American Society of Clinical Oncology, American College of Radiology and Oncology

Nursing Society.31

The activities of the CoC are coordinated through the Approvals, Cancer Liaison and

Quality Integration committees.

The main role of the CoC is to:

• set standards for quality multidisciplinary cancer care delivered in hospitals and

survey hospitals to assess compliance with these standards

• collect standardised quality data from approved hospitals to measure treatment

patterns and outcomes

• use these data to evaluate hospital performance; and

• develop educational programs.

The CoC Cancer Standards have recently been reviewed. Standards of the CoC

Volume I: Cancer Program Standards (1995) included 151 standards, 47 of which were

mandatory; the new Cancer Program Standards 2004 contains only 36 standards, all of

which are mandatory. Further detail is provided in Chapter 2 and in Appendix IV.

All hospitals, freestanding treatment centres and health care networks are eligible to

participate in the CoC Approval Program. To be eligible, each facility needs to ensure

that patients have access to the full scope of services required to diagnose, treat,

rehabilitate and support patients with cancer and their families.31 These services are

provided on-site at the facility, by referral, or are co-ordinated with other facilities or

local agencies. The basic services that must be provided by every CoC-approved

cancer program are listed in Figure 4.

Each facility is assigned to one of nine Cancer Program categories, which describe the

services available at the facility along with the requirements needed to meet each

standard.31 Categories include Teaching Hospitals, Community Hospitals or Network

Cancer Programs. Certain categories obtain exemptions from some of the standards

depending on their size and number of patients seen.


Figure 4: Basic services provided by every CoC-approved cancer program

Diagnostic Clinical laboratory Diagnostic imaging

Treatment Medical oncology Radiation oncology Surgical procedures

Other clinical American Joint Committee on Cancer (AJCC) staging Clinical research Patient guidelines Oncology nursing Pain management

Rehabilitation Support Counselling Discharge planning Hospice care Nutritional support Pastoral care Patient and family support

Prevention and early detection

(Source: ref.31 p.5)

Those services that voluntarily commit to the survey process undergo a rigorous

evaluation and review of their performance and compliance with the standards every

three years. Much of detail on the assessment process is contained in Cancer Program

Standards 2004; a summary of the main steps in the assessment process is outlined

below.31

• To be considered for an initial survey, a facility or cancer committee needs to meet

a number of eligibility requirements.


• Each facility is required to complete a web-based Survey Application Record (SAR)

30 days before the scheduled visit.

• Documentation is provided to the site surveyor a minimum of 14 days prior to the

site visit (eg annual reports, annual goals, documents related to committee

meetings, policies and procedures etc). The site is also required to undertake a

self-assessment against the standards using a point-rating system.

• During the site visit, the surveyor verifies and confirms cancer program activity by

reviewing a number of areas and documents (policies, procedures, medical

records, verification of credentialing of staff from the National Cancer Registrars

Association etc).

• At a minimum, the site surveyor requests meetings with other members of the

cancer committee or other members of the cancer care team:31

o clinical research

o hospice services

o nursing Social Services

o quality improvement

o diagnostic radiology

o radiation oncology

o pastoral care

o discharge planning team

o public education.

• At completion of the visit the surveyor outlines the strengths and weaknesses and

offers suggestions to correct any deficiencies.


• Award notification takes place 8–12 weeks following the survey. On approval, the

service is provided with a certificate and press release etc. An Approved Cancer

Program Performance report is prepared.

• A listing of all CoC-approved programs appears on the Cancer Program page of

the American College of Surgeons website.

The following point rating system is used to assign a compliance rating to each

standard:31

1+: Commendation

1: Compliance

5: Non-compliance

8: Not Applicable

Based on the rating criteria specified for each standard, a compliance rating is

assigned by the facility, surveyor and Cancer Program staff. A deficiency is defined as

any standard with a rating of 5. A deficiency in one or more standards will affect the

approval award. Table 1 summarises the four accreditation decisions that can be

awarded.

Table 1: Approval award matrix

Full approval (three years)

Three-year approval

with contingency

Non-approval Approval

deferred (valid only for new programs)

36 Standards No deficiencies One to seven deficiency(ies) (up to 19% of Standards)

Eight or more deficiencies (22% or more of Standards). Requires recommendation by the Program Review Subcommittee and confirmation by the Committee on Approvals

One deficiency (2% of Standards)

(Source: ref.31 p.9)


Link to external accrediting agencies

Standard 1.1 of the Cancer Program Standards 2004 states that a facility is to be

accredited by a recognised authority, appropriate to the type of facility.31 No survey is

performed if a facility is not accredited by one of the accrediting agencies recognised

by the CoC. These include:

• JCAHO

• American Osteopathic Association (AOA)

• Accreditation Association of Ambulatory Healthcare Agencies (AAAHC)

• American College of Radiology (ACR)

• Health facility licensure agency (usually located within the State Department of

Health).

Data

The CoC model uses a web-based data collection approach. A portion of the

information collected in the SAR describing the facility’s resources and services is

automatically shared with the American Cancer Society (ACS) as part of the Facility

Information Profile System (FIPS) and is posted on the ACS Web site

(www.cancer.org). This facility-specific information is made available to cancer

patients, caregivers and the general public, with the aim of aiding informed decisions

about their options for cancer care.31

The facility can use the SAR or access FIPS directly to update the resource and

service information for sharing with the ACS. By accessing FIPS directly, the facility is

also provided the option to release annual caseload data as submitted to the CoC’s

National Cancer Data Base (NCDB). This provides the public with site and stage data

for cancer patients seen at the facility.31


Password-protected access to FIPS is provided to the cancer registrar, cancer

committee chair, and Cancer Liaison Physician through an e-mail notification system.

The SAR and FIPS are accessed through CoC Datalinks located on the Cancer

Programs page of the ACS website.31

The Cancer Program Surveyors also review the facility’s web-based SAR prior to the

on-site visit.31

Aspects of the CoC model for consideration

• The CoC Approvals program is strongly led by peer clinicians and supported with

educational programs developed and coordinated by the CoC.

• CoC approval indicates that the full scope of services required to diagnose, treat,

rehabilitate, and support patients with cancer and their families are available.

Services may be are provided on-site at the facility, by referral, or co-ordinated with

other facilities or local agencies. Nine levels of cancer services have been defined

and the required standards for each service level have been identified.

• Standardised information that is collected from each facility by the SAR is collated

and can be accessed by the public through the Internet and the website of the ACS.

• The CoC accreditation process is quite resource intensive, and a large number of

requirements need to be met by a service before it becomes eligible for

accreditation.

• Services may experience difficulties in obtaining the resources or up-skilling staff

required to establish a cancer registry or database required to support the

accreditation process.

England and Wales

The Calman-Hine report A Policy Framework for Commissioning Cancer Services

(1995) made a number of recommendations about the structure and organisation of


local cancer services in England and Wales. It proposed a new structure of cancer

services based on a network of expertise in cancer care reaching from primary care,

through to Cancer Units in district hospitals to specialist Cancer Centres.32

The establishment of this new cancer services structure led to the development of

national standards for cancer care33 and related assessment processes, as regions

and local cancer networks sought to monitor and assess the quality of services they

provided. These standards cover ten topics that span the patient pathway, from patient

information, access to specialist staff, and diagnostic and oncology services through to

palliative care and the organisation of cancer services (further detail on these

standards is outlined in Chapter 2).

Assessment of cancer services in England and Wales has a strong peer-review

component.33 Site visits are undertaken initially on a two-yearly basis at minimum;

however, once compliance with the standards has been achieved, visits occur on a

three-yearly cycle, with an annual performance report prepared as part of the NHS

Trust’s Clinical Governance reports.33 Due to the devolved nature of the NHS health

system, each region is responsible for developing their own protocols for assessment

visits33 and for ensuring that assessment teams receive appropriate training and

support, including specifications for the collection of pre-visit baseline information and

visit formats. A national core training program has been developed in an effort to

encourage a consistent approach to peer review.33

In each region, a Regional Cancer Quality Improvement Group oversees the appraisal

process. This group includes a lead clinician, cancer leads, a representative from the

cancer registry and others as agreed locally. This group reports to a Regional Cancer

Steering Group or Regional Cancer Taskforce, which is responsible for the regional

implementation of the NHS Cancer Plan. This reporting structure allows for local quality

monitoring and assists in monitoring quality improvement process nationally (see

Appendix XII).

A first step in the assessment process requires that cancer service providers undertake

self-assessment of their performance against the standards for all cancer types. This is

undertaken using a nationally developed self-assessment template distributed to

networks via Regional Cancer Co-ordinators. The aim of the self-assessment is to

identify progress against all the standards and to develop action plans and cancer


network service delivery plans. These reports are then made available to Regional

Cancer Quality Improvement Groups to inform assessors prior to their site visit.

Peer review visits are undertaken by multidisciplinary teams. Regions determine the

composition of assessment teams ensuring that they contain representation from

clinicians external to the network. However, it is recommended, for example, a team

involved in assessment of radiotherapy and chemotherapy services includes a clinical

oncologist and a medical oncologist/chemotherapy nurse specialist, respectively.33

The peer review team determines whether each standard has been achieved. Findings

are summarised in a written report, based on a national template, which is presented to

the Regional Cancer Quality Improvement Group. Assessment reports are also shared

with the relevant NHS Trusts and the host cancer network.

Where a service does not comply with the required standards, the network

management team develops an agreed action plan with the Regional Cancer Quality

Improvement Group. The action plan is monitored regularly33 and services can be

temporarily closed if there are serious concerns, or some other reconfiguration of a

service can be sought if there is a continual failure to meet requirements.33

An independent assessment of cancer services is also undertaken by the Healthcare

Commission, as part of its mandate to report on the provision of health care in the

NHS. The peer-assessment reports are made available to the Healthcare Commission

to assist in its inspections.

The Cancer Services Collaboratives (CSC) were established in 1999, led by the NHS

Modernisation Agency. The CSC is a national improvement program operating across

the NHS and forms the key implementation strategy for the NHS Cancer Plan,

supporting local teams within the 34 cancer networks in England to achieve change

and improve services for patients.34


Aspects of the English/Welsh model for consideration

• Strongly based and resourced from the health regions, and driven by national

reporting requirements for the NHS, rather than led by professional colleges as is

the case for the CoC.

• Strong support provided by Cancer Services Collaboratives, providing an

environment for sharing of information about successful initiatives to improve

quality of cancer services. Their strong stakeholder structure enables commitment

from all groups.

• While it is a process that can be tailored to local needs and circumstances, this can

lead to unnecessary duplication of effort in the development of assessment,

reporting and training programs and formats. It can also lead to an inconsistent

approach to assessment between regions as surveyors undergo different training

programs.

• No external assessment agency is involved, and while members of the assessment

team are encouraged to come from outside the region or network and this may be

perceived that system lacks objectivity.

• There is a need to ensure the right mix of people in the assessment team to ensure

there are a wide variety of skills available.

Scotland

Cancer in Scotland: Action for change35 provides a national strategy framework

document for cancer services in Scotland. The Scottish Executive Health Department

Cancer Branch is responsible for continuing policy development and the

implementation of Cancer in Scotland with the Scottish Cancer Group as the co-

ordination hub. The Group is headed by the Lead Clinician for Cancer Services in

Scotland. It has a standing agenda focusing on regional investment plans, 6-monthly

monitoring reports and the work of targeted sub-groups, including Referral Guidance,

Quality Improvement, and Radiotherapy Activity Planning.


Cancer services in Scotland have been grouped into three regional networks. Each

region is headed by Regional Cancer Advisory Group (RCAGS) which provides a

strategic advisory and planning role for the local cancer services and the NHS

Boards.36 An organisation review of the RCAGS was to be conducted in 2004 with the

Scottish Executive, NHS QIS and RCAGS working together to develop a Quality

Assurance/Accreditation Framework for cancer services. It was expected that each of

the three regional networks within Scotland would seek accreditation during the

summer of 2004.37

At the time of undertaking this scoping study the specific details of the new

accreditation framework were not available. Standards development and accreditation

processes were in previously in place under the CSBS.

In January 2003, NHS QIS was established as a Special Health Board to better

coordinate and integrate activity on clinical effectiveness and quality improvement.38,39

The Clinical Standards Board was incorporated into NHS QIS, as was the Clinical

Resource and Audit group (CGRAG); Heath Technology Board for Scotland (HTBS);

Nursing and Midwifery Practice Development Unit (NMPDU); and the Scottish Health

Advisory Service (SHAS).

The role of NHS QIS is to:

• set national standards, by working with the health professionals and the public, and

to assess the performance of NHS Scotland against these standards

• monitor performance by collecting and publishing data about clinical performance;

by commissioning clinical audits; sharing best practice and investigating serious

service failures

• provide advice, guidance and support to NHS Scotland on effective clinical practice

and service improvements.39

A number of tumour-specific standards have previously been published by the CSBS,

covering breast,40 colorectal,41 gynaecological (ovarian)42 and lung cancer.43 These

standards have been used in conjunction with generic standards44 that applied more

generally to clinical services. These standards were set in partnership with healthcare


professionals and members of the public and were based on the patient journey,

covering areas such as referral, time to diagnosis of cancer, multidisciplinary and

supportive care, staff education and training, and communication and information

sharing between care providers and patients.40 The CSBS also worked collaboratively

with SIGN.40 Within each standard, ‘essential’ criteria were to be met wherever a

service was provided. Other criteria were ‘desirable’ in that they were to be met in

some parts of the service (further detail about the standards is provided in Chapter 2).

Under the previous accreditation process, each Trust was asked to undertake a self-

assessment of their service against the standards. A review team performed an

external peer review of performance on behalf of the CSBS in relation to the standards.

The review team had a multidisciplinary structure and included health professionals

and members of the public, led by an experienced clinician and supported by staff from

the Board. The CSBS then reported findings of the self-assessment and peer review to

the Trust under review. NHS Boards were required to meet the standards as part of

their annual performance assessment.40

Aspects of the Scottish model for consideration

• The accreditation process is supported by a strong clinical network that promotes

the sharing of ideas and the improvement of health care as opposed to an

inspectorial process

• Concern has been expressed by consumers that the CSBS only had the power to

produce reports on an organisation’s performance rather than implement any real

action to improve cancer services45

• It is unclear whether there are any sanctions applied to those service who do not

comply with standards


Canada

There is no specific cancer accreditation process currently operating in Canada;

instead, activity has focused on implementing the five priorities for action in the

Canadian Strategy for Cancer Control (CSCC). These include:

• establishing mechanisms and improving capacity for collaborative guideline and

standards development

• establishing integrated prevention systems

• improving resources and systems for delivery of supportive care/rehabilitation and

palliative care

• establishing a human resource planning database and co-ordinated approach to

planning

• establishing national priorities for strategic investments in cancer research.46

In an effort to address the first priority action on standards development and guidelines,

the CSCC has established a Standards Action Group (S-AG) to develop a core set of

national cancer indicators. These indicators will be tied to standards that can be used

to monitor key processes and outcomes aligned with the strategic goals of CSCC.

They will also be linked to accreditation standards used CCHSA. The indicators will be

applied to all types of organisations offering cancer services and will have a systems

focus rather than a disease- or/tumour-site focus.47

A conceptual framework for a core set of national indicators for cancer has also been

developed by the S-AG. It focuses on four quality dimensions: responsiveness, system

competency, client/community focus and work life. The framework also reflects the

patient’s journey across the continuum of care.47

As a first step in the development cancer indicators the S-AG undertook a literature

review and environmental scan of key cancer indictor initiatives across Canada, USA,

the UK and Australia.47 Four hundred indicators were identified from the literature

review and these were mapped against the conceptual framework in an effort to


identify common areas and major gaps in indicators development. The future activity of

the S-AG will be to prioritise action on developing indicators in targeted gap areas.

New Zealand

In New Zealand, priorities for cancer are outlined in the New Zealand Cancer Control

Strategy, released in August 2003.48 The Strategy is the first phase in the development

and implementation of a comprehensive and co-ordinated program of cancer control in

New Zealand and outlines the goals, objectives, principles, planning, use of resources

and responsibilities for both Government and non-Government agencies. A key

objective is to develop, implement and undertake an on-going refinement of national

and regional standards, guidelines and protocols. A minimum data set will also be

developed to measure performance and outcomes.48

A systems approach has been adopted as a means of enhancing health services within

New Zealand. The IQ Action Plan: Supporting the Improving Quality Approach49 sets

out activities and actions that organisations, particularly the Ministry of Health and

District Health Boards (DHBs), will undertake to progress quality approaches in health.

There are no new or additional legislative or regulatory requirements imposed under

the plan to address standards and quality. The quality of the health sector in New

Zealand is currently measured and reported on by Quality Health NZ, through the

Health Accreditation Program for New Zealand (HAPNZ).

C a n c e r a c c r e d i t a t i o n m o d e l s i n A u s t r a l i a

The level to which cancer-specific accreditation models have been developed in

Australia varies considerably. At the time of preparing this report, the only national

cancer-specific accreditation system operating in Australia is for BreastScreen

Australia. A quality program for radiation oncology services is currently being

developed. Most activities occurring at a State and Territory level involve the

development of cancer plans or cancer services frameworks. Information has been

provided about these activities as they will impact on the development of a national

cancer service accreditation model.


BreastScreen Australia

BreastScreen Australia, the national mammographic screening program, was

established in 1991 to reduce mortality and morbidity from breast cancer through early

detection. BreastScreen Australia offers two-yearly mammograms to women at over

five hundred screening locations across Australia, via fixed, relocatable and mobile

units. The program targets women aged 50–69; however all women aged 40 and older

are eligible to attend for screening.50

The BreastScreen Australia program is funded jointly by the Australian, State and

Territory governments. The Australian Government coordinates policy formulation,

national data collection, quality control, monitoring and evaluation, and accountability.

Within each State and Territory, a State Coordination Unit (SCU) has responsibility for

implementation of the Program within its jurisdiction. There are currently 35 Services

operating across Australia. Each Service screens between 1,000 and 65,000 women

each year.51

The National Advisory Committee (NAC) to BreastScreen Australia is the national body

that has to date coordinated policy for the Program. This Committee was replaced by

the Australian Screening Advisory Committee (ASAC) in September 2004. The role of

ASAC is discussed on page 99.

The quality improvement program and accreditation

The quality improvement program within BreastScreen Australia includes education

and training, review and an accreditation program, overseen by the National Quality

Management Committee (NQMC).52 The focus of the quality improvement program is

to ensure that minimum National Accreditation Standards (NAS) are maintained and to

develop strategies for continuous review and improvement of care. The NAS were

reviewed and updated by the NBCC in 2002, on behalf of the Department of Health

and Ageing.

The accreditation process provides an external assessment of the extent to which each

Service is meeting minimum standards for practice. In total there are 175 NAS for the


provision of breast screening and assessment Services within BreastScreen Australia.

These standards are described in Appendices VI and XI.

Accreditation process

To achieve accreditation, a Service needs to demonstrate to the NQMC that it meets

the NAS to an acceptable level. The accreditation system is tiered, with various levels

of accreditation attainable. Each NAS is allocated a risk rating as a way of considering

the impact that not meeting the standard will have on the key outcome area of the

program, and a decision tool has been developed to improve decision making against

the NAS during the accreditation process. The process followed for a Service that has

been previously accredited is outlined below:53

Self-assessment by Service:

• All Services must undertake a self-assessment to support and improve their

Service quality. The assessment forms part of their accreditation application.

• The self-assessment involves a review of the Service’s performance against the

NAS and consideration of the risks as defined in the Decision Tool.54

Annual data reports:53

• Each Service is required to provide an annual data report to the NQMC.

• The reports contain data on all the quantitative components of the NAS. All

standards that are not met are noted as are strategies to address these gaps in

performance.

• Data auditors and site visitors use the reports to assist their reviews of the Service.

In addition, the NQMC uses the reports to monitor performance between

accreditation visits.


Data audit and subsequent report:53

• An independent data audit is conducted prior to the site visit.

• The audit assesses whether data management practices comply with the data

management standards and procedures as required by data auditor guidelines and

the NAS.

A site visit and subsequent report:53

• An external review of a Service to assess compliance with the NAS is conducted.

• The site visit team usually consists of five members. The site visit team must

include a radiologist and program manger or head of Service with Service

management responsibilities. Other members of the site visit team are selected

depending on the requirements of, or the difficulties experienced by, the Service.

These may include a surgeon, radiographer, medical director, counsellor, expert in

quality management or a consumer. In future all site visitors must be accredited as

BreastScreen Site Visitors having completed the BreastScreen Site Visitors

Training Package (currently in development).

• The site visitors summarise their findings in a formal report.

Any response from the Service to issues raised:53

• Following the site visit, the Service is given the opportunity to respond to the Site

Visit Report. The Service can provide an explanation for why individual standards

were not met and a proposed plan and timeframe to improve performance.


Recommendation to the NQMC by the State Accreditation Committee (SAC):53

• After the site visit the SAC and SCU (and possibly the head of the Service) meet to

determine the SAC’s recommendation to the NQMC about the Service’s level of

accreditation.

Consideration and subsequent accreditation decision by the NQMC:53

• The NQMC considers the Service’s application and all material provided, including

the data audit, site visit report and recommendations of the SAC

• The NQMC decides whether a Service should be accredited and the level of

accreditation to be granted.

Provisions for appeal:53

• BreastScreen Services have the right to appeal accreditation decisions. They may

appeal against the decision not to accredit the Service or the term of the

accreditation granted. If the NQMC, on review, does not revise its original decision,

the matter is referred to an Appeal Committee.

Levels of accreditation

There are five levels of accreditation an existing Service can attain each with varying

time frames; non-accreditation is also possible.53 The details are outlined in Table 2.


Table 2: Standards achieved at different levels of accreditation Accreditation level Achieved standard

Four-year accreditation with commendation

Service performs highly against all standards.

Four-year accreditation Service performs well against most standards, including all level 1 standards.

Two-year accreditation Service meets all level 1 standards but not a significant proportion of level 2 and 3 standards.

Two-year accreditation with high priority recommendations

Service meets the requirements for a two-year accreditation term other than meeting a number of level 1 standards.

Provisional accreditation Two years provisional accreditation for new Services.

Non-accreditation Service does not meet requirements for accreditation for two-year accreditation with high priority recommendations, or accreditation has lapsed.

Non accreditation53

A Service that is not accredited due to its inability to meet the requirements for two-

year accreditation with high priority recommendations will not be able to:

• operate as a BreastScreen Australia Service

• use the BreastScreen Australia logo or any logo or material that identifies it with the

program, including State and Territory versions of the logo.

Accreditation resources

BreastScreen Australia is currently updating all resources to support the accreditation

process. These include an accredited site visitors training package developed for

BreastScreen Australia by the ACHS. Options to formally accredit the site visitor

training package with the most appropriate accrediting body are also currently being

explored. Additionally a full set of accreditation forms, to be made available in both an

electronic and paper-based form are also being developed.


Aspects of BreastScreen Australia model for consideration

• The BreastScreen Australia accreditation process is inclusive, with all 34 Services

undertaking accreditation.

• There is a large degree of ownership of the process, which drives Services to attain

accreditation.

• Current costs associated with accreditation are less than those that would be

imposed by an external independent agency, as the costs are currently assumed by

jurisdictions.

• The use of a decision tool employs a risk management approach to decision-

making. Risk management is a well-recognised, objective approach to provide a

structure without sacrificing flexibility. It also has the advantage of enabling the use

of a tiered system of accreditation.55

• National accreditation processes ensure a constant approach. Supported by newly

developed resources including: accredited site visitor training package,

accreditation forms; accreditation handbook and accreditation decision- making tool

• The robustness, objectivity, transparency and credibility of the process may be

seen to be compromised, since those who develop the standards also accredit the

Service.

Australian Screening Advisory Committee56

In April 2004 the Australian Government Minister for Health and Ageing approved the

establishment of ASAC. ASAC became operational on 14 September 2004. The

purpose of this group is to provide expert advice the Australian Health Ministers’

Advisory Council (AHMAC) and the Minister on screening issues. The ASAC will take

the place of both the BreastScreen Australia NAC and the Cervical Screening Program

National Advisory Committee.


ASAC Terms of Reference:

• to provide advice to AHMAC and the Minister for Health and Ageing on national

policy and quality standards and existing and emerging screening programs

• oversee the monitoring and evaluation of screening programs

• oversee, develop priorities for, and monitor communication strategies

• provide a focus for informed comment and debate

• develop and implement a work program addressing agreed and emerging priorities

• to assist the ASAC four working groups have been established and these include:

o Monitoring and Evaluation Working Group

o Policy and New Technology Working Group

o Quality Assurance and Workforce Working Group

o Communication, Recruitment and Education Working Group.

Radiation oncology

In November 2002, the Radiation Oncology Jurisdictional Implementation Group

(ROJIG) was established by Australian Health Ministers to respond to the Baume

Inquiry into Radiation Oncology, within the broader context of cancer care delivery.57

The ROJIG recognised the need, through its Quality Working Group, for systematic,

nationally applicable quality initiatives for radiotherapy services and staff, as most

quality-related activities occurred on a facility level, with State and Territory legislation

covering radiation safety.57

The Quality Working Group considered a proposal for the development of a quality

program, through which a comprehensive accreditation program for radiotherapy might

be advanced. This proposal was developed by the Tripartite Committee, a


representative body for three radiotherapy professions: the Faculty of Radiation

Oncology (FRO) of the Royal Australian and New Zealand College of Radiologists

(RANZCR); the Australian Institute of Radiography (AIR); and Australasian College of

Physical Scientists and Engineers in Medicine (ACPSEM).

This Quality Program focused on three quality components:

• an overarching quality program including elements such as continuing education,

maintenance of equipment, planning and treatment procedures, data collection,

radiation safety and ability to participate in clinical trials.

• an Incident Monitoring System for Radiation Oncology

• a dosimetry program.

With support from the Quality Working Group, the Tripartite Committee submitted a

funding proposal to the Australian Government Department of Health and Ageing for

consideration.58 In an effort to progress certain elements within the proposal, the

profession is currently working with the Australian Council for Safety and Quality in

Health Care to ensure that the incident monitoring system for radiation oncology links

in with the overarching quality and safety incident monitoring system. In order to inform

the development of a national dosimetry program, the Australian Government

Department of Health and Ageing has funded a pilot dosimetry program.

Australian State and Territory activity

At the State and Territory level, only New South Wales and Victoria are in the process

of developing cancer-specific accreditation processes. Activity in the other jurisdictions

has been mainly at the strategic level, such as the development of cancer plans,

service capability frameworks or Taskforces that can be used as a basis to support the

development of cancer standards and cancer service accreditation systems in these

jurisdictions. In some States, where there is no specific cancer accreditation-related

activity, initiatives focus on quality and safety through the establishment of Quality

Councils or mechanisms such as data registries and clinical governance structures.


New South Wales (NSW)

In June 2003, the NSW Government established the Cancer Institute NSW under the

Cancer Institute (NSW) Act 200359 to accelerate improvements in cancer control in

NSW. Part 4 of the Cancer Institute (NSW) Act 2003 gives legislative power to the

Cancer Institute NSW to:

• accredit programs relating to cancer control, including prevention and screening

programs

• undertake the assessment of any cancer control service or program in the public

health system as may be required by the Minister for Health or the Director-General

from time to time and to report to the Minister for Health or the Director-General on

the outcome of that assessment.

The Act does not contain any details on how this assessment process will be

undertaken, how it links in with current accreditation processes or bodies, or what

incentives or possible sanctions could be used for complying and on-complying

services.

Goal 32 of the NSW Cancer Plan60 outlines a proposed approach for the development

of a Quality Accreditation Program, however it only states that:

“Organisations that are committed to providing optimal cancer care will be invited to

participate in a voluntary, peer-reviewed accreditation process. Evaluation processes

may be outsourced and will include site visits and review of data collected by the local

team. At the end of the review, a report will detail achievements and suggested areas

for improvement. All accredited services will be promoted in the NSW Directory of

Cancer Services” 60

The Goal also states that the Cancer Institute NSW will work collaboratively to

determine performance indicators and minimum standards for quality management,

clinical and psychological services, cancer research, cancer information, education

programs and fundraising programs. These criteria will be reviewed by the Clinical

Effectiveness Advisory Committee and the Clinical Excellence Commission. Currently


the criteria developed by the CoC in the USA are being examined as a basis for the

development of clinical accreditation. This is covered in more detail in Chapter 2.

Victoria (VIC)

A standards development and accreditation process for cancer services in Victoria has

been outlined in A Cancer Services Framework for Victoria (2003), which provides an

integrated service model for metropolitan and rural cancer services. A Ministerial

Taskforce for Cancer has been established to oversee the implementation of

improvements recommended in the Framework.61 The Framework proposes that a set

of evidence-based standards for cancer care be developed for ten of the most

frequently occurring cancers. Under the proposed framework, tumour stream-specific

Reference Groups comprising clinical experts, patient and community representatives,

service managers and others will be established for each of the State-wide tumour

streams to provide advice on the development of standards (see Chapter 2). They will

also play a role in the accreditation process.61

It has been proposed that the accreditation of cancer services in Victoria should take a

supportive/quality improvement approach rather than a regulatory/compliance

approach. All elements of a service, including members of a multidisciplinary team,

would be required to participate in the audit program. The assessment process would

also be managed by an independent body external to the Department of Human

Services, such as the ACHS or Standards Australia.

Under the proposed accreditation approach, health-care institutions providing services

within particular tumour streams would be encouraged to seek accreditation for the

level of services that they provide or intend to provide.61

The audits would involve data collection and provision of service performance and

outcomes to the local reference group and then to the State-wide reference group. The

data from the audit process would also be fed into State-wide cancer collections to

provide State-wide performance and outcome data. Hospital-based cancer registries

would be used as a mechanism for efficient audits at hospital level.61


It has been proposed that financial incentives could be used to encourage incentives

for services to seek and maintain accreditation. Incentive funds could be used to

employ cancer care coordinators and to promote accredited services to patients and

referring practitioners (notably general practitioners and non-cancer specialists who

detect or diagnose cancer).61

Within Victoria, work has been conducted by BreastScreen Victoria on behalf of the

Department of Human Services to develop a set of performance indicators for public

hospital breast services. Ten performance indicators have been developed covering

areas of timeliness, breast nurse contact, complete pathology reporting,

multidisciplinary care, referrals to medical and radiation oncology, communication with

general practitioners and complications of treatment. The indicators are currently being

trialled and evaluated in hospital breast services and standards to support the

indicators are in development.62

Queensland (QLD)

Much of the activity in Queensland has focused on the development of a Clinical

Services Capability Framework (SCF), which outlines the minimum support services,

staffing, safety standards and other requirements required in both public and private

health facilities to ensure safe and appropriately supported clinical services.63

In the Framework, clinical services provided by a facility have been classified as either

core clinical services or supporting clinical services. Core clinical services fall into four

areas: emergency services (retrieval services are not specified); surgical services

(including endoscopy services); medical services; and maternity services. Support

services are often ‘stand alone’ and can be provided or accessed off site. On-site

services include critical care, neonatal services, anaesthetic services and operating

suite services. Off site-services include diagnostic imaging, interventional radiology,

nuclear medicine, pathology and pharmacy service.63

Future updates of the Service Capability Framework are planned, including an annual

review and the addition of capability requirements for non-acute health services such

as oncology, renal and rehabilitation services. This will ensure the SCF continues to

reflect current best practice in clinical standards.63


Western Australia (WA)

In March 2003, the Western Australian Government appointed a Health Reform

Committee (HRC) to develop a major system-wide reform agenda to improve the future

quality and financial sustainability of the health system in Western Australia. In relation

to cancer, the Commission recognised that there was fragmentation in the delivery of

cancer services whereby tertiary and secondary level hospitals developed cancer care

services independently of each other. This resulted in the two major tertiary hospitals

having competitive models of care, with little tumour sub-specialisation in some types

of cancer. Optimal sub-specialisation was not developed due to inadequate tumour

caseloads at each hospital.64

The HRC recommended that a State Centre for Cancer Care be established to

integrate and co-ordinate delivery of cancer care across the State.65 During 2004, the

State Government announced the establishment of a State Centre for Cancer Care at

Sir Charles Gairdner Hospital. This Centre will be linked with other metropolitan and

regional service providers through an integrated service model of care and will include

on-site ambulatory radiotherapy, medical oncology, haematology, day surgery,

diagnostic imaging and blood taking.

The Committee also recommended that a Director of Cancer Services for Western

Australia be appointed. Some of the key tasks to be encompassed by this role include

the coordination of cancer services state-wide, an audit of WA Cancer Services within

the first 12 months and the development of a WA Cancer Plan.64

The Strategic Plan for Safety and Quality 2003-2008 provides a strategic framework for

health services in WA and is designed to promote the delivery of consumer-focussed,

safe, quality health care. An audit of current accreditation systems and methodologies

across WA by the Safety and Quality Health Council highlighted the fact that no single

accepted method for accrediting health care organisations currently exists. This

information will be used to develop and implement an agreed standard quality

accreditation framework for health services that supports quality improvement across

the health system.


Australian Capital Territory (ACT )

The strategic document, Quality First: a commitment to quality and safety in ACT

Health Services66 recognises the urgent need to address quality and safety issues in

the acute setting. It defines the dimensions of quality and provides some guiding

principles. Quality First includes a Quality and Safety Framework and an Operational

Plan to advance Quality Improvement. The focus for 1999-2004 is public hospital

services.

While there are no specific cancer accreditation activities currently in development in

the ACT, there are a number of projects that do have a strong focus on quality and

safety and could impact on cancer services. These include a clinical health

improvement program, an adverse incidents events monitoring system (AIMS), a cross-

portfolio clinical governance group and a consumer feedback mechanism. The ACT

Facilities Code of Practice 2001 encourages, and in some cases mandates, the use of

external systems such as ACHS to improve organisations and the delivery of health

services.

Tasmania (TAS)

As is the case in other States and Territories, cancer-related services in Tasmania are

accredited in accordance with relevant professional and legislative requirements such

as BreastScreen and NATA, but there are no specifically accredited integrated cancer

services.67

The Tasmanian Department of Health and Human Services (DHHS) is involved in the

development of a general strategic plan for cancer control. A discussion paper entitled:

A Better Future for Cancer Control in Tasmania67 has been produced and the State

Government recently agreed to establish a Tasmanian Cancer Control Task Force.

The establishment of a Tasmanian Cancer Task Force would progress the

development of a strategic plan for cancer control in Tasmania, and discussions are

currently being held with key stakeholders, especially clinicians, to garner their support

for its establishment.


A key priority that would be addressed by a newly created Cancer Taskforce would be

the collection of cancer statistics in Tasmania to assist with monitoring, evaluation and

accreditation activities.

Northern Territory (NT)

Building Healthier Communities- A Framework for Health and Community Services

2004-2009 published in February 200468 outlined priorities for health in the Territory.

Some of the projects to be undertaken may impact on cancer services. For example,

some of the performance measures for Divisional Business Plans link into national

programs for breast cancer and cervical cancer, eg encouraging Well Women’s

Screening Programs. Within the area of Acute Care, one of the designated activities is

to begin service planning for a Cancer Services Plan. The timeframe for this activity is

June 2005.66

A NT Quality Council has been established and met for the first time in July 2004. The

Council was formed in June 2004. It will focus on developing new safety and quality

initiatives in the primary care, community heath care and public health care sectors.

The Council also has links to the Acute Care Quality Committee that focuses on

hospitals and is currently chaired by the principal medical Advisor to the Minister for

Health.

A review of health care services in the NT (Bansemer Review) also recommended

maintaining accreditation of all hospitals and the pursuit of accreditation for other health

services and the formation of Clinical Reference Groups to advise the NT Department

of Health on quality and safety issues.

South Australia (SA)

In May 2002, the Generational Health Review (GHR) was commissioned by the SA

Department of Health Services to examine the systems and delivery of health care

services in South Australia. The GHR noted the duplication of planning, assessment

and delivery of services and the fragmentation in the health system. Better Choices,

Better Health (April 2003)68 made a number of recommendations including the setting


up of a State-wide clinical senate to provide advice on clinical planning and to develop

a State-wide framework for quality and safety benchmarks and standards. The

Department of Human Services is seen as having a continuing and strengthening role

in the co-ordination of State-wide planning, including tertiary and quaternary services,

when it is not feasible or desirable for these to be managed at a local level.67

As part of the reform process, three regional health services areas have been

established in metropolitan Adelaide, replacing 12 hospital and health services boards

(July 2004) and it is also recommended that Networked Clinical Service Groups

(NCSGs) be formed to oversee clinical service provision.67

First Steps Forward, published in June 2003,69 focused on strategies to address the

GHR recommendations to provide better governance, better services and better

system support. It is recognised that there is a changing disease burden from cancer

for South Australians. The Department of Human Services has completed, but not yet

implemented, a review of cancer services.

The SA government will also legislate for a stronger role for the South Australian

Quality Council to support the work in addressing issues of quality and effectiveness in

health care.

Key issues to be considered in the development of an Australian model for cancer services accreditation

A number of models of accreditation have been presented both internationally and

nationally, that may be considered in the development of a national model of

accreditation for cancer services in Australia. From the literature review and

consultations, key issues have been highlighted that are relevant when planning,

developing and implementing a national cancer services accreditation system.

The appropriateness of the model to the context in which it will function

• Structure of the health system and any relevant legislative requirements


• Funding of health care services in Australia by Federal, State and Territory

governments

• Jurisdictional responsibility for provision of health care services

• Public/private sector involvement in the provision of cancer services

The structure of the accreditation agency/ies

• Independence of the agency/ies

• Representation in governance structure eg composition of Board and involvement

of consumers

Appropriate assessment process

• Assessment process that is achievable by health care services in terms of cost,

time and resources required

• Avoidance of duplication in accreditation processes

• Use of agreed standards against which to assess performance

• Use of ratings for performance that could initially focus on process

• Use of appropriate, trained assessors

• An appeals process and review for cancer services disputing ratings/results

• Defining the relationship between standards development and assessment


Support for continuous quality improvement

• Availability of resources eg funding, staff development, and training to assist cancer

services address identified deficits

Compliance by cancer services to accreditation processes

• Measures to encourage compliance eg incentives

• Appropriate levers related to funding, membership of a designated cancer service

The accreditation/validation of the nominated accreditation agencies

• Use of an external, independent agency to accredit the nominated accreditation

agency/ies

• Compliance of agencies with such a ‘validation’ process and appropriate sanctions

for non-compliance

Data issues

• Adequate data collection, monitoring, reporting and review to support accreditation

process

Appropriate representation in the accreditation processes

• Broad consultation with health professionals, health services providers and

consumers at all stages of the process, from development of standards to the

accreditation process


Transparency

• relationship between standards development and assessment to ensure credibility

and transparency

• reporting of results of accreditation

• accessibility of results to consumers


R e f e r e n c e s


breast services in Victoria. Melbourne. Victorian Government Department of

Human Services, 2004.

2. Matthews Pegg Consulting. Standards setting and accreditation literature review

and report. Canberra. Safety and Quality Council (Australian Council for Safety

and Quality in Health Care), 2003.

3. Skok A, Swerrissen H, Macmillan J. Standards and quality improvement

processes in health and community services: a review of the literature. Bundoora.

Quality Improvement Council Limited, 2000.

4. Shaw CD. External quality mechanisms for health care: summary of the ExPeRT

project on visitatie, accreditation, EFQM and ISO assessment in European Union

countries. Int J Qual Health Care 2000;12:169-175.

5. Arah O, Klazinga NS, Delnoiji DMJ, et al. Conceptual frameworks for health

systems performance: a quest for effectiveness, quality and improvement. Int J

Qual Health Care 2003; 15:377-398.

6. Minister of Health. The New Zealand Cancer Control Strategy. Wellington.

Ministry of Health and New Zealand Cancer Trust, 2003.

7. Sandrick K. Everything you want to know about the joint commission. Trustee

2004; 57:17-21.

8. Bohigas L, Heaton C. Methods for external evaluation of health care institutions.

Int J Qual Health Care 2000; 12:231-238.

9. Health Care Commission: “Frequently Asked Questions”. Found at

http://www.healthcarecommission.org.uk/AboutUs/AboutUsFAQs/fs/en?CONTEN

T_I.... (accessed September 2004).


10. NHS in England, “Star ratings”, Found at

http://www.nhs.uk/england/aboutTheNHS/starRatings/default.cmsx (accessed

September 2004).

11. Schyve P. The evolution of external quality evaluation: observations from the

Joint Commission on Accreditation of Healthcare Organizations. Int J Qual Health

Care 2000; 12:255-258.

12. Joint Commission on Accreditation of Healthcare and Organization. Public

information:

http://www.jcaho.com/htba/hospitals/survey+process/public+information.htm.

(Accessed September 2004).

13. 2002 National Health Accreditation Report. Ottawa. Canadian Council on Health

Services Accreditation, 2003.

14. Clinical Accountability, Service Planning and Evaluation (CASPE). About CASPE.

http://www.caspe.co.uk/about_caspe.htm. (Accessed August 2004).

15. Horton R. Why is Ian Kennedy’s Healthcare Commission damaging NHS care?

Lancet 2004; 364:401-402.

16. Sloane T. A Commission out of joint. Modern Healthcare 2004; 34:20.

17. Australian Council for Safety and Quality in Health Care. Standards Setting and

Accreditation Systems in Health: Consultation Paper. Safety and Quality Council,

2003.

18. Australian Council on Healthcare Standards: www.achs.org.au.

19. The EQuIP Guide: A Framework to Improve Quality and Safety of Health Care,

3rd Edition. Ultimo. Australian Council on Healthcare Standards, 2002.

20. Heaton C. External peer review in Europe: an overview from the ExPeRT Project.

Int J Qual Health Care 2000; 12:177-182.


21. Shaw C, Heaton C. Summary of the ExPeRT Project. CASPE Research, 2004

Available at: www.caspe.co.uk/expert/final_summary.htm. (Accessed

07/06/2004).

22. Private Health Industry Quality and Safety Committee:

http://www.phiqs.gov.au/stratplan.htm.

23. Private Health Industry Quality and Safety Committee. State and Territory

licensing arrangements for private health facilities. Draft information paper.

Australian Government Department of Health and Ageing, December 2003.

24. Report of the lessons learned from accreditation: working group of the National

Aged Care Forum. Canberra. Commonwealth Department of Health and Ageing,

2002.

25. Aged Care Standards and Accreditation Agency “About Review Audits – What

happens when a home does not comply with the Accreditation Standards?”.

www.accreditation.aust.com/accreditation/audits.html#6.

26. Principles for the appointment of consumer representatives: a process for

governments and industry. Consultation draft. Commonwealth Consumer Affairs

Advisory Council, May 2002.

27. Braithwaite J, Healy J, Dwan K. The Governance of Health Safety and Quality.

Ideas Paper prepared for the Australian Council for Safety and Quality in Health

Care. Canberra. 2004.

28. Swerrissen H, Macmillan J, Skok A. A review of quality improvement approaches

in health and community services. Canberra. Commonwealth of Australia, 2000.

29. Heidmann EG. The Contemporary Use of Standards in Health Care. World Health

Organisation, 1993.

30. Gray L. Two Year Review of Aged Care Reforms. Canberra. Commonwealth of

Australia, 2001.


31. Commission on Cancer. Cancer Program Standards 2004. Chicago. American

College of Surgeons, 2003.

32. A policy framework for commissioning cancer services. A report by the expert

advisory group on cancer to the chief medical officers of England and Wales.

1995. Available at

http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAn

dGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4071083

&chk=%2Bo6fka.

33. Department of Health. Manual of Cancer Services Standards. London. National

Health Service Executive, 2000.

34. Bevan H, Williamson J. (Presented at the ACN council meeting 16 September

2003) The cancer services collaborative: a nationwide programme to improve the

experience and outcomes of people with cancer by redesigning and co-ordinating

their care.

35. NHS Scotland. Cancer in Scotland - action for change. Edinburgh. Scottish

Executive, 2001.

36. Robson K. Cancer services in Scotland. The Scottish Parliament, 2002.

37. NHS Scotland. Cancer in Scotland - action for change: bowel cancer framework

for Scotland. Edinburgh. Scottish Executive, 2004.

38. NHS Quality Improvement Scotland website: http://www.nhshealthquality.org.

39. NHS Quality Improvement Scotland Annual Report 2002-2003. NHS Quality

Improvement Scotland, 2003.

40. Clinical standards: breast cancer. Edinburgh. Clinical Standards Board for

Scotland, 2001.

41. Clinical standards: colorectal cancer. Edinburgh. Clinical Standards Board for

Scotland, 2001.


42. Clinical standards: gynaecological (ovarian) cancer. Edinburgh. Clinical

Standards Board for Scotland, 2001.

43. Clinical standards: lung cancer. Edinburgh. Clinical Standards Board for Scotland,

2001.

44. Clinical standards: generic. Edinburgh. Clinical Standards Board for Scotland,

2002.

45. Christie B. Scotland’s way to guarantee quality. BMJ 2000: 320:78.

46. Canadian strategy for cancer control. Action Plan document: priorities for action.

www.cancercontrol.org, 2002.

47. Canadian Council on Health Services Accreditation. Literature review and

environmental scan for cancer control indicators. Canadian Strategy for Cancer

Control Standards Action Group, 2004.

48. Minister of Health. The New Zealand Cancer Control Strategy. Wellington.

Ministry of Health and the New Zealand Cancer Control Trust, 2003.

49. Minister of Health. IQ action plan: supporting the improving quality approach.

Wellington. Ministry of Health, 2003.

50. BreastScreen Australia. Marketing and media: frequently asked questions.

www.breastscreen.info.au/marketing/faq.htm (Accessed August 2004).

51. BreastScreen Australia. National Accreditation Standards. (Draft). BreastScreen

Australia, 2002.

52. National Quality Management Committee of BreastScreen Australia. Quality

Improvement for BreastScreen Australia. Unpublished. BreastScreen Australia,

1999.

53. BreastScreen Australia. National accreditation handbook (draft for consultation).

BreastScreen Australia, 2004.


54. BreastScreen Australia. National accreditation standards: decision tool to assist

with accreditation decision-making against the national accreditation standards.

BreastScreen Australia, 2002.

55. HB 228 Guidelines for Managing Risk in HealthCare. Australian and New Zealand

Handbook Standards Australia & Standards New Zealand. Standards Australia,

2001.

56. Screening Advisory Committee. Agenda item 4. Obtained from 13-14 September

2004 meeting

57. Radiation Oncology Jurisdictional Implementation Group (ROJIG) - final report

September 2003. Australian Government Department of Health and Aging, 2003.

58. ROJIG Quality Working Group. Brief for: development of a radiation oncology

quality program.

59. Cancer Institute (NSW) Act 2003: as at 14 November 2003. Available at:

www.cancerinstitute.org.au/cancer_inst/about/about.html.


61. Barton M, Frommer M, Olver I, et al. A cancer services framework for Victoria and

future directions for the Peter MacCallum Institute. State Government of Victoria,

Australia, Department of Human Services, 2003.


breast services in Victoria. Melbourne: Victorian Government Department of

Human Services, October 2004.

63. Clinical services capability framework: public and licensed private health facilities,

version 2.0. Brisbane. Queensland Health. (In press. To be released in 2005).

64. Ward M, Bishop J, Theile D, et al. Options for clinical services October 2003: a

paper prepared by the Role Differentiation Project Group Clinicians for the Health

Reform Committee to facilitate public discussion. Perth. Government of Western

Australia, 2003.


65. A healthy future for Western Australians: report of the Health Reform Committee.

Government of Western Australia Department of Health, 2004.

66. Quality First: a commitment to quality and safety in ACT Health Services.

Publication 01/0670. ACT. Canberra. ACT Department of Health, Housing and

Community Care. 2001.

67. Private correspondence with Gail Raw, Cancer Screening & Control Services at

the Tasmanian Department of Health and Human Services. August 2004.

68. Building healthier communities: a framework for health and community services

2004-2009. Northern Territory Government Department of Health and

Community Services, 2004.

69. Better Choices, Better Health. Final report of the South Australian Generational

Health Review. Government of South Australia. 2003.

70. First Steps Forward. South Australian Health Reform. Government of South

Australia. 2003.


4 . O U T C O M E S O F T H E S C O P I N G S T U D Y

Development of an accreditation system for cancer services in Australia is complex.

Australia has a mixed model of care for patients with cancer involving both public and

private health sectors. In addition Australia’s unique geography presents the challenge

of ensuring equity across rural and remote areas. This is further complicated by the mix

of Federal and State/Territory governance. Moreover, cancer service delivery is an

evolving process in all States and Territories with cancer frameworks and plans at

differing stages of development.

This chapter does not seek to define one model for cancer services accreditation in

Australia. Instead, it outlines key elements that should be considered when

implementing an accreditation model. These key elements have been identified

through the comprehensive stakeholder consultation process and review of existing

national and international systems for standards development and accreditation in

healthcare and cancer services. The chapter also highlights a number of issues or

areas of controversy that require further consideration when implementing

accreditation.

S e t t i n g s t a n d a r d s

It is recommended that standards are set at a national level to ensure consistency

across Australia. However, the standards should incorporate sufficient flexibility to take

account of Australia’s mix of public and private systems and both urban and rural

contexts. In particular standards should not discourage participation by small, low

caseload services but should encourage linkages and networking to larger specialist

units.

There is a need for multidisciplinary input into the standards development process.

Clinical input will ensure long-term ownership of the accreditation process, while

technical expertise in developing standards will also be needed. Consumer input is

important to ensure that a patient focus is maintained.


Duplication of existing standards should be avoided and opportunities to streamline the

process should be sought. Stakeholder consultations have highlighted the need to

keep the number of standards to a minimum so that the process remains manageable.

There is some debate over whether standards should focus on process or outcome. It

is recommended that a staged approach is used whereby minimum standards that

focus on process are agreed initially with a view to phasing in aspirational standards

that may be based on outcomes later. However, the link between process indicators

and outcomes should be made explicit so that the inclusion of each standard in the

accreditation process can be justified.

Standards should be based on the national Cancer Services Standards Framework

(see Appendix VII), incorporating areas of:


• patient focus

• accessibility

• facility requirements

• elements in the patient pathway




• research.

In each area of the Framework, standards should be clearly defined, measurable and

evidence-based. Standards already exist for some of these areas (see Appendix VIII)

and duplication or ‘reinventing the wheel’ should be avoided. For others, the growing

number of evidence-based clinical practice guidelines for the management of cancer

will provide a useful basis for standards development.


As cancer service delivery in Australia is evolving, it will be important to establish

appropriate standards review and revision processes with feedback from a range of

key stakeholders.

A n A u s t r a l i a n m o d e l f o r c a n c e r s e r v i c e s a c c r e d i t a t i o n

It is recommended that an Australian model for cancer services accreditation should

focus on quality improvement, with compliance rewarded and support provided to

encourage improvement, rather than being a regulatory process with non-compliance

penalised. The system should be voluntary but with efforts made to gain support and

buy in from key stakeholders to increase participation. Processes should be

implemented to provide evidence of compliance with standards.

The accreditation system should be clinician-led, incorporating both self-assessment

and peer review, with a written report produced by assessors and presented to the

accrediting body to inform an accreditation decision. Consumer involvement throughout

the accreditation process will also be an important contributing factor in encouraging

participation and compliance. The impact of public demands for an assurance that their

health service is delivering high quality and safe health care cannot be underestimated.

The number of levels of accreditation awarded will need to be agreed and could be

used to indicate compliance, provisional compliance and non-compliance.

A three-year accreditation cycle is recommended; however, it should be recognised

this cycle should incorporate the development of action plans that are monitored on an

annual basis, with feedback provided to facilities as necessary. If existing accreditation

agencies are used, there is a need to consider the demands of existing accreditation

cycles on the availability of assessors.

Outcomes of the accreditation process should be made publicly available. Support and

education should be provided to services following accreditation to rectify problem

areas and improve service on an ongoing basis. For those services who fail to reach a

required standard but disagree with the accreditation decision, there should be a

transparent and accessible appeals and mediation process.


In developing the accreditation system it is important to ensure that the burden on

health services and facilities is minimised. Common user-friendly data collection tools

and forms should be established. The accreditation process should be reviewed at

intervals, for example at the end of each accreditation cycle, to drive improvement in

the accreditation system.

C o n d u c t o f a c c r e d i t a t i o n

The accreditation system should follow a peer-review process with an accreditation

team including oncology health professionals, technical experts and consumers. The

team should receive training and support and an external and independent quality

assurance system should be in place so that the suitability of the agency and

assessors for undertaking the accreditation process is assured. Following the peer

review process, the accreditation team should make a recommendation to the relevant

accrediting body about whether accreditation should be awarded; ultimately the

accreditation decision will rest with the accrediting body. Development of a risk

assessment tool to aid accreditation decisions, such as that used currently by the

National Quality Management Committee of BreastScreen Australia, may be

considered.

The Australian health system is complicated by Federal and State-/Territory-level

funding and by the mix of public and private health services. While standards should be

set at a national level, a question remains about whether there should be one national

accrediting body to ensure consistency or whether multiple agencies, either at a

national or State and Territory level, should undertake the process. Multiple agencies

have the benefit of avoiding a monopoly. However, if multiple agencies do undertake

the process it will be important for linkages to be established between them so that

there are commonalities in terms of terminology and processes and to promote

consistency and comparability. Regardless of whether there is one or more accrediting

body it is important that a degree of autonomy from Government control is maintained.


L i n k a g e t o e x i s t i n g a c c r e d i t a t i o n a g e n c i e s

In order to avoid overlap and duplication of effort, the use of existing accrediting bodies

within Australia should be considered. If multiple agencies are used, links between

them should be established from the outset and maintained with protocols for regular

and ongoing communication agreed. The timing of accreditation cycles should be

coordinated to streamline the process for services.

C o m p l i a n c e

The success of an accreditation system will depend on the ability to embed it into the

organisational culture of each health service and facility. A focus on continuous quality

improvement rather than enforced regulation will assist in this process. It will be

important to gain buy-in from all relevant stakeholders at both a facility level and a

health service level from the outset through demonstration of the benefits of

compliance with standards and continuous quality improvement. Ongoing feedback

and support are also critical in demonstrating the benefits of the process. Minimising

the number of standards and the administrative effort required to undertake an

accreditation process, as described above, will also be important in ensuring

compliance with the process.

Consideration should also be given to appropriate levers for accreditation. A possible

example includes rewarding compliance with additional funding. Public reporting of

accreditation results may also act as a lever, with referrals prioritised to services that

have achieved an appropriate accreditation level.

I s s u e s

There are a number of issues that will need to be considered in developing an

accreditation system for Australia. A key issue relates to workforce, both in terms of the

resources needed to undertake the accreditation process and difficulties of workforce

shortages in speciality areas that may preclude a service from meeting key standards.


It will be important to consider ways of providing support to those services with

workforce shortages so that they can achieve improvements following a poor

accreditation result and to ensure that a poor result is not exacerbated further by

difficulties in recruitment of new staff due to a provisional accreditation status. The

development and maintenance of linkages between smaller and larger sites will be

important to ensure service access for all patients regardless of where they live.

Leadership of the accreditation process both at a national and local level will be crucial

to ensure its successful uptake. Champions will be needed at every level to drive the

process and engender support from peers.

The cost implications of accreditation need to be considered and incorporated into

health service funding structures. Currently the cost of undertaking accreditation is high

for many services, both in terms of fees and staff time and resources, thereby affecting

participation. Minimising the number of accrediting bodies and streamlining the process

is likely to contribute to a reduction in the cost associated with accreditation.

The success of an accreditation system is reliant on adequate data collection. Cancer

services and facilities will need to have adequate data collection systems in place, with

data managers appointed to manage this process. The benefits of data collection in

providing evidence of gaps and quality improvement must be demonstrated to staff

within a facility to encourage support for the process.

C o n c l u d i n g r e m a r k s

Development of a national accreditation system for cancer services in Australia is

achievable. There are many lessons that can be learned from existing national and

international models. Key to the success of the process will be wide stakeholder

involvement, a focus on quality improvement and provision of adequate feedback and

support to encourage participation. Australia already has a number of systems in place

that can be built on or adapted to focus specifically on cancer services. The outcomes

of this scoping study will be crucial in informing a nationally consistent approach to

cancer services accreditation.


A P P E N D I X I : S C O P I N G S T U D Y M E T H O D O L O G Y

S c o p i n g s t u d y o v e r v i e w

In June 2004 the National Breast Cancer Centre signed a Memorandum of

Understanding with The Cancer Council Australia, to work in collaboration with the

Australian Cancer Network to undertake a scoping study of current international and

Australian cancer service accreditation systems and processes.

This 5-month study aimed to critically examine international and Australian cancer

service accreditation systems and standards to identify:

• key principles, criteria and common themes

• possible barriers to/or relevant issues about implementation

• models that may be applicable to the Australian health care system.

The findings of the study presented in this discussion paper may inform the future

development of a national accreditation system for cancer services.

The study involved two key components:

• a review of national and international literature regarding accreditation and

standards development

• consultations with key national and international stakeholders.


K e y q u e s t i o n s

The scoping study aimed to consider the following key questions:

• Who are the relevant key accreditation bodies?

• What are their governance structures?

• What assessment processes/approaches do they use?

• What criteria do they base their accreditation decisions on?

• What levels of accreditation exist?

• What sanctions or disincentives are used for those organisations who do not meet

the accreditation process?

• What processes are in place to provide feedback into the accreditation decision?

• How are the accreditation results reported to the public?

• How is accreditation used to improve patient care?

• What standards are applied under the accreditation process?

• How are these standards developed?

• What processes are in place to measure these standards?

D e v e l o p m e n t C o m m i t t e e

The project was overseen by a Development Committee comprising experts in the field

of health care accreditation (see Acknowledgements). Development Committee

meetings were held at the project outset, at intervals throughout the project and on


completion of the final report to provide direction and feedback on project progress. In

addition, progress reports were provided to the Development Committee by the NBCC

at intervals throughout the project.

L i t e r a t u r e r e v i e w

The NBCC undertook an initial search of the international literature. This search

confirmed that there are only a small number of journal articles that relate specifically to

the accreditation of cancer services. Additional articles or publications were identified,

mainly through organisations who deliver accreditation systems in health, either in

Australia or overseas, along with journals specialising in safety and quality issues such

as International Journal for Quality in Health Care.

A number of literature reviews have already examined standards and accreditation

processes in the health care sector. These include:

• Standards and Quality Improvement Processes in Health and Community Services:

a literature review completed in 2000 by Anita Skok, Associate Professor Hal

Swerissen and Jenny Macmillan

• Standards Setting and Accreditation Literature Review and Report produced by

Matthews Pegg Consulting Pty Ltd on behalf of the Australian Council for Safety

and Quality in Health Care

• The Development of Standards in Breast Disease, a review of the literature

produced by BreastScreen Victoria.

The scoping study builds on material already collected through these reviews, but

focuses specifically on cancer accreditation related activity.

I n t e r n a t i o n a l a c t i v i t y

The project reviewed literature on international cancer service accreditation systems

and processes for the following countries:


• United States of America (eg Commission on Cancer, Joint Commission on

Accreditation of Healthcare Organisations)

• United Kingdom (eg National Health Service Quality Improvement Scotland, The

Calman-Hine plan and a framework for improving cancer services, NHS cancer

care in England and Wales)

• Canada (eg Canadian Council on Health Services Accreditation, Quality

Determinants of Organised Breast Cancer Screening Programs)

• New Zealand (eg Quality Health New Zealand).

In addition, the NBCC approached overseas experts and accrediting agencies via

email for their input to the scoping study. The groups contacted are listed in Appendix

II.

A u s t r a l i a n a c t i v i t y

Within Australia, the study considered current activities in service accreditation and

service improvement frameworks as they apply to cancer. A number of stakeholders

and key organisations were consulted. These are outlined in Appendix II. Stakeholders

were identified in consultation with members of the ACN Accreditation Development

Committee, from the literature review, web searches and from other consultations.

A letter of invitation was sent to key stakeholders seeking a face-to-face meeting or

teleconference. These meetings aimed to identify common principles, themes, success

and barriers of both existing and proposed accreditation programs and to explore other

relevant initiatives.

The consultations focused on key issues for accreditation of cancer services, including:

• Complexities in defining a cancer service

• Consumer views and involvement in the accreditation and standards development

process for cancer services


• Importance of safety and quality as elements of an accreditation model

• Legislative requirements that impact on accreditation processes

• Government, cancer service and accreditation provider relationships, in particular

how they relate to cancer service frameworks and cancer plans currently under

development in Australia

• Overview of current accreditation and related standards development processes in

the health sector (including governance structures and process, successes and

challenges, and lessons learnt)

• Differences between the accreditation of private and public health services

• Workforce implications relating to accreditation

• The importance of transparency in reporting accreditation results

• Data collection and monitoring issues.

In total over 40 consultations were undertaken. The groups approached for

consultation and summaries of outcomes from key consultations are listed in Appendix

II.


A P P E N D I X I I : O R G A N I S A T I O N S S T U D I E D A N D S T A K E H O L D E R S C O N S U L T E D

O r g a n i s a t i o n s s t u d i e d / a p p r o a c h e d : A u s t r a l i a

Accreditation bodies

• Australian Council on Healthcare Standards (ACHS)

• SAI Global Assurance Services

• Quality Improvement Council (QIC)

• Aged Care Standards and Accreditation Agency

• Australian General Practice Accreditation Limited (AGPAL)

• BreastScreen Australia

• National Association of Testing Authorities (NATA)

Health Departments, National Committees, Cancer Institutions and Health Organisations

• Australian Government Department of Health and Ageing

• Australian Council for Quality and Safety in Health Care

• Cancer Strategies Jurisdictional members in each State and Territory Health

Department


• Cancer Institute NSW

• National Cancer Control Initiative (NCCI)

• National Pathology Accreditation Advisory Council (NPAAC)

• Radiation Oncology Jurisdictional Implementation Group (ROJIG)

• The Royal Australian and New Zealand College of Radiologists (RANZCR)

• Royal Australasian College of Surgeons (RACS)

• Royal College of Pathologists of Australasia (RCPA)

• The Royal Australian College of General Practitioners (RACGP)

• The Royal Australasian College of Physicians (RACP)

• Medical Oncology Group of Australia (MOGA)

• The Cancer Nurses Society of Australia (CNSA)

• Australian Medical Association (AMA)

• Australian Day Surgery Association

• Australian Medical Council (AMC)

• Victorian Ministerial Taskforce for Cancer

• Victorian Government Cancer Initiatives – Cancer Service Framework

• ACT Health

• Queensland Health

• Department of Health and Human Services, Tasmania


• Department of Health and Community Services, Northern Territory

• Department of Human Services, South Australia

Private Health Industry Bodies

• Private Health Industry Quality and Safety Committee (PHIQSC)

• Australian Health Insurance Association (AHIA)

• Australian Private Hospitals Association (APHA)

O r g a n i s a t i o n s s t u d i e d : I n t e r n a t i o n a l

• American College of Surgeons – Commission on Cancer (CoC)

• Joint Commission on Accreditation of Healthcare Organizations (JCAHO) – USA

• Health Canada

• Canadian Council on Health Services Accreditation (CCHSA)

• Clinical Accountability, Service Planning and Evaluation (CASPE)

• Commission for Health Improvement – UK

• Department of Health – UK

• Health Care Commission – UK

• Health Quality Service – UK

• International Organization for Standardization (ISO)

• International Society for Quality in Health Care – ALPHA (ISQUA)


• Ministry of Health (New Zealand) – Cancer Control Initiatives

• Quality Health New Zealand (QHNZ)

• NHS Quality Improvement Scotland (QIS)

• Scottish Executive Health Department Centre for Change and Innovation (CCI)

• Joint Accreditation System of Australia and New Zealand (JASANZ)

S t a k e h o l d e r s c o n s u l t e d

Face to face meetings/teleconferences

Individual/Organisation Topics discussed Ms Diane Flecknoe-Brown Program Manager for Health, SAI Global

• Overview of ISO standards development process. • Overview of the differences between ISO and ACHS

accreditation processes. • Overview of draft cancer service standards developed

in Australia. Dr Patrick Cregan Specialist Cancer Surgeon at Nepean Hospital & Chair, Quality & Clinical Effectiveness Advisory Committee, Cancer Institute NSW

• Role of the Quality and Clinical Effectiveness Committee

• Possible model for undertaking accreditation of cancer services within NSW based on the American College of Surgeons Commission on Cancer Approval Program.

• Minimum data set for cancer and data collection issues.

Mr Brian Johnston Chief Executive, Australian Council on Healthcare Standards

• Overview of the ACHS Accreditation processes/EQuIP • Role of ACHS in accessing services against the Mental

Health Standards. • Overview of standards development process. • Differences between QIC and ACHS.


Individual/Organisation Topics discussed Professor Bruce Barraclough Chair, Australian Council for Quality and Safety in Health Care

• Overview on the role of the Council and its relationship to AHMAC and Senior Quality Officials Forum.

• Overview of the Standards and Accreditation Framework Working Party and its proposed national accreditation model.

• Workforce implications of accreditation. • A set of principles for the accreditation of cancer

services have been developed by the ACN Accreditation Development Committee.

Dr Rosemary Knight Director, Cancer and Services Framework Section, Australian Government Department of Health and Ageing

• Defining cancer services and explaining their complex nature of delivery within Australia.

• National Service Improvement Framework provides a useful template to illustrate the importance of addressing care across the patient’s cancer journey.

Associate Professor Lawrence Lau Chair, The Accreditation Guidelines and Quality Committee, The Royal Australian and New Zealand College of Radiologists.

• Associate Professor Lau is overseas for an extended period. Contact has been made with a College representative, Susan Nicols, who has sent NBCC a range of relevant reading material on the accreditation standards for diagnostic and interventional radiology.

Mr Russell McGowan Chair, Cancer Alliance Network

• Any accreditation system should be patient and outcomes focused.

• The role of consumer assessors in accreditation processes.

• Public disclosure of accreditation results is important. • Important to take account of consumer needs and

issues outside acute care. E.g. palliative care or treatment complications.

Dr David Weedon (represented by Radha Gaind and Blair O’Connor) National Pathology Accreditation Advisory Council (NPAAC) Secretariat at the Australian Government Department of Health and Ageing

• Overview of NPAAC’s role in developing accreditation and standards for pathology laboratories.

• Overview of the relationship between NPAAC, NATA and HIC in the accreditation process.

• Overview of the standards development and review process.

• Overview of NATA assessment process.


Individual/Organisation Topics discussed Mr Russell Schneider CEO, Australian Health Insurers Association (AHIA) and members of the AHIA Hospital Provider Relations Committee

• Safety and quality are essential issues of concern to Private Health Insures as their customers seek access to treatment that is safe and effective.

• Defining a patient’s cancer treatment journey between the public and private sector.

• Publicising accreditation results.

Ms Christine Gee Chair, Accreditation Working Group of the Private Health Insurance Quality and Safety Committee

• Overview of the Private Health Insurance Quality and Safety Committee (PHIQS) and its Accreditation Working Group.

• Private hospitals undertake a number of accreditation and quality audits (for Govt, accreditation bodies and private health insurers) and these are often expensive exercises and can lead to a duplication of effort.

Ms Sally Crossing Cancer Voices NSW

• Supports the NSW Clinical Service Framework as a tool for improving cancer services. Need to unify current activities and clarify who is responsible for relevant undertakings.

• Trained consumer representatives in accordance with CCAAC guidelines established by the Australian Government.

• Transparency in reporting accreditation results. Professor Jim Bishop

Chief Cancer Officer & CEO, Cancer Institute (NSW)

• Discussion of the NSW Cancer Plan • Institute has remit to accredit cancer control programs • Role of Quality & Clinical Effectiveness Advisory

Committee Associate Professor Paul Harnett Chair, Clinical Services Advisory Committee, Cancer Institute (NSW) & Director Cancer Services, Wentworth & Western Sydney Area Health Service

• Overview of role of NSW Cancer Services Framework in context of accreditation

• Importance of involving Directors of Area Cancer Services in NSW

• Description of Western Sydney Area Health Service Directory of Cancer Services and importance of using a peer-review process to determine inclusion of services in the directory

Dr Michael Donnellan Prince of Wales Private Hospital, Randwick, NSW

• Discussion of what accreditation means – 4-step process to improve quality of care, involving standards, inspection, an accrediting body and financial effects

• Three levels for accreditation: facilities, processes, outcomes

• Discussion of some of the issues – eg need for data managers, the need for data to be linked to a benchmarking process, need for an appeals process

• Suggested workshop for key stakeholders


Individual/Organisation Topics discussed Professor Alan Coates Chief Executive Officer, The Cancer Council Australia

• Discussion on what constitutes a cancer service • Discussion of potential barriers and enablers to a

cancer accreditation service • Discussion of the key principles for an accreditation

service Dr Mary Turner Convenor, Quality Working Group, Radiation Oncology Jurisdictional Implementation Group (ROJIG) /Metropolitan Health & Aged Care Services, Department of Human Services, Melbourne

Ms Elise Davies Manager, Cancer Co-ordination Unit, Department of Human Services, Melbourne

Ms Leonie Scott Quality Improvement Cancer Co-ordination Unit, Department of Human Services, Melbourne

Professor Richard Smallwood Chair, Ministerial Taskforce for Cancer, Department of Human Services, Melbourne

Professor Robert Thomas Director, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne

• Victoria currently in the process of developing a cancer accreditation model based on findings in the Cancer Services Framework

• Specific standards will be developed for ten tumour streams

• Breast Cancer performance indicators currently being trialled through the Victorian BreastCare Performance Indicator and Standards Project

• Importance of establishing integrated cancer services through linkages and networking structures. This is especially relevant in rural areas where access to comprehensive services may not be possible.

• Importance of consumer involvement during the accreditation process

• High quality data collection supports the identification of variations in patterns of care

• Role of Professional Colleges in managing professional education and development

• Accreditation should be based on peer-support rather than a punitive approach.

• Any accreditation model needs to take account of discipline specific issues e.g. radiation oncology

• Australian Government role in providing a nationally consistent approach to accreditation through an agreed set of guiding principles.


Individual/Organisation Topics discussed Dr Liz Kenny Royal Australian and New Zealand College of Radiologists (RANZCR) representative on the Quality Working Group (RORIC)

• discussions about ROJIG report and formation of RORIC

• RORIC Quality Working Group to focus on overarching quality program, incident monitoring system, and dosimetry program (Newcastle trial underway)

Ms Cathy Balding, Manager, Victorian Quality Council

• Quality Council reports to the Minister, works with services to encourage implementation, works in parallel with Department policy

Professor Mark Elwood Director, National Cancer Control Initiative (NCCI)

• Importance if high quality data collection that can be used by clinicians to improve their performance

• Discussion on a range of NCCI activities that may inform a cancer accreditation model. E.g. Clinical Cancer Core Data Set and Data Dictionary Version 5, Optimizing Cancer Control Australia

• Importance of taking into account credentialling arrangements in an accreditation process

Professor Bruce Armstrong Head, School of Public Health, The University of Sydney

• Discussion of what constitutes a cancer service – from diagnosis of a malignancy onwards; questions whether palliative care should be included and highlights the importance of an evidence base

• Discussion of Cancer Centres model from UK and the importance of including linkages as part of the accreditation process

• Discussion of distinction between accreditation and performance measurement

• Issues of funding Professor Helen Bevan

Director for Innovation and Knowledge, NHS Modernisation Agency, UK

• Discussed current status of UK Cancer Services • Changes to GP standards • Importance of levers • Important aspects of accreditation process, including

peer review basis, appropriate standards, distinction between quality assurance and quality improvement

Ms Marissa Vecchio

CEO, Australian General Practice Accreditation Limited (AGPAL)

• Described the process for GP accreditation through AGPAL, including governance, assessor training, reporting and follow-up

Professor Ray Lowenthal

Royal Hobart Hospital • Overview of accreditation - role for cancer services • Defining a cancer services and essential components • Private/public sector issues

Ms Alison Amos

BreastScreen Victoria, Central Planning and Coordination Unit, Vic

• Progress report on the implementation of the Victorian BreastCare Performance Indicator and Standards Project


Individual/Organisation Topics discussed Ms Kate Cameron Chair, Cancer Nurses Society of Australia, The University of Adelaide

• Workforce issues in nursing • Professional competencies in cancer nursing

Associate Professor David Ball

Chair, Lung Service, Peter MacCallum Cancer Centre

• Update on radiation oncology services in Australia • Standards and accreditation for radiation services • Resources issues that may impact on accreditation • Centralisation of cancer services • Specific issues at Peter MacCallum

Dr Heather Wellington

Director, HPA Consulting Ltd

• Role of ACSQHC in developing a National Framework for Accreditation Systems in Health

• Importance of appropriateness of health care • Accreditation as a regulatory process • Principles for accreditation • Levers to influence implementation

Consultations undertaken with Australian Government Department of Health and

Ageing representatives:

• Carolyn Scheetz, Director, Quality Assurance Workforce and Compliance Section,

Quality Outcomes Branch, Ageing and Aged Care Division

• Alan Singh, Director, GP Registration Practices and Accreditation Section, GP

Programs Branch, Primary Care Division

• Lynne Clune on behalf of Andriana Koukari, Director, Population Screening

Section, Targeted Prevention Programs Branch, Population Health Division

• Damian Coburn, Director, Radiation Oncology Section, Diagnostics and

Technology Branch, Medical and Pharmaceutical Service Division

• Louis Young on behalf of Kirsty Cheyne-Macpherson, Director, Office of the Safety

and Quality Council, Safety and Quality Branch, Health Service Improvement

Division

• Peter Callanan, Director, Health Services Reform Section, Private Health Insurance

Branch, Acute Care Division


Consultations undertaken with State and Territory Health Departments

• Cancer Strategies Jurisdictional members in each State and Territory Health Department were contacted by email

Responses received by letter/email: international contacts and Professional Colleges within Australia

Individual/Organisation Topics discussed Dr Debra Graves

President, The Royal College of Pathologists of Australasia

• Mentioned the NATA accreditation process and requested no new accrediting body for pathology

• Discussed existence of other national accreditation standards such as AGPAL and ACHS

• Suggested that accreditation issues should be dealt with generally first followed by identifying needs for subspecialties

Professor Ian Olver

Chair, Medical Oncology Group of Australia

• Supportive of a model of accreditation based on multidisciplinary treatment and supportive care

• Stressed importance of linkages from smaller centres to larger comprehensive cancer centres

• Mentioned role of credentialing Mr Ian Watts (on behalf of Prof Michael Kidd) National Manager GP Advocacy and Support, RACGP

• Provided details on the current review of RACGP’s Standards for General Practices

Prof Mike Richards National Clinical Director, Cancer Services Collaborative, NHS Modernisation Agency, UK

• Provided follow-up contacts

Dr Anna Gregor Lead Clinician, Cancer Services Scotland, UK

• Will provide information on accreditation of service delivery models

Dr Gillian Bohm

Principle Advisor Quality Improvement and Audit, Ministry of Health, NZ

• Provided a written progress report on the implementation of the IQ Action Plan in New Zealand

Mr John Collins

Chair, Breast Section, Royal Australasian College of Surgeons

• Importance of the surgical training program

• Role of the National Breast Cancer Audit run through College and the Australian Safety and Efficacy Register of New Interventional Procedures – Surgical (ASERNIP-S)


A P P E N D I X I I I : I S Q U A ’ S I N T E R N A T I O N A L P R I N C I P L E S F O R H E A L T H C A R E S T A N D A R D S 2 0 0 4 – S E C O N D E D I T I O N

1. Standards contribute to quality and performance improvement in the health organization and the wider health system.

• Accountability and responsibilities for quality and performance improvement are defined. • Accountability to the public for information on the services assessed and their quality is

demonstrated. • A quality system is in place that integrates continuous improvement into all aspects of

performance and includes systematic quality monitoring and the evaluation and improvement of care and services.

• Legal requirements and health policy are recognised and integrated into the standards where appropriate.

2. The scope of standards is patient/client focused and encompasses the management and support infrastructure of that organization or service.

• The scope of standards is clearly defined and covers a whole organization or patient/client service.

• The patient/client continuum of care or service is reflected in the standards. Standards cover access, assessment, planning, delivery, evaluation, and ongoing care and service.

• Service planning, delivery and evaluation occur in partnership with patients/clients and carers.

• The responsibilities of the governance and management that support the organization or service are defined and their performance is evaluated.

• The responsibilities of the services that support patients/clients are defined and their performance is evaluated.

3. The content of the standards is comprehensive and reflects the following nine dimensions of quality: accessibility, appropriateness, capacity, continuity, effectiveness, efficiency, responsiveness, safety and sustainability.

• Services are accessible: o services are physically accessible o communities are able to access a range of services that are appropriate to their

defined needs o waiting times for services are acceptable to the communities they serve o services are culturally and spiritually sensitive to their communities o the mission or purpose and functions of the organizations or services being

assessed are clearly defined. 5

• Services are appropriate: o services are based on the assessment of patient/client needs o services are based on established and accepted standards and evidence based

guidelines o services reflect patient/client preferences and choices where possible


o key policies and procedures or processes are specified.

• Services are capable: o staff have relevant qualifications, skills and experience and, where appropriate,

are credentialed o personnel are trained, developed and evaluated o facilities and equipment are appropriate for the services provided.

• Services are continuous: o admission and entry processes are coordinated o services are planned and coordinated over time, and between individuals,

teams and services o end of service or discharge is planned with the patient/client o services are coordinated across inpatient and community services.

• Services are effective: o desired outcomes are identified and their achievement measured o key indicators are used to measure and improve performance.

• Services are efficient: o services are provided in a timely and cost effective manner while achieving

desired results o services are provided in accordance with individual and organizational plans

and budgets o resource utilisation is reviewed.

• Services are responsive: o patient/Client rights to dignity, confidentiality, information, effective

communication and choice are respected o patients/Clients participate in their own care/service processes o consumers participate in the planning of the delivery of the health service o patients’/Clients’ satisfaction with services is measured and complaints and

concerns addressed.

• Services are safe: o facilities and equipment meet safety requirements o there is a coordinated approach to risk management o risks relating to care and the environment are identified and managed o incidents, adverse events and near misses are reported and used to improve

services o the health and safety of staff are protected.

• Services are sustainable: o staff and stakeholders are involved in organization-wide strategic planning o service planning is based on the organization’s strategic direction and

considers environmental and financial factors o staff are recruited and trained and their competence maintained to meet service

requirements o facilities and equipment are systematically maintained and updated o innovation and research are supported.

4. Standards are planned, formulated and evaluated through a defined process.


• The development and revision of standards is planned: o the views of professional, purchaser, provider and consumer groups on the

need for new or revised standards are obtained and used in the development and improvement of standards

o standards are developed and revised in accordance with a plan that includes outcomes, priorities, resources and timeframes and the principles underpinning the standards

o relationships with the standards of other organizations and professional and regulatory requirements are considered so that duplication is minimised

o standards are based on current research, evidence and sound practice.

• Stakeholders are involved in the development and revision process: o professional, purchaser, provider and consumer interests are represented in the

standards’ development and revision process o consultation processes are appropriate to the groups being consulted o standards are tested by providers and assessors prior to approval to ensure

they are understandable, relevant and achievable o new and revised standards are approved by the standards setting body before

final implementation.

• A defined process is used to introduce standards: o information and education are provided to users and assessors of the new and

revised standards to support interpretation and implementation o revisions of standards are publicised and distributed to users and assessors in

sufficient time for them to develop an understanding of the standards before the date of implementation. Parameters and timeframes and any transitional arrangements are clearly identified.

• Standards are evaluated and revised: o the views and satisfaction of users, assessors and interest groups on standards

are documented and monitored o data from the use and review of standards are analysed and evaluated to assist

with improving standards o there is a defined process and timetable for evaluating and revising standards

on a regular basis.

5.0 Standards enable consistent measurement.

• Standards and criteria can be rated consistently: o there is a clear rating system for measuring performance against each standard

and/or criterion o guidelines or other information are provided to assist users to rate consistently o standards are able to be consistently interpreted.

• Overall achievement of the standards can be measured: o there is a well-defined system for measuring overall achievement of a set of

standards in a consistent way.

• The measurement system is evaluated: o the satisfaction of users with the measurement and rating system is evaluated

and results used to make improvements.


A P P E N D I X I V : D E S C R I P T I O N O F C A N C E R S T A N D A R D S – I N T E R N A T I O N A L

USA1 England and Wales2 Scotland3,4

Body developing standards

Commission on Cancer (CoC) National Health Service (NHS) National Health Service Quality Improvement Scotland (NHS QIS) - incorporates the Clinical Standards Board of Scotland (CSBS)

Principles for standard development

Standards are developed according to the following principles:

• Clinical services should provide state-of-the-art pre-treatment evaluation, staging, treatment, and clinical follow-up for cancer patients seen at the facility

Based on the principles of the Calman-Hine report:

• High-quality care, available to all, as close to home as possible

• Public and professional education to assist the early recognition of cancer symptoms, together with

Key principles applicable to all clinical standards:

• focused on clinical and non-clinical factors that impact on the quality of care

• written in simple language • based on evidence • written to take account of

other recognised standards

1 Commission on Cancer. Cancer Program Standards 2004. American College of Surgeons Chicago 2003

2 National Health Service Executive. Manual of cancer services standards. London. NHS, 2000 3 Clinical Standards: Generic. Edinburgh. Clinical Standards Board for Scotland, 2002

4 Clinical Standards: Breast cancer. Edinburgh. Clinical Standards Board for Scotland, 2001



for primary, secondary, tertiary, or quaternary care

• Goal setting, activity monitoring, improvement of care and evaluation of patient outcomes are performed by a multidisciplinary cancer committee

• Patient consultation and physician education through cancer conferences

• The quality improvement program forms the mechanism for evaluating and improving patient outcomes

• The cancer registry and database is used as the basis for monitoring the quality of care

national screening programmes

• Clear information and assistance to patients and their families about options and outcomes

• Patient-centred services, taking account of patients’ views and preferences

• Primary care involvement and good communication between different service providers at all stages

• Attention to psychosocial aspects of care at all stages

• Cancer registration and careful monitoring of treatment and outcomes.

and clinical guidelines • explicit and measurable • focus on outcomes, process

and structure • few in number • achievable but stretching • developed by healthcare

professionals and members of the public

• consulted on widely • published on paper and

electronically on the Internet • regularly reviewed and

revised to make sure that they are relevant and up-to-date.

Format of standards

For each standard the following is provided:

Standards specify what needs

Title – summarises the area of focus



• An explanation of the definition and requirement(s) of the standard

• A statement or chart of the specification(s) by category

• A detailed explanation of the documentation required to demonstrate compliance

• A definition of the rating for compliance, non-compliance, or commendation

must be met to demonstrate that various objectives are met. Objectives relate to ten ‘topics’ that span the patient pathway and the organisation of service.

Standards classified as Level 1 or Level 2 to indicate relative priority.

Standards statement – explains the level of performance to be achieved

Rationale – provides the reasons why the standard is considered important

Criteria (essential/desirable) – states exactly what must be achieved for the standards to be reached.

Areas covered by standards

Standards of the CoC Volume I: Cancer Program Standards (1995) included 151 standards of which 47 were mandatory. Following a review, the new Cancer Program Standards 2004 contains only 36 standards, and all are required to be met. These standards cover:

Institutional and programmatic resources

• facility accreditation

426 standards in total

Standards underpinned by a three-tier structure: topics, objectives and standards.

Ten topics span the patient pathway and the organisation of cancer services. These include:

• patient centred care • multidisciplinary team

Generic clinical standards are applied together with tumour- specific standards

Generic clinical standards cover:

• patient focus: assessment, patient involvement, patient information, patient/staff communication, patient feedback, access to



Cancer committee leadership

• level of responsibility and accountability

• membership • program activity coordinators • meeting schedule • duties and responsibilities

Cancer data management and cancer registry operations

• staff qualifications • data collection • data reporting • special studies

Clinical management

• clinical services • treatment services • other clinical services

Research

• clinical trial information • clinical trial accrual

Community outreach

• imaging & pathology • non-surgical oncology

support to cancer units • radiotherapy • chemotherapy • specialist palliative care • education, training and

continuing professionals development

• communication between primary secondary and tertiary sectors

• management and organisation of cancer services

services, discharge arrangement

• Safe and effective clinical care: clinical guidelines, risk management, risk environment, staff/HR

Note that these generic clinical standards and risk management issues have been incorporated into newly drafted standards for Healthcare Governance that cover:

• structure and process • delivering services • information • supporting services

Example of areas covered in the clinical standards for breast cancer:

• referral process • time to diagnosis of cancer • multidisciplinary working • support • education and training • communication and



• supportive services • prevention and early

detection programs • monitoring community

outreach

Professional education and staff support

• facility-based education • cancer registry staff

education

Quality improvement

• studies of quality and outcomes

• patient care improvement

information sharing • audit • clinical trails • assessment and care

planning • waiting for treatment • surgical management • radiotherapy • adjuvant systemic therapy • chemotherapy • symptom management • drugs • equipment • outcomes

Process of standards development

Standards developed by members of the Cancer Programs Standards Workgroup, which is principally comprised of clinicians.

Standards developed in consultation with healthcare professionals, professional bodies, voluntary sector and the public. Regional input from services and networks co-ordinated by Regional Cancer Co-ordinators.

Project group comprising appropriate healthcare professionals and members of the public oversee the development and consultation on the standards, manage external peer review and report its findings to the Board. Draft standards are modified after being piloted in some Trusts.



The manual of standards will be revised annually. Tumour specific guidance will be covered every two years.

Individual project groups ensure that the standards are regularly evaluated and revised.

Specific consumer involvement

No specific consumer involvement is noted.

American Cancer Society, a USA consumer advocacy group is a member organisation of CoC.

Draft standards were accessible on the internet and NHS website for comment

Standards developed in partnership with members of the public, through their representation on Project Group, participation in open meetings, consultations, and written responses to draft standards.

Standards are based on the patient’s journey as they progress through different parts of the health service.

Consumers can also be part of review visits


A P P E N D I X V : D E S C R I P T I O N O F S T A N D A R D S I N A U S T R A L I A – C A N C E R A N D O T H E R R E L E V A N T S T A N D A R D S

General Practice1,2,3 Pathology4,5,6,7 BreastScreen8,9,10 Radiology11,12 Private Sector 13

Body developing standards

The Royal Australian College of General Practitioners (RACGP)

The National Pathology Accreditation Advisory Council (NPAAC)

National Quality Management Committee (NQMC) of BreastScreen Australia

The Royal Australian and New Zealand College of Radiologists (RANZCR) through its Quality and

Private Health Industry Quality and Safety Committee (PHIQS)

1 Standards for General Practices (3rd Edition), Data for field testing. The Australian College of General Practitioners, July 2004 2 AGPAL – “Accreditation Frequently asked questions” www.agpal.com.au/subpage.asp?page=faq&Id=2&subId=27 3 AGPAL – General practice Accreditation Survey Visit Workbook- Nov /Dec 1998 - confidential 4 Australian Government Department of Health and Ageing – “NPAAC – Function” www.health.gov.au/npaac/functions.htm accessed 23/8/2004 5 NATA website – www.nata.asn.au 6 Matthews Pegg Consulting. Standards Setting and Accreditation Literature Review and Report. Canberra. Safety and Quality Council (Australian Council for Safety and Quality in Health Care), 2003, p.106 7 Standards for Pathology Laboratories. National Pathology Accreditation Advisory Council, 2002 8 Breast Screen: Evaluation report 9 BreastScreen Australia. National accreditation handbook (draft for consultation). BreastScreen Australia, 2004 10 BreastScreen Australia. National accreditation standards: decision tool to assist with accreditation decision-making against the national accreditation standards. BreastScreen Australia, 2002 11 The Royal Australian and New Zealand College of Radiologists – General Information and History www.ranzcr.edu.au/open/q&aprogram/generalhistory.htm 12 Accreditation Standards for Diagnostic and Interventional Radiology Version 6.2 Standards and Indicators. The Royal Australian and New Zealand College of Radiologists, 2004 13 PHIQSC. Private Sector Quality Criteria www.phiqs.org.au/stratplan.htm\



Accreditation Program

Principles The guiding principles on how standards are to be applied to any accreditation process state that accreditation should:

• aim to attain the highest quality of general practice in an achievable and gradual manner

• provide a publicly recognisable measure of quality in general practice

• be voluntary, but should have tangible benefits

• be for a defined period

• be an educational and developmental process and not a punitive one

• be in the hands of

Publications produced by NPAAC provide guidance to laboratories and accrediting agencies about minimum standards considered acceptable for good laboratory practice.

Failure to meet these minimum standards may pose a risk to public health and patient safety.

The standards are grouped into ten clusters that represent the key aims of the BreastScreen Australia Program:

• To ensure that the Program is implemented in such a way that significant reductions can be achieved in morbidity and mortality attributable to breast cancer

• To maximise the early detection of breast cancer in the target population

• To ensure that screening for breast cancer in Australia is provided in dedicated and

That the RANZCR Quality and Accreditation Program will:

• be developed, controlled and administered by RANZCR

• be designed to ensure quality radiological practice which meets community needs

• aim to enrol all practices providing medical imaging services

• be credible, effective and implementable

• address professional, technical and administrative

The standards reflect PHIQS ’s terms of reference which focus on a range of specific private health industry safety and quality issues including:

• strengthening accreditation arrangements in the private health sector

• strategies for implementation of evidence-based medicines, care and prevention;

• quality use of pharmaceuticals and other medical supplies

• workforce issues such as credentialing processes from medical staff in



the profession.

accredited screening and assessment Services as part of the BreastScreen Australia Program.

• To ensure equitable access for women aged 50-69 years to the Program.

• To ensure that Services are acceptable and appropriate to the needs of the eligible population.

• To achieve high standards of program management, service delivery, monitoring and evaluation and accountability.

The NQMC has attempted to set standards that maintain a high quality screening program

standards

• focus initially on major factors critical to the delivery of quality medical imaging services and refine over time

• be global in scope but incremental in implementation

private hospitals

• consumers' role and participation in private hospital service delivery,

• strategies to minimise avoidable interventions; and focus on patient safety



and that are achievable by most Services within the Australian context. Australian data have been considered in setting the standards where available to ensure that they are achievable by most Services.

Format of standards

There are 15 standards grouped into five main areas of practice. These describe the qualities required for a practice activity.

Each standard contains criteria which describe key components of the standard and are classified as essential or desirable.

Each criterion has a number of indicators, which assist

Standards are written in broad principles, designed to serve without alteration for many years. Under each standard there is a ‘commentary’ that outlines the minimum requirements for compliance. Sometimes these refer to international standards such as ISO/IEC 17025.

The National Accreditation Standards (NAS) are sometimes referred to as data and non-data standards or items. This reflects the fact that some are quantitative (can be reported against the data reports) while others are qualitative in nature.

Each standard has been allocated a risk rating of Level 1,2 and 3, with Level 1 standards having the highest risk and

The standards cover professional, technical and administrative areas.

Under each area, there is:

• a standard • an indicator • minimum evidence

required to show compliance

Standards developed in five key areas. For each area, criteria list a set of minimum requirements that private hospitals and day hospitals must meet in order to be accredited.



surveyors to assess compliance. These indicators are classified as key or non-key indicators.

therefore the most important.

The Decision Tool groups each of the 175 standards into a table with the following headings:

• performance objective

• standard • cluster • likelihood of not

meeting standards • consequence of

not meeting standard

• risk category.

Areas covered by standards

The following standards were field tested in July 2004 for the development of the 3rd Edition of the Standards for General Practice:

NPAAC produce standards and guidelines. Currently there are 17 documents relating to pathology.

The Standards for

There are 175 NAS against which performance is measured.

The standards are grouped into ten

Accreditation Standards for Diagnostic and Interventional Radiology include:

Professional Standards covering

Five areas covering: • Management of the

operation of the hospital

• Clinical practices • Safety and Quality

of Medication • Personnel



Practice services:

• access and availability

• (urgent/) medical matters

• appointments • telephone/

electronic advice

• home visits/care outside normal opening hours

• staffing • communication • practice

information • consultation times • informed patient

decisions • costs: referral/

consultation/ additional

• interpreter services • written health

information • diagnosis/

management of specific health problems

• evidence based

Pathology Laboratories are outlined below as an example:

Laboratory ethics:

• wellbeing of patients and confidentiality of patient information must be the primary consideration

• the laboratory shall have policies and procedures that maintain ethical standards and ensure that staff treat human samples, tissues or remains with due respect.

Quality systems:

• employ a quality management system to ensure that the services provided by the

clusters:

• Assessment • Information given • Cancer detection • Management • Continuity,

counselling and support

• Participation • Data management • Timeliness • Equitable access • Unnecessary recall

the following roles:

• radiologist • radiographer • sonographer • nuclear medicine

technologist • MRI technologist • BMD technologist • nurse • service engineer • equipment

assessor

Technical standards covering:

• equipment • radiation safety • MRI safety • nuclear medicine

safety • ultrasound safety • sedation,

anaesthesia and resuscitation

• infection control • environment • imaging procedure

manuals • imaging procedure

• Consumer rights



practice • consistency • health records/

summaries • consultation notes • prejudicial/

irrelevant statements

• care integration • working with other

services • referral documents • health

promotion/risk reduction/ prevention

• continuity of care • continuity:

relational, management & information.

Rights and needs of patients:

• respectful/ culturally appropriate care

• refusal of treatment • further opinions • discontinuation/

pathology service meet acceptable standards for good laboratory practice.

Staffing, supervision and consultation:

• sufficient pathologists, scientific, technical and support staff (with appropriate qualifications, training and experience) to supervise and conduct the work

• supervision and direction of the laboratory by a pathologist or other medical practitioner or senior scientist with appropriate qualifications and experience

• Staff who can advise on the selection of tests, the evaluation and

standards

Administrative Standards covering the following issues:

• clinical standards • patient and referrer • general practice

management • staff management.



transfer of care • patient feedback • third party • patients in distress

Quality improvement and education:

• quality improvement (activities)

• safety management

• education • qualifications: GP,

non-medical & administration staff

• reference materials • interpersonal skills

Practice management:

• human resources • personnel roles • induction program • occupational health

& safety • (health/)

information management,

interpretation of results and the validity of the methods.

Facilities:

• provide sufficient effective space and facilities for satisfactory provision of the service.

Pre-analytical phase:

• ensure information is available for requesting doctors and patients on available Services; Services should be provided in response to a clearly documented request identifying patient, practitioner requesting the testing, tests requested. There must be clearly



access & transfer • reviewing and

acting on reports • clinically significant

tests • QA & CPD consent • research activities • patient accounts • practice

management • leadership • GP autonomy • review of

administration

Physical factors:

• practice facilities • confidentiality and

privacy • physical access • telecommunication

system • equipment • doctor’s bag • clinical support

processes • schedule 8 drugs • cold chain

management

documented identification of patient and specimens.

• specimen collection should be performed in appropriate facilities and under appropriate conditions. Specimen collection, specimen transport and processing must preserve the quality and integrity of the specimen.

Analytical phase:

• equipment, instrumentation and analytical procedures must be appropriate to the tests being performed and form part of an ongoing quality system.



• perishable materials

• cleaning, disinfection, sterilisation and decontamination

• infection control • precleaning and

cleaning • waste

Post-analytical phase:

• reports containing test results shall be provided to the person requesting testing with a minimum of delay commensurate with good laboratory practice and patient care

• records of test requests, equipment history and service, testing procedures, results of test procedures on patient specimens, quality control and proficiency testing for consistency (quality assurance) material, shall be kept in a readily accessible form.

Health and safety:



• effective levels of health and safety must be maintained.

Audit and assessment:

• the service shall systematically audit all aspects of the operations to determine compliance of the service with quality objectives

• laboratories must be enrolled, participate and perform to an acceptable standard in external proficiency testing programs covering all test methods performed in the laboratory and for which such programs are available.



Process of standards development

Standards developed/ reviewed by the RACGP National Expert Committee on Standards for General Practices (NECSGP). The process includes:

• research • consultation with

stakeholders • writing of draft

standards • field testing of

standards • data analysis and

possible rewrite of some standards, criterions and indicators

The NECSGP contains representation from general practitioners, practice managers and consumers with expertise in standards development.

NPAAC’s Document and Review Liaison Committee is responsible for establishing working parties and sub-committees to draft standards and guideline documents:

1. Draft document prepared

2. Public consultation process

3. NPAAC endorsed documents submitted to Minister for Health & Ageing for consideration

4. Once approved, documents added to Schedule 1 of the Health Insurance (Accredited Pathology Laboratories – Approval) Principles 2002.

NQMC developed standards in consultation with the State and Territory BreastScreen Services, consumers and representatives of the disciplines, professions and occupational groups involved in the Program.

A RANZCR Committee, the Accreditation Guidelines and Quality Committee (AG&QC), was appointed.

This Committee, with input from other College members and the support of the College secretariat, developed a set of professional, technical and administrative Standards which practices were expected to meet. The Standards were based on the American College of Radiology Standards.

Standards developed by PHIQS, which contains representation from health funds, private hospitals and day hospital facilities, clinicians, consumers and the Australian Government.

Once the standards were developed, agreement was reached with leading accreditation agencies such as ACHS and SAI Global to incorporate the criteria into their standard accreditation processes



Specific consumer involvement

Review of standards involves consultation with consumers, through representation on the NECSGP.

A practice must also collect some form of patient feedback as part of the accreditation process.

All NPAAC documents circulated for public consultation before NPAAC endorsement.

Consumer representation in all aspects of accreditation program:

- consumer representation on NQMC

- consumer representation on site visitor teams

- review of NAS in consultation with and with the support of consumer organisations.

No consumer representation on the Accreditation Guidelines and Quality Committee.

Consumers are represented on PHIQS.

Review and revision of standards

The Standards are reviewed approximately every 3 years. They were revised in 2000 based on research and feedback from accreditation process. This led to the development of Standards for General Practices (2nd Edition).

Standards reviewed every 2-3 years.

The National Accreditation Requirements (NARs) were developed and implemented in 1991 by the National Advisory Committee to the National Program for the Early Detection of Breast Cancer (now BreastScreen Australia).

Standards developed over time to incorporate changes in regulations, and in accordance with the Program principles.

They were initially developed in 1999 for Stage 1 of implementation of accreditation, and revised for Stage 2

The Australian Government Department of Health and Ageing proposed in 2003 that the standards undergo an annual review.14



3rd edition currently in preparation.

These requirements were reviewed and revised in 1994. The NQMC initiated a second review of the NARs in 1999. The resulting NAS were endorsed, with amendments, in July 2001 by the NAC, and became operational on 1 July 2002. The NAS are revised and amended by the NQMC as required.

(commenced November 2001). The latest version, for Stage 3, was published February 2004.

Accrediting body

Australian General Practice Accreditation Limited (AGPAL)

National Association of Testing Authorities (NATA)

NQMC The Chair of Medical Imaging Accreditation Advisory Committee (MIAAC) recommends accreditation to both RANZCR and NATA

ACHS, SAI Global and Benchmark Certification


A P P E N D I X V I I : C A N C E R S E R V I C E S S T A N D A R D S F R A M E W O R K

A Cancer Services Standards Framework has been developed that could be used to

guide the establishment of national cancer standards in Australia. The Framework is

based on mapping of current activity in standards development, internationally and

within Australia, and consultation and feedback provided during the Scoping Study.

S a f e t y , q u a l i t y a n d o u t c o m e s

Safe and effective care

Protocols and processes should be in place to ensure that:

• safe and effective care is provided, in line with evidence-based clinical guidelines,

eg infection control

• a health and safety framework is in place to facilitate communication and

management of health and safety risk associated with cancer care

• a risk management strategy is developed, implemented and assessed across the

cancer service

• adverse incident management and monitoring systems are developed and

implemented.

Quality improvement (QI)

Cancer services should ensure that provision is made to:


• plan, implement and evaluate strategies that aim to measure or improve quality and

outcomes for patients

• implement improvements that directly affect cancer patient care and document

outcomes

• participate in prospective clinical audits that aim to identify and address clinically

important variations in practice

• participate in quality assurance programs

• provide feedback to senior management about all QI activities and outcomes.

Patient outcomes

Protocols and processes should be place to ensure that:

• collection of data occurs to enable local service performance indicators to be

compared against national performance indicators.

P a t i e n t f o c u s


• all cancer patients have access to appropriate, culturally specific and relevant

information regarding their disease and management at all stages of the cancer

journey

• all cancer patients are involved in decisions concerning their care to the extent that

they wish

• the care of cancer patients is co-ordinated throughout the continuum of care; this

may include the use of care co-ordinators, care plans etc


• patient feedback about the cancer service is sought and evaluated.

A c c e s s i b i l i t y


• all cancer patients have access to specialist diagnostic, treatment and supportive

care in accordance with evidence-based guidelines

• the minimum time of notification of diagnosis after undertaking a diagnostic

procedure is in accordance with relevant guidelines

• patients under specialist cancer care have access to after hours care and support.

F a c i l i t y r e q u i r e m e n t s

• The facility within which a cancer service is located should be accredited by a

recognised accreditation agency to ensure that institutional and program resourcing

standards are in line with generic healthcare facility standards, such as those used

by the Australian Council on Healthcare Standards, covering:

o appropriate and timely service provision

o leadership and management principles

o consumer participation, including privacy and complaints handling systems

o strategic human resource management

o information management and appropriate use/evaluation of data

o occupational health and safety, including maintenance of facilities and

equipment


o health and safety risk management, including infection control, emergencies

and security

o continuous improvement for the organisation.

Specific standards that relate to the governance of a cancer service may include:

• a formalised management structure to clearly define the involvement of all service

providers, managerial staff, clinicians, patient representatives, volunteer services

and the private sector

• a ‘lead clinician’ to assume responsibility for co-ordinating tumour-specific programs

within a service or network of services

• formalised and documented structures for the establishment and operation of

clinical reference groups/tumour boards for the common types of cancers; these

groups would be involved in activities associated with:

o assessment of overall staffing requirements for a service

o development of workforce strategies

o analysis of patient outcomes

o service reporting requirements

o dissemination of service reports

o evaluation of cancer service databases

o network arrangements of cancer services

o other relevant governance issues

The Private Health Industry Quality and Safety Committee (PHIQS) has developed

quality criteria in the following five areas:

• management of the operation of the hospital


• clinical practices

• safety and quality of medication

• personnel

• consumer rights.

The PHIQS has endorsed that the private health care facilities should be accredited by

industry-recognised and approved accreditation agencies, eg ACHS and SAI Global,

and that the Private Sector Quality Criteria be included as a component of standard

accreditation requirements.

E l e m e n t s i n t h e p a t i e n t p a t h w a y

Population screening services1

• Population screening services should be accredited in accordance with the

recommendations of the Australian Screening Advisory Committee.

Familial clinics

• Genetic testing, pre- and post-test counselling and advice about familial aspects of

cancer should be offered in accordance with clinical practice guidelines.

Diagnostic services (covering radiotherapy and pathology)


• diagnostic services are accredited by a recognised accreditation agency, eg

National Association of Testing Authorities (NATA) and Royal Australian and New

Zealand College of Radiologists (RANZCR).

1For the purposes of this Framework, Population Screening services for asymptomatic people are not considered part of a cancer service, but have been included in an effort to assist with mapping current activity


• an agreed policy for the appropriate referral of patients to diagnostic services is

implemented

• agreed operational policies are in place for the communication of a patient’s

diagnosis of cancer to the patient’s general practitioner

• pathology and radiology data collection and reporting processes conform to quality

requirements as set out by respective Professional Colleges.

Clinical management

Rather than define the size of cancer services and the roles and responsibilities of key

staff members, standards for clinical management could define the minimum scope of

clinical services needed to provide high quality cancer care to patients, based on the

adoption of evidence-based guidelines produced by key national organisations in the

areas of:

• surgical management

• radiotherapy

• chemotherapy

• symptom management

• pain management.

There is potential for defining cancer program categories relating to service capability

as a component of an accreditation process. Those services that are small in size or

have restricted access to staff due to remoteness of location could show proof of

provision of these services by providing evidence of linkages to other services in their

region or network, such as a formal referral process.


Supportive care


• all cancer patients have access to optimal evidence-based psychosocial care

• all cancer patients have access to relevant information about supportive care

services

• appropriate psychosocial support is provided to staff involved in the care of patients

with cancer.

Palliative care


• patients have access to evidence-based palliative care services for areas such as

symptom management, psychosocial, social and spiritual/cultural support

• patients have access to information about palliative care services and providers.

Rehabilitation


• Rehabilitation services are provided are on site or by referral, such services may

include:

o career counselling

o physical therapy

o speech therapy


o stomal therapy.

Community outreach


• patients and their families have access to community outreach services

• patients have access to a directory of local support services eg genetic testing,

grief counselling, nutritional advice, home care, pastoral care, support groups,

libraries etc

• services provide evidence of participation in preventive initiatives such as smoking

cessation.

Follow-up

• Appropriate follow-up procedures should be defined, explained to patients and

implemented, according to relevant evidence-based clinical practice guidelines.

Co-ordination and communication between elements in the patient pathway

Protocols and processes should be in place to:

• facilitate the smooth and timely progression of patients and their carers between all

care settings eg through access to a care co-ordinator, provision of a detailed

discharge plan

• ensure that information about an individual patient is communicated effectively to

all those involved in that patient’s care, whether at primary, secondary or tertiary

level

• facilitate the involvement of general practitioners at all relevant stages of care


• ensure that information about cancer services is developed and made available to

patients, their families and health professionals

• ensure that referral guidelines are in place for each procedure and /or service to

cover issues such as:

o appropriateness and timeliness of urgent referrals

o inter-specialist referrals

o linkages to private sector services

o links to outreach services

o network arrangements.

M u l t i d i s c i p l i n a r y c a r e


• patients with cancer are managed by a multidisciplinary team, regardless of

geographical remoteness or size of the cancer service

• the multidisciplinary team includes, as a minimum, representatives of the relevant

core disciplines, as recommended in relevant evidence-based clinical practice

guidelines

• where multidisciplinary teams are not established, appropriate referral protocols or

linkages (such as teleconferencing) are established to ensure availability of

multidisciplinary input

• care is provided in accordance with the NBCC Principles of Multidisciplinary Care

that relate to the team, communication, the full therapeutic range, standards of care

and involvement of the patient

• cancer services have access to evidence-based guidelines


• staff have access to all the appropriate clinical information required to support

clinical decisions making and facilitate the delivery of quality, timely services to

patients.

P r o f e s s i o n a l a n d s t a f f d e v e l o p m e n t


• staff position descriptions are based on relevant professional competencies and

requirements, as set out by professional colleges

• cancer services are accredited with appropriate Colleges as training facilities

• nursing care is provided by nurses with specialised knowledge and skill in cancer

care

• staff training needs are assessed and an associated training strategy is developed

and monitored

• mechanisms and incentives are in place for all healthcare professionals in a cancer

service to participate in training and continuing professional development activities

• formal professional development and quality assurance programs, such as those

managed by professional colleges, are available for clinicians

• regular communication skills training is undertaken by staff within a cancer service

• services are encouraged to host cancer-related educational opportunities, eg

symposia, videoconference, lectures, conferences.

D a t a m a n a g e m e n t a n d c a n c e r d a t a b a s e o p e r a t i o n s



• the nationally agreed minimum dataset is implemented to reduce duplication of

effort and encourage consistency of reporting

• accurate and timely collection of appropriate outcome data is facilitated through

effective management of high quality databases

• procedures are implemented to ensure that data about staging is recorded on

medical records

• a plan is developed to evaluate the quality of the cancer database, which would

include procedures to monitor casefinding, accuracy of data collections, abstracting

timeliness, follow-up and data reporting

• data managers and staff participate in ongoing cancer-related educational

activities.

R e s e a r c h

Protocols and processes are in place to ensure that:

• clinicians promote awareness about clinical trials and encourage participation of

patients in appropriate clinical trials for which they are eligible

• patients have access to information about appropriate clinical trials, including

benefits and possible side effects, to enable them to provide informed consent to

participate.

• data managers are encouraged to assist with enrolments and to provide adequate

support for the collection of necessary data.


A P P E N D I X V I : A P P R O A C H E S T O C A N C E R S T A N D A R D S I N A U S T R A L I A – S T A T E A N D T E R R I T O R Y A C T I V I T Y

N e w S o u t h W a l e s

New South Wales Health has developed a set of cancer service standards as part of its

Clinical Service Framework for Optimising Cancer Care in NSW (2003). In July 2003

the Cancer Institute NSW was established to carry forward this work.

The NSW Cancer Plan, which was circulated to consumers, health professionals and

key cancer organisations for comment during the development of the framework, has

identified the following strategic principles for better cancer control, to guide the

development of standards:

• co-ordination of cancer control

• cancer prevention and early detection

• cancer service provision – the patient’s journey:

o patient/consumer certified practices

o state-wide planning of cancer services

o co-ordination and integration of healthcare professionals

o evidence-based clinical practice

o multidisciplinary care and peer review

o sub-specialisation and optimal caseload


o evaluation of practice outcome

o research driven clinical practice

• cancer information

• cancer education and workforce

• cancer research

• quality accreditation

• cancer fundraising.

Standards

In the Clinical Service Framework, the standards cover;

• implementation, monitoring and review of standards in cancer care in NSW

• an area-wide approach to optimising cancer care

• patient-centred care

• access to appropriate clinical services

• multi-disciplinary care

• communication between primary, secondary and tertiary services

• education, training and continuing Professional Development.

In general, the standards are based on a generic cancer services approach, rather than

the service delivery and clinical management of site-specific cancers. However, the

standards do include the introduction of formalised and documented structures for the


establishment and operation of Area-wide site-specific clinical groups for the common

cancer types.

A previous survey of Health Services in NSW indicated a lack of compliance with

existing standards, often related to workforce issues. A set of compliance tasks has

now been incorporated. Each standard in the Framework indicates the compliance

tasks or targets that need to be met by Area Cancer Services, and the method by

which compliance should be demonstrated. Monitoring and review of standards of

cancer care in NSW will be undertaken annually by the Cancer Institute.

Part 4 of the Cancer Institute (NSW) Act 2003 provides the Cancer Institute NSW with

the power to assess and accredit programs and services relating to cancer control.

Details on how this will be undertaken are currently under development.

V i c t o r i a

The Department of Human Services (DHS) commissioned the development of a

Cancer Services Framework for Victoria in 2002 by a national expert consultancy

group, the Collaboration for Cancer Outcomes Research and Evaluation (CCore).

The principles upon which the Cancer Services Framework are based include:

• Effective management of an integrated statewide cancer program

• Maximal geographic access for patients and their carers/families to high quality

care

• Population based services

• Access to a full range of services from prevention, screening, early detection,

diagnosis, treatment, rehabilitation, supportive care and palliative care

• Public and private sector cancer services available and patients can choose

between them


• Multidisciplinary cancer care to ensure effective and efficient patient management

• Correlation between caseload and quality of services

• Information systems and data collection for monitoring of cancer services and

outcomes

Level of consumer involvement is unclear. Staff from a wide variety of health services

(both public and private) were consulted throughout the State in the development of the

Framework. Professional and research organisations, representatives from patient

support and advocacy groups also participated in the process.

It is proposed that a State-wide Reference Group will be established for each tumour

stream. Each State-wide Reference Group will be responsible for:

• overseeing the development of the standards of care that are to apply to its

respective tumour stream across Victoria

• providing advice on criteria and processes for auditing the performance of health

services in relation to the standards

• reviewing the results of audits

• providing a focus of expertise for the development of guidelines and information

resources.

The State-wide Reference Groups will draw on expertise from the Victorian

Cooperative Oncology Group (VCOG) Advisory Committees, sponsored by The Cancer

Council Victoria

The format of the standards is to be decided. Currently examining the format of cancer

standards used internationally.


Standards of care will be developed for generic application as well as for 10 specific

tumour streams which account for 90% of the total cancer incidence in Victoria:

1. Genito-urinary cancers (prostate, bladder, kidney and testis)

2. Colorectal cancer

3. Breast cancer, where a set of Performance Indicators have been developed

4. Lung cancer

5. Skin cancers (melanoma)

6. Haematological malignancies (lymphomas, leukaemias, and myeloma)

7. Gynaecological cancers

8. Head and neck cancers

9. Upper gastro-intestinal cancers (oesophagus, stomach, pancreas, and hepato-biliary system)

10. Central nervous tumours

The standards will cover early detection, diagnosis, staging, pathology, surgical

oncology, radiation oncology and medical oncology management, psychosocial

support, information for patients, rehabilitation, service co-ordination, data for quality

improvement.

Facility standards for each standard of care will also be developed. (Based on

nationally endorsed standards)

It is proposed that an audit of standards of care and facility standards will form the

basis of the accreditation of services. The process of assessment for accreditation

could be managed by an independent body external to the DHS, such as the Australian

Council on Healthcare Standards or Standards Australia.


A P P E N D I X V I I I : M A P P I N G C U R R E N T C A N C E R S T A N D A R D S A N D R E L A T E D A C T I V I T Y A G A I N S T K E Y C A N C E R F O C U S A R E A S

Key focus areas

Current cancer standards and related information available in Australia (including standards, guidelines, best practice recommendations and other relevant activities)

FACILITY REQUIREMENTS

Facility requirements for both public and private sector services

• Generic healthcare facility standards based on standards developed by key health care accreditation agencies, eg ACHS, SAI Global and QIC. These include EQuIP and ISO 9001

• Covered to some extent in standards developed by the Royal Australian

College of General Practitioners (RACGP), The National Pathology Accreditation Advisory Council (NPACC), the National Management Committee of BreastScreen Australia and the Royal Australian and New Zealand College of Radiologists (RANZCR)

• Covered to some extent by the Private Sector Quality Criteria developed

by the Private Health Industry Safety Committee (PHIQS)

PATIENT FOCUS

Patient focus issues

• National Health and Medical Research Council. General Guidelines for Medical Practitioners on Providing Information to Patients. Canberra. Commonwealth of Australia,1994

• National Breast Cancer Centre and National Cancer Control Initiative.


Clinical practice guidelines for the psychosocial care of adults with cancer. Camperdown. National Breast Cancer Centre, 2003

• Covered to some extent by the National Breast Cancer Centre Principles

of Multidisciplinary Care

SAFETY, QUALITY AND OUTCOMES

Safe and effective care, Quality improvement Patient outcomes

• Australian Council for Safety and Quality in Health Care. Open disclosure standard: a national standard for open communication in public and private hospitals following an adverse event in health care. Commonwealth of Australia, 2003

• Australian Council for Safety and Quality in Health Care. National

Guidelines for Credentials and Clinical Privileges. Commonwealth of Australia, 2002

• Covered to some extent by generic healthcare facility standards

developed by key health care accreditation agencies such as ACHS, SAI Global and QIC. These include EQuIP, ISO 9001

• Covered to some extent by standards developed by the Royal Australian

College of General Practitioners (RACGP), The National Pathology Accreditation Advisory Council (NPACC), the National Management Committee of BreastScreen Australia and the Royal Australian and New Zealand College of Radiologists (RANZCR)

• Covered to some extent in the Private Sector Quality Criteria developed

by the Private Health Industry Safety Committee (PHIQS) • National Breast Cancer Audit. Royal Australasian College of Surgeons

(ASERNIP-S)


• PapScreen clinical audit. Department of General Practice, Victoria • National Patient Safety Education Framework Project. (Framework in

development by University of Sydney for ACSQHIC to guide the development of educational programs for all health care workers; will include key competencies)

ACCESSIBILITY

Accessibility

• BreastScreen Australia. National accreditation standards for BreastScreen services, 2001

• Elements covered in clinical practice guidelines (see listing under

Clinical Management) • Elements contained in ACHS, ISO standards that cover patient access

to facilities, information etc

ELEMENTS IN PATIENT PATHWAY

Population screening services1

• BreastScreen Australia. National accreditation standards for Breastscreen services, 2001

• The Cancer Council New South Wales, The Royal Australian College of

General Practitioners. Screening for Cancer: A Guide for General Practitioners. Sydney. The Cancer Council New South Wales, 2001

• National Health and Medical Research Council. Screening to prevent

cervical cancer: guidelines for the management of women with screen-

1 Population screening services have been included here in an effort to map current activity


detected abnormalities. 1994 (Currently under revision - Draft Guidelines for the Management of Women with Screen Detected Abnormalities, 2004)

• National Health and Medical Research Council. Guidelines for the

Prevention, Early Detection and Management of Colorectal Cancer (CRC) Version 2. Canberra. Commonwealth of Australia, 1999 (Currently being revised)

• National Breast Cancer Centre. Position statement: Early detection of

breast cancer. 2004

Familial clinics

• National Breast Cancer Centre. Advice about Familial Aspects of Breast Cancer and Ovarian Cancer: A Guide for Health Professionals. Sydney. iSource, National Breast Cancer Centre, 2000

• Australian Cancer Network. Familial Aspects of Bowel Cancer: A Guide

for Health Professionals. Sydney. Australian Cancer Network, 2002 • Carrick S, Kirk J and Kefford R. A plan for a national familial cancer

support facility. National Cancer Control Initiative. Melbourne, 2000

Diagnostic services (covering radiology and pathology)

• NATA - Standards for Pathology Laboratories • RANZCR- Accreditation standards for diagnostic and intervention

radiology • Australian Cancer Network, National Breast Cancer Centre, Royal

College of Pathologists of Australasia. The Pathology Reporting of Breast Cancer: A Guide for Pathologists, Surgeons, Radiologists and Oncologists. Recommendations of the Australian Working Party 2nd edition. Sydney. Australian Cancer Network, 2001


• National Breast Cancer Centre, The Royal Australian College of General Practitioners. The Investigation of a New Breast Symptom: A Guide for General Practitioners. Sydney. National Breast Cancer Centre, 1997

• National Breast Cancer Centre. Breast imaging: a guide for practice.

Camperdown. National Breast Cancer Centre, 2002 • National Breast Cancer Centre. Breast fine needle aspiration cytology

and core biopsy: a guide for practice. National Breast Cancer Centre, 2004

• Pedersen K and Elwood M. Regulation of in vitro diagnostic tests in

Australia. National Cancer Control Initiative. Melbourne, 2001

Clinical management Covering the areas of: • Surgical management • Radiotherapy • Chemotherapy • Symptom and pain management

• Quality program for Radiation Oncology developed by Tripartite Committee

Breast cancer • National Breast Cancer Centre. Clinical Practice Guidelines for the

Management of Early Breast Cancer. Second edition. Canberra. Commonwealth of Australia, 2001

• National Breast Cancer Centre, The Royal Australian College of General

Practitioners. The Management of Early Breast Cancer for GPs: Action Based on Evidence. Sydney. National Breast Cancer Centre, 1997

• National Breast Cancer Centre. Clinical Practice Guidelines for the

Management of Advanced Breast Cancer. Canberra. Commonwealth of Australia, 2001

• National Breast Cancer Centre. The management of the woman with


metastatic breast cancer. A guide for GPs. National Breast Cancer Centre, 2001

• National Breast Cancer Centre. The clinical management of ductal

carcinoma in situ, lobular carcinoma in situ and atypical hyperplasia of the breast. Camperdown. National Breast Cancer Centre, 2003

• National Breast Cancer Centre. Clinical practice guidelines for the

management and support of younger women with breast cancer. Camperdown. National Breast Cancer Centre, 2003

• National Breast Cancer Centre. Radiotherapy and breast cancer. 1999 Lung cancer

• Australian Cancer Network. NHMRC Clinical practice guidelines for the prevention, diagnosis and management of lung cancer. The Cancer Council of Australia, 2004

Colorectal cancer

• Australian Cancer Network. NHMRC Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer (CRC) Version 2. Canberra. Commonwealth of Australia, 1999

• Australian Cancer Network. NHMRC Guidelines for the Prevention, Early

Detection and Management of Colorectal Cancer: A Guide for General Practitioners. Canberra. Commonwealth of Australia, 1999

Skin cancer • National Health and Medical Research Council. Clinical Practice


Guidelines for the Management of Cutaneous Melanoma. Canberra. Commonwealth of Australia, 2000

• Australian Cancer Network and NHMRC. Non-melanoma skin cancer:

guidelines for treatment and management in Australia. Canberra. Commonwealth of Australia, 2003

• Australian Cancer Network, National Health and Medical Research

Council, Royal Australian College of General Practitioners. Non-melanoma skin cancer: summary card for general practitioners. Australian Doctor

Ovarian cancer • Australian Cancer Network and National Breast Cancer Centre. Clinical

practice guidelines for the management of women with epithelial ovarian cancer. Camperdown. National Breast Cancer Centre, 2004

Pain management • National Health and Medical Research Council. Acute Pain

Management: Information for General Practitioners. Canberra. Commonwealth of Australia, 1999

• National Health and Medical Research Council. Acute Pain

Management: Scientific Evidence. Canberra. Commonwealth of Australia, 1999

• Therapeutic Guidelines: Analgesic. Melbourne. Therapeutic Guidelines,

1997

Prostate cancer


• Australian Cancer Network. NHMRC Clinical practice guidelines: evidence-based information and recommendations for the management of localised prostate cancer. Canberra. Commonwealth of Australia, 2003

Guidelines in development

Lymphoma • Guidelines for the diagnosis and management of lymphoma (Australian

Cancer Network)

Supportive care

• National Breast Cancer Centre. Clinical Practice Guidelines: Providing Information, Support and Counselling for Women with Breast Cancer. Canberra. Commonwealth of Australia, 2000

• National Breast Cancer Centre and National Cancer Control Initiative.

Clinical practice guidelines for the psychosocial care of adults with cancer. Camperdown. National Breast Cancer Centre, 2003

• National Breast Cancer Centre. Clinical practice guidelines for the

management and support of younger women with breast cancer. Camperdown. National Breast Cancer Centre, 2004

Palliative care • Therapeutic Guidelines: Palliative Care. Melbourne. Therapeutic Guidelines, 2001

• Mitchell G, Bowman J, McEniery J, Eastwood H. The Blue Book of

Palliative Care: Evidence Based Clinical Guidelines for Primary Practitioners. Third Edition. Canberra. Commonwealth Department of Health and Aged Care, 1999


• Commonwealth Department of Health and Aged Care. National

Palliative Care Strategy. Canberra. Commonwealth Department of Health and Aged Care, 2000

• O’Brien B, Blue I, Nugent J and Rogers, JA. A model of palliative care

service delivery with application in rural and urban settings. Adelaide. Commonwealth Department of Health and Family Services, 1997

Rehabilitation

Rehabilitation is covered in guidelines for specific cancers mentioned above

Community outreach

Preventive interventions • National Health and Medical Research Council. Guidelines for

Preventive Interventions in Primary Health Care: Cardiovascular Disease and Cancer. Canberra. Commonwealth of Australia, 1997

Follow-up

• Covered in clinical practice guidelines listed under Clinical management

Co-ordination and communication between elements in the patient pathway

• Covered in clinical practice guidelines listed under Clinical management

MULTIDISCIPLINARY CARE

Multidisciplinary Care

• The Principles of Multidisciplinary Care (NBCC) cover issues of team, communication, full therapeutic range, standards of care and involvement of the patient

• Cancer standards in the Clinical Service Framework for Optimizing

Cancer Care in NSW, Cancer Institute NSW


PROFESSIONAL AND STAFF DEVELOPMENT

• Professional Colleges provide professional development eg RACS - Departmental of Professional Standards covers Continuing Professional Development for Fellow and Maintenance of Professional Standards for those who are not College members. A Credentials Committee reviews education, training, licences and references of surgeons seeking appointment

• Australian Council for Safety and Quality in Health Care. National

Guidelines for Credentials and Clinical Privileges. Commonwealth of Australia, 2002

• Medical Workforce Advisory Committee. Established by AHMAC to

advise on national medical workforce issues such as supply, distribution. Produces reports eg Specialist O&G Workforce 2003-2013, 2004

• Quality Assurance and Workforce Working Group of the Australian

Screening Advisory Committee

DATA MANAGEMENT AND CANCER DATABASE OPERATIONS

Data management and cancer database operations

National Cancer Control Initiative. Clinical Cancer Core Data Set and Data Dictionary Version 5 (November 2001) National Health Data Committee. National Health Data Dictionary. Version 12. Australian Institute of Health and Welfare. AIHW Cat No: HWI43. Canberra. Australian Institute of Health and Welfare, 2003 Health Data Standards Committee. Data Set Specification, Cancer (clinical). National Health Data Dictionary. Version 12. Supplement. AIHW Cat No:


Hw171. Canberra. Australian Institute of Health and Welfare, 2004

RESEARCH

Clinical trials/research

• Many cancer guidelines recommend that patients participate in clinical trials (see list under Clinical Management)

• International Conference on Harmonisation. ICH Harmonised Tripartite

Guideline for Good Clinical Practice


A P P E N D I X I X : C O M P A R I S O N O F A P P R O A C H E S T O A C C R E D I T A T I O N I N H E A L T H I N F O U R C O U N T R I E S 1

United States2 United Kingdom3 Canada4 New Zealand1,5,6

Type of health care system7

Pluristic, with combined state and federal regulation; private-sector driven; mainly privately funded; assess to Medicare and Medicade for the disadvantaged

Nationalised, but with recently devolved responsibility; publicly funded (Health Authorities and Trusts)

Federal, territorial and provincial; mixed but mainly public funding (Medicare)

Services provided by both public and private providers; publicly funded (through District Health Boards)

Accrediting body

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Healthcare Accreditation Programme (HAP)

Canadian Council on Health Services Accreditation (CCHSA)

Quality Health New Zealand (QHNZ) – Te Taumata Hauora (trading name of the NZ Council on Healthcare Standards)

1 Matthews Pegg Consulting. Standards Setting and Accreditation Literature Review and Report. Canberra. Safety and Quality Council (Australian Council for Safety and Quality in Health Care), 2003 2 Joint Commission on Accreditation of Health Organisations website. http://www.jcaho.org/ 3 CASPE website. http://www.caspe.co.uk/ 4 Canadian Council for Health Services Accreditation website. http://www.cchsa.ca/ 5 New Zealand Cancer Control Trust website. http://www.cancercontrol.org.nz/ 6 New Zealand Ministry of Health. Cancer control in New Zealand website. http://www.moh.govt.nz/cancercontrol 7Arah O, Klazinga NS, Delnoiji DMJ, et al. Conceptual frameworks for health systems performance: a quest for effectiveness, quality and improvement. Int J Qual Health Care 2003; 15:377-398



Established 1952 1990 1958 (formerly Canadian Council on Hospital Accreditation)

1990 (formerly NZ Council on Healthcare Standards)

Nature of body Independent, not-for-profit Board composed of physicians, dentists, administrators, nurses and consumers

Independent, not-for-profit Independent, not-for-profit Board has 14 representatives from health providers and national health associations, Professional Colleges and consumers. It also has two government observers (federal and provincial)

Independent, not-for-profit Governed by a board of five directors who are nominated from members consisting of accredited organisations, professional associations, colleges, health provider organisations and consumer organisations.

Level of participation 17,000 accredited organisations in the USA and overseas These include hospitals (more than 4,500 or nearly 80% of all hospitals in the USA8), free-standing surgery centres, primary care centres, diagnostic and therapeutic centres, aged care nursing homes, mental health clinics and home care services

150 health care organisations accredited These include community hospitals, community service, Primary Care Trusts, local health groups, NHS private patient units, independent hospitals and mental health and learning disability services

Approximately 1000 organisations These include services in the area of brain injury, acute care, assisted reproductive technology, Canadian Forces Health Services, cancer care, community health services, Correctional Services Canada, First Nations and Inuit health services, health systems, home care, long-term care, mental health, rehabilitation, substance

Around 130 health care sites currently accredited These include hospitals, mental health services, community and home care services, hospices, primary care services and Maori health providers

8 Sandrick K. Everything you want to know about the joint commission. Trustee 2004; 57:17-21



abuse and problem gambling, and Veterans Affairs Canada

Standards development

All standards developed in consultation with industry and consumers – standards reviewed every 2 years

Standards developed in cooperation with health care organisations and through industry consultations – standards reviewed every 2 years

Standards developed through consultation with health professionals throughout Canada

Standards developed following consultation, testing and trialling with the health and disability sectors in New Zealand

Nature of standards Different standards and accreditation programs for different health care services

Standards are grouped into four accreditation programs: • Independent Healthcare • Scottish Health Services • The NHS in England and

Wales • Private Patient Units.

Different standards and accreditation programs for different health care services

Eight standards modules tailored to different service types, eg long-term care, community care, acute care etc

Assessment approach (3 yearly cycle)

• Self assessment against standards

• On-site survey every 3 years

• Accreditation survey provided to the organisation for comment


• On-site survey • Written report provided to

an independent Professional Advisory Board who make accreditation decision


• On-site survey • Written report including

ratings against criteria and recommendations for action


• On-site survey • Written report with

recommendations • Organisation drafts a

Quality Action Plan to address recommendations




Six accreditation decisions: 1. Accreditation with full

standards compliance 2. Accreditation with

requirements for improvement

3. Provisional accreditation 4. Conditional accreditation 5. Preliminary denial of

accreditation 6. Accreditation denied

Accreditation awarded for 1, 2 or 3 years depending on level of compliance with standards, or accreditation may be deferred. Assessment report contains accreditation decision and recommendations for improvement (basis for CQI). 60% of recommendations must be implemented before next survey.

Four options: 1. Accreditation 2. Accreditation with

Condition: Report (organisation must report on recommendations within a time period)

3. Accreditation with

Condition: Focused visit (additional on-site visit to check progress on recommendations)

4. Non-accreditation

Three options: 1. Accreditation awarded for

3 years subject to implementation of Quality Action Plan and maintenance of standards

2. Deferral of accreditation

until improvements made, ie can be awarded Pre-Accreditation Endorsement, which meets Ministry of Health certification requirements while organisation is working towards full accreditation. (This is a legislative requirement).

3. No accreditation

Mandating/ sanctions

No legislated requirement for accreditation but link between accreditation and access to Medicare funds

No legislated requirement for accreditation (some facilities must be registered by the Healthcare Commission – HAP has minimum standard for Commission inspections)

Voluntary – no mandating in legislation and no link to Medicare funding

No statutory means to enforce accreditation of health care services in NZ. Certain types of health care are subject to certification under the Health and Disability Services (Safety) Act. QHNZ incorporates these standards of the Act


United States2 United Kingdom3 Canada4 New Zealand1,5,6 into its accreditation process.

Internal mechanismsfor ensuring compliance

Unannounced on-site evaluations and Office of Quality Monitoring receives, evaluates & tracks complaints

Requirement that 60% of recommendations must be implemented before next survey

Accreditation decision allows additional monitoring for certain organisations

Visit conducted 18 months after accreditation to monitor progress. Also conducts monitoring requirements for Ministry of health certification requirements

Public reporting List of accredited organisations & survey results are posted on website. Public involved in review of standards and notified when each organisation surveyed.

List of accredited orgs on website

List of accredited organisations on Website and aggregate findings in published reports. Does not disclose findings of individual organisations.

List of accredited organisations posted on website and in QHNZ newsletter

Externally accredited organisation

Accredited through International Society for Quality in Health Care (ISQua)

A member of ALPHA council of the International Accreditation Federation, part of the International Society for Quality in Health Care (ISQua). Accredited through ISQua.


A P P E N D I X X : C O M P A R I S O N O F A P P R O A C H E S T O A C C R E D I T A T I O N I N A U S T R A L I A – A C R O S S H E A L T H C A R E 1

ACHS QIC ISO 9001 (represented in Australia by SAI Global)

Accrediting body Australian Council on Healthcare Standards (ACHS)

Quality Improvement Council (QIC) International Organisation for Standardisation (ISO)

Established 1974 1987 (formerly the Community Health Accreditation and Standards Program, became QIC in 1997)

1947

Nature of body Independent, not-for-profit Independent, not-for-profit Non-government organisation Level of participation

Over 900 hospital and healthcare organisations

Over 400 organisations 140 countries

Standards/ program

Evaluation and Quality Improvement Program (EQuIP). Three approaches. • EQuIP Certification • EQuIP Corporate • EQuIP In-depth Reviews

National Review and Accreditation Program

ISO 9000 series (ISO 9001, ISO 9002, ISO 9003) for Quality Management

1 Matthews Pegg Consulting. Standards Setting and Accreditation Literature Review and Report. Canberra. Safety and Quality Council (Australian Council for Safety and Quality in Health Care), 2003




Standards developed by expert working groups, with industry consultation and pilot testing. Endorsed by ACHS Standards Committee and approved by ACHS Board.

Standards set or endorsed by QIC for use by licensed providers

Regular standards-setting processes of ISO based on consultation with industry, governments, and users

Nature of standards Standards are grouped into six functional areas. Each standard has a number of criteria that have specific elements and guidelines that describe practices within the standard.

Core module with six additional service specific modules (also other QIC endorsed standards)

ISO 9001 – includes requirements relating to five main areas: quality management system, management responsibility, resource management, product/service realisations and measurement, analysis and improvement.

Assessment approach

• Self-assessment against standards • Site visit by surveyors • Written report to organisation with

recommendations. Organisation completes Quality Action Plan to address recommendations

Review is by one of three organisations in Australia licensed by QIC according to procedures mandated and in relation to standards developed and owned by QIC. Self assessment, on-site survey, review team report provided to organisation, formal feedback session, and organisation develops quality workplan. Licensed provider furnishes documentation to QIC who then, signs accreditation certificate following clearance.

Self-auditing; certification of conformity from an independent quality system certification body (eg SAI Global Assurance Services)




• Full accreditation – 4 years • Partial – if High Priority

Recommendations are noted • No accreditation – if at least Moderate

Achievement or higher is not gained in Safe Practice and Environment standard.

Accreditation for 3 years (has to meet essential requirements and develop suitable quality workplan)

Certification of compliance (Quality Endorsed Company Certification)

Mandating/ sanctions

No clear capacity to apply sanctions but can withdraw accreditation. Can impact where government compliance is required, eg Aged Care facilities.

No clear capacity to apply sanctions (other than removal of accreditation) unless government mandates compliance

Voluntary – except certain organisations may require ISO compliance

Internal mechanisms for ensuring compliance

Periodic review part of cycle – 2 years after organisation-wide survey

Organisations must provide 6-monthly progress reports against their quality workplan

An external audit is required on site every 12 months

Public reporting Accredited organisations listed on website. Is moving towards offer of public disclosure by organisations of aspects for improvement and activities to be undertaken.

List of accredited organisations on website Organisations that have received certification may publicise this fact in accordance with guidelines produced by ISO


A P P E N D I X X I : C O M P A R I S O N O F A P P R O A C H E S T O A C C R E D I T A T I O N I N A U S T R A L I A – S P E C I A L I S T A R E A S O F H E A L T H C A R E 1

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Aged Care GPs2,3,4 Mental Health1

Pathology5,6,7,8 BreastScreen9,10,11 Radiology12,13

Accrediting body

Aged Care Standards and Accreditation

Australian General Practice Accreditation

Australian Council on Healthcare Standards (ACHS) and Quality

National Association of Testing Authorities (NATA)

National Quality Management Committee of

The Royal Australian and New Zealand College of Radiologists

1 Matthews Pegg Consulting. Standards Setting and Accreditation Literature Review and Report. Canberra. Safety and Quality Council (Australian Council for Safety and Quality in Health Care), 2003 2 Standards for General Practices (3rd Edition), Data for field testing. The Australian College of General Practitioners, July 2004 3 AGPAL – “Accreditation Frequently asked questions” www.agpal.com.au/subpage.asp?page=faq&Id=2&subId=27 4 AGPAL – General practice Accreditation Survey Visit Workbook- Nov /Dec 1998 - confidential 5 Australian Government Department of Health and Ageing – “NPAAC – Function” www.health.gov.au/npaac/functions.htm accessed 23/8/2004 6 NATA website – www.nata.asn.au 7 Matthews Pegg Consulting. Standards Setting and Accreditation Literature Review and Report. Canberra. Safety and Quality Council (Australian Council for Safety and Quality in Health Care), 2003, p.106 8 Standards for Pathology Laboratories. National Pathology Accreditation Advisory Council, 2002 9 Breast Screen: Evaluation report 10 BreastScreen Australia. National accreditation handbook (draft for consultation). BreastScreen Australia, 2004 11 BreastScreen Australia. National accreditation standards: decision tool to assist with accreditation decision-making against the national accreditation standards. BreastScreen Australia, 2002 12 The Royal Australian and New Zealand College of Radiologists – General Information and History www.ranzcr.edu.au/open/q&aprogram/generalhistory.htm 13 Accreditation Standards for Diagnostic and Interventional Radiology Version6.2 Standards and Indicators. The Royal Australian and New Zealand College of Radiologists, 2004


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Agency Limited (AGPAL) Improvement Council (QIC)

BreastScreen Australia (BSA)

(RANZCR) and the National Association of Testing Authorities (NATA)

Established 1998 1997 ACHS and QIC are endorsed by the Australian Government to conduct external assessments against the standards

1947 1991 1949 RANZCR established; 1947 NATA established; accreditation program began being developed 1997 and was joined with NATA in 1999

Nature of body

Independent company limited by guarantee

Not-for-profit company. Not accredited by any other organisation Established and managed by eight member GP organisations

ACHS – refer to Appendix X QIC – not-for-profit Company

Independent, private, not-for-profit company, operating as an Association and owned by its members

Multidisciplinary expert committee appointed by the Australian government. Secretariat support provided by NBCC.

RANZCR - professional college NATA - independent, private, not-for-profit company

Level of participation

All aged care residential services seeking Australian Government residential care subsidies

Over 80% of Australia’s general practices

All public mental health services were expected to have booked assessment against standards by June 2003

All pathology services seeking accreditation: all services must be accredited to access the Medicare Benefits Schedule.

A network of 35 dedicated Screening and Assessment Services at over 500 locations throughout Australia, many of these serviced by mobile

In the future: all medical imaging services will be required to be accredited in order to access the Medicare Benefits Schedule


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As of June 2003, there were 2628 NATA accredited facilities (includes inspection, chemical, mechanical and medical testing) 1460 laboratories participated in the proficiency testing program

units. All BreastScreen Services must be accredited to operate as a BreastScreen Service and use the BreastScreen Australia logo or material that identifies it with the Program

Standards/ program

Standards detailed in the Quality of Care Principles 1997

RACGP Standards for General Practice

National Standards for Mental Health Services

National Pathology Accreditation Advisory Council Standards – primarily Standards for Pathology Laboratories; plus additional test specific guidelines and standards. Also, internationally recognised standard ISO/IEC 17025:1999;

National Accreditation Standards (NAS) / Quality Improvement Program

Accreditation Standards for Diagnostic and Interventional Radiology Also use the internationally recognised standard ISO/IEC 17025:1999; The accreditation program is modelled on the NATA Accreditation Program The most recent version of the standards was


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published February 2004


Standards detailed in the Quality of Care Principles 1997 developed by the Australian Government in consultation with stakeholders

Standards set by RACGP with a review period of about 3 years

Standards jointly developed by the ACHS, QIC and the Area Integrated Mental Health Services

The National Pathology Accreditation Advisory Council (NPAAC) is responsible for developing and maintaining standards and guidelines, with input from the Royal College of Pathologists of Australasia and public consultation. The most recent standards became effective in January 2003. Drafted by NPAAC committees and circulated for public consultation prior to NPAAC

The National Accreditation Requirements (NARs) developed and were implemented in 1991 by the National Advisory Committee to the National Program for the Early Detection of Breast Cancer (now BreastScreen Australia). These requirements were reviewed and revised in 1994. The NQMC initiated a second review of the NARs in 1999. The review involved consultation with the State and Territory BreastScreen Services, consumers and representatives of the

Developed by The Accreditation Guidelines and Quality Committee of RANZCR


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endorsement; then to Minister for Health & Ageing for consideration.

disciplines, professions and occupational groups involved in the program. The resulting NAS were endorsed, with amendments, in July 2001 by the NAC, and became operational on 1 July 2002. A review and update of the NAS was conducted by the NBCC in 2002 on behalf of the DoHA. The NAS are revised and amended by the NQMC as required.

Nature of standards

Four standards encompassing 44 indicators relating to the organisation’s services and activities (separate system of certification for physical standards of residences)

15 standards grouped into five main areas which describe the activities and facilities that are essential for accreditation

11 general standards (a number with additional parts); three sections in the standards: • 1–7: related to

universal issues that address issues of human rights, dignity, uniqueness and community acceptance.

Standards for Pathology Laboratories written in broad principles, designed to remain largely unchanged over time; nine main standards groups. NATA assessments of laboratories for quality and safety

There are 175 NAS against which performance is measured. The NAS are referred to as data and non-data standards or items. This reflects that some are quantitative, while others are qualitative in nature. Each standard has been allocated a

The RANZCR Accreditation Standards for Diagnostic and Interventional Radiology are in three main standards groups: professional, technical and administrative. NATA assessments of laboratories for quality and safety are


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• 8–10: related to mental health service organisational structure and links between parts of the mental health sector.

• 11: describe the process of delivering care on a continuum commencing with access to the mental health service and concluding with exit from the mental health service.

Standard 11.4 has five parts describing treatment and support available.

are conducted against criteria based on the internationally recognised standard ISO/IEC 17025 (laboratory’s management systems and criteria to determine technical competence) (replaced by ISO 15189). Additional standards, guidelines and performance measures specific to areas of testing, eg. gynaecological cytology.

risk rating as a way to consider the impact of not meeting that standard on the key outcome area of the program. Standards are grouped according to their risk by levels of 1,2 and 3, with level 1 standards having the highest risk and therefore the most important to meet. The standards are grouped into ten clusters that represent the key performance objectives of BreastScreen Australia: • Assessment • Information given • Cancer detection • Management • Continuity,

counselling and support

• Participation • Data management

conducted against criteria based on the internationally recognised standard ISO/IEC 17025


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• Timeliness • Equitable access • Unnecessary recall

Assessment approach

Facilities can apply to meet standards, or if accredited, can apply for a higher ratings award to reflect achievements beyond standards. The main steps in the process are specified in the Accreditation Grant Principles 1999. Every 3 years:

• service applies for accreditation by submitting a self assessment against standards

Accreditation optional but there is PIP incentive: • GP practice

registers for accreditation – 12 months to make changes before assessment

• GPs apply self-assessment against Standards Survey

• Assessor visit (peer review)

• Assessment takes approximately 4–5 hours

• Report of survey

ACHS approach is as per approach used in relation to EQuiP [but also involves a mental health surveyor and a consumer surveyor on the survey team] Steps in the ACHS review process: (a) Incorporating the

standards into practice within all mental health services

(b) Self-assessing using EQuIP

(c) Organising an

To access the Medicare Benefits Schedule, pathology services must apply to the HIC annually to be ‘Accredited Pathology Laboratory (APL): - Must be NATA accredited (occurs every 2 years) - Must provide evidence about successful participation in external quality assurance programs such as those of the RCPA Quality Assurance

To achieve accreditation a service needs to demonstrate to the NQMC, that it meets the NAS to an acceptable level. The accreditation system is tiered, with various levels of accreditation attainable. The accreditation process includes: • provision of data on

all of the NAS by the service (in annual data reports and through a data audit);

• self-assessment by

The assessment processes/ criteria have developed over time. Stage 1 was implemented November 1999-October 2001 Stage 2 was implemented November 2001- October 2003. During Stages 1 and 2, brief accreditation was granted, but renewal required moving to at least the next stage. The third and final phase began early 2004. The assessment


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• Assessment team reviews application ‘desk audit’ & undertakes ‘site audit’ to assess against all 44 standards, with residents having the opportunity for input

• Report from assessment team provided to organisation for feedback

• If there are recommendations, schedule for monitoring (every year or more often) and timeline for addressing these is prepared

Also have Agency spot checks – through ‘support

visit provided to the organisation

• Continuous Quality Improvement Cycle – accreditation process repeated every 3 years

Some standards require implementation of consumer surveys Access to private/ personal information during accreditation process bound by current Qualified Privilege – permission to access patient information should be granted by patient

ACHS in-depth review incorporating the standards

Surveyors provide a summary of major findings to the mental health service, including an assessment of strengths and opportunities and suggestions for improvement, separate to, and before, an organisation-wide summation conference. The surveyors make a recommendation to the ACHS that the service receive a Certificate of Recognition if they consider that the standards have been satisfactorily

Programs Pty Ltd. NATA accreditation:NATA compares pathology services against Standards for Pathology Laboratories, ISO/IEC 17025 and other testing specific measures as appropriate. On-site visit by NATA assessment team (at least 1 day, depending on size of service) involving:• review of case

records • interviews with

laboratory management, analysts, technical and support staff

• review of all documented policies and

the service; • a site visit and

subsequent report; • any response from

the service to issues raised;

• recommendation to the NQMC by the State Accreditation Committee (SAC); and

• consideration and subsequent accreditation decision by the NQMC.

State Coordination Units (SCU) work with services to ensure they meet the NAS and to organise accreditation activities. A service’s approach to accreditation should be integrated into its overall quality improvement program.

process consists of two components: document review and on-site peer assessments:

1. Accreditation requirements package sent to practices upon enquiry

2. Applications returned to RANZCR, with the application fee

3. Acknowledgment letter sent to practice with pre-assessment questionnaire/check list

4. Practice submits questionnaire/check list and a copy of its quality manual (QM)

5. Review of QM and feedback given prior to assessment or at the assessment. Further documentation may be requested prior to


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contact visit’ (random and targeted – brief assessment if found to be still meeting accreditation requirements, plus assess if need ‘review audit’); or ‘review audit’ Also conduct Agency-initiated ‘review audits’ • can be spot

checks if there is belief that the facility is not complying or if changes to service

• for spot checks, same on-site assessment process is followed, and management receives major findings; Service

incorporated into everyday practice. Similar process for QIC

procedures • investigation of:

training, supervision, testing methods, quality control, equipment, recording & reporting of results, physical environment

Exit meeting held between laboratory representative(s) and the NATA team – open discussion of assessment results, to allow clarification of any misunderstandings. Formal report of assessment findings, including recommendations for action to improve any deficiencies identified during assessment. The laboratory must

the assessment 6. An (optional)

advisory visit may be requested from NATA.

7. An on-site assessment is arranged with the site at a mutually convenient date and time. Assessors review site protocols and procedures with the Accreditation requirements.

8. Audit findings presented at exit meeting.

9. Final written report issued to the site, detailing conditions for accreditation, once the Medical Imaging Accreditation Advisory Committee (MIAAC) has reviewed and approved draft report


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is given 7 days to respond

Australian Government can also do unannounced spot checks Encourages facilities to develop plans for continuous improvement

provide NATA with documentation to show remedial action has been taken; if significant deficiencies, follow-up visit may be required. Reassessments carried out every 2 years, more frequently if required, eg significant changes to resources, procedures, or scope of accreditation; following unsatisfactory performance in proficiency testing program. Proficiency Testing: This is the means for independent

issued to the site at the end of the assessment.

10. Site formally responds to conditions for accreditation.

11. (Follow up visit/ assessment, if required)

12. Chair of the Medical Imaging Accreditation Advisory Committee (MIAAC) recommends accreditation to RANZCR College Council and NATA Board.

13. Practice notified of accreditation.

Practices meeting Stage 3 accreditation are granted joint RANZCR/ NATA accreditation. All matters relating to


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verification by peer experts of laboratory tests results to ensure ongoing testing accuracy. Participation is mandatory. Requirements: a) prior to gaining accreditation with NATA b) at least once every 2 years for each major area of test/measurement, where available c) when requesting significant extensions or variations to terms of accreditation d) when requesting additional signatory approvals (where relevant).

professional and technical requirements handled through RANZCR; AGQC remains focal point for all maters relating to accreditation.


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Assessors for Accreditation

Must be registered with the Quality Society of Australasia (QSA) (see www.qsanet.com for criteria); updated annually – must meet set core competencies before QSA course. Approximately 400 assessors, one-third on Agency staff; two-thirds contracted. Must do minimum of two audits per year. Usually one assessor, but can have up to three depending on facility size.

Concept is peer review – all assessors work within general practice All assessors must fulfil a set of eligibility criteria set by AGPAL and undergo training conducted by AGPAL Team of two assessors – either GP/non-GP or GP/GP team. Non-GP works in general practice, usually practice manager The type of team is nominated by the practice seeking accreditation Assessors attend a

ACHS Assessors employed by ACHS

Assessment Team = one NATA employee and one or more fellows of the RCPA. The greater the scope of testing, the more experts involved. The technical expert assessor (RCPA fellow) undertakes the assessment on a volunteer basis. NATA invites technical experts to become assessors. Before becoming an assessor, applicants must: •complete Technical Assessor Questionnaire • undertake NATA training course Also field specific Assessor Forums held: assessors

Site visitors must undergo accredited training (program currently in development). Site visit teams consist of a range of people from various disciplines/areas relevant to breast screening.

Assessment Team = one NATA employee and one or more peer assessors. Peer assessors are peer professionals, including radiologists and technologists. Assessors are invited (based on qualifications, experience etc). Approval of each assessor is granted by the Chair of MIAAC. Assessors are required to complete a questionnaire and attend the NATA training course. Assessors are unpaid, but all travel and accommodation costs incurred are paid for. Assessors are asked to undertake 2-3 assessments per year.


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one-day training course

meet to discuss technical issues.

Cost of Accreditation

Facilities pay according to number of beds: re-accreditation is free if <20 beds; tapered subsidy if 20-25 beds; $3,000 + fee/bed for >26 beds

Costs GP practice $1,295/FTE in practice (GP/non GP) or $1,495 for GP/GP team - $200 less for renewals

Facilities pay: • Accreditation fee – based on size & scope of the facility: $1855 + 3 categories (advisory visit, documentation review, initial assessment), each charged at $176/ hour AND • Annual NATA membership – also ranges, eg one technical unit = $2717; one GP laboratory = $900 (all + extra / distance from city GPO)

The NQMC and secretariat service are funded by BreastScreen Australia through the Australian Government Department of Health and Ageing Accreditation of Services including site visits are funded by the State/Territory BreastScreen Program.

Facilities pay: • Accreditation fee – $1855 ($955 for single modality sites) + three categories (advisory visit, documentation review, initial assessment), each charged at $176/ hour AND • Annual NATA membership – ranges, eg one technical unit = $2717 three technical units = $5720 (all + extra / distance from city GPO)


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Accreditation Decisions

Agency makes accreditation decision based on report from assessment team, feedback from the facility and relevant information from the Australian Government Department of Health and Ageing. After agency reviews audits can choose to revoke accreditation or vary period of accreditation. Facilities can be accredited for a period up to 4 years (but usually 3 or less if ‘all or most’ expected standards outcomes are met).

Accreditation Review Committee grants accreditation on behalf AGPAL Board, based on: recommendations from assessors and report writers; initial appeals & objections from assessors or practice; actions taken by practices towards updating; actions to be taken when practice no longer meeting Standards. Accreditation granted under three levels: • Full accreditation

for 3 years if every standard met;

• Conditional accreditation including actions

ACHS can award a ‘Certificate of Recognition’ that the National Standards for Mental Health have been incorporated into practice. The standards are not prescriptive. Understanding the intent of each standard and criteria will assist in applying it in a practical manner to a particular service.

The assessment team report is considered by the NATA Accreditation Advisory Committee relevant to the field of the laboratory, to make a recommendation regarding accreditation. Accreditation is granted by the Board of NATA. Accreditation is granted for up to 3 years.

The NQMC adopts a risk management approach to decision making and utilises a decision making tool to improve decision making against the NAS. The NQMC meets four times a year and out of session if required. The following levels of accreditation are available: • Four –yearly

accreditation with commendation

• Four –yearly accreditation

• Two yearly accreditation

• Two yearly accreditation with high priority recommendations

• Provisional accreditation

The assessment team prepares a draft report which is reviewed and approved by MIAAC (a joint RANZCR/ NATA committee) before being issued to the site. The site responds to conditions for accreditation, and then the Chair of MIAAC makes a recommendation regarding accreditation to the RANZCR Council and NATA Board. Accreditation at Stage 3 will be granted for up to 3 years, at which time reassessments are expected to occur.


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that must be taken within specified timeframe to obtain full accreditation

• Accreditation with unconditional recommendations

or suggestion for improvement

• Non-accreditation

Mandating/ Sanctions

Sanctions may be applied by the Department of Health and Ageing – including removal as an approved Australian Government provider; removal of funding; appointment of an administrator; no approval for new residents etc

No clear capacity to apply sanctions (other than removal of accreditation). AGPAL doesn’t believe accreditation should be punitive – should be educative –gives practices more time to change to be in line with standards

Under current Australian Health Care Agreements, all mental health services must have booked an external assessment against the National Standards by 30 June 2003 in order to maintain Medicare funding.

Proficiency testing mandatory. If unsatisfactory, accreditation can be removed; can indicate ‘suspended’ on accreditation report. In order for a pathology laboratory to be eligible for funding under Medicare, it must be accredited under the

A service that is not accredited due to its inability to meet the requirements for 2 year accreditation with high priority recommendations will not be able to: • operate as a

BreastScreen Australia service;

• use the BreastScreen Australia logo or any logo or material that

Implementation of accreditation is in a staged process. The goal is to implement mandatory accreditation by the end of 2005, when accreditation will be linked to accessing Medicare benefits.


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Incentives – access to Commonwealth PIP; RACGP CPD points; promotional tools etc

NATA/RCPA scheme

identifies it with the program


Agency may arrange an audit at any time, identify improvements to be made within a specified time, vary the accreditation period etc

May express concerns in writing to practice. Practice may respond.

Standard ACHS and QIC processes (refer to Appendix X)

Compliance ensured through proficiency testing programs. If results of a laboratory are unsatisfactory, NATA may conduct a reassessment of accreditation Also, shorter reassessment periods can be specified.

The SAC is appointed by the jurisdiction and is independent of the NQMC. Its role is to oversee accreditation activities within its State or Territory and to work with members of the SCU and with service providers to support the provision of quality services within BreastScreen Australia. The SAC notifies NQMC if accreditation timeframes are unable to be met, and liaises with the SCU and the NQMC. It also makes


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recommendations to the NQMC on the accreditation of services. The NQMC does not consider accreditation applications without a recommendation from the relevant SAC.

Public reporting

List of accredited organisations is listed on website. Accreditation reports and services that have had sanctions applied are also listed on website

Total number of general practices accredited is listed on website Public can search for accredited practices by name, address, suburb, or postcode; Accredited practices can display AGPAL logoInformation about standards and accreditation available for public on website

ACHS and QIC list the organisations involved in their accreditation processes on their websites

List of accredited organisations available on the NATA website – lists facility details, tests undertaken, whether accredited or not, date last accredited and when renewal is due

The NQMC secretariat provides a Certificate of Accreditation to the SAC for provision to the service. BreastScreen Services who are accredited have use of the BreastScreen Australia logo and relevant State or Territory BreastScreen Australia is currently developing an information pamphlet for consumers outlining the accreditation process and levels of. accreditation.


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Status of all services soon to go on BreastScreen Australia website (in development)


A P P E N D I X X I I : C O M P A R I S O N O F A P P R O A C H E S T O C A N C E R S E R V I C E S A C C R E D I T A T I O N – I N T E R N A T I O N A L 1

USA2 England and Wales3 Scotland4,5 Accrediting body Commission on Cancer (CoC) Regionally coordinated key review

process of the National Health Service (NHS).

National Health Service Quality Improvement Scotland (NHS QIS) -incorporates the Clinical Standards Board of Scotland (CSBS).

Established 1922 2000

2003 Five Predecessor organisations (Clinical Resource and Audit Group, Clinical Standards Board for Scotland, Health Technology Board for Scotland, Nursing and Midwifery Practice Development Unit, Scottish Health Advisory Service)

Nature of body Established by the American College of Surgeons. It is a consortium of

Government Special Health Board – national remit to focus on specific areas of

1 Matthews Pegg Consulting. Standards Setting and Accreditation Literature Review and Report. Canberra. Safety and Quality Council (Australian Council for Safety and Quality in Health Care), 2003 2 Commission on Cancer. Cancer Program Standards 2004. American College of Surgeons Chicago 2003 3 National Health Service Executive. Manual of cancer services standards. London. NHS, 2000 4 Clinical Standards: Generic. Edinburgh. Clinical Standards Board for Scotland, 2002 5 Clinical Standards: Breast cancer. Edinburgh. Clinical Standards Board for Scotland, 2001


USA2 England and Wales3 Scotland4,5 professional organisations involved in the care of cancer patients.

healthcare. Independent in that it chooses own work plan

Level of participation Over 1,400 CoC approved cancer programs in the US and Puerto Rico (ie 25% of all hospitals)

34 cancer networks across England and Wales.

Visits all NHS Boards and Trusts, the Scottish Ambulance Service and the State Hospital Board for Scotland. Undertakes visits to specific groups, eg palliative care hospices, breast and cervical screening. Will cover each of the three regional health groups.


All standards developed in consultation with industry and consumers. Standards are reviewed every 2 years.

National Standards and Performance Indicators for cancer services developed in consultation with healthcare professionals, professional bodies, voluntary sector and the public. Published in Manual of Cancer Services Assessment Standards

In partnership with healthcare professionals and public

Nature of standards Different standards and accreditation programs for different healthcare services. Each facility is assigned to a Cancer Program category (there are nine in total). Certain categories obtain exemptions from some of the standards depending on their size and number of patients seen.

There are 426 standards, that cover 10 topics spanning the patient care pathway covering organisation of cancer services, patient information, access to specialist staff, and diagnostic and oncology services through to palliative care, communication, and organisation of cancer services.

Set of generic standards focusing on patient care and safe and effective clinical care plus standards for specific areas, eg palliative care


USA2 England and Wales3 Scotland4,5 Assessment approach

3-yearly accreditation cycle:

• Facility needs to meet a number of eligibility requirements.

• Each facility, 30 days before the scheduled site visit, is required to complete a web-based Survey Application Record (SAR).

• Documentation is provided to the site surveyor a minimum of 14 days prior to the site visit (eg annual reports, annual goals, document related to committee meetings, policies and procedures etc). The site is also required to undertake a self-assessment against the standards using a point rating system.

• During the site visit, the surveyor verifies and confirms cancer program activity by reviewing a number of areas and documents (more polices, procedures, medical records, verification of credentialing of staff from the National Cancer Registrars Association etc).

Cancer services undertake self-assessment against standards followed by a peer review site visit by a multidisciplinary team. Peer review team submits a written report, based on a national template, to the relevant Regional Cancer Quality Improvement Group.

• Self-Assessment • External peer review • Investigation of serious failures



• At a minimum, the site surveyor also requests meetings with other members of the cancer committee or other members of the cancer care team

• At the completion of the visit the surveyor outlines the strengths and weaknesses and offers suggestions to correct any deficiencies.

Award notification takes place 8 – 12 weeks following survey.

An Approved Cancer Program Performance report is prepared.

• On approval, service is provided with certificate


Four accreditation decisions. • Full 3-year approval (a service

complies with all standards) • 3-year approval with contingency

(one to seven standards are rated as deficient. Full approval is awarded following the submission of documentation for corrective action)

• Non approval (eight or more deficiencies)

Services are either accredited or not accredited. Those failing accreditation produce an agreed action plan to address shortfalls. The peer review reports also form part of the Healthcare Commission’s internal assessments, a star rating is awarded based on four categories.

Most criteria to be met are essential. It is expected that they will be met wherever a service is provided. Other criteria are desirable, in that they are being met in some parts of the service and demonstrate levels of quality, which other providers of a similar service should strive to achieve.


USA2 England and Wales3 Scotland4,5 • Deferred Status (only for a new

service that is deficient in one standard. Compliance must be shown within 12 months, otherwise a service must reapply for a survey).

Mandating/Sanctions No legislated requirement for accreditation but link between accreditation and access to Medicare funds.

Mandatory. The cancer standards form a central part of the NHS Cancer Plan introduced in 2000.

NHS Boards need to meet the standards as part of their annual performance assessment and the Scottish Executive has instructed NHS Boards to take account of the advice of NHS QIS.


Deficiencies need to be addressed and site visits can be scheduled

An action plan is developed to address shortfalls. Follow-up visits can occur. Service can be temporarily closed if the concerns are serious.

• Site visits • Follow-up of serious failures An investigation of a situation can be requested by members of the public, the Scottish Executive, the NHS or the NHS QIS.

Public reporting A listing of all CoC-approved programs appear on the Cancer Programs page of the American College of Surgeons website.

Reported on the NHS website. Reports made available on website. Public can take part in review process.

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