About NZCHS                                                                                                           

Quality Health New Zealand – Te Taumata Hauora – is the trading name of the New Zealand Council on Healthcare Standards, New Zealand’s national accreditation body for hospitals and other health and disability services.  Quality Health has been designated as an auditing agency by the Ministry of Health under the Health and Disability Services (Safety) Act 2001.  This means that it can undertake audits to the approved sector standards for the purposes of Ministry of Health certification, either through an audit to the sector standards or in conjunction with an accreditation survey to Quality Health standards.

Established in 1990, Quality Health New Zealand is the leading accreditation body for health and disability services.  It is an independent non-profit organisation and is constituted as an incorporated society.  It was set up as the New Zealand Council on Healthcare Standards (NZCHS) to provide a voluntary accreditation programme for hospitals and other health services.  Initial funding came from Government, the Health Boards Association, and the Private Hospitals Association.  Regional Health Authorities then provided financial support to enable developmental activities (including the preparation of standards).  Quality Health has been financially independent since 1995.  It is mainly funded from the fees paid by participants in its Accreditation Programme and clients of its other assessment services.

Quality Health is Committed to Serving

Quality Health is a membership organisation.  Our membership consists of organisations participating in the Accreditation Programme; professional associations and colleges; health provider organisations; and health consumer organisations. 

The role of members is to provide strategic input and advice; to nominate Directors for the Board; and to ensure Quality Health remains relevant to the sector and continues to make a positive difference. Quality Health is unique in New Zealand’s health and disability sector in drawing together consumer, professional and provider interests.

Membership of the Accreditation Programme provides the following tools and services over a three year cycle:

Additional standards and education sessions are at the member organisation's cost. Membership entitles the organisation to one

survey in a three year period. If no accreditation is awarded after the survey and another survey is required within the three year period, that survey will be at a cost to the organisation equivalent to an additional year's membership fee. This will cover the direct costs of the survey only.

International Partnerships                                                                                         

Quality Health New Zealand was established as the New Zealand Council on Healthcare Standards with support from the Australian Council on Healthcare Standards (ACHS). A series of pilots was carried out to test the relevance to New Zealand's health service of the Australian hospital accreditation model, which had operated since 1974. For the first two years of its life, Quality Health staff and surveyors worked alongside their Australian colleagues to learn the complex skills of operating an accreditation programme and successfully applied the ACHS model to a range of health and disability services. The ACHS programme is in turn based on the US programme operated by the Joint Commission on Accreditation of Healthcare Organisations (JCAHO) that had its genesis in 1917. The United States programme started under the auspices of the American College of Surgeons where it naturally had a clinical focus. In 1951, the programme was embraced by a wider range of stakeholders - professional organisations, provider groups and Government representatives - in the form of the JCAHO.

The Quality Health accreditation model therefore is based on over 85 years' practical experience in quality assessment. It now has strong links with the JCAHO, the Canadian Council on Health Services Accreditation (CCHSA), the United Kingdom Health Quality Service (HQS - formerly King's Fund Organisational Audit [KFOA]), as well as the ACHS. Along with these accreditation bodies, Quality Health is a member of the ALPHA Council of the International Accreditation Federation, part of the International Society for Quality in Health Care (ISQua). Other accreditation bodies represented on the ALPHA Council are from South Africa, Japan, Malaysia, France, Spain, the Netherlands, Finland and Argentina.

Quality Health New Zealand and the Australian Council on Healthcare Standards recently entered into a memorandum of understanding to further their common objectives by working together on the clinical indicator programme, the development of accreditation standards and processes, the development of training packages, the sharing of information and the provision of opportunities for surveyors to operate in both countries.

Another aspect of peer assessment is evaluation of Quality Health's performance as an accrediting body. In 1996, it underwent its first international evaluation. It was evaluated against agreed standards by the chief executives of the ACHS, CCHSA and the KFOA. The ACHS had a similar review in 1997 and the CCHSA in 1998. This rolling peer assessment programme was formalised by ISQua as an international accreditation programme for national accreditation bodies in 1999, with agreed standards for assessing the performance of accreditation bodies and international principles against which to measure an accreditation body's national standards. Following its second international evaluation in October 1999 by representatives from the CCHSA, ACHS, HQS and JCAHO, Quality Health was the first national accreditation body to be accredited by ISQua.  It has subsequently been accredited again following its third international evaluation in December 2003.

Accreditation                                                                                                           

Accreditation to Quality Health New Zealand standards is a structured process of organisational performance assessment carried out by peers for the purpose of continuous quality improvement.  The Accreditation Standards cover all aspects of client care and service as well as the organisational systems that support the provision of that care and service.  Health professionals and managers whose expertise and credibility are recognised and respected in the health and disability sector carry out the Quality Health Accreditation surveys.

The Quality Health Accreditation Programme is a comprehensive ongoing partnership between Quality Health and health and disability service providers.  Importantly, it puts in place a framework to guide services’ continued development.  The programme comprises a three year cycle of on-site education and planning, organisational self-assessment supported by Quality

Health staff, an initial preview, an accreditation survey, post-survey quality action planning, progress visits and ongoing quality improvement. 

The accreditation standards modules available are:

Not-for-profit health organisations.

Accreditation Programme                                                                                           

The Quality Health New Zealand Accreditation Programme has been developed by Quality Health to support health and disability services to achieve excellence through best practice.  Participation in this programme one of the most effective ways for health organisations to examine the quality of their services.  It is voluntary, independent of government, and based on peer assessment by health professionals.  It provides the framework for establishing and maintaining quality care, services and safety.  Effective use of the Programme requires the whole organisation to be committed to improving its performance.  Accreditation assists health and disability services to

■ improve their overall performance

■ develop strong leadership

■ enhance teamwork

■ develop effective clinical and management systems

■ focus on their clients

■ enjoy a culture of continuous quality improvement

■ meet Ministry of Health certification requirements.

Organisations that successfully achieve Quality Health standards through participation in the Accreditation Programme are awarded Quality Health New Zealand Accreditation, the official acknowledgement of an organisation’s achievements and commitment to continuous quality improvement.  At the same time, their compliance with the sector standards for Ministry of Health certification may be assessed, enabling them to achieve certification where relevant.

Components of the Programme

As shown in the diagram above, Accreditation Programme participants are guided and supported by Quality Health through a three year cycle comprising a number of elements.

-Client Service Plan

Every client is allocated a Client Service Manager who works with the organisation to develop a Client Service Plan.  This plan details services to be provided by Quality Health, which includes a planning and staff education visit, preview, the timing of submitting a self-assessment and quality action plan, survey/audit, and post-survey a follow-up progress visit .

-Self-Assessment

Organisations need to assess their achievements and outcomes regularly to improve performance.  Using the Quality Health assessment tool, organisations compare their performance against the Quality Health New Zealand Standards (which incorporate the requirements of the certification standards) at the beginning of their participation.  This provides a baseline measurement against which to measure their progress and achievements.  Continuous review is built into the improvement process.

-Preview

At least twelve months before the proposed audit/survey date, most first time organisations will receive an on site preview focused on areas of their choosing, to help them to assess their progress towards achieving the standards and to determine whether the audit/survey date is a realistic target.

-Self-Assessment Support Service

Three months before an audit/survey, organisations are required to finalise and return their self-assessment to Quality Health, demonstrating how they are addressing issues, and outlining strengths and opportunities for improvements.  Client Service Managers are available to give assistance on any issue of concern throughout the programme including interpretation of standards, recommendations made by auditors/surveyors, difficulties encountered in improving services or areas where options require further discussion.

-Survey/Audit

An accreditation survey (and simultaneously, where required for certification purposes, a certification audit) is conducted by trained Quality Health surveyors/auditors - health peers who provide feedback on overall performance.  The survey involves validation by surveyors/auditors of the organisation’s achievements in relation to Quality Health standards and the relevant approved sector standards by a review of documentation; interviews with the governing body, managers, committees and service teams; observation; assessment of client care and service through examining clinical records; discussions with clients and families; meeting with groups of stakeholders, and discussions with managers and staff to verify any provisional findings.  The surveyors/auditors provide feedback to the chief executive and senior management at the end of the survey/audit to outline their major findings, and where required by the organisation, also provide a summary of their findings to staff. 

-Survey and Audit Report

Following each survey/audit a report (or reports) of the surveyors'/auditors' findings is compiled to provide the organisation or service with

A number of processes are undertaken to ensure that the report is accurate and consistent, and that assessment is objective and consistent between organisations. The client organisation is provided with a copy of the draft accreditation report to give them the opportunity to correct any errors of fact before the report is finalised.

-Quality Action Plan

After receiving the survey/audit report, organisations are

requested to draft a Quality Action Plan (QAP) that specifically addresses the recommendations or corrective actions within a designated timeframe.  This Quality Action Plan becomes an agreement between the organisation and Quality Health.  Accreditation may be withdrawn should action not be taken to address recommendations within the agreed timeframe.  Organisations provide Quality Health with reports on progress with implementing the QAP at required times during the accreditation cycle.

-Quality Health New Zealand Accreditation

Organisations that successfully achieve Quality Health New Zealand Accreditation receive a Certificate of Accreditation.  Accreditation is for three years, subject to continued participation in the Accreditation Programme, implementation of the agreed Quality Action Plan, and the maintenance of standards. 

If an survey/audit reveals that there is a major risk to client, staff or visitor safety or there are significant deficits in a number of key areas, no accreditation status will be awarded.  If there is an area of risk or a limited number of significant improvements needed to achieve the standards, and these can be actioned in a short timeframe, accreditation may be deferred until the risk is eliminated or the improvements have been made. 

If an organisation is not granted three year accreditation it may appeal this decision on the grounds that the report is inaccurate or incomplete and that those inaccuracies or omissions were not due to shortcomings on the part of the organisation during the audit/survey.

-Ministry of Health Certification

For services or organisations that have applied to the Ministry of Health for certification, Quality Health will prepare a separate certification audit report on compliance with the relevant sector standards to submit to the Ministry of Health for certification purposes.  If some of the approved standards for certification have not been met to a satisfactory level, the service or organisation may need to address the deficiencies before the report can be finalised.  The certification decision is the responsibility of the Ministry of Health.

-Announcement of Accreditation

A public relations kit is forwarded with the completed survey report to help organisations announce their achievement of Quality Health New Zealand accreditation.  Quality Health also assists with the release of media statements and provides accreditation seals and publicity via its newsletter and website.

-Progress Visits

Progress visits by a Quality Health surveyor/auditor (larger services will require more than one surveyor/auditor) are made once or twice during the period of accreditation, depending on the recommendations from the survey/audit, and are designed to support ongoing quality improvements, confirm standards are being maintained or exceeded, review the organisation’s achievements and outcomes in relation to its quality action plan, and assist with interpreting the intent of the standards.  They also provide an opportunity to advise the client on new or revised standards pertinent to their next audit/survey.  The organisation receives a report containing the findings of the progress visit.

Products and Services                                                                                                

Quality Health New Zealand provides a range of performance assessment and quality improvement services and is a Designated Auditing Agency for Ministry of Health certification purposes, as well as providing auditing services for ACC.

Auditing: providing audits against each of the several sets of standards required by the Ministry of Health for certification.  In addition, we provide ACC Workplace Safety Management Practice audits, Accident and Medical clinic audits for ACC endorsement,

and audits to other standards and service specifications.

Accreditation: a comprehensive package involving survey against Quality Health’s standards.  An ongoing quality improvement framework is part of the Accreditation Programme. 

Clinical Indicator Service: a comparative results service for measuring and comparing treatment processes and outcomes for acute health service clients in Australia and New Zealand.

Focused Benchmarking Programme: designed specifically for aged care services in Australia and New Zealand, providing opportunities for comparison between services and using indicators relating to certification and accreditation standards.