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NSQHS and RACGP assessment checklist
1Before the assessment
- Confirm which standards apply to you, and which actions or indicators are not applicable, with your accrediting agency.
- Name who answers for each standard, and who holds its evidence.
- Run the Commission's monitoring tool or a self-assessment, and close what it finds.
- Keep a one-page summary of how the service runs, and what improved this year.
2Clinical governance
- The reports the governing body reads, and the actions it took.
- Your last three incidents, what you learned and what changed.
- Credentialing and scope of practice current for every clinician.
- A record of who accessed patient records, and why.
3Partnering with consumers
- How informed consent is taken, recorded and revisited.
- How a patient who does not speak English is cared for.
- Feedback received this quarter, and what you changed because of it.
- Costs explained before care, in writing.
4Communicating for safety
- Three approved patient identifiers used at every transfer of care.
- Five handovers an assessor could read cold, signed and dated.
- How critical information reaches the clinician who can act on it.
- Notes documented contemporaneously, with changes visible.
5General practice
- Every 5th edition mandatory indicator mapped to its evidence.
- Follow-up of results and referrals that closes, with a record.
- One quality improvement activity this year, with its result.
- A plan for the 6th edition, started now.
6What an NSQHS and RACGP assessor may ask
- Show me how you learned from your last incident. What to show, the sequence of events, the review, and what changed afterwards.
- How do you know your healthcare records are complete and contemporaneous? What to show, notes made at the time, signed, with any change visible.
- How is informed consent obtained and recorded? What to show, what the patient was told, when they agreed, and where it is written.
- What information goes with a patient at clinical handover? What to show, the minimum content you defined, in a structured letter, signed.
- How do you communicate with patients who speak another language? What to show, conversations and information in the patient's own language.
- How do patients know what their care will cost? What to show, fees and policies shown before the patient commits.
- Who can see patient records, and how would you know? What to show, roles, access controls and an access log.
- How does the governing body monitor safety and quality? What to show, the reports leaders read, and the decisions they led to.
AAppendix, Action readiness, one row per action
- A.1Standard ______ Action ______ Applicable, yes or no ______
- A.2Policy or process ______
- A.3How it is implemented ______
- A.4How it is monitored and reported ______
- A.5What improved this year ______
- A.6Evidence lives in ______ Owner ______