Transcript HACC National Standards Training Presentation

HACC National Standards
Training
1
Today’s Objectives
To provide participants with an:

increased awareness of the HACC National
Standards Instrument (NSI)

understanding of the independent
assessment process
Australian Healthcare Associates
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Today’s Program
1. Introduction
15 mins
2. HACC National Standards
20 mins
3. Assessment Process
20 mins
Break
10 mins
4. Assessment Exercise
70 mins
5. Consumer Feedback
15 mins
6. Questions, Evaluation
of Training and Close
30 mins
Australian Healthcare Associates
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1. Introduction

What are the HACC National Service Standards?

What is the HACC National Standards Instrument?

How is the National Standards Instrument being
implemented?
Refer Training Manual Section 1
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1. Introduction
 HACC National Service Standards

A common reference point for quality control

Define aspects of service quality and expected
outcomes for consumers via seven objectives
Refer Training Manual Section 1
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1. Introduction
 HACC National Service Standards cont’d
Objective 1 - Access to Services
Objective 2 - Information & Consultation
Objective 3 - Efficient & Effective Management
Objective 4 - Coordinated, Planned and Reliable Service
Delivery
Objective 5 - Privacy, Confidentiality, Access to Personal Info.
Objective 6 - Complaints & Disputes
Objective 7 - Advocacy
Refer Manual Section 1.2
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1. Introduction
 HACC National Service Standards cont’d
Objective 3
Efficient and Effective Management
Consumers
Objective 1
Access
Objective 5
Privacy,
Confidentiality &
Access to Personal
Information
Refer Manual Section 2.1
Objective 2
Information and
Consultation
Objective 6
Complaints and
Disputes
Objective 4
Coordinated,
Planned & Reliable
Service Delivery
Objective 7
Advocacy
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1. Introduction
 HACC National Service Standards cont’d

Each of the seven objectives have expected
consumer outcomes documented as 27 Service
Standards.
Refer Manual Section 2.1
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1. Introduction
 HACC National Standards Instrument (NSI)

Quality improvement tool

Measures the extent of agency compliance with the
HACC National Service Standards via 25
performance questions

These 25 performance questions can be mapped to
the 27 service standards
Refer Manual Section 2.1
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1. Introduction
Service Standards & Performance Questions
National
Service
Standards
Performance
Questions
1 - Access
5
3
2 - Info & Consultation
3
3
3 - Management
3
6
4 - Service Delivery
5
7
5 - Privacy & Confidentiality
3
2
6 - Complaints & Disputes
4
3
7 - Advocacy
4
1
27
25
National Objectives
Total
Refer Manual Section 2.1
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1. Access to Services
HACC NSI
2. Information and
Consultation
3. Efficient & Effective
Management
7 HACC National
Service Standard
Objectives
4. Coordinated, Planned and
Reliable Service Delivery
5. Privacy, Confidentiality &
Access to Personal Info.
6. Complaints and Disputes
7. Advocacy
27 Service
Standards
Consumer
Outcomes
National
Standards
Instrument
25 Performance
Questions
11
1. Introduction
 Implementation of the NSI

Today’s training and information

Agency self-assessments

Independent assessments by AHA

Consumer Survey
Refer Manual Section 1.3
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2. HACC National Standards

What does my agency need to do to meet the
National Standards?

How should my agency use the National Standards
Instrument?
Refer Manual Section 2
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2. HACC National Standards

7 Objectives

27 National Service Standards

25 Performance Questions
Agencies will be assessed against their
demonstrated ability to respond to the
25 Performance Questions
Refer Manual Section 2.1
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2. HACC National Standards
 Performance Questions
Objective 1: Access to Services
1. How does your Agency prioritise need and allocate
resources?
2. How can your Agency demonstrate that access to services by
special needs groups occurs on a non-discriminatory basis?
3. How does your Agency ensure that a consumer’s previous
refusal of a service does not prejudice future attempts to
access your Agency’s services?
Refer Manual Section 2.1
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2. HACC National Standards
 Performance Questions
Objective 2: Information and Consultation
4. How does your Agency ensure that consumers are aware of
their rights and responsibilities?
5. How does your Agency ensure that consumers are informed
about available services?
6. How does your Agency ensure that consumers are informed
about the basis of service provision, including any changes
that may have to occur?
Refer Manual Section 2.1
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2. HACC National Standards
 Performance Questions
Objective 3: Efficient and Effective Management
7. What information on the level of need in your community does
your Agency collect?
8. How can you show that your Agency builds this information into
service development?
9. How can your Agency show that as a consequence of service
evaluation, services are changed or modified?
10. How can your Agency show that it involves consumers in
service management?
Refer Manual Section 2.1
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2. HACC National Standards
 Performance Questions
Objective 3: cont’d
11. How can you show that your Agency practices Accountable
Management?
12. How does your Agency ensure that staff are appropriately
skilled/competent to carry out services for consumers?
Refer Manual Section 2.1
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2. HACC National Standards
 Performance Questions
Objective 4: Coordinated, Planned & Reliable
Service Delivery
13. How does your Agency ensure that it regularly monitors
consumer needs? How often does your Agency conduct
formal reviews of consumers and how is the time for formal
review determined?
14. How do you inform consumers and staff of the individually
tailored service or care which consumers should receive?
15. How does your Agency ensure that consumers’ cultural needs
are taken into account when providing care/support?
Refer Manual Section 2.1
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2. HACC National Standards
 Performance Questions
Objective 4: cont’d
16. How does your Agency ensure that the special needs of
consumers with dementia, memory loss and similar disorders
and their carers are taken into account?
17. How does your Agency ensure that the special needs of
consumers with intellectual disabilities are taken into account?
18. Describe the referral process used by your Agency, including
factors taken into consideration, and any follow up action taken by
your agency.
19. How does your Agency cooperate with other agencies in order
to meet consumer needs?
Refer Manual Section 2.1
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2. HACC National Standards
 Performance Questions
Objective 5: Privacy, Confidentiality and Access to
Personal Information
20. How does your Agency ensure that the release of
consumer information occurs with the consent of the
consumer or their advocate or guardian?
21. Does your Agency enable consumers to access their
personal information upon request?
Refer Manual Section 2.1
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2. HACC National Standards
 Performance Questions
Objective 6: Complaints and Disputes
22. How does your Agency ensure that consumers are aware of
the complaints process?
23. How can your Agency demonstrate that consumer
complaints are dealt with fairly, promptly, confidentially
and without retribution?
24. How can your Agency demonstrate that it can offer
assistance to help with the conflict about a service between
a consumer and his/her primary carer?
Refer Manual Section 2.1
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2. HACC National Standards
 Performance Questions
Objective 7: Advocacy
25. How does your Agency ensure that advocates are involved
in representing the rights and concerns of consumers?
Refer Manual Section 2.1
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2. HACC National Standards
 Using the National Standards Instrument
1. Self Assessment with Verification

completes NSI by writing answers and assembling evidence

NSI scores completed by agency

self-assessment verified by independent assessor
2. Joint Assessment

completes NSI by writing answers and assembling evidence

NSI scores completed in conjunction with independent
assessor
Refer Manual Section 2.2
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2. HACC National Standards
 Using the National Standards Instrument
Two Tools to Assist in Completing the NSI
1. Commonwealth’s HACC NSI and Guidelines
2. Assessment Tool developed by AHA containing
examples of evidence that would support the ratings
Refer Manual Section 2.3
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3. Assessment Process

How will the independent assessment be conducted?

How is the NSI score calculated?

How will the assessment findings be reported?

What do I do if I want to appeal the assessment
findings?

When will the independent assessments commence?

What happens after the assessment?
Refer Manual Section 3
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3. Assessment Process
 Key Steps
1. Notification. AHA contacts your agency.
2. Information. Detailed information is sent to your agency.
3. Pre-Assessment.
- pre-review questionnaire
- consumer survey (example)
- client written consent (example)
4. Survey Returns. Consumers return survey responses to
AHA for analysis.
Refer Manual Section 3.1
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3. Assessment Process
 Key Steps cont’d
5. Site visit. Independent assessment including Exit Interview.
6. Reporting. Assessment Summary and Action Plan to agency.
7. Feedback. Agency provides any comments to AHA.
8. Finalisation. Documents amended as necessary and sent to
agency; information to DHS.
9. Agency Action. Agency documents and implements their
planned actions.
Refer Manual Section 3.1
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3. Assessment Process
 How to Achieve a ‘Met’ Rating
Two Levels of Performance Criteria for each of the 25
Performance Questions
Minimum criteria - to avoid ‘not met’ rating
Further requirements - to achieve ‘met’ rating
To achieve a ‘met’ rating, agencies must demonstrate
they satisfy both the minimum criteria and further
requirements for that Performance Question
Refer Manual Section 3.1
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3. Assessment Process
 Calculating the NSI Score
Met =
score of 2
Partly Met =
score of 1
Not Met =
score of 0
Refer Manual Section 3.2
(for that question)
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3. Assessment Process
 Assessment Score Summary by Objective
Objective
Performance
Questions
1.
Access to Services
1,2,3
2.
Information and Consultation
4,5,6
3.
Efficient and Effective
Management
7,8,9,10,
11,12
4.
Coordinated, Planned and
Reliable Service Delivery
13,14,15,16,
17,18,19
5.
Privacy, Confidentiality and
Access to Personal Information
20,21
6.
Complaints and Disputes
22,23,24
7.
Advocacy
25
Questions
Not
Applicable
Number of
Applicable
Questions
Assessment Findings
Met
(x 2)
Partly Met
(x 1)
Not Met
(x 0)
X2
X1
X0
Total
Score
Compliance Indicator
(Total Score divided by
No. of Applicable
Questions)
Sub Total
Factor
Total Score
Compliance Indicator - Total Score divided by Number of Applicable Questions
Instrument Score - Compliance Indicator multiplied by 10
Refer Manual Section 3.2
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3. Assessment Process
 Assessment Score Summary Example
Objective
Performance
Questions
Questions
Not
Applicable
Number of
Applicable
Questions
Met
(x 2)
1.
Access to Services
1,2,3
3
3
2.
Information and Consultation
4,5,6
3
2
3.
Efficient and Effective
Management
7,8,9,10,
11,12
6
6
4.
Coordinated, Planned and
Reliable Service Delivery
13,14,15,16,
17,18,19
6
5
5.
Privacy, Confidentiality and
Access to Personal Information
20,21
2
2
6.
Complaints and Disputes
22,23,24
3
1
7.
Advocacy
25
1
16
Sub Total
24
Partly Met
(x 1)
Not Met
(x 0)
1
1
1
1
1
19
4
1
Factor
X2
X1
X0
Total Score
38
4
0
Compliance Indicator - Total Score divided by Number of Applicable Questions
Instrument Score - Compliance Indicator multiplied by 10
Refer Manual Section 3.2
Total
Score
Compliance Indicator
(Total Score divided by
No. of Applicable
Questions)
6
2.00
5
1.67
12
2.00
11
1.83
4
2.00
3
1.00
1
1.00
Assessment Findings
42
1.75
17.5
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3. Assessment Process
 Categories of Overall Performance
NSI Scores can range from 0 to 20
Instrument Score
Range
Overall Performance
Against the Standards
More than 17.4
High
Between 17.4 and 15
Good
Between 14.9 and 10
Basic
Less than 10
Poor
Refer Manual Section 3.2
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3. Assessment Process
 Reporting and Action Plan
Assessment Summary

details of when the assessment took place

who was involved, at which site, for which service types

overall score

scores against each of the seven objectives
Action Plan

recommended actions against 25 performance questions

space for agency’s action plan ‘ what’, ‘who’, ‘when’
Refer Manual Section 3.3
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3. Assessment Process
 Appeals
Three Stage Process
1. Agencies can comment on draft Assessment and
Action Plan prior to finalisation
2. Appeals form can be submitted to AHA. Appeals
action may involve teleconference, site visit or reassessment where necessary
3. If still unresolved, External Appeals form can be
lodged with independent third party
Refer Manual Section 3.3
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3. Assessment Process
 Assessment Timetable
Three Phases Commencing May 2003
Phase 1 - mix of agencies
(~ May to Aug 03)
Phase 2 - local government, ethno specific, ATSI
(~ Sept 03 to Feb 04)
Phase 3 - agencies subscribing to other QA processes
(~ Mar 04 to June 04)
Refer Manual Section 3.3
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3. Assessment Process
 After the Assessment

Three year cycle

Follow up of Action Plan implementation

Process to be finalised by DHS
Refer Manual Section 3.3
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10 Minute Break
Please return to your seats promptly
Refer Manual Section 3.3
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4. Assessment Exercises

How do I use the NSI and the self-assessment tool?

What will the independent assessor be looking for?
Refer Manual Section 4
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4. Assessment Exercises
 What to do now

Form groups of 4 - 6, with people from you own or similar
services

Elect a scribe and spokesperson

Name your group and decide on service type

You will be allocated a performance question

Document evidence to demonstrate minimum and further
requirements

Rate your response

Feedback
Refer Manual Section 4
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5. Consumer Feedback

What is the Consumer Survey Instrument (CSI)?

How does the CSI link to the Assessments?

How will my agency’s clients be surveyed?

What will happen to the CSI results?
Refer Manual Section 4
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5. Consumer Feedback
 Link to Assessment Process

Developed by Commonwealth and AIHW

Highlights quality issues from a consumer perspective

Will be used as qualitative input into the assessment
process

Assists in:
- identifying potential problem areas
- improving agency performance
- improving knowledge of consumers’ needs
Refer Manual Section 4
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5. Consumer Feedback
 How the CSI will be used

Written survey where appropriate
- reduced administrative burden on agency
- non-intrusive for clients and carers
- client confidentiality not an issue
- results can be analysed prior to assessment

Alternatives include surveys in other languages, focus
groups and telephone surveys

Summary of results will be provided to agency, and
collated with other agencies’ results for DHS
Refer Manual Section 4
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Hot Tips for Agencies

Work through the NSI with your team

Awareness of Special Needs Groups as defined by
the Standards and relevance

Client assessment and consent process

Client orientation, particularly to rights and the
complaints process

Staff and volunteer orientation, particularly to client
rights and the complaints process

Know where to locate your evidence
Refer Manual Section 2.1
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Questions ?
Please complete the training evaluation survey inside your
manual and return to the presenters at the end of the session
Refer Manual Section 3.3
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For Further Information
Australian Healthcare Associates
Ph:
1300 788 667
e-mail:
[email protected]
web:
www.ahaconsulting.com.au
Department of Human Services
www.health.vic.gov.au/agedcare/hacc/index.htm
Commonwealth Department of Health & Ageing
www.hacc.health.gov.au
Refer Manual Section 3.3
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