What is NSAP
The National Standards Assessment Program (NSAP) is a national framework for continuous quality improvement built on the Palliative Care Australia Standards for providing quality palliative care for all Australians (4th ed, 2005).
Services will register to undertake a formal self-assessment using the NSAP program. It is suggested that services formally assess themselves against the Standards every 2 years.
Services will need to:
- establish a multi-disciplinary team,
- identify and collate evidence and data,
- undertake a structured process of review,
- develop an action plan for identified high priority areas for quality improvement,
- submit a report of the outcomes of their assessment and action plan to the NSAP national project team, and
- undertake the peer-review process (optional).
Timeline
Before undertakin the formal self-assessment process, services need to sign-up in order to recieve the NSAP Guide and assess their organisational readiness to proceed to the self-assessment stage. There is not time limit for this stage.
On average, the self-assessment process should take between 8 - 10 weeks to complete. A maximum of 12 weeks will be allocated for the completion of the self-assessment component of NSAP, starting from the date of registration.
A full list of evidence sources for each standard is provided in the NSAP Guide to assist services. Evidence can be drawn from a wide variety of documents, information, data and surveys which will need to be available should you choose to proceed to peer-review.
Statistical data and other primary sources of evidence should be incorporated wherever possible.
Evidence collected for accreditation programs can be used for NSAP and similarly, and evidence collected during the NSAP process can be used for accreditation purposes.
Data collection using audit tools
NSAP recommends using audit tools on a regular basis to provide your service with information about its processes and, importantly, the outcomes for patients and families.
There are numerous tools available for services to collect audit data, including data from the Pallaitive Care Outcomes Collaboration (PCOC), NSAP audit tools and other clinical audits. Details about the different audit tools available are provided upon Sign Up.
Self-assessment is a mechanism through which organisations can review current practice, identify barriers and develop implementation strategies and monitor and evaluate their outcomes. Self-assessment is a component of reflective practice.
Self-assessment is undertaken using a multi-disciplinary team approach. It is recommended that a team of ideally 7 members (at least 4 but no more than 10) be established to review the evidence of achievement for each standard (including audit and clinical indicator data) and to agree on the appropriate rating.
A detailed step-by-step guide to the self-assessment process is provided in the Guide.
The NSAP self-assessment process is used to review organisational performance based on the Standards, culminating in the submission of a self-assessment report.
Further information on self-assessment is available from the NSAP Guide, available upon sign up.
The self-assessment team will also be responsible for the development of an improvement action plan for those standards that were identified as priority areas for improvement (i.e. allocated a rating of A or B in the assessment process).
Peer review
The purpose of the peer review process is to validate the self-assessment undertaken by the services. It is not an independent review and assessment process. The NSAP peer reviewer will work with the NSAP multi-disciplinary self-assessment team to review and validate the evidence used in the assessment process and the rating for each standard.
Peer review is an important, although not compulsory, component of NSAP.
The NSAP process is based on the Plan-Do-Study-Act (PDSA) model. The NSAP process is divided into four sections.
- Plan - during the Sign Up stage, services should be completing the relevant steps (steps1-4) identified in the NSAP process
- Do - during the 12 weeks from registration, services should undertake step 5
- Study - during the 12 weeks from registration, services should complete steps 6 and 7, as identified in the process diagram
- Act - after submitting a service report, services should complete step 9 - implementiong the service's action plan. Step 8 - peer review is also part of this process but is optional.
The National Standards Assessment Program has many benefits for participating services:
- an opportunity to objectively assess your service against the Standards
- a formal mechanism for identifying areas and developing strategies for improvement
- an opportunity to participate in a peer review and receive a benchmark report to see how your service compares to peers and services nationally
- ability to promote that your service has been externally validated as meeting the Standards
- support from the NSAP team and PCOC Quality Improvement Facilitators whilst participating
- ability to use outcomes of NSAP for accreditation purposes (and vice-versa)
- ability to track your progress over several cycles of NSAP.
NSAP is a service level activity - this means that while you can register for peer assessment, the initial self-assessment is undertaken by members within the individual service. This provides an opportunity for self-reflection and to promote change internally.
Staff from all areas of a service, whether administration, clinican, allied health, volunteers or management can participate in the assessment.
The process of working with the other team members felt cohesive, informative and beneficial. I learnt a lot from the different perspectives about our service and have a greater appreciation of our strengths
Comment from an NSAP Pilot service
Would you like to read more on the NSAP pilot? Click here for further information.