Medical and Primary Health Care Accreditation

QAS International have been helping medical organisations to develop and implement systems for over a decade, allowing organisations to gain accreditation and ensuring processes are in place to continually improve the quality of service delivery.

Our experience in the health and primary care field has involved working with the following standards:

  • ISO 9001:2008 Quality Management System – Requirements
  • Medicare Local Accreditation Standards
  • Quality Improvement Council (QIC) Standards and Accreditation Program
  • RACGP Standards for General Practices
  • Australian Council on Health Care Standards (ACHS)
  • Commonwealth Home and Community Care( HACC) Program
  • AS 4801:2001 Occupational Health and Safety Management System – Requirements
  • ISO 14001:2004 Environmental Management System Requirements
  • ISO 31000:2009 Risk Management Standard
  • AS/NZSISO19011:2003 – Guidelines for Auditing
  • AS 2828.1-2012 Paper Based Health Records
  • HB 254-2005 Governance, Risk Management and Control Assurance;
  • AS 8001-2003 Fraud and Corruption Control
  • ASX Good Governance: Principle 7 references
  • AS8000 – 2003 Corporate Governance – Good Governance Principles

QAS International has a range of documents, forms and templates, tools and options for clients to use to build systems and processes to manage: clinical services and risk, primary health care programs, HR management, information management, document and records control, audit, evaluation and compliance, financial management, work health and safety, and continual improvement, etc. Typically our consultancy, support processes and assistance involves the following steps:

  1. On-site verification of the Gap Analysis against the relevant accreditation Standard, relevant statutory and regulatory requirements;
  2. conduct a “Risk Assessment” of the Gaps that have been identified (at Step 1) identify appropriate levels of controls, monitoring and review;
  3. develop an Accreditation Work Plan (to redress the Gaps identified at Step 1 and Risks identified at Step 2);
  4. review and where required set up best practice electronic document and records control folder and filing systems for the organisation to use;
  5. conduct ‘risk sensitivity ratings and apply access restrictions to relevant electronic documents and records folders;
  6. assist staff in the migration of documents and records into the new electronic folder/filing structure;
  7. develop the Quality, Safety, Clinical, Programs, Clinical Governance, Finance Manuals, documentation, forms, templates, register s and spreadsheets that are required for accreditation;
  8. providing assistance with building and strengthening required accreditation systems and processes;
  9. monitor progress towards the goal of accreditation and provide project reports to senior management and the Board;
  10. provide training to staff to ensure that staff understanding what is required of them and assist staff with the implementation of the approved policies, processes and procedures;
  11. working on-on-one with staff and managers to implement appropriate management systems in their areas of responsibility;
  12. provide “Document Control” training to staff who will be required to correctly maintain the organisations Manuals, forms and templates as “Controlled Documents”;
  13. conduct internal audits and trial accreditation audit prior to accreditation – to establish the level of compliance with approved policies, processes and procedures;
  14. write up the internal audit reports and develop a Corrective Action Plan to action any gaps identified in the Internal Audits;
  15. assist organisations to take the required audit corrective actions to ensure that they are “accreditation ready”;
  16. make any changes to Quality Management System documentation – identified during the internal audits;
  17. conduct (in conjunction with senior management) ‘Management Reviews” of the effectiveness of the organisations Management Systems in meeting the organisations goals and objectives,
  18. assist the organisation to register for formal accreditation, and
  19. provide follow-up support and internal auditing services to organisations as required and at least annually.