National Safety and Quality Digital Mental Health Standards

Published by the Australian Commission on Safety and Quality in Health Care

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ISBN: 978-1-925948-74-5

© Australian Commission on Safety and Quality in Health Care 2020

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Australian Commission on Safety and Quality in Health Care. National Safety and Quality Digital Mental Health Standards. Sydney: ACSQHC; 2020

Disclaimer

The content of this document is published in good faith by the Commission for information purposes. The document is not intended to provide guidance on particular healthcare choices. You should contact your health care provider for information or advice on particular healthcare choices.

The Commission does not accept any legal liability for any injury, loss or damage incurred by the use of, or reliance on, this document.

Acknowledgement

The Commission would like to thank all of our partners for their contributions to the development of the NSQDMH Standards and their continuing commitment to improving safety and quality across the Australian healthcare system.

Introduction

Digital mental health services have seen significant growth over the past decade, offering new and innovative ways for consumers, carers and families to access services. Digital mental health services can be used as standalone supports that are self-managed or therapist-guided, or as a complement to in-person services. Digital services may be easier to access than in-person services, and sometimes can be accessed anonymously to protect service user identity¹ and encourage fuller disclosure and engagement.

There is growing evidence regarding the important role digital mental health services can play in the delivery of services to consumers, carers and families.² Some digital mental health services can be as effective as in-person services, while others have not been subject to rigorous evaluation processes or evidence collection.

The Australian Commission on Safety and Quality in Health Care (the Commission) developed the National Safety and Quality Digital Mental Health (NSQDMH) Standards in collaboration with consumers, carers, families, clinicians, service providers and technical experts.

The development of the NSQDMH Standards is a significant first step in providing safety and quality assurance for digital mental health service users and their support people, and best practice guidance for service providers and developers across the three areas outlined below.

The primary aim of the NSQDMH Standards is to improve the quality of digital mental health service provision and to protect service users, and where relevant, their support people, from harm. The NSQDMH Standards provide a quality assurance mechanism that tests whether relevant systems are in place to ensure that expected standards of safety and quality are met. The NSQDMH Standards provide a nationally consistent statement about the standard of care service users and their support people can expect from a digital mental health service.

What is a digital mental health service?

It is recognised that there are distinct specialist mental health, suicide prevention and alcohol and other drug sectors that provide services to often distinct cohorts.

For the purpose of the NSQDMH Standards, mental health, suicide prevention and alcohol and other drug services delivered via a digital platform come under the term of digital mental health services. These can include provision of information, digital counselling services, treatment services (including assessment, triage and referral services) and peer-to-peer support services, that are delivered via telephone (including mobile phone), videoconferencing, web-based (including web-chat), SMS or mobile health applications (apps). 

The NSQDMH Standards are not intended to apply to more generic wellness services, which are not offering specific health services to service users or their support people. Standalone electronic health or medical records, decision support tools for clinicians, analytic services, services that primarily provide support and education to health professionals, clinical practice management software, and clinical workflow and communication software are excluded under the definition of digital mental health services for the purposes of the NSQDMH Standards. 

What do the NSQDMH Standards cover?

There are three NSQDMH Standards, which cover clinical and technical governance, partnering with consumers, and the model of care which includes communicating for safety and recognising and responding to acute deterioration. 

The three NSQDMH Standards are:

• Clinical and Technical Governance Standard, which describes the clinical and technical governance, safety and quality systems and the safe environment (including privacy, transparency, security and stability of digital systems) that are required to maintain and improve the reliability, safety and quality of digital mental health care, and improve health outcomes for service users.
• Partnering with Consumers Standard, which describes the systems and strategies to create a person-centred digital mental health system in which service users and where relevant, their support people are:

1. Included in shared decision-making 
2. Partners in their own care 
3. Involved in the development and design of quality digital mental health care.

• Model of Care Standard, which describes the processes for developing and delivering digital mental health services, minimising harm to service users, their support people and others, communicating for safety and recognising and responding to acute deterioration in mental state.

Each standard contains:

• A description of the standard
• A statement of intent
• A list of criteria that describe the key areas covered by the standard
• Explanatory notes on the context of the standard
• Item headings for groups of actions in each criterion
• Actions that describe what is required to meet the standard.

How should the NSQDMH Standards be applied?

The NSQDMH Standards are voluntary and should be applied at the level of the service provider that makes digital mental health services available to service users and their support people. 

Not all actions within each standard will be applicable to every digital mental health service. A service provider may provide more than one digital mental health service and may see the application of the NSQDMH Standards differ across those services.

The applicability of actions and the extent of the strategies required will be determined by the size, risk to service users and their support people, and the complexity of the service provider’s digital mental health services. The model of care for the digital mental health service may also inform whether an action is relevant. To meet the NSQDMH Standards, service providers will need to work closely with developers of digital mental health services in relation to the design, development and delivery of their products to service users and their support people.

While service providers may provide services other than digital mental health services, the NSQDMH Standards are not intended to be applied to those other service components.

The Commission intends to develop further guidance for service providers and service users to support the implementation of the NSQDMH Standards.

Alignment with other standards

In developing the NSQDMH Standards, the Commission has adapted some actions and terminology from the National Safety and Quality Health Service (NSQHS) Standards (second edition).³

Where a service provider that is required to meet the NSQHS Standards offers digital mental health services, only the actions unique to the NSQDMH Standards are recommended for implementation in addition to the NSQHS Standards. This ensures that the issues specific to digital mental health services are given appropriate focus.

A word about language 

The language we use is important and must be selected wisely. It has the power to offer hope and encouragement or to convey pessimism or low expectations. It can exacerbate or mitigate the significant stigma that exists towards mental illness, alcohol and other drug use and suicide. 

The terminology in common use across different domains in the health sector is not universal, particularly in referring to those who seek assistance from health services. The NSQDMH Standards refers to those who use digital mental health services as service users. 

Where reference is made to consumers, carers and families, as opposed to service users, this is intended to specifically refer to those with lived experience, who may or may not have used digital mental health services. 

Individuals who provide support and reassurance to service users are referred to as support people and may be a family member, friend or paid support worker.

An organisation that makes digital mental health services available to service users and their support people is referred to as a service provider.

The services, whether they are information services, digital counselling services, treatment services (including assessment, triage and referral services), or peer-to-peer services, and irrespective of the digital medium through which they are provided, are referred to in the NSQDMH Standards as digital mental health services. 

This terminology is adopted for clarity of purpose within the NSQDMH Standards, but it is not a requirement that service providers adopt the language used in the NSQDMH Standards within their own organisation.

A glossary is provided within this document to aid the reader in understanding the terms used.

More information

For more information on the NSQDMH Standards visit the Commission’s website: www.safetyandquality.gov.au/dmhs

You can access a range of digital mental health services on the Australian Government’s digital mental health gateway Head to Health: headtohealth.gov.au

Clinical and Technical Governance Standard

Service providers have a responsibility to the community for continuous improvement of the safety and quality of their services, and ensuring that they are person centred, safe and effective.

Intention of this standard

To implement a clinical and technical governance framework that ensures service users and their support people receive safe and high-quality care.

Criteria

Governance, leadership and culture

Service providers set up and use clinical and technical governance systems to improve the safety and quality of care. 

Safety and quality systems

Safety and quality systems are integrated with governance processes to enable the service provider to actively manage and improve the safety and quality of care. 

Workforce qualifications and skills

The workforce has the right qualifications, skills and supervision to ensure the delivery of safe and high-quality care to service users and their support people.

Safe environment for the delivery of care

The environment promotes safe and high-quality care for service users and their support people.

Explanatory notes 

Delivering digital mental health services requires consideration of both clinical and technical governance to ensure safe and high-quality service delivery and service user experience.

Clinical and technical governance should be integrated components of a service provider’s corporate governance. Good governance ensures that everyone – from the workforce to managers and members of governing bodies, such as boards – is accountable to service users, their support people and the community for assuring the delivery of digital mental health services that are safe, effective, integrated, high quality and continuously improving. 

Clinical governance

Thorough research has identified the elements of an effective clinical governance system and the effect of good clinical governance on health service performance.^4-6

Clinical governance is the set of relationships and responsibilities established by a health service provider between its governing body, executive, workforce, service users and their support people, and other stakeholders to ensure good clinical outcomes. It ensures that the service provider and service users and their support people can be confident that systems are in place to deliver safe and high-quality health care and continuously improve services. 

Leaders have an important role in influencing the quality of care by setting priorities, shaping culture, supporting the workforce, engaging effective digital mental health services, and monitoring progress in their safety and quality performance. Managers and the workforce also play an important role in clinical governance, aligning clinical and technical priorities and supporting continuous quality improvement. 

The Australian Commission on Safety and Quality in Health Care (the Commission) has developed the National Model Clinical Governance Framework⁷ to support the delivery of safe and high-quality care. Service providers should refer to the framework for more details on clinical governance, and the associated roles and responsibilities.

Technical governance

Technical governance is the system by which the use of digital information and communication technology is directed and controlled. It includes leadership, organisational structures, strategy, policies, and processes to ensure that the provider’s digital technology sustains and extends the organisation’s strategies and objectives. 

Service providers should take a systematic approach to the governance of information management and information and communication technology, which is incorporated within their corporate governance framework.

Implementing this standard

This standard integrates actions for the clinical and technical governance of digital mental health services. Recognising the shared elements (for example, leadership, culture, incident management) and interdependencies, service providers may need to cross-reference actions between the clinical and technical workforce to minimise duplication and improve outcomes.

Each service provider needs to put in place strategies for clinical and technical governance that consider its own circumstances and context. 

Governance, leadership and culture

1. Service providers set up and use clinical and technical governance systems to improve the safety and quality of care.

Safety and quality systems

Safety and quality systems are integrated with governance processes to enable the service provider to actively manage and improve the safety and quality of care.

Workforce qualifications and skills

The workforce has the right qualifications, skills and supervision to ensure the delivery of safe and high-quality digital mental health care to service users.

Safe environment for the delivery of care 

The environment promotes safe and high-quality care for service users and their support people. 

Partnering with Consumers Standard

Service providers develop, implement and maintain systems to partner with service users and their support people. These partnerships relate to the planning, design, delivery, measurement, review and evaluation of digital mental health services. The workforce uses these systems to partner with service users and their support people.

Intention of this standard

To create services in which there are mutually valuable outcomes by having:

• Service users and their support people as partners in planning, design, delivery, measurement, review and evaluation of digital mental health services
• Service users as partners in their own care, and with their support people, in line with the model of care and to the extent that they choose.

Criteria

Partnering with service users in their own care

Systems that are based on partnering with service users in their own care, and with their support people, are used to facilitate the delivery of care. Service users are partners in their own care, with their support people, in line with the model of care and to the extent that they choose.

Health and digital literacy

The service provider takes account of the health and digital literacy of service users and their support people and ensures that communication occurs in a way that supports effective partnerships. 

Partnering with service users in design and governance 

The service provider partners with service users and their support people in the design and governance of digital mental health services. 

Explanatory notes 

Partnerships with consumers, carers and families in health care are integral to the development, implementation and evaluation of health policies, programs and services. Service providers should ensure that these partnerships underpin the delivery of their digital mental health services.

Effective partnerships exist when people are treated with dignity and respect, information is shared with them, and participation and collaboration in healthcare processes are encouraged and supported to the extent that people choose.⁸

Delivering care that is based on partnerships provides many benefits for service users and their support people, and service provider organisations. Effective partnerships, a positive experience for service users, and high-quality health care and improved safety are linked.

Achieving effective partnerships when health care is delivered by digital means can occur at three levels⁹: 

• At the individual level, partnership with the service user is demonstrated through the delivery of respectful care and the provision of information relevant to their care. Service users and, where appropriate, their support people should be encouraged and assisted to participate in their own care and self-management, and engaged in making decisions and planning care, to the extent that they choose. This form of partnership is not reliant on the service user engaging with any specific individual in the service, rather it is evidenced in the way the service engages with the service user.
• At the level of a digital mental health service, partnerships relate to the participation of service users, consumers, carers, families and support people in the planning, design, monitoring and evaluation of the digital mental health service and any changes in the service. Engaging with service users and their support people in the design of digital mental health services is essential to maximise the usability and accessibility of the service.
• At the level of the service provider, partnerships relate to the involvement of service users, consumers, carers, families and support people in overall governance, policy and planning. This level overlaps with the previous level in that a service provider may offer various digital mental health services. Service users, consumers, carers, families and support people may be members of key committees for the service provider, in areas such as clinical governance, technical governance, and service design, and where relevant also in areas such as education, ethics and research. 

The processes involved with these partnerships will vary according to the type of digital mental health service and its model of care.

Organisational leadership and support are essential to nurture partnerships at all three levels. Supporting effective consumer, carer and service user partnerships may mean supporting multiple mechanisms of engagement and modalities. Meaningful methods of engagement range from representation on committees and boards, to contributions at focus groups, to feedback received. Engagement may occur face-to-face or via digital means, including social media. Taking the diversity of service users and their support people into account is also necessary to achieve the best results. 

Partnering with service users in their own care

1. Systems that are based on partnering with service users in their own care, and with their support people, are used to facilitate the delivery of care. Service users are partners in their own care, with their support people, in line with the model of care and to the extent that they choose. 

Health and digital literacy

The service provider takes account of the health and digital literacy of service users and their support people and ensures that communication occurs in a way that supports effective partnerships. 

Partnering with service users in design and governance 

The service provider partners with service users and their support people in the design and governance of digital mental health services.