Accreditation to national safety and quality standards

The Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme was approved by Australian Health Ministers in 2011. The AHSSQA Scheme defines the roles of:

• the Commission to develop and maintain the Standards and approve accrediting agencies to perform accreditation assessments.
• the state and territory governments to regulate health service organisations mandatory accreditation against National Safety and Quality Standards (the Standards) for each jurisdiction; and
• health service organisations to implement the actions required to meet the Standards.

Nationally, all public hospitals, private hospitals, and day hospitals must be accredited to the National Safety and Quality Health Service Standards (NSQHS Standards).

The Commission also develops other National Safety and Quality Standards under the AHSSQA Scheme that may be more applicable to some services provided by HSPs.

Background to the AHSSQA Scheme and the National Safety and Quality Standards approved under the Scheme (external site).

Fact sheets about the AHSSQA Scheme processes for health service organisations (external site).

The Department of Health Licensing and Accreditation Regulatory Unit (LARU) is the state regulator responsible for regulating accreditation of all public and private hospitals, private day hospitals (Class A) and public dental services as per the AHSSQA Scheme in Western Australia.

LARU monitors the accreditation status and reviews the accreditation reports for all

• public health service providers (and their contracted entities where applicable)
• private hospitals and
• private day hospitals (Class A). 

LARU, as the regulator of accreditation for public, private and day hospitals in WA:

• monitors health services accreditation regimes to ensure compliance with the AHSSQA Scheme
• reviews the accreditation assessment outcome reports of public health service providers and private hospitals including Class A private day hospitals
• represents WA on the Australian Commission on Safety and Quality in Health Care Regulators Working Group
• facilitates sharing the knowledge of emerging trends and issues relating to the quality and safety of health care provision in Western Australia
• approves health services transition to other National Safety and Quality Standards.

It is a national requirement from the Australian Commission on Safety and Quality in Health Care (ACSQHC) that, from 1 July 2023, all public and private hospitals and day procedure services undergoing accreditation to the National Safety and Quality Health Service (NSQHS) Standards, are assessed via short notice assessments (rather than the previous announced assessments). Other health service organisations may voluntarily choose to be assessed at short notice, or it may be a requirement of licencing or funding contracts. Information and resources relating to short notice assessments can be found on the ACSQHC site here.

Health service organisations implementing other National Safety and Quality Standards approved under the AHSSQA Scheme (external site) are generally assessed via announced visits unless it is a requirement of licencing or funding contracts, or they choose to be assessed at short notice.

Interim Assessment Pathway (external site) is undertaken by new health service facilities within 10 working days from the commencement of service provision. Accrediting agencies use the National Safety and Quality Health Service Standards (second edition) Guide to Interim Accreditation (external site) to assess new health service organisations that have not previously provided patient care. Health services with interim accreditation, are to undertake an accreditation review within 12 months of the commencement of the initial assessment and accrediting agencies are to have completed the processes of assessment and awarding accreditation (where eligible) within 18 months.

All public and private hospitals including Class A private day hospitals in Western Australia (WA) are required to achieve and maintain accreditation to the National Safety and Quality Health Service Standards (NSQHS Standards) (external site).

Accreditation reporting and information must be provided to the Licensing and Accreditation Regulatory Unit (LARU) as outlined in Timeframes for submission of accreditation information and reporting to LARU (PDF 79KB).

As per Mandatory Policy 0134/20 (PDF 122KB), the following Health Service Providers (HSPs) and the services they deliver are required to achieve and maintain accreditation to National Safety and Quality Service Standards under the AHSSQA Scheme:

• Child and Adolescent Health Service
• East Metropolitan Health Service
• North Metropolitan Health Service
• South Metropolitan Health Service
• WA Country Health Service.

Public health services must update their accreditation details by October 31 annually by completing the Public Health Service Facility Accreditation Registration Form (PDF 287KB) and forwarding this to LARU. Any updates to the information on the form need to be communicated to LARU as soon as possible.

The Australian Commission on Safety and Quality in Health Care developed the National Safety and Quality Primary and Community Healthcare Standards (NSQPCH Standards) for services that deliver health care in a primary and/or community setting. These standards were formally launched on 12 October 2021, with assessment to these standards commencing from 1 May 2023. The following information aims to assist health service organisations looking at undergoing accreditation to the NSQPCH Standards.

1. Is your health service required to be accredited to the National Safety and Quality Health Service (NSQHS) Standards?

Reasons your health service may be required to remain accredited to the NSQHS Standards include, but are not limited to:

• private funding requirements,
• service agreements with your system manager,
• contracting arrangements with a health service provider,
• your facility is licensed as a Private Hospital or Class A healthcare facility with the Licensing and Accreditation Regulatory Unit (LARU) in WA.

2. Does your health service provide healthcare that aligns with the NSQPCH Standards and its actions?

Review the following information to ensure the care provided by your health service and the cohort of clients/patients treated aligns with and maps against the actions in the NSQPCH Standards:

• Fact sheet for healthcare services: Accreditation to the National Safety and Quality Primary and Community Healthcare Standards (external site)
• Fact sheet for healthcare services - Implementing the National Safety and Quality Primary and Community Healthcare Standards (external site)
• Transitioning from the National Safety and Quality Health Service Standards to the National Safety and Quality Primary and Community Healthcare Standards | Australian Commission on Safety and Quality in Health Care (external site)
• Particularly noting the mapping information at the end of this resource
• National Safety and Quality Primary and Community Healthcare Standards | Australian Commission on Safety and Quality in Health Care (external site)
• National Safety and Quality Primary and Community Healthcare Standards Guide for healthcare services | Australian Commission on Safety and Quality in Health Care (external site)

3. Has your health service decided to request accreditation to the NSQPCH Standards?

If after reviewing the above information you believe that it is appropriate for your health service to transition to accreditation against the NSQPCH Standards (and away from the NSQHS Standards) you must:

• Determine if the accrediting agency your health service is currently contracted to can assess your service to the NSQPCH Standards.
• Seek approval from LARU if the health service seeking to transition to the NSQPCH Standards is mandated to undergo accreditation to the NSQHS Standards. To seek approval, health services must email LARUAccreditation@health.wa.gov.au with the following information:
• Confirmation from the Chief Executive of the health service acknowledging that they approve the transition of assessment and accreditation to the NSQPCH Standards.
• Confirmation that the health service’s accrediting agency are able to assess the service against the NSQPCH Standards.
• Details of each service area that is looking to transition to accreditation against the NSQPCH Standards including:
• The type of care that is delivered by the service and a description of the cohort of clients/patients that you provide care to.
• The rationale for why each of these services would be more appropriately assessed against the NSQPCH Standards.
• Once received, LARU will review this information and contact you if further discussion is required.

For general advice about the NSQPCH Standards contact the Australian Commission on Safety and Quality in Health Care via email AdviceCentre@safetyandquality.gov.au or call 1800 304 056.

For advice relating to accreditation against the NSQPCH Standards in WA or approval to change accreditation standards, email LARUAccreditation@health.wa.gov.au or call 6373 2245.