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Accreditation to national safety and quality standards

Accreditation is our way of helping health services deliver safe, high-quality care. It’s a formal process where healthcare services are independently assessed against nationally recognised standards. 

Overview

The information on this page outlines the steps health services need to take to achieve accreditation to the following standards.

Accreditation to these standards is coordinated under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme.

Visit the following pages for information on other standards and schemes.

Accreditation is a formal process where health services are assessed against nationally recognised standards. It is a quality assurance mechanism that tests whether relevant systems are in place to ensure that expected standards of safety and quality are met.

Assessment is the process of reviewing a service has met standards. Accreditation is the outcome awarded to successful services.  Assessments generally occur every two or three years.

This page describes the steps you need to take to achieve accreditation to one of our National Safety and Quality Standards. There are supporting resources linked throughout, and we are available to help with any questions you may have. Contact our Safety and Quality Advice Centre from 9am to 4pm, Monday to Friday. 

Language

We use the term ‘health services’ to describe any organisation delivering services accredited to one of the standards described on this page. 
 

Roles and responsibilities

  • Develop and maintain standards
  • Approve accrediting agencies
  • Receive assessment outcomes data and report on accreditation
  • Liaise with regulators and accrediting agencies
  • Report to Health Ministers
  • Develop and maintain accreditation schemes
  • Determine which health services need to be assessed to which standards
  • Collaborate in developing accreditation schemes
  • Make decisions about how a service operates if it does not comply with standards  
  • Assess health services against standards, according to the rules of the accreditation scheme
  • Comply with the policies and rules of the accreditation schemes
  • Provide data to and liaise with the Commission and the regulators
  • Cooperate on standardising consistent assessment processes
  • Implement standards relevant to their service
  • Maintain accreditation in accordance with the relevant accreditation scheme
  • Support provision of assessment outcomes data
  • Provide feedback on the performance of accrediting agencies
  • Engage consumers to participate in the assessment process by providing feedback, when and where relevant

Pre assessment 

Confirm which standards are right for you

All public and private hospitals, day procedure services and most public dental practices are required by health regulators to be accredited to the NSQHS Standards . 

Some healthcare services may require accreditation to National Safety and Quality Standards as part of a contractual, funding or licensing agreement.

You may also choose to undertake voluntary accreditation to confirm that you are meeting expected safety and quality standards, and to provide reassurance to the public about your service.

If you are unsure which standards are right for you, contact our Safety and Quality Advice Centre. 

Engage an approved accrediting agency

We have a rigorous process for approving independent accrediting agencies to assess healthcare services against our standards. We ensure they have adequate knowledge, capability and certifications to conduct assessments.

Your chosen accrediting agency will conduct your assessment according to the Commission’s requirements and timeframes.

View our list of approved accrediting agencies to choose an agency that is right for you.  

What if I need to change accrediting agencies?

You may choose to change accrediting agencies, if your regulator allows it (if applicable) and you are not in the middle of an assessment. If your assessment has already started, you must finish it before you can change agencies.

For more information, refer to the advisory that is specific to the standards you are being accredited to.

Understand your assessment model

What is an assessment model?

An assessment model is how an accrediting agency will conduct the assessment. For example, in-person or virtually or a combination of both. The assessment may be scheduled in advanced or done at short notice. 

What are the different assessment models?

All assessment models evaluate the healthcare service’s compliance with relevant actions in the standards they are being accredited to.

Assessors review documents, inspect the facilities and interview key personnel, consumers and patients in person.

Services being assessed against the NSQHS Standards (including the Integrated Health and Aged Care Services Module and the National Clinical Trials Governance Framework) and the National Safety and Quality Cosmetic Surgery Standards are required to complete on-site assessments.

In a virtual assessment, assessors review documents, inspect the facilities and interview key personnel using various digital tools and processes.

A hybrid assessment is when some assessors participate virtually, and others participate in person.

Hybrid and virtual assessments are generally available to services being assessed against the National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards) or National Safety and Quality Digital Mental Health Standards (Digital Mental Health Standards).

Assessors review policies, documents, reports and other records using an agreed method, such as uploaded files or screen-sharing applications. It does not include a facilities inspection or interviews with key personnel.

A desktop assessment may be conducted before a hybrid assessment to give the assessors a thorough understanding of the healthcare service’s policies, operational scope and service model. Desktop assessments are generally available to services being assessed against the Primary and Community Healthcare Standards or the Digital Mental Health Standards.

Notification periods

All services being assessed against the NSQHS Standards (including the Integrated Health and Aged Care Services Module and the National Clinical Trials Governance Framework) will be assessed at short notice. 

Other health services may voluntarily choose to be assessed at short notice, or it may be a requirement of licencing or funding contracts.

Short notice assessment ensures the outcome reflects day to day practices. Healthcare services are given a 24-hour notice of the assessment start date. 

Read more about short notice assessments

An announced assessment is scheduled in advance and must commence at least four months before the current accreditation expiry date. Health services are given at least four weeks’ notice of the assessment start date. 

Health services being assessed against the Primary and Community Healthcare Standards or the Digital Mental Health Standards are generally assessed with an announced visit, unless it is a requirement of licencing or funding contracts, or they choose to be assessed at short notice.

How do I know which assessment model I am eligible for?

Eligibility depends on the type of service and the standard your service is being accredited to. Your accrediting agency will confirm your assessment model before the assessment is scheduled.

We also have specific information for different standards which can help you determine your eligibility.

For more information, refer to the resource that is specific to the standards you are being accredited to.

What if my service is newly established and has never provided clinical services?

Newly established health services being accredited to the NSQHS Standards may be eligible for interim accreditation.  The assessment should occur within 10 working days from the commencement of service provision. The advisory and guide provide detailed information. Interim accreditation satisfies the requirement for accreditation to the NSQHS Standards for the purpose of achieving second-tier default benefit eligibility under the Private Health Insurance (Benefit Requirements) Rules 2011.  

Interim accreditation does not apply to health services being accredited to other standards. These services can begin the accreditation process when they are confident they have implemented the standards, or when they are required to due to a contractual or funding arrangement. 

Determine not applicable actions

Actions within a standard that do not apply to the healthcare service’s scope of practice or clinical context may be rated ‘not applicable’. Each standard has different actions that may be considered not applicable under specific circumstances.

You can talk to your accrediting agency about what actions are not applicable for your service. These discussions should occur well before the assessment, as our approval may be required.

For more information, refer to the advisory that is specific to the standards you are being accredited to.

Determine sample sites if applicable

What is sampling?

Sampling is a structured way for accrediting agencies to assess a selected number of non-acute, community sites within a larger organisation, instead of assessing every single site.

It is used when an organisation operates at least 10 sites under one governance structure.  

When is sampling applicable?

Sampling is only allowed in very specific circumstances, depending on the type of service and the standard your service is being accredited to. Refer to the relevant advisory for more information.

Routine assessment process and timeframes

You must undertake a routine assessment according to the Commission’s requirements and timeframes to achieve accreditation. 

Initial assessment

The accrediting agency will assess a service against all relevant actions using the agreed assessment model.

If a significant risk is identified, the assessors must notify the healthcare service immediately and an action plan to remediate the risk must be developed by the healthcare service within 48 hours. 

The assessor must inform the Commission, and their accrediting agency within 48 hours that a significant patient risk has been identified and provide a copy of the action plan as soon as possible.

A significant risk is one where there is a high or an extreme probability of a substantial and demonstrable serious adverse impact for patients who access care from the healthcare service. The requirements for managing a significant risk  depend on the standards you are being assessed against.  

Initial report provided within 5 business days

The accrediting agency will provide an initial report that outlines the rating of each action assessed during the initial assessment. 

Remediation period of up to 60 business days

If one or more actions were rated ‘not met’ or ‘met with recommendations’, you will be given up to 60 business days (remediation) to implement the changes required. 

Final assessment

The accrediting agency will conduct a final assessment to review these actions and consider the additional evidence you have provided. This may occur at the end of the 60 business day period or once all additional evidence has been submitted, whichever comes first. 

Final report provided within 20 business days

The accrediting agency will provide a final report and determine the accreditation outcome. 

Assessment outcome

Accreditation will be awarded, and an accreditation certificate will be issued, if all relevant actions are rated ‘met’ or ‘met with recommendations’.

Accreditation is awarded for two or three years, depending on the assessment model used.

Information about the assessment is submitted to the Commission. If accreditation is not awarded the accrediting agency will inform the Commission and your regulator of the outcome.

For more details on the assessment process, refer to the resource that is specific to the standards you are being accredited to.      

Additional requirements 

Further details on significant risk

For further details on significant risk, refer to the advisory that is specific to the standards you are being accredited to.

Mandatory reassessment

Some services will be required to undertake a mandatory reassessment within six months of their routine assessment being finalised. This is dependent on the type of service and the standard your service is being accredited to. The criteria for mandatory reassessment relates to how many actions are ‘not met’ or ‘met with recommendations’ at the initial assessment. We will review assessment outcomes data submitted to us by accrediting agencies to determine if a service requires mandatory reassessment.

Mandatory reassessment is applicable if your service is accredited to the:

  • NSQHS Standards including the Integrated Health and Aged Care Services Module and the Cosmetic Surgery Module
  • National Safety and Quality Cosmetic Surgery Standards

It also applies to services being accredited to the National Clinical Trials Governance Framework, depending on their maturity scale status.

You can learn more in the mandatory reassessment fact sheet. 

Out-of-cycle assessment

If your service undergoes a significant operational change such as a change in ownership, expansion of service provision or relocation of physical services, an out-of-cycle assessment may be required. 

Out-of-cycle assessment is applicable if your service is accredited to the:

Extensions, appeals and special requests

Extensions

There may be circumstances that prevent a health service from undertaking an assessment at the prescribed time such as a natural disaster or a temporary cease of operations. In these circumstances, services may apply for an extension to their accreditation so that the assessment can be performed later. Extensions are applicable to all standards on a case by case basis and can be requested by an application form.

For the Primary and Community Healthcare Standards, please use this application form. The advisory on extensions and appeals outlines the requirements for supporting evidence and documentation.

For the NSQHS Standards, IHACS Module, NCTGF and Cosmetic Surgery Standards and Module, please use this application form. 

Requesting a hybrid or virtual assessment

There may be circumstances that prevent a health service from undertaking an on-site assessment such as border restrictions or public health risks.  In these circumstances, services may apply for a hybrid or virtual assessment. This is only applicable to health services who have a routine assessment scheduled as an on-site assessment.

Applications for all standards can be made by this application form. 

Appeals

Appeals about the conduct or outcome of an assessment

If you have concerns about the conduct or outcome of an assessment, you can appeal to your accrediting agency directly.

You can also appeal to us if the accrediting agency did not comply with:

Or where there is evidence that:

Appeals to the Commission will not be considered for reasons such as:

  • the health service organisation did not allow sufficient time, or comply with the reasonable directions of the accrediting agency to finalise the administration of the assessment prior to the accreditation expiry date
  • the health service organisation is transferring between accrediting agencies 

Making an appeal

Making an appeal in relation to the Primary and Community Healthcare Standards can be done using this form.

Making an appeal in relation to any other standard can be done by emailing our Safety and Quality Advice Centre. Please read our process for reviewing appeals before submitting your appeal. 
 

Post assessment

Post assessment surveys

Post assessment surveys are our way of monitoring the conduct of assessments. Agencies submit accreditation data to us, and we send out surveys to services who have recently undergone an assessment.

Your feedback is valuable and is used to ensure that the accreditation process is operating effectively.

If you have recently been assessed and not received a survey, please contact our Safety and Advice Centre. 

Feedback and complaints

The Safety and Quality Advice Centre provides support to health service organisations, assessors and accrediting agencies on the implementation of safety and quality standards and accreditation assessment requirements.

If you wish to provide feedback, make a compliant or are seeking mediation, please contact the Safety and Advice Centre.  

Exemplar practice

Exemplar practice is our way of highlighting outstanding examples of safe, high-quality care demonstrated by health services implementing our National Safety and Quality Standards. We recognise innovative and effective models of care to promote shared learning and inspire best practice initiatives across the health system.

We are in the process of updating our policy for recognising exemplar practice which describes the criteria and how to submit nominations.

An accrediting agency can still make nominations while we review the policy.

Read about two innovate services who have been awarded exemplar practice for their exceptional delivery of care. 

Transition Support Service, the Royal Children’s Hospital Melbourne

Royal Flying Doctor Service, South Australia and Northern Territory 

Assessment outcomes data and registers of accredited services

As part of our commitment to transparency in the health system, we publish assessment outcomes data and registers of services accredited to our National Safety and Quality Standards. 

Explore accredited services

Explore assessment outcomes

Last updated: 29 April 2026