Advisory details
| Item | Details |
|---|---|
| Advisory number | CMO 25/02 |
| Version number | 1.0 |
| Publication date | 10 July 2025 |
| Replaces | N/A |
| Compliance with this advisory | It is mandatory for approved accrediting agencies to comply with this Advisory |
| Information in this advisory applies to |
|
| Key relationship |
|
| Responsible officer | Margaret Banks Director, National Standards Phone: 1800 304 056 Email: AdviceCentre@safetyandquality.gov.au |
| To be reviewed | July 2026 |
Purpose
To describe the requirements for accrediting agencies to notify the Australian Commission on Safety and Quality in Health Care (the Commission) of significant consumer risks identified during assessment of the National Safety and Quality Mental Health Standards for Community Managed Organisations (NSQMHCMO Standards).
Issue
During assessment, assessors may identify a risk that has the potential to cause harm to consumers, and if it is sufficiently likely to occur, immediate action may be warranted. Accrediting agencies have signed declarations as part of the conditions of approval to notify the service provider, the relevant regulator and the Commission1 when a significant consumer risk is identified during assessment of a service provider.
Ministers have tasked the Commission with the coordination of the Australian Health Service Safety and Quality Accreditation Scheme. This includes receiving information about the assessments of service providers, such as notification of significant risk.
Requirements
A significant risk is one where there is a high probability of a substantial and demonstrable adverse impact for consumers if the practice is to continue. In each case, a significant risk will be sufficiently serious to warrant an immediate response to reduce the risk of harm. This may include interventions or changes to systems, the service environment, or where there are multiple unmet actions that impact several safety and quality systems.
While the focus of reporting by assessors will be on significant risks of consumer harm, it will not necessarily exclude other significant risks.
Where an assessor identifies one or more significant risks that could result in significant harm to consumers, while they are onsite with a service provider, the following actions are to be taken:
- Assessors are to notify both the service provider and their accrediting agency that a significant consumer risk has been identified.
- Assessors and/or the accrediting agency are to discuss immediate action to be taken with the service provider and require them to develop and submit a plan of action to remedy the risk within 48 hours.
- The accrediting agency is to notify the Commission within 48 hours that a significant consumer risk has been identified and provide a copy of the action plan as soon as practical.
Completion of the online submission form constitutes notification to the Commission.
The requirements of the online form are listed below.
About the agency
- Accrediting agency name
- Accrediting agency contact
- Email address
About the Service
- Organisation name
- Address
- Facility ID
- Organisation contact person, title or position and phone number
About the assessment
- Standard being assessed
- Assessment cycle (standard assessment, out-of-cycle assessment)
- Stage (initial or final)
- Number of assessors
- Date significant risk was identified
- Description of the significant risk
- Relevant actions in the standard
- Action taken by the assessor and/or accrediting agency
- Did the service provider provide an action plan? (yes, no)
- Copy of the service provider's action plan
Accrediting agencies are to inform their client and include relevant clauses in any contractual arrangements that information on significant consumer risk will be provided to the Commission when it is required by regulation, or policy of a government agency.