Advisory details
| Item | Details |
|---|---|
| Advisory number | PCHS26/01 |
| Version number | 1.0 |
| Publication date | March 2026 |
| Replaces | Nil |
| Compliance | It is mandatory for approved accrediting agencies to implement this Advisory |
| Applicable to |
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| Key relationship | |
| Attachment(s) | |
| Note(s) | |
| Responsible officer | Christina Lane Manager, Primary Health Care and National Standards Email: AdviceCentre@safetyandquality.gov.au |
| Review date | March 2028 |
Purpose
To describe the Australian Commission on Safety and Quality in Health Care’s (the Commission) requirements for sampling multi-site healthcare services at assessment to the National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards).
Issue
Healthcare services seeking accreditation to the Primary and Community and Healthcare Standards must undertake a desktop, virtual or on-site routine assessment.
To ensure consistency, the Commission has developed a sampling methodology, to be applied by all accrediting agencies for healthcare services where multiple sites operate under a single governance structure.
Requirements
Healthcare services may be eligible for sampling if they:
- have 10 or more sites
- are being assessed using models 2, 3 or 4.
Where 10 or more sites operate under a single governance structure, a sample of these sites may be assessed to determine whether the healthcare service organisation (organisation) as a whole meets the requirements for accreditation to the Primary and Community Healthcare Standards.
In these instances, accrediting agencies must apply a risk‑based approach when selecting a sample for accreditation, in accordance with the Commission’s sampling methodology.
Sampling methodology
Where sampling is approved, the following methodology is used for organisations with:
| 10 to 20 sites | 5 sites plus one-third of the remaining sites, rounded up to the nearest whole number |
|---|---|
| More than 20 sites | 10 sites plus one-quarter of the remaining sites, rounded up to the nearest whole number, up to a maximum of 20 sites. |
Steps for selecting the assessment sites
- The sample must include:
- the corporate or main site
- 75% of sites selected based on a risk assessment conducted by the accrediting agency. The risk assessment must take into consideration factors such as (but not limited to)
- previous assessment results
- time elapsed since the site was last assessed
- information from incident reports and complaints
- insights gained through discussions with the organisation and sites (including, but not limited to, the complexity and diversity of service provision at each site)
- 25% of sites selected at random, to ensure a representative sample of the organisation.
- Accrediting agencies must select the sample sites independently, without input or influence from the organisation. The organisation must be notified of the selected sample sites either just prior to or at the commencement of the assessment. For rural or regional sites, notification must occur no more than six weeks in advance.
- Exemptions to Step 2 may be granted for organisations where staff and patient availability is unpredictable and requires advance planning, or where advance notice is a condition of entry to the sites.
- Organisations seeking an exemption must submit a written request to the Commission, via their accrediting agency.
- The Commission will consider exemptions on a case-by-case basis, and where applicable, consult with regulators and/or funders before making a determination.
- If approval is granted, the accrediting agency may collaborate with the organisation in implementing Step 1 to maximise the number of staff, patients and sites that can be interviewed and inspected during the assessment.
Determining an assessment outcome
- For assessment reporting purposes, the organisation as a whole will be assigned a rating for each relevant action of the Primary and Community Healthcare Standards.
- All sites within the organisation must be listed in the accreditation report and testimonial, with the sample sites that were assessed clearly identified.