Advisory details
| Item | Details |
|---|---|
| Advisory number | PCHS26/03 |
| Version number | 1.0 |
| Publication date | March 2026 |
| Replaces | Nil |
| Compliance | It is mandatory for approved accrediting agencies to implement this Advisory |
| Applicable to |
|
| Key relationship | |
| Attachment(s) | |
| Note(s) | |
| Responsible officer | Christina Lane Manager, Primary Health Care and National Standards Email: AdviceCentre@safetyandquality.gov.au |
| Review date | February 2028 |
Purpose
To describe the Australian Commission on Safety and Quality in Health Care’s (the Commission) requirements for the notification of significant patient risks identified during the assessment of a healthcare service to the National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards).
Issue
Clause 7.5 of Appendix 4 of the Policy – Approval under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme to conduct assessments outlines the significant reporting requirements for agencies approved to assess to the Primary and Community Healthcare Standards.
Clarification of the significant risk management processes is provided to ensure accrediting agencies, assessors, and healthcare services comply with risk mitigation and reporting requirements.
A significant risk, for the purpose of assessments to the Primary and Community Healthcare Standards, is defined by a high or extreme risk rating. More information is available in Definition of a significant risk.
Requirements
Where an assessor identifies one or more significant risks that could result in significant harm to patients while they are conducting an assessment, the following actions are to be taken.
- Assessors must notify both the healthcare service and their accrediting agency as soon as practical when a significant risk to patients has been identified.
- The healthcare service must:
- discuss the immediate actions to be taken with the assessors and/or the accrediting agency
- develop and submit an action plan to mitigate the significant risk, in line with the requirements outlined in Attachment 1, to the accrediting agency within 48 hours of the risk being identified
- complete the action plan before the final assessment
- undertake a virtual or on-site final assessment, depending on the assessment model used and the assessment cycle at which the healthcare service was when the significant risk was identified. Refer to information in Table 1.
Table 1: Final assessment requirement if a significant risk has been identified
| Assessment model | Assessment cycle | Final assessment |
|---|---|---|
| Model 1 (Desktop assessment) |
Cycle 1 | Virtual |
| Cycle 2, and subsequent cycles (if approved) |
|
|
| Model 2 (Desktop + virtual assessment) |
All cycles | Virtual |
| Model 3 (Announced on-site assessment) |
On site | |
| Model 4 (Short-notice on-site assessment) |
- The accrediting agency must:
- notify the Commission and/or the relevant regulator that a significant risk has been identified, in line with the requirements outlined in Attachment 2, within 48 hours of the risk being identified
- conduct a virtual or on-site final assessment to verify whether the action plan has been implemented in full and determine the assessment outcome
- document the significant risk and the final action plan in the healthcare service’s assessment report.
A template of the significant risk mitigation action plan, including an example of a significant risk, has been provided for guidance. Healthcare services may choose to use the template.
Inadequate or incomplete mitigation of the significant risk may result in relevant actions being rated ‘not met’ at final assessment, preventing the healthcare service from achieving accreditation.
Completion of the online submission form constitutes notification of a significant risk to the Commission
For accrediting agencies
Accrediting agencies are to:
- inform their clients about the requirements of healthcare services when a significant risk(s) is identified during assessment and the process that will be followed such as
- the healthcare service will undergo a virtual or on-site final assessment
- information on the significant risk(s) will be provided to the Commission and if applicable
- the regulator
- the Department of Health, Disability and Ageing
- the local Public Health Unit
- relevant health care complaints commissioners
- relevant national boards.
- include relevant clauses in any contractual arrangements to give effect to the requirements in this Advisory.