Advisory details
| Item | Details |
|---|---|
| Advisory number | PCHS26/04 |
| 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 healthcare services being accredited to the National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards) that are:
- requesting additional time for remediation and/or extension of the accreditation expiry date
- seeking to appeal a decision by the Commission relating to above
- seeking to appeal on the basis the accrediting agency has not followed processes set out for the Primary and Community Healthcare Standards.
Issue
A healthcare service may experience significant delays in the assessment process due to extenuating circumstance(s). For the purpose of this advisory, an extenuating circumstance is defined as:
- natural disasters, fires, accidents, or emergencies (for example, pandemics) resulting in damage or restricted access to facilities
- changes in operational priorities, temporary cessation of clinical operations, or relocation
- changes in governance structures, such as acquisition or transfer of operations
- recent personal hardship or tragedy experienced by key workforce personnel that has had, or is likely to have, a significant impact on operations over an extended period of time, including but not limited to severe illness or death.
A healthcare service may wish to appeal an accrediting agency’s process or decision on the grounds of a breach of the:
- Policy - Approval under the AHSSQA Scheme to conduct assessments
- Policy - Avoiding and managing conflicts of interest under the AHSSQA Scheme
- Commission issued Primary and Community Healthcare Standards advisories and fact sheets.
Requirements
Healthcare services and/or their accrediting agency must refer all approval requests to the Commission in writing via the Extension and appeals form. Supporting evidence and documentation must accompany the request as outlined below.
| Type of request | Circumstance | Requirements |
|---|---|---|
| Additional time for remediation | If a healthcare service has undergone the initial phase of an assessment and requires more than 60 business days to remediate any actions rated 'not met' | Accompanied by evidence to substantiate claims of extenuating circumstance(s) |
| Extension of accreditation expiry date | If a healthcare service has previously been accredited and has an existing accrediting expiry date that is at risk of lapsing | Accompanied by evidence to substantiate claims of extenuating circumstance(s) |
| Both additional time for remediation and extension of accreditation expiry date | If additional time for remediation being granted will result in the accreditation expiry date lapsing | Accompanied by evidence to substantiate claims of extenuating circumstance(s) |
| To appeal a decision by the Commission not to extend the remediation period and/or the accreditation expiry date | When a healthcare service has previously submitted an extension request but is not satisfied by the outcome determined by the Commission |
|
| To appeal against an approved accrediting agency on the basis it did not follow processes set out for the Primary and Community Healthcare Standards | When a healthcare service has undertaken accreditation, and the accrediting agency has not followed the processes set out for the Primary and Community Healthcare Standards |
|
The Commission will not consider any requests under the following circumstances:
- the healthcare service has not allowed sufficient time to finalise administration of accreditation decisions despite guidance from the accrediting agency. For example
- delaying responses to communications from the accrediting agency
- postponing contracted obligations such as finalising payment, submitting documents and/or agreeing to assessment dates
- delaying completion of remedial actions.
- the healthcare service has transferred accrediting agencies. It is a requirement that the accrediting agency accepting the healthcare service as a client maintains the existing accreditation cycle and schedule of assessment (refer to Advisory PCHS26/05: Transitioning between accrediting agencies for the Primary and Community Healthcare Standards).
Submission form
Submit a request for an extension or an appeal using this form. The request may be submitted by the accrediting agency on behalf of the healthcare service.
After the request has been submitted
Following the submission of a request, the Commission will review the rationale submitted and collect further evidence from the healthcare service’s accrediting agency if required prior to determining the outcome of the request.
Requests may take 10 to 20 business days to be processed, dependent on the type of request submitted, rationale provided and the need to seek further information.
Outcome of a request
Should the Commission approve an extension to the healthcare service’s accreditation expiry date, the Commission will assign a revised accreditation expiry date and notify the healthcare service, accrediting agency and relevant regulators.
If the healthcare service is not satisfied with the outcome, it may seek an appeal via the Extension and appeals form. Once the Commission has issued a determination of the appeal, there is no further avenue of appeal.
For accrediting agencies
Accrediting agencies must advise the Commission of any issues that relate to their obligations as an approved accrediting agency to complete assessments of healthcare services as outlined in Appendix 4 of Policy - Approval under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme to conduct assessments.
The Commission does not consider delays that result from the operational issues of the accrediting agency as a sufficient reason to grant an extension to a healthcare service’s accreditation.
An accrediting agency must not backdate or change the date of commencement of a new accreditation cycle.