Consumers and accreditation

Awarding accreditation to a health service organisation provides assurance to the community that the organisation meets expected patient safety and quality standards.

What is accreditation?

Accreditation is an evaluation process that involves assessment by qualified external peer reviewers to assess a health service organisation’s compliance with safety and quality standards.

There is also a focus on continuous quality improvement strategies that promote safe and high quality healthcare. Awarding accreditation to a health service organisation provides assurance to the community that the organisation meets expected patient safety and quality standards.

In Australia, all public and private hospitals, day procedure services and most public dental practices must be accredited.

To become accredited, health service organisations must pass external assessments to show they have implemented all of the requirements of the National Safety adn Quality Health Service (NSQHS) Standards. The assessments are conducted by independent accrediting agencies, approved by the Australian Commission on Safety and Quality in Health Care, (the Commission) as part of the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme. The Commission coordinates national accreditation processes via the AHHSQA Scheme.

What can I expect from an accredited health service?

When you or someone you care for visits a health service organisation, you expect to receive care that is safe. Accredited health service organisations have demonstrated through an independent review that they have implemented the NSQHS Standards.

The fact that a health service organisation has been accredited does not guarantee that no one will ever experience unsafe care, but it ensures safety and quality systems that promote safe care are in place. These systems help to ensure risks are identified and managed.

How do health services become accredited?

To become accredited, a health service organisation:

  • Conducts a self-assessment to determine if each of the actions in the NSQHS Standards are being met
  • Participates in an on-site assessment conducted by an independent accrediting agency, approved by the Commission
  • Takes steps to address shortcomings in cases where the accrediting agency has found actions related to specific NSQHS Standards that have not been met.

When a health service organisation has shown it meets all of the NSQHS Standards, it is awarded accreditation. You will be able to identify accredited health service organisations by a certificate or accreditation award that states they have been assessed against the NSQHS Standards. Certificates are often hung in the front entrance or in public waiting areas of a health service organisation.

What happens if an action in the NSQHS Standards is not met?

If an action is not met at the first assessment by the accrediting agency, the health service organisation usually has 60 business days to make improvements. In 2019, during transition to the second edition of the NSQHS Standards, health service organisations have 80 business days. If at the final assessment the action is still not met, the health service organisation will not be awarded accreditation. All actions must be met to achieve accreditation.

If a health service organisation is not awarded accreditation, various sanctions may apply depending on the extent and the type of actions that were not met. Any health service organisation that does not achieve accreditation must undergo full assessment within 12 months to continue to be able to operate.

How can a consumer be involved in the accreditation process?

As a consumer, you have the opportunity to be involved at several points in the process. A health service organisation may encourage you to be involved in a variety of ways, including by:

  • Seeking your advice about safety and quality issues through complaints or feedback processes
  • Asking if you would like to be interviewed about your experience as a consumer of the health service organisation, or about your involvement in the organisation’s improvement processes, as part of the assessment process
  • Asking if you would like to review the health service organisation’s safety and quality systems or processes of care on an ongoing basis, as a consumer representative appointed to a quality improvement committee.

Contact your health service organisation to find out how to be involved in your health service organisation’s accreditation process .

How can a consumer become an assessor?

You may also be interested in undertaking training to become an assessor who reviews an organisation’s systems and processes against the NSQHS Standards from the consumer perspective. If you are interested in becoming a consumer assessor (also called a surveyor), you can contact an approved accrediting agency for more information.

Do you have any concerns or issues?

If you are concerned about a safety or quality issue at a health service organisation, you can: 

  • Share your feedback with a clinician or other staff member of the health service organisation in person
  • Write your feedback down on a feedback form
  • Contact the health service organisation’s consumer advocate or patient liaison officer to help you resolve any concerns
  • Contact your state and territory’s health complaints authority if you do not receive a response, or if you are not happy with the response you receive. These are listed below:

ACT

Australian Capital Territory

ACT Human Rights Commission
Website: www.hrc.act.gov.au/complaints 
Phone: 02 6205 2222

NSW

New South Wales

NSW Health Care Complaints Commission
Website: www.hccc.nsw.gov.au
Phone: 1800 043 159

NT

Northern Territory

Health and Community Services Complaints Commission
Website: www.hcscc.nt.gov.au
Phone: 1800 004 474 

Qld

Queensland

Office of the Health Ombudsman 
Website: www.oho.qld.gov.au
Phone: 133 646

SA

South Australia

Health and Community Services Complaints Commissioner
Website: www.hcscc.sa.gov.au
Phone: 1800 232 007

Tas

Tasmania

Health Complaints Commissioner Tasmania
Website: www.healthcomplaints.tas.gov.au
Phone: 1800 001 170

Vic

Victoria

Health Complaints Commissioner
Website: www.hcc.vic.gov.au
Phone: 1300 582 113

WA

Western Australia

WA Health and Disability Services Complaints Office
Website: www.hadsco.wa.gov.au
Phone: 1800 813 583

ACT

Australian Capital Territory

ACT Human Rights Commission
Website: www.hrc.act.gov.au/complaints 
Phone: 02 6205 2222

NSW

New South Wales

NSW Health Care Complaints Commission
Website: www.hccc.nsw.gov.au
Phone: 1800 043 159

NT

Northern Territory

Health and Community Services Complaints Commission
Website: www.hcscc.nt.gov.au
Phone: 1800 004 474 

Qld

Queensland

Office of the Health Ombudsman 
Website: www.oho.qld.gov.au
Phone: 133 646

SA

South Australia

Health and Community Services Complaints Commissioner
Website: www.hcscc.sa.gov.au
Phone: 1800 232 007

Tas

Tasmania

Health Complaints Commissioner Tasmania
Website: www.healthcomplaints.tas.gov.au
Phone: 1800 001 170

Vic

Victoria

Health Complaints Commissioner
Website: www.hcc.vic.gov.au
Phone: 1300 582 113

WA

Western Australia

WA Health and Disability Services Complaints Office
Website: www.hadsco.wa.gov.au
Phone: 1800 813 583