Consumers and accreditation

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 an assessment by an external agency to show they have implemented all of the requirements of the National Safety and 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 AHSSQA Scheme.

What is a health service organisation?

A health service organisation is a separately constituted health service that is responsible for implementing clinical governance, administration and financial management of a service unit or service units providing health care at the direction of the governing body. A service unit is one or more clinicians and members of the workforce that support care, working together to deliver health care to patients. Care can be provided in any location or setting any location or setting, including pharmacies, clinics, outpatient facilities, hospitals, patients’ homes, community settings, practices and clinicians’ rooms.

What can I expect from an accredited health service organisation?

When you, or someone you care for visits a health service organisation, such as a hospital or day procedure service, you expect to receive care that is safe. Accredited health service organisations have demonstrated through an independent review that an organisation has implemented the safety and quality systems necessary to comply with the NSQHS Standards and ensure safe care.

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 are in place that promote safe care. These systems help to ensure risks are identified, eliminated or managed.

How do health service organisations become accredited?

To become accredited, a health service organisation:

• Implements actions in the NSQHS Standards in their organisation
• Routinely conducts self-assessment process 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.

The following information are included on certificates awarded for any accreditation using the AHSSQA Scheme:

• Name of health service organisation.
• Facility unique identifier.
• List of each facility and health service covered by the award.
• For each listed facility or service, whether the applicable accreditation relates to announced or short notice assessment.
• For each listed facility or service, the relevant standards to which the accreditation relates.
• Date of commencement and expiration of the relevant accreditation cycle.
• Date accreditation is awarded.

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 has 60 business days to make improvements. 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. These sanctions may include administrative oversight by the regulator, loss of licences and/or loss of funding. Any health service organisation that does not achieve accreditation must undergo a reassessment to all eight NSQHS Standards 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 standards implementation and accreditation processes. 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 safety, quality and 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
• Speak to the Nursing Manager or lead clinician in your care
• 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 the Australian Health Practitioner Regulation Agency (AHPRA)
• 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: