Assessment to the National Safety and Quality Primary and Community Healthcare Standards

The Accreditation cycle flow chart for the Primary and Community Healthcare Standards provides an overview of the accreditation processes, including assessment timeframes and reporting requirements.

Accreditation cycle flow chart for the National Safety and Quality Primary and Community Healthcare Standards

2026

Other resource

Healthcare services generally have the flexibility to select one of four assessment models that aligns with their readiness. This approach accommodates different levels of preparedness and engagement across the sector.

For more information, refer to Primary and Community Healthcare Standards assessment models.

Assessment models of the National Safety and Quality Primary and Community Healthcare Standards

2026

Fact sheet

Healthcare services may be eligible for sampling if they:

• have 10 or more sites
• are being assessed using models 2, 3 or 4.

For more information, refer to Advisory PCHS26/01: Sampling for assessments to the National Safety and Quality Primary and Community Healthcare Standards.

During the course of conducting an assessment, assessors may identify a significant risk. A ‘significant risk’ is one where there is a high or an extreme probability of a substantial and demonstrable serious adverse impact for patients who access care from the healthcare service. 

Clarification of the significant risk management processes is provided to ensure accrediting agencies, assessors, and healthcare services comply with risk mitigation and reporting requirements. For more information, refer to Advisory PCHS26/03: Notification of significant risk for the National safety and Quality Primary and Community Healthcare Standards.

A healthcare service may wish to request additional time for remediation and/or extension of the accreditation expiry date when it experiences significant delays in the assessment process due to extenuating circumstance(s). 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.

For more information, refer to Advisory PCHS26/04: Requests for extensions and appeals for the National Safety and Quality Primary and Community Healthcare Standards.

From time to time, healthcare services may wish to change the accrediting agency they have engaged to conduct accreditation assessments. Healthcare services can transfer between accrediting agencies during a two- or three-year accreditation cycle.

For more information, refer to Advisory PCHS26/05: Transitioning between accrediting agencies for the National Safety and Quality Primary and Community Healthcare Standards.

Healthcare services accredited to the Primary and Community Healthcare Standards must be assessed at least every two to three years to maintain accreditation. During this cycle, healthcare services may undergo changes for various reasons, such as ownership transitions, relocation or the introduction of new services. Some changes can significantly increase the risk of patient harm, in which case a review of compliance with the Primary and Community Healthcare Standards may be necessary. Healthcare services may require an out-of-cycle assessment to maintain accreditation.

For more information, refer to Guidance on out-of-cycle assessments for primary and community healthcare services.

Guidance on out-of-cycle assessments for primary and community healthcare services

2026

Fact sheet

Accrediting agencies are required to provide formal documentation to healthcare services as part of the accreditation assessment process. These include:

• Accreditation report
• Accreditation certificate (if a healthcare service is deemed to have met all requirements of the specified standard)
• Testimonial.

The accrediting agency must include the following information in a testimonial that is to accompany the certificate of accreditation:

• Healthcare service name
• List of each facility and health service address 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, and any parts of the relevant standards excluded from the assessment as not applicable or not assessed
• Date of commencement and expiration of the relevant accreditation cycle.
• Date accreditation is awarded.

Exemplar practices are real-world examples of healthcare services that demonstrate best practice in the implementation of the Primary and Community Healthcare Standards. These services have safety and quality systems that are substantially higher than the general rating of ‘met’ for relevant standards or actions being assessed.

Approved accrediting agencies will be able to nominate healthcare services that have been awarded accreditation with all relevant actions rated as ‘met’ and are implementing an initiative that meets specified criteria. Initiatives considered as exemplars are:

• Designed to address a significant safety and quality issue
• Evidence-based or use best practice
• Patient-centred
• Clearly communicated to all relevant parties
• Embedded into day-to-day practice
• Regularly measured
• Sustainable
• Being appropriately evaluated
• Improving patient outcomes in the safety and quality of care delivered.

Submissions will be reviewed by the industry-based accreditation coordinating committee against specified criteria. Healthcare services that are formally recognised as exemplars will be issued with a certificate and have their case study published on the Commission’s website. This is intended to facilitate the identification and sharing of information on safe and good quality practice.