Background on Accreditation

To provide more information on the direction and principles which underpin the work of the ACHS, we have published some answers to frequently asked questions:

1.  What is the purpose of an accreditation program?

2.  Accreditation and regulation - different but linked

3.  Accreditation agencies - we explain the case for independence

4.  Is the ACHS independent?

5.  How are the Standards developed?

6.  Why should standards be developed for clinical services?

7.  How is performance information disclosed?

8.  Who should correct poor performance?


1.   The purpose of an accreditation program 

The purpose of the ACHS accreditation program is to guide the performance of organisations to deliver safe, high quality health care. 

This ACHS program is based on standards and processes developed by health care professionals for health services[1].  For a full description of ACHS Programs and Services please click here.

The granting of accreditation is the result of an independent, peer review of performance against those standards. 


  • Participating in an accreditation program or achieving accreditation status cannot be seen to provide an absolute guarantee of safety, as it has to be understood there are too many variables.

  • Accreditation can, and should be a positive indication that a culture of safety exists in an organisation.

  • Accreditation supports and facilitates the minimisation of risk.

  • Accreditation results may be used by those responsible for operational management to assist in monitoring and improving performance. 

How does the ACHS program operate?

ACHS accreditation recognises a comprehensive framework for measurement and improvement rather than being just a specific compliance audit.

[1]The Australian Council on Healthcare Standards (ACHS) The ACHS EQuIP5, Book 1 - Accreditation, Standards and Guidelines, Clinical Function, 2010, p.6 

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2.   Accreditation and regulation - different but linked 

The influence of the accreditation program should extend to all parts of an organisation and provide an overarching framework to improve care. Government regulation generally has a more limited and specific focus. 


  • A quality framework incorporates governance, service delivery, financial and administrative functions.

  • Accreditation programs can adapt to changing expectations very quickly, whereas regulation may be slow to adapt to new developments.

  • While regulation generally set minimum standards, accreditation provides an adaptable framework which outlines structures and processes to meet both regulatory requirements and local needs.

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3.   Accreditation agencies - the case for independence 

To realise the benefits of third-party review, accreditation agencies should be independent (from service providers) and transparent in their operations.

Accreditation agencies should also be accountable for their performance especially in relation to the rigour and reliability of their programs.


  • Independence ensures freedom from influence on the results of performance assessments.

  • Independence of the accrediting body (from the service provider) can enhance consumer respect for accreditation.

  • The industry is arguably more responsive to an independent accreditation program that transcends jurisdictional boundaries.

  • An independent national body is also able to bring perspectives from beyond jurisdictional boundaries.

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4.    Is the ACHS independent?

The ACHS is an independent, not-for-profit organisation, and celebrated its 40th anniversary in 2014.

Standards for evaluation, assessment and accreditation are determined by a Committee whose members are drawn from peak bodies in health, representatives of government and consumers.

ACHS is governed by a Board of directors elected by Council members and supported by a corporate management structure.

The ACHS surveyors (professionals with recent health care experience) provide a recommendation on accreditation status which is acknowledged by the CEO. Depending on the type of survey, and its outcomes, there may be a need for a vote from Councillors if an Advanced Completion (AC) has been identified.

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5.   Standards and their development

The most important issue is how standards are developed (as opposed to who develops standards).  For standards to be useful[1] they must:

1.       Address a recognised need

2.       Be evidence based (as far as practicable)

3.       Be developed through a transparent and consultative process

4.       Be outcome focused

5.       Be achievable

6.       Be measurable

Furthermore, they must be relevant, understandable and beneficial.

The ACHS recognises and supports that governments, as major funders and/or providers of services, should have a role in the development of standards.

[1] Adapted from The International Society for Quality in Health Care (ISQua), (Guidelines and Principles for the Development of Health and Social Care Standards), Fourth Edition, Version 1.0, Sept. 2013. 

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6.   Standards for clinical services

Standards for clinical services should be developed:

  • when there is a demonstrable need (such as to ensure best practice),

  • where evidence exists to support its adoption (where possible), and

  • with thorough clinical, consumer and industry consultation. 


  • Standards for specific clinical care models need to integrate into a broader organisation wide quality framework.

  • Clinician input is integral to the development of any clinical service standards.

  • All standards need to be regularly reviewed and revised to reflect growth in knowledge and expectations.  The costs and logistical requirements need to be taken into account.

  • For clinical service standards to be effective, resources to meet those standards must be provided.

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7.   Disclosure of performance information 

Appropriate information resulting from accreditation surveys should be publicly available. 


Accreditation programs were originally designed for use within a health care organisation.  However, over time consumers, health funds and corporate owners have sought increasing levels of performance related information.

How does the ACHS program operate?

In the interests of transparency the ACHS ensures a focus on providing information on accreditation performance through the biennial publication of a National Report on Health Services Accreditation Performance.  

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8.   Correcting poor performance 

It is the role of the health care organisation to have a structure in place to monitor and correct poor performance. Accreditation programs provide information that facilitates the identification and/or correction of poor performance.


  • Accreditation agencies can play a part in correcting poor performance if requested, although this is not part of the accreditation process.

  • It is important that the provision of consultancy services is clearly and transparently separated from the assessment of performance.

  • Correction of poor performance, whilst usually simple, can be complex and have significant cost, service delivery and political implications.  It is not appropriate for an accreditation agency to carry this responsibility.

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Last Review Date 12 January 2018

Overall the service provided is of a high standard and staff and surveyors are all very helpful and friendly.

ACHS member response to survey