The Australian Council on Healthcare Standards

A set of Frequently Asked Questions regarding the National Safety and Quality Health Service Standards program has been created to assist ACHS members, and those interested in changing to ACHS programs.

For further information regarding the Australian Commission on Safety and Quality in Health Care and resources to assist you with implementing the NSQHS Standards, visit their website at www.safetyandquality.gov.au.

The following brochure provides additional information on the NSQHS Standards.

  • 1. What is Accreditation?

    Accreditation is the status obtained by an organisation after a successful third party external evaluation by a recognised body to assess whether an organisation meets applicable pre-determined and published standards.

  • 2. Is the ACHS accreditation process similar to an audit?

    No. The focus of ACHS accreditation programs is to provide a framework for continuous improvement. ACHS accreditation is not quality assurance, or ticking the boxes and staying at the same level of performance. It is about establishing a structure and processes that allow quality and safety to consistently improve over time.

  • 3. Is accreditation compulsory in Australia?

    Internationally and nationally, governments and funders are increasingly seeking objective evidence of continuous improvement, responsiveness to patients and quality health outcomes in a nation's health facilities. Globally there is an increased reliance by the public sector on the results of voluntary and regulated accreditation activities. While in the private sector many insurance funds are designating selected service providers on the basis of accreditation status. There is also an increasing demand for accountability of health services for the quality of care they provide.

  • 4. Is it compulsory to collect clinical indicators?

    Not from the perspective of the ACHS. The ACHS clinical indicator program is voluntary. However, to meet the standards of the ACHS accreditation program (EQuIP) an organisation is required to collect and evaluate relevant clinical indicators. This may be done through sets of indicators other than those established by the ACHS. For example some individual state health departments mandate the collection and submission of specific indicators. The benefit of collecting ACHS indicators is the ability to compare with peers and the national rate through six-monthly reporting arrangements.

  • 5. How is the ACHS funded?

    The ACHS is an independent, not-for-profit organisation. The vast majority of our funding is from our membership base. We also sometimes receive funding from government organisations and other industry bodies, linked to individual projects.

  • 1. Is my organisation required to be assessed against the NSQHS Standards?

    Two key factors must be considered when answering this question. 1.The Australian Commission on Safety and Quality in Health Care (the Commission) has stated that “The National Safety and Quality Health Service (NSQHS) Standards are considered essential to improving the safety and quality of care for patients.” Under the new arrangements, health services such as hospitals, day procedure services and public dental clinics will be required to be accredited to the NSQHS Standards. Other health services may choose to use the NSQHS Standards as part of their internal quality systems. Accreditation to the NSQHS Standards commenced 1 January 2013 in line with individual health organisation’s current accreditation cycles. (reference: http://www.safetyandquality.gov.au/our-work/accreditation/ 2. Accreditation requirements rest with the Health Departments that regulate health services in various jurisdictions. It has been agreed that all (public and private) hospitals and day procedure services and public dental clinics will need to be accredited to the NSQHS Standards. However, some States and Territories have determined that additional services will also be required to be assessed to the NSQHS Standards. You should contact your relevant Health Department if you have any queries on specific health service accreditation requirements.

  • 2. Do dental practices have to be assessed to the NSQHS Standards?

    Public dental clinics are required to be accredited to the NSQHS Standards. Other dental practices will be encouraged to participate in accreditation to the NSQHS Standards on a voluntary basis for the first time. For private practitioners, the process will be established as a self-regulated scheme driven by the industry through the Australian Dental Association Inc (ADA). Dental practices participating in accreditation will need to work with an approved accrediting agency of their choice to demonstrate that they met the NSQHS Standards. The Commission is developing a range of resources to assist dental practices with implementing the NSQHS Standards and these can be accessed at the following link: http://www.safetyandquality.gov.au

  • 3. My organisation is required to be accredited to the NSQHS Standards – what are my options?

    Organisations that are required to be accredited to the NSQHS Standards can choose from two ACHS products: 1. The ACHS National Safety and Quality Health Services (NSQHS) Standards program, 2. The ACHS EQuIPNational program (EQuIP5 + National Standards) which addresses the additional areas of EQuIP5 but has had all the existing duplication between EQuIP5 and the National Standards removed. More details on these programs are contained below in the relevant sections.

  • 4. What program does the ACHS recommend I do?

    The ACHS is proud to recommend our EQuIPNational product as this comprehensive program covers both the NSQHS Standards and other areas that are of key importance in the delivery of health care services and addressing the risks associated with the management of health care services. The EQuIPNational program complements the NSQHS Standards by reviewing the “support” and “corporate” aspects of healthcare delivery in addition to the NSQHS Standards. An organisation which undertakes the EQuIPNational program will have a wide ranging program that will stand them in good stead and will cover additional jurisdictional/regulatory requirements. ACHS can give advice on all its program options through its Customer Services Managers (CSMs), and will pass on any knowledge regarding State and Territory requirements, as that is declared. As ACHS is not a regulatory body, ACHS recommends that member organisations contact their relevant State or Territory regulatory bodies to confirm exact accreditation requirements.

  • 5. Can ACHS accredit health services to the NSQHS Standards?

    Yes, the ACHS is an approved accrediting agency. This means the Commission has approved ACHS to assess health services to the NSQHS Standards. The ACHS offers two ways to become accredited to the NSQHS Standards – either through the ACHS NSQHS Standards program, or through the EQuIPNational program. Both of these programs offer an organisation accreditation to the NSQHS Standards.

  • 6. What is the length of each program membership?

    The ACHS NSQHS Standards program is a three year membership program. EQuIPNational is a four year membership program.

  • 7. What happens to recommendations from previous EQuIP surveys?

    ACHS will transfer those recommendations that map to the NSQHS Standards to be reviewed at the NSQHS Standards survey.

  • 8. Where can I get a copy of the Commission’s NSQHS Standards?

    Copies of the National Safety and Quality Health Service (NSQHS) Standards are available from the Commission’s website and can be downloaded from: http://www.safetyandquality.gov.au/publications/national-safety-and-quality-health-service-standards/

  • 9. Is there a guide for the Commission’s NSQHS Standards?

    The Commission has developed a range of resources to assist health services implement the NSQHS Standards. These include: Safety & Quality Improvement Guides for each NSQHS Standard and Accreditation Workbooks. These are available from the Commission’s website at http://www.safetyandquality.gov.au

  • 10. Is the ACHS producing a mapping document between the NSQHS Standards and EQuIP?

    No, the Commission requires that the NSQHS Standards must be used in their original format and must not be adapted or replicated in any other format.

  • 11. Do I need to complete a self-assessment to the NSQHS Standards?

    The ACHS NSQHS Standards program requires that organisations undertake a self-assessment and provide evidence of their achievement to the Standard level. In addition the organisation will complete an action plan against any ‘not met’ actions.

  • 12. Can I still get help from my ACHS Customer Services Manager?

    Yes. All ACHS member organisations are entitled to assistance from a dedicated Customer Services Manager (CSM) who can support you.

  • 13. What would the ACHS recommend I do now to start the first steps towards meeting the new NSQHS Standards?

    The ACHS recommends that you become familiar with the NSQHS Standards and utilise the Safety & Quality Improvement Guides and Accreditation Workbooks to conduct a gap analysis for your organisation. The more familiar you are with the NSQHS Standards the easier you will find it is to understand and demonstrate evidence against them. We would also recommend that you become familiar with the Commission’s website at www.safetyandquality.gov.au as they not only produce the NSQHS Standards but have an extensive range of other resources and tools to assist you. You can contact your CSM if there is further, specific information you require, if it has not already been covered here.

  • 14. Does ACHS plan to have an online tool for both EQuIPNational and the new NSQHS Standards?

    Yes. The ACHS has developed a new online tool for our members, the Assessment Recording Tool (ART).

I have been involved with Accreditation and the ACHS for 19 years and have found them to be a leading accrediting agency, if not the best for health care organisations.

ACHS member response to survey