What is accreditation?

Accreditation is an important way for members of the public to know that a healthcare provider has met certain safety and quality standards. At ACHS, we are authorised to assess government accreditation standards. ACHS also has a well-established set of standards which provide optional accreditation for specific types of healthcare organisations.

Five Key Elements

Accreditation systems comprise the following:

Accreditation systems comprise the following:
  • Governance or stewardship function
  • A standards-setting process
  • A process of external evaluation of compliance against those standards
  • A remediation or improvement process following the review
  • Promotion of continuous quality improvement.

Frequently asked questions about accreditation

What is accreditation?
It’s the status a healthcare organisation receives after a successful third party external evaluation by a recognised body. It indicates that the organisation has met relevant pre-determined and published standards.
Is accreditation similar to an audit?
No. While our accreditation does require an organisation to meet certain standards, it’s also about continuous improvement. Our accreditation isn’t about ticking the boxes and staying at the same level of performance. It’s about establishing a structure and processes that allow quality and safety to consistently improve over time.
Is accreditation to the NSQHS standards compulsory in Australia?
State and territory health departments determine which health service organisations must be assessed against the NSQHS Standards. All public and private hospitals, day procedure services and public dental practices are required to be accredited to the NSQHS Standards.
Is my organisation required to be assessed according to the NSQHS standards?
This depends on your organisation’s specific focus and nature of your offering. Requirements for accreditation are determined by the health departments that regulate health services in various jurisdictions. All hospitals, day procedure services and public dental clinics in Australia need to be accredited by NSQHS Standards. However, some states and territories have stipulated that additional healthcare providers also need to be assessed under the NSQHS. Contact your relevant health department if you have any specific enquiries regarding accreditation.

NSQHS Standards accreditation

ACHS is a Commission-approved accrediting agency for NSQHS standards:
-    ACHS National Safety and Quality Health Services (NSQHS) Standards program
-    ACHS National Safety and Quality Health Services (NSQHS) Standards Short Notice Assessment program.

Both programs meet the requirements of the Australian Health Services Safety and Quality Accreditation (AHSSQA) Scheme.

The ACHS NSQHS Standards Announced Assessment Program is a three-year membership consisting of one onsite assessment of all eight NSQHS Standards. The scheduling of the assessment is done in consultation with the health services but must occur once in a three-year cycle and at least four months prior to the accreditation date.

The ACHS NSQHS Standards Short Notice Assessment Program is a three-year membership consisting of three onsite assessments of 3-4 standards each assessment, with at least two standards being assessed twice during the three-year cycle. Health services are given 48 hours’ notice of the assessment.
Where can I get a copy of the NSQHS standards?
The standards are available from the Commission’s website here
Is ACHS independent and how is it funded?
The ACHS is an independent, not-for-profit organisation.

Since 1974, we have been developing standards for healthcare organisations, in partnership with government and other industry stakeholders. Today, our standards are used around the world. Our Council includes peak bodies in health, representatives of government and consumers. We are governed by a board of directors which is elected by Council and Board appointed and supported by a corporate management structure. We are also advised by a team of assessors with recent professional healthcare experience.

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.
What is the purpose of accreditation?
Accreditation has several benefits. Importantly, it offers peace of mind to people who are choosing a healthcare provider; a way of knowing that the provider has met the very latest industry standards and is therefore likely to provide a high quality of care.

Accreditation also helps minimise risk and improve outcomes in the healthcare sector by setting standards that organisations can aspire to. Becoming accredited is a great way for an organisation to focus on improving its overall performance.
How can I learn about an organisation’s accreditation performance?
Relevant and appropriate information from accredited assessments is generally made publicly available by the healthcare organisation.
Who should correct poor performance?
Accreditation programs provide information that helps an organisation identify and improve performance. However, it’s up to the organisation itself to put a structure in place to monitor and improve its health and safety.

Ready to take the next step?

If you’re interested in finding out more about ACHS or our accreditation programs and membership, you can: