Glossary and Acronyms



Accreditation Public recognition of achievement by a health care organisation, of requirements of national health care standards.  The status obtained by an organisation after a successful third party external evaluation by a recognised body to assess whether an organisation meets applicable per-determined and published standards

ACHS The Australian Council on Healthcare Standards, Australia's leading independent, not-for-profit organisation dedicated to improving the quality and safety of health care through continual review of performance, assessment and accreditation

Certification ACHS' quality management program for newly established and other health care organisations that have not yet implemented a formal quality program

Clinical indicator A measure of the clinical management and outcome of care; a method of monitoring consumer / patient care and services which attempts to 'flag' problem areas, evaluate trends and so direct attention to issues requiring further review

Consumer / patient People who directly or indirectly make use of health services

Corporate governance  Understood to be the system by which organisations are directed, controlled and held to account

Credentialing The process of accessing and conferring approval on a person's suitability to provide a defined type of health care

Criteria The measurable key components of a standard; that are necessary for meeting the standard

EQuIP Evaluation and Quality Improvement Program, ACHS' framework to improve the quality and safety of health care

Evaluation Judging the value of something by gathering valid information about it in a systematic way and by making a comparison. The purpose of evaluation is to help the user of the evaluation to decide what to do, or to contribute to scientific knowledge

Inter-rater reliability Ensuring consistency between and within survey teams on ratings of the criteria within each standard

ISQua The International Society for Quality in Health Care, a not-for-profit, independent organisation with members in over 70 countries that works to provide services to guide health professionals, providers, researchers, agencies, policy makers and consumers, to achieve excellence in health care delivery, and to continuously improve the quality and safety of care

Member An organisation participating in an ACHS accreditation program

Policy A documented statement that formalises the approach to tasks and concepts which is consistent with organisational objectives

Procedure A set of documented instructions conveying the approved and recommended steps for a particular act or sequence of acts

Process A series of actions, changes / functions that bring about an end or a result

Quality  The extent to which the properties of a service or product produces a desired outcome

Risk Management The culture, processes and structures that are directed towards realising potential opportunities whilst managing adverse effects6

Safety Freedom from hazard

Standard Describes the overall goal; for example, high quality care for patients with desirable outcomes

Surveyor A health professional trained by ACHS to assess the performance of health care organisations against EQuIP standards




AC Advanced Completion

ACHS The Australian Council on Healthcare Standards

ACHSI ACHS International

ACSQHC The Australian Commission on Safety and Quality in Health Care

AHHA Australian Healthcare and Hospitals Association

ARC Australian Research Council

ART Assessment Recording Tool

AIHI Australian Institute of Health Innovation

AMA Australian Medical Association

APHA Australian Private Hospitals Association

CSM Customer Services Manager

DU ACHS Development Unit

EAT Electronic Assessment Tool

EQuIP Evaluation and Quality Improvement Program

EQuIP 4 the 4th edition of the ACHS Evaluation and Quality Improvement Program

EQuIP5 the 5th edition of the ACHS Evaluation and Quality Improvement Program

GA Gap Analysis

IAP International Accreditation Programme

ISQua The International Society for Quality in Health Care

NSQHSS National Safety and Quality Health Service Standards

OWS Organisation-Wide Survey

PIRT Performance Indicator Reporting Tool

POS Performance and Outcomes Service

PR Periodic Review

PSA Pre-Survey Assessment

QI Quality Improvement

QIC Quality Improvement Committee

QMT Quality Monitoring Tool

SAC State Advisory Committee

SAS Self-Assessment Survey

VMO Visiting Medical Officer

Last Review Date 18 April 2019

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