Accreditation guideline

Guideline number: QH-HSDGDL-032-5:2022

Effective date: 31 January 2024

Review date: 31 January 2027

Supersedes: Version 1.3

On this page:

  1. Purpose
  2. Scope
  3. Accreditation requirements
  4. Responsive regulatory process
  5. Supporting and related documents
  6. Definitions of terms
  7. Approval and implementation
  8. Version control

1. Purpose

This guideline describes the mandatory accreditation requirements outlined within the Patient Safety Health Service Directive.

2. Scope

This guideline applies to all Hospital and Health Services (HHSs).

3. Accreditation requirements

3.1 Hospitals, day procedure services and health care centres

  • All Queensland Health hospitals are required to maintain accreditation against the National Safety and Quality Health Service (NSQHS) Standards.
  • All Queensland Health Multi-Purpose Health Services (MPHS) are required to maintain accreditation against the National Safety and Quality Health Service (NSQHS) Standards and Multi-Purpose Services Aged Care module.
  • All Queensland Health owned and operated primary and community-based facilities, are required to maintain accreditation against either the NSQHS Standards or National Safety and Quality Primary and Community Healthcare (NSQPCH) Standards.
  • HHSs are required to select an accrediting agency that is approved by the Australian Commission on Safety and Quality in Health Care (ACSQHC). A list of the approved agencies can be located on their website located here.
  • If the facility does not meet the standards accreditation requirements, the HHS has 60 business days from the initial assessment, to address any actions that requires remediation.
  • Following assessment, the HHS must provide to the Executive Director, Patient Safety and Quality, Clinical Excellence Queensland:
    1. immediate advice if a significant patient risk (one where there is a high probability of a substantial and demonstrable adverse impact for patients) is identified during an onsite visit, also identifying the plan of action and timeframe to remedy the issue, as negotiated between the assessors and/or the respective accrediting agency and the HHS.
    2. a copy of any initial assessment report within two days of receipt by the HHS,
    3. notification if mandatory reassessment is required.
    4. a copy of the final assessment report within seven days of receipt by the HHS
    5. immediate advice should any action be rated ‘not-met’ by the accrediting agency following the final assessment of an accreditation event, resulting in the facility or service not being accredited. In this instance a responsive regulatory process may be enacted under section 4.
  • The following ACSQHC Standards/Module are optional for Queensland Health owned and managed public hospitals, MPHS, and primary/community health care centers:
  • The following ACSQHC Standards are not applicable to Queensland public hospitals, day procedure services and health care centers (howsoever titled):

3.2 Newly established sub-acute or low care service (e.g. satellite hospitals, walk-in clinics).

  • Accreditation requirements for a newly established sub-acute or low care service are required to be endorsed by the peak HHS Clinical Governance Executive Committee and made in consultation with the Hospital and Health Board.
  • Self-assessment by the HHS
    • Prior to commencement of new services, an internal self-assessment by the HHS is required to be conducted against either the NSQHS Standards or the NSQPCH Standards; and an action plan developed to address improvements.
  • Assessment by an accrediting agency
    • If the HHS facility/service is an extension of an existing model in the HHS, and operating under the same governance structure and uses the same safety and quality systems; the facility/service can be assessed along with its membership hub at the next accreditation assessment.
    • If the new HHS facility/service is not an extension of an existing model in the HHS, does not operate under the same governance structure or use the same safety and quality systems; assessment against either the NSQHS Standards or NSQPCH Standards is required.
    • If assessed against the NSQHS Standards, interim assessment is required to be conducted within three (3) months of the start of clinical services. Full assessment is to be finalised within 18 months from the commencement of services.
    • If assessed against the NSQPCH Standards, full assessment is required to be conducted within three (3) months of the start of clinical services. Subsequent assessments can be aligned with other services in the HHS.
  • Reporting obligations to the Executive Director, Patient Safety and Quality, Clinical Excellence Queensland are outlined in Section 3.1.

3.3 General practices

  • General practices owned or managed by the HHS must maintain accreditation against the Royal Australian College of General Practitioners (RACGP) Standards; under the National General Practice Accreditation (NGPA) Scheme.
  • The HHS is required to select their accrediting agency from the list of approved providers published by the ACSQHC.
  • Following assessment, the HHS must provide to the Executive Director, Patient Safety and Quality, Clinical Excellence Queensland:
    1. immediate advice if a significant patient risk (one where there is a high probability of a substantial and demonstrable adverse impact for patients) is identified during an onsite visit, also identifying the plan of action and timeframe to remedy the issue as negotiated between the assessors and/or the respective accrediting agency and the HHS,
    2. copy of any ‘not-met’ assessment report within two days of receipt by the HHS,a copy of the final assessment report within seven days of receipt by the HHS; and
    3. immediate advice should any action be rated ‘not-met’ by the accrediting agency following the final assessment of an accreditation event, resulting in the facility or service not being accredited. In this instance a responsive regulatory process may be enacted under section 4 (see below).

3.4 Residential aged care facilities

  • Residential aged care facilities, owned and managed by the HHS, must maintain accreditation against the Aged Care Quality Standards in accordance with the requirements of the Aged Care Quality and Safety Commission (ACQSC).
  • Following assessment against the Aged Care Quality Standards, the HHS must provide to the Executive Director, Strategic Policy and Legislation Branch.
    1. a copy of any ‘not-met’ report within two days of receipt of the report by the HHS, including reports against the Aged Care Module of the NSQHS Standards.
    2. the accreditation report within seven days of receipt of the report by the HHS, including reports against the Aged Care Module of the NSQHS; and
    3. immediate advice should any action be rated ‘not met’ by the accrediting agency following the final assessment of an accreditation event, resulting in the facility or service not being accredited.

3.5 Breast screen

  • BreastScreen Queensland managed by the HHS must maintain accreditation and deliver screening and assessment services in accordance with the BreastScreen Australia National Accreditation Standards.

3.6 Non-government organisations (NGO) funded by Queensland Health for delivery of specified service types

  • HHSs contracting a NGO vendor to provide healthcare, must ensure the vendor has progressed accreditation according to the requirements of the QH Patient Safety Health Service Directive and Accreditation Guideline.

    For contracted mental health services:

    • Mental health (psychosocial) – assessment under the National Standards for Mental Health Services or Human Services Quality Standards (inclusive of mental health services) or National Safety and Quality Health Service Standards
    • Mental health (clinical and psychosocial) – National Safety and Quality Health Service Standards, and
    • Youth mental health services – National Standards for Mental Health Services or National Safety and Quality Health Service Standards.

    The NGO vendor must provide the outcomes of the accreditation assessments to the HHS for consideration as specified in the contract for healthcare services.

4. Responsive regulatory process

  • A responsive regulatory process is utilised in the following circumstances:
    1. where a significant patient risk is identified by a certified accrediting agency during an accreditation process; and/or
    2. where an HHS has failed to address ‘not met’ actions of the specified standards within required timeframes.
  • An initial regulatory response will begin with a process of verifying the scope, scale and implications of the reported issues, a review of documentation, and may include one or more site visits by nominated specialty experts.
  • The regulatory process may include one or a combination of the following actions:
    1. Seek further information from the HHS.
    2. Request a progress report for the implementation of an action plan.
    3. Escalate non-compliance and/or risk to the Performance Review Meeting.
    4. Provide advice, information on options or strategies that could be used to address the non-met actions within a designated time frame.
    5. Connect the hospital to other hospitals that have addressed similar deficits or have exemplar practice in this area.
  • In the case of serious or persistent non-compliance and where required action is not taken by the HHS the response may be escalated. The Department may undertake one or a combination of the following actions:
    1. Restrict specified practices/activities in areas/units or services of the HHS where the specified standards have not been met.
    2. Suspend particular services at the HHS until the area/s of concern are resolved.
    3. Suspend all service delivery at a facility within an HHS for a period of time.

5. Supporting and related documents

6. Definition of terms

Term Definition / explanation / detailsSource
Action rated ‘not-met’ Part or all of the requirements of the action were not met; improvements were required. ACSQHC
Action rated ‘met with recommendation” The requirements of an action were largely met across the organisation, with the exception of a minor part of the action in a specific service. ACSQHC

7. Approval and implementation

Guideline custodian
Executive Director, Patient Safety and Quality, Clinical Excellence Queensland.

Approving officer
Deputy Director General, Clinical Excellence Queensland, Department of Health.
Approval date: 31 January 2024
Effective from: 31 January 2024

8. Version control

VersionDateComments
1.0 21 Dec 2022 New guideline
1.1 31 January 2024

Clarification of accreditation requirements for Satellite hospitals and NGO related contracts. Minor edits relating to changes made by ACSQHC.

1.217 April 2024Clarification in relation to accreditation against other Standards and Modules developed by the ACSQHC.
1.329 November 2024

Clarification of accreditation requirements for primary/community facilities (including newly established sub-acute and low care facilities)

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Last updated: 30 January 2024