Accreditation guideline

Guideline number: QH-HSDGDL-032-5

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, health care centres and multi-purpose health services

Hospitals, day procedure services and health care centres:

• All Queensland Health hospitals and day procedure services are required to maintain accreditation against the National Safety and Quality Health Service (NSQHS) Standards.
• All Queensland Health owned and operated primary and community-based health care centres, 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 require remediation.
• Following assessment, the HHS must provide to the Executive Director, Patient Safety and Quality, Clinical Excellence Queensland:
  1. Notification of a significant patient risk (one where there is a high probability of a substantial and demonstrable adverse impact for patients) if this 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 as ‘not-met’ by the accrediting agency following the final assessment resulting in the facility or service not being accredited. In this instance a responsive regulatory process may be enacted under section 4.

Multi-purpose health services:

• All Queensland Health Multi-Purpose Health Services (MPHS) are required to maintain accreditation against the National Safety and Quality Health Service (NSQHS) Standards and the Integrated Health and Aged Care Services Module.
• The Australian Commission on Safety and Quality in Health Care (ACSQHC) supports streamlined accreditation arrangements for services that are required to meet both the NSQHS Standards and the Aged Care Quality Standards (ACQS).  Section 109-10 of the Aged Care Rules 2025 set out the circumstances for which a stream-lined health service standards assessment is allowed.
• HHSs with MPHS’s delivering Commonwealth-funded aged care services must also be registered as a provider with the Aged Care Quality and Safety Commission (ACQSC). Residential aged care homes, including those that are part of MPHS’s must be approved by the ACQSC.
• Following assessment where the facility assessed is registered with the ACQSC the HHS must provide to the Executive Director, System Policy Branch, System Policy and Planning Division:
  1. A copy of the final assessment report within seven days of receipt by the HHS
  2. 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.

Other ACSQHC Standards /Modules:

• The following ACSQHC Standards/Modules are optional for Queensland Health owned and managed public hospitals, MPHS, and primary/community health care centres:
  • Environmental Sustainability and Climate Resilience Healthcare Module
  • National Safety and Quality Digital Mental Health Standards

• The following ACSQHC Standards are not applicable to Queensland Health public hospitals, day procedure services and health care centres (howsoever titled):
  • National Safety and Quality Cosmetic Surgery Standards
  • National Safety and Quality Mental Health Standards for Community Managed Organisations

3.2 a. Out of Cycle Assessments

• Organisations undergoing change may present an increase in risk of harm to patients. When this occurs a review of compliance with the standards may be warranted.  Some situations that may be considered material change are as follows:
  • Changes or prolonged gaps in key leadership or executive positions across a number of positions
  • Significant increase in complexity of the scope of service provision
  • Relocation of the health service organisation to new facilities
  • Merger of one or more health service organisations

• 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.

• Requests for an out of cycle assessment will be considered by the Australian Commission on Safety and Quality in Health Care on a case-by-case basis with input from the Regulator.
• Further decision support resources may be accessed here.

b. Newly established sub-acute or low care service (e.g. Satellite Health Centres, 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
  • Further decision support resources may be accessed here.
  • 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.

3.2 c. Newly established public hospitals – new facility only (not applicable if a change of name or address)

• A newly established public hospital is one where a Hospital Declaration Process – Public Hospital is required, including the allocation of a unique facility code occurs within the Corporate Reference Data System CRDS.
• Hospitals seeking to be declared as a public hospital will be required to provide details of accreditation.  Either as currently accredited (interim or full certificate) or in the process of obtaining accreditation, either scheduled or being negotiated
• Accreditation requirements for a newly established service are required to be endorsed by the peak HHS Clinical Governance Executive Committee and made in consultation with the Hospital and Health Board and in collaboration with the Regulator

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 homes, home support and transition care programs

• The Aged Care Act 2024 (Commonwealth) and Aged Care Rules 2025 prescribe conditions that apply to registered providers. All registered providers must meet universal conditions covering quality and safety standards, the Statement of Rights, workforce screening and suitability checks, continuous improvement, timely service changes and compliance with any additional requirements set out in the Aged Care Rules 2025.
• Residential aged care homes must be approved by the ACQSC. The ACQSC will specify the maximum number of residential care places the provider is authorised to operate at that location.
• HHSs, as registered providers, must comply with the Strengthened Aged Care Quality Standards (Strengthened Standards) that apply to the registration categories, as well as all relevant provider obligations and conditions.  HHSs will have their registration audited at the organisation level, rather than at the service level.
• HHSs that deliver government-funded aged care services under the Aged Care Act 2024 (Cth) must be registered in all relevant registration categories with the Aged Care Quality and Safety Commission:
  • Category 1 – Home and community services
  • Category 2 – Assistive technology and home modifications
  • Category 3 – Advisory and support services
  • Category 4 – Personal care and care support in the home or community (including respite)
  • Category 5 – Nursing and transition care
  • Category 6 – Residential care (including respite)

Transition Care Program

• From 1 November 2025, the ACQSC will have legal authority to review and monitor registered providers providing Transition Care Program (TCP) services against all applicable requirements under the Act and the Rules (which include the Strengthened Standards). This includes providers who deliver services under TCP and who also deliver health services.
• The ACQSC will conduct quality audits to assess whether registered providers are delivering TCP in accordance with the Strengthened Standards.
• HHSs providing TCP services in a standalone residential aged care home or in a home and community setting will be required to have their provider registration audited against the Strengthened Standards by the ACQSC.
• HHSs delivering both residential TCP services and health services from an approved residential care home in rural and remote areas (Modified Monash Model (MMM) 3-7) who are already accredited under the Australian Health Services Safety and Quality Accreditation Scheme to the NSQHS Standards will be able to use the Integrated Health and Aged Care Services (IHACS) Module to meet their aged care quality requirements.
• All other residential TCP services (i.e., those delivered in a standalone residential aged care home (not an MPHS) or those located in a metropolitan or regional area (MMM 1-2), will be required to have their provider registration audited against the Strengthened Standards by the ACQSC. Those specific services have been advised of their compliance obligations as communicated to them by the Executive Director System Policy Branch.
• In regard to the provider registration renewal process, including audit and graded assessment against the strengthened Standards, the HHS must provide to the Executive Director, System Policy Branch, System Policy and Planning Division:
  1. advice that an invitation to renew registration has been received from ACQSC, within seven days of receipt of the invitation by the HHS.
  2. a copy of the Notice of Decision within seven days of receipt of the report by the HHS, if a grade of either minor non-conformance, conformance, or exceeding is received for each strengthened Standard.
  3. a copy of the Notice of Decision within two days of receipt of the report by the HHS, if a grade of major non-conformance is received for any strengthened Standard.
  4. immediate advice if the ACQSC varies, revokes or suspends the HHSs registration under the Aged Care Act 2024 (Cth).

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 an NGO vendor to provide healthcare must specify alignment with the related accreditation types defined in the NGO Quality Requirements Framework and ensure that the vendor has progressed accreditation against the relevant standards according to the requirements of this Guideline.
• The NGO vendor must provide the outcomes of the accreditation assessment to the HHS to demonstrate meeting compliance as specified in the contract for healthcare service provision.

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.

• The ACQSC may prescribe additional conditions to a provider’s registration if it is necessary to manage any risks. It is also noted that registered providers must also meet specific conditions related to their registration category/ies.

• 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

• Hospital and Health Boards Act 2011 (Qld)
• Hospital and Health Boards Regulation 2012 (Qld)
• Australian Health Service Safety and Quality Accreditation Scheme
• Aged Care Act 2024 (Cth)
• Aged Care Rules 2025 (Cth)
• Australian Commission on Safety and Quality in Health Care
• Aged Care Quality and Safety Commission
• National Safety and Quality Health Service Standards
• NSQHS Standards Aged care module
• RACGP Standards 5th edition
• Aged Care Quality Standards
• Strengthened Quality Standards
• BreastScreen Australia National Accreditation Standards
• Transition Care Program Guidelines

6. Definition of terms

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

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