Department of Health

Registration, accreditation and governance of community health centres

Community health centres must follow these performance and accreditation standards.

The Health Services Act 1988External Link provides a framework for community health centre (CHC) governance and accountability. The framework includes a voluntary registration scheme and performance standards.

Registration

CHC's that are not part of a health service register with the department to receive funding for community and dental health programs.

CHCs can apply to register.

In line with the Health Services Act 1988, the department maintains a register of CHCs. The register records:

  • the name of each registered CHC
  • the address of each registered CHC
  • contact information for each registered CHC
  • names and contact details of board members.

Currently, there are 24 CHCs that are registered to receive community health and dental funding from the department.

They are subject to ongoing performance monitoring under the legislation and their funding and service agreement with the department.

Registered CHCs operate as companies limited by guarantee. The Australian Securities and Investments CommissionExternal Link website explains ASIC requirements for such companies.

Changes to governance

Each registered CHC is required to notify the department within 30 days every time a significant change occurs to their organisation’s governance, management or core operating policies; for example:

  • significant changes to the constitution and legal status of the registered CHC, such as changes to the company's objects or the number, type and pecuniary interests of directors
  • major changes to the service profile of the registered CHC that would impact on performance targets
  • any events that were reported to the registered CHC's insurer
  • borrowings, including finance leases and bank overdrafts of 8 per cent of total departmental funding or $500k, whichever is lower
  • changes to financial viability or risk management processes
  • changes in the accreditation status of the registered CHC.

Compliance against performance standards is monitored through an annual attestation from registered CHCs.

From 1 July 2023, CHCs that hold organisation wide accreditation against either the National Safety and Quality Health Service Standards, or the National Safety and Quality Primary and Community Healthcare Standards, and have met all service agreement financial accountability requirements, will be able to provide evidence of their accreditation status in lieu of completing the annual attestation.

Accreditation and standards

Accreditation is an important part of the regulatory framework for community health services. Accreditation provides assurance to government and the community that systems are present to protect the public from harm and ensure the quality of services provided.

Accreditation requirements

Accreditation is a condition of registration as a Community Health Centre under the Health Services Act (1988), and a Community Health Program funding requirement.

Community health services must be accredited by a body or entity certified by the International Society for Quality in Health Care or the Joint Accreditation System of Australia and New Zealand.

Accreditation must cover the whole organisation and include standards that assess governance, management, quality and safety.

Applicable standards

For registered community health services, applicable standards include the following:

Integrated community health services are subject to the accreditation requirements of their parent health service and must comply with the National Safety and Quality Health Service Standards.

All public dental services must be assessed against either the National Safety and Quality Primary and Community Healthcare Standards or the National Safety and Quality Health Service Standards.

Performance standards for registered community health services only

Performance standards represent the standard of operation for registered community health services (described as community health centres) and are a requirement of registration under the Health Services Act (1988).

To be registered and maintain registration under the Act, community health services must demonstrate compliance against 5 areas of performance:

  • Governance
  • Management
  • Financial management
  • Risk management
  • Quality (accreditation and service delivery)

Compliance against the performance standards is monitored through an annual attestation from registered community health services.

Performance standards for registered community health services were gazetted in the Victoria Government Gazette (PDF)External Link on 5 March 2009 and came into effect on 30 June 2009.

Clinical governance

Community health services should be guided in the development and delivery of clinical governance systems by the Safer Care Victoria Clinical governance frameworkExternal Link or the Community services quality governance frameworkExternal Link .

Human Services Standards

Compliance with the Human Services StandardsExternal Link is a requirement for all organisations that receive funding from the Department of Families, Fairness and Housing to deliver services directly to clients. Many community health services will be in scope of these Standards.

The Department of Families, Fairness and Housing is changing how it regulates services and replacing the current Human Services Standards with new Social Service Standards as part of a new Social Services Regulatory Framework expected to commence in 2024. For information and timelines, visit the Human Services Regulator webpageExternal Link .

Child Safe Standards

Compliance with the Child Safe Standards is a Child Wellbeing and Safety Act (2005) requirement and applies to all community health services.

New Child Safe Standards were introduced on 1 July 2022. From 1 January 2023, the Secretary of the Department of Health will become the sector regulator for health organisations in relation to these Standards.

Quality accounts

All public health services and registered community health services are required to submit an annual Quality accountExternal Link .

Public health services with integrated community health services must address community health in their accounts.

Quality accounts provide the Victorian community with an account of a service's performance and improvement work across several domains, including accreditation.

Family Violence Multi-Agency Risk Assessment and Management Framework (MARAM) and information sharing

The Family Violence Multi-Agency Risk Assessment and Management (MARAM) Framework and information sharing schemes ensure that services effectively address family violence and promote child wellbeing and safety.

Community health services are among the organisations prescribed under regulations for MARAM and information sharing. For further information and requirements see the Frequently asked questions about information sharing and MARAM webpageExternal Link

Other accreditation and regulatory requirements

Community health services receive funding from across the Department of Health, as well as the Department of Families, Fairness and Housing, other state government departments, the Commonwealth government and local government.

Community health services should refer to all relevant program guidelines and regulators to identify applicable accreditation and regulatory requirements in addition to those outlined in this document. This should include, but is not limited to:

How compliance with accreditation requirements is monitored

The Department of Health monitors compliance by community health services with accreditation requirements through existing regulatory and performance monitoring processes. This includes:

  • Performance monitoring activity in accordance with:
  • Annual attestation for gazetted standards (registered community health services only)

Community health services also report to the public on their accreditation status as part of their annual Quality accountExternal Link .

Governance resources

The Australian Centre for Healthcare GovernanceExternal Link (ACHG) helps the healthcare sector know more about governance. It also guides and supports healthcare organisations in meeting their significant governance responsibilities. It offers, for example, opportunities for individuals and groups to participate in governance forums and networks.

Reviewed 11 September 2023

Health.vic

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Community Performance and Governance team

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