Department of Health

Key messages

  • From 1 July 2023 mandatory short notice assessment to the NSQHS Standards replace existing announced and voluntary short notice assessments of hospital and day procedure services.
  • These assessments support continuous implementation of the Standards and reduce the administrative burden of preparing for an accreditation assessment.
  • This change applies to all health service organisations where licencing requires accreditation to the NSQHS Standards

Short notice assessments

  • All health service organisations that are assessed to the NSQHS Standards will be required to undergo short notice assessments.
  • A short notice assessment may occur at any time during a three-year accreditation cycle. It will involve an on-site assessment of all applicable actions from the eight NSQHS Standards during a single assessment visit.
  • The introduction of short notice assessments will ensure the assessment outcome reflects day to day practice, identifies gaps and supports health service organisations to improve safety and quality systems and process.

Short notice example

24 hours’ notice is the equivalent of 1 business day Monday to Friday. If health services are contacted any time on a Monday, the 24 hours is all of Tuesday and the assessors will arrive on Wednesday morning. Health services would be contacted on a Thursday, the 24 hours is all of Friday for the assessors to arrive on Monday morning.

Exclusion period

  • Health service organisations may identify up to 20 business days per accreditation cycle for exclusion of a short notice accreditation assessment. Health service organisations may incur accreditation costs if assessors arrive on site for an assessment and services are not operational.
  • Requests for exclusion should include a rationale and supporting evidence to confirm that a short notice assessment on those dates would directly impact consumers or that consumers of the service would be unavailable.
  • Excluded dates will not be accepted where a mandatory repeat assessment is required. These are scheduled assessments that must occur within the specified timeframe.

Voluntary short notice

  • Health service organisations that are currently being voluntarily assessed at short notice will complete the current cycle of assessments before transitioning to mandatory short notice assessments.
  • Health service organisations that have registered but not commenced a voluntary short notice assessment will move directly to mandatory short notice assessments.
  • Health service organisations that have completed one short notice assessment to three or four standards, will have their next assessment to the remaining unassessed standards and then move to mandatory short notice assessments.
  • Health service organisations that have completed two short notice assessments, will have the remaining standards assessed at the next assessment and then move to mandatory short notice assessments.
  • The current accreditation expiry date will remain unchanged for each of these health service organisations.

Assessment process

  • Within five days of an assessment, a summary report on the initial assessment is provided to the health service that details all actions rated not met or met with recommendations. This report also provides information on evidence seen and explanation for the rating.
  • Health services with actions not met or met with recommendations that meet the reassessment criteria will be required to undergo assessment within six months to ensure outstanding actions have been remediated.
  • The reassessment visit is announced.
  • At reassessment assessors will review all actions rated not met and met with recommendations.
  • For an organisation to retain its accreditation, all actions must be met or met with recommendations. If there are not met actions following the reassessment, the organisation will have a 60 business days (three months) remediation period.
  • At the end of the remediation period, there is a final reassessment, that may be onsite.
  • The accrediting agency will have 20 business days to finalise its report on the reassessment.

Hospital accreditation flowchart

Hospital accreditation flowchart
Hospital accreditation flowchart

Notification from assessing agency to DH
– at same time as health service notification

Notification to DH of significant risk
– within 2 days

Health service notification to DH of any Unments
– within 24 hours

Support for rectification
– DH and SCV

Download Hospital accreditation flowchart

Reviewed 24 August 2023


Contact us

For information and assistance about public hospital accreditation

Regulator Department of Health

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