Key messages

  • The Department of Health and Human Services (the department) has a responsibility as (jurisdictional) Regulator for overseeing accreditation compliance in Victoria.
  • Clear roles and processes are defined for managing the outcomes of all accreditation assessments.
  • The department is responsible for monitoring any organisation that fails to gain accreditation.
  • The department will notify Safer Care Victoria and/or the Office of the Chief Psychiatrist if a significant risk is identified during the assessment cycle, or in the event of a ‘not met’ outcome.

There are three possible assessment outcomes of the NSQHS Standards (second edition):

  • rectification of core actions that are ‘not met’ 
  • identification of any ‘significant risks’ to patients 
  • health services not being awarded accreditation following a rectification period 

The department is required to be notified by the health service within a pre-determined timeframe for any of the above. 

Rectification of actions ‘not met’

If a health service is found to not meet the requirements of a NSQHS standard the health service will have 60 days from the receipt of the accrediting agency’s report to take measures to rectify any actions ‘not met’.

The health service is required to notify the department immediately, and the department, Safer Care Victoria (SCV) and/ or the Office of the Chief Psychiatrist (OCP) will meet with the health service within three days to discuss its planned rectification measures and may provide the health service with support or resources to address specific issues.

The health service will only be awarded accreditation once it has been has established that the ‘not met’ actions have been rectified. 

When a ‘significant risk’ is identified

If an accrediting agency identifies a ‘significant risk of patient harm’ during the assessment of a health service, it must immediately notify the health service and the department.

The agency will then develop a plan of action with the health service and SCV to remedy the issues. The department, as regulator, will be responsible for monitoring the reported non-compliance and taking further action if the health service does not rectify its patient safety risk.

In the case of a significant risk being identified in a clinical mental health service, the department will notify both SCV and the OCP.

Health services not being awarded accreditation following a rectification period

If a health service receives actions ‘not met’ following remediation or accreditation is not awarded or withdrawn, the accrediting agency is required to notify the health service and the department immediately and the department will escalate the regulatory response to the Secretary of the department and the Minister for Health and/ or the Minister for Mental Health.

The department will initiate direct intervention based upon the level of risk to patients and the number and nature of the actions ‘not met’. The health service will remain under intensive monitoring until accreditation is achieved, which will be a period of no greater than 12 months. The health service will be required to undergo re-assessment to all eight NSQHS Standards within 12 months.

The following documents provide detailed information for second edition NSQHS standards accreditation.

Accreditation policy for Victorian public health services

This document provides a policy overview of the roles and responsibilities of the health service organisation, the commission, the accrediting agency, the department, and SCV and the OCP.

Appendix 1: Accreditation regulatory business rules

This document provides definitions and a glossary, and clear processes for the roles and responsibilities for each of the potential outcomes of an accreditation assessment.

Appendix 2: Accreditation process

This document provides mapping of the processes for the roles and responsibilities for each of the potential outcomes of an accreditation assessment.

Appendix 3: Accreditation notification contacts and timelines

This document provides a tabled list of key contacts within the department, as regulator, and timelines in which to contact the regulator for all health service types accredited to the second edition.

Extension process for public health service organisations

This document provides clear steps for a health service to apply to the regulator for an extension to their accreditation expiry date (this only applies during the Transition period ending 31 December 2019).

Process to apply for the short notice pathway

This document provides clear steps for a health service to apply to the regulator to join the short notice assessment pathway.

Contact details