Accreditation implementation for public and private hospitals in Western Australia

What is accreditation?

Accreditation certifies that an organisation has met particular set of standards that they were assessed against.

The 2 conditions for accreditation in health care are an:

  • explicit definition of quality (that is, the standards)
  • independent review process aimed at identifying the level of congruence between practice and the quality standards.

What is the purpose of accreditation?

Accreditation is one method that promotes safety and quality in health care. It demonstrates a health service’s commitment to achieving high quality and safe care for the:

  • patients
  • residents
  • individuals it serves.

It is important to note that neither accreditation, nor any quality system, can provide an assurance that an adverse event will not occur in a health service.

Accreditation implementation in Western Australia

The Licensing and Accreditation Regulatory Unit (LARU) is the appointed Regulator for Accreditation in Western Australia.

The role of LARU includes:

  • overseeing all aspects of the AHSSQA Scheme
  • monitoring the implementation and compliance with the NSQHS Standards
  • undertaking an accreditation registration process for health services
  • receiving accreditation information from health services and accrediting agencies
  • utilising a responsive regulatory process to deal with identification of significant risk (external site) or where core items of the NSQHS Standards have not been met
  • providing representation and advice on matters pertaining to accreditation
  • providing advocacy and education on matters pertaining to accreditation and regulation.

Accreditation standards for Western Australia

From 1 January 2013 all public and private hospitals and private day hospitals that provide general anaesthesia in WA are required to be accredited to the National Safety and Quality Health Service (NSQHS) Standards (external site) under the Australian Health Service Safety and Quality Accreditation Scheme.

The process is outlined in the Department of Health Operational Directive OD 0410/12 Implementation of the Australian Health Service Safety and Quality Accreditation Scheme and the National Safety and Quality Health Service Standards in Western Australia (external site), dated 18 December 2012.

Private hospitals and Class A day facilities are required under OD 0410/12 to comply with additional licence terms and conditions which are provided at the time of Licence Renewal.

Accreditation to the NSQHS Standards will be in addition to existing requirements for accreditation to other standards.

How does a health service register accreditation in Western Australia?

Existing health services have registered for accreditation with LARU.

New health services are required to submit a completed accreditation registration form within 3 months of the commencement of the service.

There are separate registration forms for public and private health services.

Accreditating agencies

Health services are required to engage an accrediting agency, registered with the Australian Commission on Safety and Quality in Health Care, to undertake their accreditation assessment against the NSQHS Standards.

A current list of registered accreditation agencies is available from the Australian Commission on Safety and Quality in Health Care (external site).

The approved accrediting agency engaged to conduct the accreditation assessments will set the schedule of accreditation surveys against the NSQHS Standards.

Most approved accrediting agencies operate on either a 3 or 4 year cycle.

This means each health service is fully assessed against the ten NSQHS Standards at least once during each cycle in addition to a mid-cycle review against Standards 1, 2 and 3.

Each step of the accreditation process includes a review of recommendations from past assessments and the organisation’s safety and quality plan.

New health services

New facilities are required to arrange for an interim accreditation, This is to occur within 10 working days from the commencement of service provision.

Further information can be found in the ACSQHC Interim Accreditation of New Health Services – Advisory A13/02 (external site) and Interim accrediting of new health service organisations (external site)

More information

  • Licensing and Accreditation Regulatory Unit
    Phone 9222 4027
    Fax 9222 4077
    Level 1, B Block
    WA Health
    189 Royal Street
    East Perth WA 6004
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Licensing and Accreditation Regulatory Unit