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Public hospital accreditation

How Victorian public hospitals are accredited under NSQHS Standards, the process and oversight.

The Australian Commission on Safety and Quality in Health Care is responsible under the National Health Reform Act 2011 for the formulation of standards relating to health care safety and quality matters and for formulating and coordinating national models of accreditation for health service organisations.

Who needs to be accredited

All Victorian public health services must undergo regular assessments to maintain their accreditation through the Australian Health Service Safety and Quality Accreditation Scheme (AHSSQA).

These include:

  • metropolitan (this includes specialist and denominational health services
  • regional
  • subregional
  • local and small rural and multi-purpose services
  • clinical mental health services provided by public health services (including Forensicare)
  • public dental housed within health or
  • community health services.

National Safety and Quality Health Service (NSQHS) Standards

The National Safety and Quality Health Service Standards (NSQHS) (second edition) comprises of eight standards that ensure all health services have rigorous and consistent safety and quality systems.

The Victorian Department of Health (the department) as the regulator is responsible for monitoring the accreditation status of health service organisations.

The department, in conjunction with Safer Care Victoria, supports health service organisations to address and resolve issues, concerns and recommendations arising from accreditation.

Non compliance

Where there is non-compliance, the department in its regulatory role, may increase surveillance and monitoring of the health service organisation until it achieves full compliance.

The department's role is prescribed by a range of legislation including action under the Health Services Act 1988, Mental Health and Wellbeing Act 2022, and the terms of the Performance monitoring framework (for community health services, and other providers not included in the Health Services Act 1988 compliance.

Accreditation updates

From 1 July 2023 mandatory short notice assessment to the NSQHS Standards replaced existing announced and voluntary short notice assessments of hospital and day procedure service. For more information see Changes to accreditation: Short‑notice assessments.

Accreditation resources and further information

Additional information is available on the Australian Commission on Safety and Quality in Health Care website:

Updated