National Safety and Quality Health Service Standards Accreditation Policy

Applicable to: This Policy is applicable to the following Health Service Providers in relation to any public health services delivered that are a part of a public hospital, public mental and dental health services: North Metropolitan Health Service, South Metropolitan Health Service, East Metropolitan Health Service, WA Country Health Service and Child and Adolescent Health Service.


The purpose of this Policy is to set the business rules that govern the Department of Health’s (the Department) regulatory approach for Health Service Providers to achieve mandatory accreditation to the National Safety and Quality Health Service Standards (NSQHS Standards) as per the Australian Health Service Safety and Quality Accreditation Scheme (the AHSSQA Scheme).


The National Health Reform Act 2011 (the Act) specifies the role of the Australian Commission on Safety and Quality in Health Care (the Commission) for the formulation of the NSQHS Standards. The Act also has the provision for the establishment of a national accreditation scheme. In 2011 Australian Health Ministers approved the AHSSQA Scheme and agreed to mandate that all Australian hospitals and day procedure centres should be accredited to the NSQHS Standards.


The AHSSQA Scheme defines the roles and responsibilities of the Commission, the state and territory governments, health service organisations and accrediting agencies in relation to national accreditation. The AHSSQA Scheme defines the Commission’s responsibility to maintain and update the NSQHS Standards and approve accreditation agencies to perform accreditation assessments; State and Territory responsibility to regulate health service organisation mandatory accreditation against the NSQHS Standards for each jurisdiction; and the responsibility of Health Service Providers to implement the actions required to meet the NSQHS Standards.


The Licensing and Accreditation Regulatory Unit (LARU), is the state regulator responsible for regulating accreditation of all public and private hospitals and private day hospitals (Class A) as per the AHSSQA Scheme in Western Australia.


This Policy is a mandatory requirement under the Clinical Governance, Safety and Quality Policy Framework pursuant to section 26(2)(d) of the Health Services Act 2016.


This Policy supersedes 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.

Date of effect: 06 May 2020

Policy Framework

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