Accreditation

About the data

The above measures look at:

• health service accreditation (including Dental Health Services Victoria)
• residential aged care accreditation
• surgical site infection surveillance status.

About health service accreditation

Heath services (including Dental Health Services Victoria) must be compliant with the National Safety and Quality Health Service Standards (NSQHS Standards) to be accredited to provide patient care and services. Full compliance is listed as 'achieved'.

More information: NSQHS Standards

About compliance with Aged Care Standards 

In Victoria, a number of residential aged care services are provided by public health services and are subject to national Aged Care Quality Standards.  It is a requirement that all residential aged care facilities are accredited and maintain full compliance with relevant standards.

The data presented reflects compliance with all accreditation standards, across all residential aged care facilities that fall under a public health service in Victoria. They do not reflect the overall accreditation status of a health service's residential aged care facilities.

All public residential aged care facilities in Victoria are presently fully accredited. Non-compliance in the data reflect only new instances of non-compliance against one or more accreditation standards at one or more residential aged care facilities that fall under a health service.

More information: Aged Care Accreditation Standards

About Surgical Site Infection Surveillance status

A hospital patient can develop a Surgical Site Infection (SSI) after surgery involving an incision or when they have/have had an intravenous line (IV) inserted.

SSIs are surgery complications that can have serious consequences and can result in a patient requiring further treatment.

Data is collected for SSIs that occur in Victorian public hospitals for the following procedures:

• coronary artery bypass grafts
• hip arthroplasty
• knee arthroplasty
• caesarean section (for The Royal Women’s Hospital and Mercy Health only)
• ICU central line associated bacteraemia.

Where a health service is equal to or lower than the statewide rate of SSIs, it is listed as 'achieved'. Otherwise it is not achieved.

Data are only shown for hospitals that undertake orthopaedic joint replacements and/or coronary artery bypass surgery and/or have an ICU.

Results are lagged by one quarter.

Results are reported quarterly using 6 months' rolling data.

Note

• Data sources: Australian Commission on Safety and Quality in Health Care, Aged Care Standards and Accreditation Agency, Victorian Hospital Acquired Infection Surveillance System (VICNISS) and Dental Health Services Victoria. Data extracted on 16 January 2024
• There are no statewide results for these measures
• No data indicates no results are available
• Results for the current financial year are preliminary and may change from quarter to quarter, final results will be available in November. Results from the previous financial year have been finalised
• From 6 February 2023, Monash Health commenced providing maternity services at Sandringham Hospital, replacing The Women's.
• On 23 February 2023, Monash Health opened the Victorian Heart Hospital. 
• Kilmore District Health Service voluntarily amalgamated on 1 November 2023 into Northern Health. Results for Kilmore District Hospital are now presented under Northern Health.
• Care needs to be taken when assessing results and comparing them to prior periods
• VICNISS data submission was made voluntary for the surveillance period 1 July 2021 to 31 March 2022. As such care needs to be taken assessing results and comparing to prior periods.