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About us


What is Accreditation?

Accreditation is a form of external review to assure the quality of a process, service or organisation. Central to this process is allowing a group of people external to the hospital to review and verify that certain standards are being met.

There are many forms of accreditation that the Hospital is involved in. Some of these are at a department level, e.g. ISO / NATA. At a total hospital level, we are accredited by the Australian Council on Healthcare Standards (ACHS). The ACHS is an independent, not for profit group whose members are private and public healthcare organisations.

The program of accreditation used by the ACHS is based on a set of standards known as EQuIP (Evaluation and Quality Improvement Program). The EQuIP framework has been revised several times and the current version is known as EQuIP 4.

The program is based on a 4 year cycle, where organisations are asked to undertake certain EQuIP events every year:

Year 1: Self Assessment

The hospital undertakes a Self Assessment where we are asked to rate ourselves according to a set of criteria. The ACHS reviews the Self assessment and provides feedback on how the organisation may improve performance.

Year 2: Organisation Wide Survey (OWS)

The hospital prepares a Self Assessment, which is followed up by a team of ACHS surveyors who come to the hospital to verify that we have achieved the things that are documented in the Self Assessment. They also decide, based on the evidence that they see, whether the hospital should maintain the ratings we have given ourselves.

The surveyors make recommendations on improvements that could be made, or in some instances they identify areas that require the immediate attention of the organisation. Depending on the findings, Accreditation is granted at this point in time. The maximum Accreditation period that can be given is 4 years.

Year 3: Self Assessment

The hospital submits a Self Assessment to show what has been improved since the OWS. The ACHS reviews the document and provides feedback to the hospital.

Year 4: Periodic Review

The hospital prepares a Self Assessment which is followed up by a team of ACHS surveyors for verification. This is a smaller survey than the OWS, with a smaller team of surveyors for a shorter period of time. The team verify that we have continued to improve and that the recommendations made at the OWS have been actioned. Depending on the findings, accreditation can be continued or withdrawn at this point.

The idea behind the 4 year cycle is that the hospital is regularly assessing itself to see how we can continuously improve the services we provide.

The Children's Hospital at Westmead awarded 4 years Accreditation

During the Organisation Wide Survey held in October 2008, The Australian Council on Healthcare Standards awarded The Children's Hospital at Westmead (CHW) full accreditation (4 years).

CHW takes accreditation and continuous improvement very seriously and is continually working on improving services for patients, families, carers and staff of the hospital to ensure that an excellent standard of care is maintained.

CHW was given a rating of:

  • Outstanding Achievement for our:
    • Pain & Palliative Care service.
    • Research program.
  • Extensive Achievement for:
    • Many of our clinical functions including evaluation of care provided, using evidence based practice, medication safety and infection control.
    • Establishing mechanisms for involving consumers in planning, provision, monitoring and evaluation of the health service to support improvement.
    • Our continuous quality improvement system and our commitment to improving performance in care and service delivery.
    • Our Incident and Complaint management processes.
    • Human resource planning.
    • Our credentialing and defining scope of clinical practice processes.
    • Our medical record system.
    • Our Policy & Procedure system &qmp; processes.
    • Our safety management systems.
    • Our waste and environmental management processes

What we are working on

  • Improving care planning
  • Risk Assessments for pressure ulcers and falls
  • Ward security systems

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This page was updated on Wednesday, 27 January 2010.

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