Accreditation processes review

Find out more about our review of existing processes and procedures of accreditation authorities in the National Registration and Accreditation Scheme

Learn more about accreditation organisations

About the Processes for progress review

Accreditation of Australia’s registered health practitioners is an essential element of the National Scheme. It seeks to fulfil the National Scheme’s public protection objective by ensuring people seeking registration as a health practitioner have the knowledge, skills and professional attributes necessary to practise their profession safely and competently in Australia. Appropriate accreditation underpins the health practitioner registration process and is a cornerstone of the National Scheme.

Health ministers commissioned this review in response to the recommendations made by Professor Michael Woods in his 2018 Review of Accreditation Systems within the National Registration and Accreditation Scheme. Health ministers accepted in full the recommendation that our office undertakes a review of the complaint and appeal processes of accreditation organisations. Health ministers also broadened the review’s scope to include consideration of the procedural aspects of accreditation processes more generally to ensure fairness and transparency.

Health ministers accepted the Accreditation Systems Review’s recommendation that the Ombudsman and Commissioner’s jurisdiction be extended to include the administrative actions of accreditation organisations. 

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Scope of the review

This Processes for progress review considers the quality of the existing complaint and appeal processes of organisations performing accreditation functions within the National Scheme. The review also generally considers the fairness and transparency of accreditation processes.

This review suggests there are five key principles underpinning effective and efficient processes including that processes are:

  • People-centred: Accreditation can affect both individuals (such as students and trainees) and the broader community. A people-centred approach ensures processes are respectful and accessible and based on the needs of the individual and/or community.
  • Transparent: It is widely accepted that organisations providing services that benefit the public should be open and transparent about their processes. Providing information about all relevant processes can reduce uncertainty for individuals, assist in managing expectations, and create greater accountability for the organisation’s staff.
  • Responsive: Responsiveness ensures that matters are dealt with as quickly as possible and escalated where appropriate. Proportionate and appropriate processes are built on a commitment to timeliness.
  • Fair: When people believe an organisation’s processes are fair, they are more likely to trust in the organisation and accept its decisions. For processes to be fair, and perceived to be fair, all matters must be managed equitably, and in line with the organisation’s stated policy and the principles of procedural fairness.
  • Accountable: All staff must clearly understand their roles and responsibilities in relation to a process to ensure accountability. Public reporting on relevant processes and ongoing monitoring and evaluation is similarly important for accountability.

The review’s assessment of existing complaint and appeal processes is largely based on principles derived from the Australian Standard AS/NZS Guidelines for complaint management in organisations (10002:2022). Some consideration is also given to the Commonwealth Ombudsman’s Better practice guide to complaint handling.

Health Ministers requested that the review give particular attention to the processes of specialist medical colleges in relation to the accreditation of training sites. Part one of the review focussed on the findings and recommendations regarding specialist medical training site accreditation.

The review continues to assess a range of different accreditation processes which support the exercise of accreditation functions under the National Law. The review’s broader findings in relation to the accreditation of programs of study and education providers, and the assessment of overseas qualified practitioners, will be outlined in a subsequent report.

  • Our office can assist with complaints about the processes of accreditation organisations.

  • Learn more about the role of accreditation organisations.

  • Find out more about how our office provides a free and independent complaint handling service for the public and health practitioners.

Find out more about how to make a complaint to the Ombudsman or to the Commissioner.


Processes for progress review report – Part one (PDF)

Appendices - Processes for progress review report – Part one

Foreword and summary of recommendations - Processes for progress review report – Part one

Part one: A roadmap for greater transparency and accountability in specialist medical training site accreditation

The part one report focusses on the review’s findings and recommendations regarding specialist medical training site accreditation.

The report was published on 10 November 2023 following Health Ministers' support of the recommendations.

Effective accreditation of Australia’s specialist medical training sites supports quality and safe patient care. Australia is fortunate in being highly regarded for the quality of its specialist medical practitioners and training.

The review found that the complex arrangements underpinning accreditation in the National Scheme have created an environment where gaps have emerged in the accountability mechanisms for processes related to the accreditation of specialist medical training sites. For example, the accreditation of specialist medical training sites is not a recognised accreditation function under the Health Practitioner Regulation National Law (the National Law).

Concerns also continue to be raised regarding specialist medical training site accreditation standards and requirements, and their ability to respond appropriately to immediate workforce needs and broader workforce planning undertaken by jurisdictional health departments across Australia.

These circumstances give impetus to ensuring specialist medical training site accreditation processes are people-centred, transparent, fair, responsive and accountable.

Part one of the Processes for progress report outlines the review’s findings on key processes related to specialist medical training site accreditation in relation to five priority areas for improvement:

  1. Enhancing accountability and transparency in accreditation standards
  2. Ensuring fairness and transparency in accreditation processes and assessments
  3. Clarifying and strengthening monitoring processes for accredited training sites
  4. Developing an appropriate framework for:
    • assessing and managing concerns about accredited training sites
    • managing non-compliance with the accreditation standards, including processes for making adverse changes to a training site’s accreditation status (such as placing conditions on, suspending or withdrawing accreditation).
  5. Ensuring grievances about accreditation processes and decisions are managed fairly and transparently.

The review has focussed on delivering practical, outcome-focussed recommendations to provide a roadmap for progress. In recognition of capacity and time constraints, recommendations have been graded by priority.

On 1 September 2023, Health Ministers issued a policy direction to clarify expectations regarding the accreditation of specialist medical training sites. The policy direction included that the Australian Health Practitioner Regulation Agency (Ahpra) and the Medical Board of Australia (the Medical Board) require the Australian Medical Council (the AMC) to work with jurisdictions and colleges on an implementation plan for the review’s suggestions for reform. This recognises that a collaborative and coordinated approach is necessary to successfully implement the review’s recommendations.

The Ombudsman has welcomed recognition by colleges and health jurisdictions of the importance of working together to achieve positive change.

Download the report Part one: A roadmap for greater transparency and accountability in specialist medical training site accreditation

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