Healthcare facility licensing

A health care facility is a premises upon which prescribed medical or dental procedures are carried out and/or a premises where overnight patient stays are provided.

The operator of a health care facility must hold a Health Care Facility Activity Licence.

Current Health Care Facilities Legislation

Licences are currently issued under the ACT Health Care Facilities Code of Practice 2001 and the Public Health (Health Care Facilities) Declaration 2001.

Prescribed medical and dental procedures are defined by the current Risk Declaration as activities carried out for medical or cosmetic reasons by a health care professional, involving:

  • the administration of general, spinal, epidural or major regional block anaesthetic or intravenous sedative for the purpose of performing an elective procedure, not including mandibular blocks;
  • endoscopy;
  • dialysis, haemofiltration or haemoperfusion;
  • prolonged intravenous infusion of a single cytotoxic agent or sequential intravenous infusion of more than one cytotoxic agent; or
  • cardiac catheterisation.

New Health Care Facilities Code of Practice and Public Health Risk Declaration

On 27 March 2022, changes to the licensing and regulation of Health Care Facilities in the ACT come into effect:

The new Code aims to protect the community from the public health risks associated with the operation and management of health care facilities that undertake any declared public health risk procedures. These changes have been introduced to ensure a safe and robust health system and bring the ACT in line with other Australian jurisdictions. The new Code is made under the Public Health Act 1997 (the Act).

The new Risk Declaration provides a legislative framework to govern Health Care Facilities in the ACT to support the safety and quality of care for patients undergoing procedures that may pose a risk to health. 

What are the key changes?

  • The definition of a Health Care Facility (HCF) has been amended to apply to  premises: where a declared public health risk procedure is performed or that provides overnight inpatient services under the care of a registered medical professional.
  • Cosmetic procedures have been added to the declared public health risk procedures  
  • Health and safety standards have been added to the new Code; and
  • HCFs will be required to be accredited under the National Safety and Quality Health Service (NSQHS) Standards.
  • Facilities will be licensed as either hospitals or day procedure centres depending on whether overnight patient stays are provided. The ACT categorisation of a HCF as a hospital or day procedure centre is separate and independent hospitals declared under the Private Health Insurance Act 2007 (Cwlth). 

The six declared public health risk procedures are:

  • Intravenous anaesthesia & sedation
  • Cardiac Catheterisation
  • Chemotherapy (cytotoxic infusion)
  • Cosmetic procedures
  • Gastrointestinal endoscopy
  • Renal Dialysis (haemodialysis)

A HCF can be licensed to provide one or more public health risk procedures.

Health Care Facilities Public consultation

A discussion paper titled Update to the Licensing and Regulation of Health Care Facilities was released for stakeholder consultation between 10 August and 18 September 2020. A total of 17 submissions were received from a mix of professional bodies, licenced entities and individuals.

All stakeholders broadly supported that HCFs should engage with the National Safety and Quality Health Service (NSQHS) standards, improve reporting requirements, and operate with greater transparency in-line with other jurisdictions.

Licence applications

The Health Protection Service (HPS), within ACT Health is responsible for the local management and regulation of HCFs in the ACT. This includes issuing HCF licences, ensuring HCFs are meeting their licence requirements. This is done to make sure health consumers have access to safe and quality health services. HPS is responsible for oversight of the licensing and regulation of HCFs in accordance with the Act.

HPS also works closely with the Australian Commission on Safety and Quality in Health Care to support HCFs to meet their obligations under the NSQHS Standards.

The Health Protection Service encourages applicants to discuss their fit-out plans and proposed procedures with us. Please call 02 5124 9700 during business hours or email hps@act.gov.au.

An application for a Health Care Facility Activity Licence can be submitted online or in hard copy. Applications must be accompanied by the fee and fit-out plans.

Please send application form and plans:

  • online;
  • by email hps@act.gov.au;
  • by post to Health Protection Service, Locked Bag 5005, Weston Creek, ACT 2611; or
  • in person at Health Protection Service, 25 Mulley Street, Holder (during business hours, 9:00 am to 4:30 pm weekdays).

If you need to update or change the details on your licence, please apply online for a Health Care Facility Licence Variation.

If ownership of the facility changes, please submit a Transfer of Ownership form.

Forms:

Current licence fees

Please see the table below for licence fees.

Type of Facility Annual Fee
Accredited facility (<200 beds) $676
Accredited facility (>200 beds) $1350
Non-accredited facility $1010
Dental practitioner $270

Please note: there is a $82 fee for transfer of a licence.

Accreditation

National Safety and Quality Health Service Standards Accreditation

Under the new Code, HCFs will be required to be accredited against National Safety and Quality Health Service Standards will be required by provisions made under the new Code and the Public Health Act.

  • New HCFs are required to undertake an interim assessment against the NSQHS Standards within 10 days of commencing operation and must be assessed against all relevant NSQHS Standards within 12 months of commencing operation.
  • HCFs that were previously licenced as non-accredited facilities must gain full accreditation to the National Safety and Quality Health Service (NSQHS) Standards by 26 March 2023.

New facility operators should use an accreditation agency from the list approved by the Australian Commission on Safety and Quality in Healthcare.

If you have any questions, please contact the Health Protection Service on 02 5124 9700.

Structure of Facilities

HCF Building class

  • Buildings that provide medical treatment services are considered a Class 9A building under the Building Code of Australia. 
  • Plans to construct or modify buildings in the ACT are assessed by the Environment, Planning and Sustainable Development Directorate (EPSDD). 
  • The construction of health care facilities in the ACT may be certified by the EPSDD as a Class 9A building.  

Please see the following links for compliance with relevant health care facility structure standards.

For more information on building guidelines for the ACT, please see the Environment, Planning and Sustainable Development Directorate website:

Information Management

All general records maintained by health care facilities must be stored in accordance with Australian Standards. This includes storage of accounts, insurance documents and correspondence.

The procedure for storing medical, or health records is set under Part 5 of the ACT Health Care Facilities Code of Practice 2001.

Food Safety

If you provide food to your patients, you must register as a food business. You must also meet the requirements of the Food Act 2001, the Food Regulation 2002 and the Australia New Zealand Standards Code. This may include the option of a Food Safety program for providing food to vulnerable groups.

You can discuss your food safety obligations with our public health officers on 02 5124 9700 or hps@act.gov.au.

Nutritional Assessment

Health care facility licensees must ensure all food provided is consistent with the Australian Dietary Guidelines.

Laundering

Health care facility licensees must ensure all linen used is cleaned in accordance with Australian Standards. You can purchase Standards from SAI Global.

Clinical Waste Management

Clinical waste arises from the treatment and care of patients. Clinical waste includes hypodermic needles, scalpels, tissue and fluid specimens, pharmaceuticals and materials that have been in contact with these substances.

Health care facility licensees must comply with the Clinical Waste Act 1990 and the Clinical Waste Manual 1991. These documents detail the requirements about the storage, treatment, transportation and disposal of clinical waste. This includes the engagement of an approved entity for the removal of clinical waste from a facility.

ACT legislation

ACT Health encourages you to familiarise yourself with relevant ACT legislation including:

  • Public Health Act 1997
  • Public Health (Health Care Facilities) Declaration 2001 (scheduled to be revoked 27 March 2022)
  • The Health Care Facilities Code of Practice 2021 (commences 27 March 2022)
  • Public Health (Code of Practice) Determination 2001 (scheduled to be revoked 27 March 2022)
  • The Public Health (Health Care Facility) Risk Declaration 2021 (commences 27 March 2022)
  • Children and Young People Act 2008
  • Clinical Waste Act 1990
  • Food Act 2001
  • Health Records (Privacy and Access) Act 1997
  • Medical Treatment (Health Directions) Act 2006
  • Medicines, Poisons and Therapeutic Goods Act 2008
  • Radiation Protection Act 2006
  • Work Health and Safety Act 2011

You can find these Acts and other legislation on the ACT Legislation Register.

Contact the Health Protection Service

Our office hours are 9:00 am to 4:30 pm on weekdays.

You can contact us on 02 5124 9700 or hps@act.gov.au. The fax number is 02 5124 5554.

Health Protection Service is located at 25 Mulley Street, Holder ACT 2611.

The postal address is Locked Bag 5005, Weston Creek ACT 2611.

Page last updated on: 4 Jan 2022