Accreditation and Quality

Royal Rehab Private Petersham is fully certified and committed to providing high quality rehabilitation services.

Royal Rehab Private Petersham holds full current certification against the National Safety and Quality Health Service Standards (NSQHS) (Version 2). These standards were introduced by the Australian Commission on Safety and Quality in Healthcare in 2013 as industry standards for public and private hospitals. They were updated and revised in November 2017 following identified gaps in the first edition including mental health and cognitive impairment, health literacy, end-of-life care, and Aboriginal and Torres Strait Islander health.

NSQHS Standards

These 8 standards and 148 actions include:

  • Standard 1: Governance for Safety & Quality in Health Service Organisations
  • Standard 2: Partnering with Consumers
  • Standard 3: Preventing and Controlling Healthcare and Associated Infections
  • Standard 4: Medication Safety
  • Standard 5: Comprehensive Care
  • Standard 6: Communicating for Safety
  • Standard 7: Blood Management
  • Standard 8: Recognising and Responding to Acute Deterioration

External Auditors from Global Mark Pty Ltd audit our compliance against these 8 standards.  Accreditation against the NSQHS Standards is mandatory for hospitals.


Royal Rehab Private Petersham is also committed to providing high quality rehabilitation services. Please refer to Royal Rehab Private Petersham’s Business Policy which outlines our commitment to the provision of quality services and our strategies to achieve this.

We routinely collect data to measure our performance and benchmark our outcomes with other private rehabilitation facilities and national benchmarks. Some of the ways in which we do this are as follows:

  • We collect Functional Independence Measure (FIM)data for patients that are admitted to our inpatient rehabilitation program. FIM is the national rehabilitation outcome measure tool. We submit this data to the Australasian Rehabilitation Outcomes Centre (AROC) in order to benchmark our outcomes with other private rehabilitation facilities and the national benchmark.
  • We participate in the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program. We collect and submit data against hospital, medical and rehabilitation clinical indicators in order to be able to benchmark our performance with other private rehabilitation facilities and national benchmarks.
  • We participate in the bi-annual National Stroke Foundation Rehabilitation Audit to compare our service provision and stroke outcomes to the standards outlined in the Clinical Guidelines for Stroke Management 2017.
  • We collect and monitor our clinical data on falls, pressure injuries, infections, antimicrobial stewardship and medication safety.
  • We routinely ask patients to complete surveys on their experiences at Royal Rehab Private Petersham and use this information to further improve our services.