Accreditation and Quality

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

Royal Rehab Private Ryde and Royal Rehab Ryde 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.

Accredited Certification NSQHS Standards Global Mark

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.

Short Notice Assessment

From July 2023, Royal Rehab will be subject to mandatory short notice assessments against the National Safety and Quality Health Service (NSQHS) Standards. The introduction of short notice assessments will ensure the assessment outcomes reflect day to day practices, identify gaps and supports the improvement of our organisation.

Additional benefits of short notice assessments include;

  • Support continuous compliance with the NSQHS Standards and quality improvement strategies
  • Transfer the focus of assessments from preparation to assessment of day-to-day practice
  • Remove the administrative burden of preparation for accreditation, enabling the workforce to redirect their efforts to other priorities
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Royal Rehab supports a shared understanding of quality, safeguards and clinical governance across the organisation, ensuring that clinical governance systems are implemented effectively, supporting safe and quality care for patients, client and consumers. Royal Rehab’s commitment to providing safe and high-quality care, along with a focus on continuous improvement, is backed by this robust Clinical Governance framework.


As part of the continuous quality improvement process, we also 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 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.