With Australia’s accreditation process for cosmetic surgery rolling out, clinics must be more prepared than ever. this feature unpacks the accreditation process and outlines what facilities need to do to remain compliant and audit-ready.
With new implementation resources released by the Australian Commission on Safety and Quality in Health Care this past June, the National Safety and Quality Cosmetic Surgery Standards are rapidly moving from policy to practice – requiring all cosmetic surgery facilities to prepare for independent accreditation assessments.
A spokesperson from the Commission told AMP this past September: ‘We anticipate accreditation to the Cosmetic Surgery Standards to begin Q1 2026.’
Whether a facility seeks full accreditation under the new Standards or adopts the accompanying Cosmetic Surgery Module (for those already accredited under the NSQHS Standards), the onus is now firmly on providers to demonstrate compliance across governance, infection control, medication management, informed consent and consumer engagement.
Accreditation is carried out under the Australian Health Service Safety and Quality Accreditation Scheme (AHSSQA Scheme) and provides independent assurance that a facility meets the national benchmarks for safe, high-quality care in cosmetic surgery settings.
Why were the standards introduced?
Developed by the Australian Commission on Safety and Quality in Health Care, the Cosmetic Surgery Standards represent a nationally coordinated response to long- standing concerns around patient safety and inconsistent practices in the cosmetic surgery sector. These concerns were spotlighted by media investigations and formal reviews in 2022, prompting Health Ministers to mandate systemic reform.
The Cosmetic Surgery Standards, released in late 2023, form part of a broader regulatory framework that includes revised Ahpra and TGA guidelines, as well as new endorsement pathways for practitioners. These reforms aim to improve accountability, transparency and patient protection.
Closing the gaps
Cosmetic surgery in Australia operates outside traditional models of clinical necessity, placing unique demands on regulation. The procedures involved are invasive, often elective and are conducted across a variety of settings that range in scale and governance. Prior to these reforms, gaps in licensing, credentialling and informed consent processes had been linked to a number of adverse outcomes and consumer complaints.
In 2022, Health Ministers agreed to urgent reforms aimed at improving safety in the cosmetic surgery industry. They instructed the Australian Commission on Safety and Quality in Health Care to develop a National Licensing Framework for cosmetic surgery facilities, alongside the National Safety and Quality Cosmetic Surgery Standards.The intent is to set clear, enforceable benchmarks for all facilities delivering surgical aesthetic procedures, including those operating outside licensed hospital environments.
Seven domains, 101 actions
The Cosmetic Surgery Standards are structured around seven core domains, each with discrete actions that practices must demonstrate compliance with:
- Clinical Governance (26 actions) – leadership, risk, quality improvement
- Partnering with Consumers (13 actions) – informed consent, patient engagement
- Preventing and Controlling Infections (18 actions)
- Medication Safety (12 actions)
- Comprehensive Care (12 actions) – risk assessment, aftercare
- Communicating for Safety (10 actions)
- Recognising and Responding to Acute Deterioration (10 actions)
Each action (there are 101 of them) is assessed using a four-point scale: met, met with recommendations, not met, or not applicable. The Commission has also released a Monitoring Tool to help services track compliance internally. This Excel-based tool provides a colour-coded dashboard, self-assessment fields and audit prompts.
For services already accredited under the NSQHS Standards, a Cosmetic Surgery Module with 20 additional actions is used instead of full re-accreditation.
The Cosmetic Surgery Standards apply to any facility where cosmetic surgery is performed, from small day clinics to large multidisciplinary organisations. Cosmetic surgery is defined as a procedure involving cutting beneath the skin to change appearance, without medical indication. Non-surgical procedures such as injectables fall outside the scope of these Standards.
The first two standards form the clinical governance framework underpinning the remainder, with detailed action items to support implementation. While many actions mirror the NSQHS Standards, others are tailored specifically to the risks and expectations of cosmetic surgery practice.
Accreditation process and timelines
Services are expected to become accredited directly to the Cosmetic Surgery Standards, or if already accredited under the NSQHS Standards, implement the Cosmetic Surgery Module. Accreditation assessments are conducted under the AHSSQA Scheme by an approved accrediting agency. The accreditation process includes:
- Choose an accrediting agency: Practices must engage an approved agency and enter into a formal agreement.
- Self-assessment: Services review their operations against the relevant Standards. They may request that specific actions be deemed ‘not applicable’ based on scope of practice.
Self-assessment is a continuous process and should include documentation such as governance frameworks, clinical risk registers, credentialing records, incident logs and evidence of consumer engagement.
- Initial assessment: An onsite assessment is scheduled and announced in advance. Surveyors inspect documentation, interview staff and consumer representatives, and assess evidence against each action in the Standards. The accrediting agency provides the service with a formal report within five business days of the assessment, outlining the rating for each action and any required follow-up.
- Remediation period: If any actions are rated as ‘not met’ or ‘met with recommendations’, practices have 60 business days to address the issues and submit evidence of improvement. Where key information, personnel or consumer representatives were not available at the time of assessment, services will have up to five business days to arrange interviews or provide the accrediting agency with additional evidence for consideration.
- Final assessment and determination: After reviewing the remediation evidence, the accrediting agency issues a final report, including the assessment outcome. If all requirements are met, the service is awarded accreditation for a three-year cycle. Accreditation confirmation is issued within five business days of final determination.
Once the first accreditation expires, the next cycle will require a short notice assessment (24-48 hours’ notice), in keeping with the approach used for other national safety and quality standards.
Appeals and regulatory reporting
If a practice disagrees with an accreditation outcome, it can appeal through the accrediting agency. If unresolved, the matter can be escalated to the Commission.
Regulatory bodies such as state health departments and the Medical Board of Australia are notified of serious risks or accreditation failures, and may take further action regarding licensing or practitioner registration.
“Designate a senior staff member, such as a practice manager or nurse, to oversee compliance activities, coordinate documentation and serve as the main point of contact during assessments.”
What facilities need to do
For services new to accreditation, preparing for assessment requires the development or refinement of clinical governance frameworks, documentation of consent and communication processes, incident management systems and credentialing of practitioners. Practices must also demonstrate compliance with advertising restrictions and show that patients are fully informed of risks, costs and recovery expectations.
Preparing for accreditation – whether under the full Cosmetic Surgery Standards or the Cosmetic Surgery Module – requires structured, proactive effort. Clinics should take the following steps to ensure they are audit-ready:
Appoint a compliance leader
Designate a senior staff member, such as a practice manager or nurse, to oversee compliance activities, coordinate documentation and serve as the main point of contact during assessments.
Review and update practices
Use the Monitoring Tool and Flowchart factsheet on the Commission’s website to cross- check your clinic’s policies and procedures against the updated Cosmetic Surgery Standards. It’s particularly important for NSQHS- accredited services to ensure that existing systems meet both the general and cosmetic-specific requirements.
Document thoroughly
Maintain clear, well-organised records for all processes, policies and action items. This includes governance frameworks, risk registers, credentialing documentation, informed consent forms, audit results and any remediation activities.
Create a process manual
Develop or update a clinic operations manual that reflects current workflows, responsibilities and required forms. Ensure all staff are trained in new procedures introduced as part of the Cosmetic Surgery Standards.
Prepare for assessment
During the onsite visit, surveyors will request evidence for each applicable action. A formal assessment report is issued within five business days of the visit. If any actions are rated ‘not met’ or ‘met with recommendations,’ services will have 60 business days to remediate and provide follow-up documentation.
Submit additional evidence if needed
If key personnel or consumer representatives are unavailable during the visit, services have up to five business days to arrange interviews or supply additional documentation.
Even for experienced, NSQHS-accredited facilities, the Cosmetic Surgery Module introduces new areas of focus – including patient psychological screening, infection control tailored to cosmetic procedures and enhanced post- operative care protocols. These must be clearly addressed in both policy and practice.
The Cosmetic Surgery Standards set a new baseline for clinical and organisational governance in aesthetic practice. By formalising accreditation for all facilities performing cosmetic surgery, the Commission aims to ensure that patients receive consistent, high-quality care regardless of setting. For providers, the Standards offer a clear framework to benchmark performance, identify risks and embed a culture of safety and transparency.
Resources and guides are available to support implementation of the Cosmetic Surgery Standards and the Cosmetic Surgery Module on the Australian Commission on Safety and Quality in Health Cares’s website at safetyandquality.gov.au/standards/national-safety-and-quality-cosmetic-surgery-standards.
These include a flowchart of an assessment, fact sheet on the process for accreditation and a monitoring tool (spreadsheet) that lets clinics/facilities track progress against each action.
Scope & structure
The Standards apply to all services – ranging from small boutique clinics to large hospital-based practices – where cosmetic surgery is performed. Recognising the variation in practice settings, the Commission has created two pathways:
- Standalone Cosmetic Surgery Standards for clinics not otherwise accredited under NSQHS.
- Cosmetic Surgery Module for services already NSQHS- accredited, comprising 20 additional cosmetic-specific actions.
Of the 101 actions that make up the full Cosmetic Surgery Standards, 81 align with the existing NSQHS requirements, while 20 are tailored to the unique risks and requirements of cosmetic surgery.
Cosmetic surgery, for the purposes of the Standards, is defined as an invasive procedure involving cutting beneath the skin for aesthetic purposes, without clinical necessity. Non-surgical treatments such as injectables do not fall under this scope.
