Healthcare facility licensing

• Administration of anaesthesia: the administration of general, epidural, or major regional anaesthetic block (excluding mandibular blocks), or intravenous sedation
• Cardiac catheterisation
• Chemotherapy (cytotoxic infusion)
• Abdominoplasty (tummy tuck)
• Belt lipectomy
• Brachioplasty (armlift)
• Bicep implants, tricep implants, calf implants, deltoid implants, pectoral implants
• Breast augmentation or reduction
• Buttock augmentation, reduction or lift
• Facelift, other than a mini-lift, that does not involve the superficial musculoaponeurotic system (SMAS)
• Facial implants that involve inserting an implant on the bone, or surgical exposure to deep tissue
• Fat transfer that involves the transfer of more than 100 millilitres litres of lipoaspirate
• Labiaplasty
• Liposuction that involves the removal of more than 1000 millilitres of lipoaspirate
• Mastopexy or mastopexy augmentation
• Monsplasty
• Neck lift
• Penis augmentation
• Rhinoplasty
• Vaginoplasty
• Gastrointestinal endoscopy
• Renal dialysis (haemodialysis)

The following are not defined as a health care facility: 

• a residential care facility within the meaning of the Aged Care Act 1997 (Cwlth)
• crisis accommodation
• a veterinary clinic
• a private residence
• a patient transport service or
• any premises operated by, or on behalf of, the Commonwealth.

This form can be used by a licensed health care facility to fulfil the Preparation of Annual Reports requirements outlined in Standards 5.5 and 5.6 of the Health Care Facility Code of Practice 2021.

Downloadable template

• Health Care Facility Annual Report Template

The Health Care Facility Code of Practice 2021 sets out the minimum standards required to operate a health care facility in the ACT. The Code of Practice aims to protect the community from the public health risks associated with the operation and management of health care facilities.

The Code of Practice is enforceable under the Public Health Act. Participation in the Australian Health Service Safety and Quality Accreditation Scheme and compliance with the National Safety and Quality Health Service Standards is required by the Code of Practice.
 

Standard 5.2 of the Health Care Facility Code of Practice 2021 provides that the following incidents must be notified to the Chief Health Officer:

• the transfer of a patient to another health care facility as a result of an injury sustained at the facility, or iatrogenic condition
• any critical incident that might reasonably place facility systems or its occupants (including staff) at risk (e.g. flood, fire, building or structural collapse, serious equipment failure or shortage, sustained power or water failure, etc)
• the unexpected death of any patient under the care of the facility
• any incident listed under the Australian Sentinel Events List.

Notification must take place within two business days. Health care facility licence holders should use the HCF Notifiable Incident Notification Form (licensed) and public health care facilities should use the Health Care Facility Incident Notification Form (non-licensable) to ensure they meet all notification requirements. A report must be prepared for the Chief Health Officer for notified incidents providing further details about the notifiable incident within 100 days of the incident occurring. Health care facility licence holders and public health care facilities should use the Notifiable Incident Review Report Template to ensure they meet all notifiable incident reporting requirements. 

It is strongly advised that health care facility licence holders and public health care facilities conduct a post 6-month investigation incident recommendations implementation review to determine whether the resulting incident investigation recommendations have been implemented and are effective. To assist health care facility licence holders with post incident reviews ACT Health have developed the following template Notifiable Incident Recommendations Implementation Report template.

For more information about notifiable incidents, refer to the Code of Practice.
 

Applicants and licensees are advised that ACT Health does not provide advice on the design, construction or operation of a health care facility, nor on the application of the National Safety and Quality Health Service (NSQHS) Standards. In line with their obligations under the Health Care Facility Code of Practice 2021, facility owners and operators should engage a suitably qualified and experienced person to provide advice and guidance on addressing risks associated with their facility.

Anyone seeking to construct or modify a health care facility is strongly encouraged to make early contact with the Environment, Planning and Sustainable Development Directorate and Access Canberra for specific information about the planning and construction of buildings in the ACT. 

An application for a Health Care Facility Licence can be submitted using any of the following: 

• online form
• by email to hps@act.gov.au
• by post to Health Protection Service, Locked Bag 5005, Weston Creek, ACT 2611; or

To update or change your licence details, please use the Health Care Facility Licence Variation form listed below.

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

Forms:

• Online licence application form
• Online licence variation form
• Online transfer of ownership form

Alternatively download these forms:

• Licence application form
• Licence variation form
• Transfer of Ownership Form

*The ACT categorisation of health care facility licence types as ‘day procedure’ or ‘hospital’ licences is separate and distinct from the definition of hospitals declared under the Private Health Insurance Act 2007 (Cwlth).

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

Telephone: 02 5124 9700 
Email: hps@act.gov.au
Postal address: Locked Bag 5005, Weston Creek ACT 2611.