The NSW Ministry of Health Regulation and Compliance Unit monitors private health facilities to ensure compliance with the NSW licensing standards set by the:

The aim is to:

  • ensure the maintenance of appropriate and consistent standards of health care and professional practice in private health facilities and
  • ensure safe practice in the delivery of health care in private health facilities.

Compliance and enforcement policy

The Ministry of Health's compliance and enforcement policy adopts a staged, risk management approach to compliance and enforcement that identifies facilities at risk of non-compliance and enables the development of appropriate strategies to facilitate compliance. All facilities are assessed using a Regulatory Activity Rating System that enables decision making based on current evidence about the relationship between the consequences, the likelihood of a particular risk indicator and the effect on patient safety.

Risk identification

Six categories of risk indicators have been identified to facilitate the monitoring and control of risks affecting patient care and safety. The six categories are based on regulatory requirements in line with the Private Health Facilities Act and Regulation.

The risk indicator categories are:

  1. Licensing
  2. Governance / Management
  3. Environment
  4. Clinical care
  5. Quality improvement
  6. Compliance.

Risk assessment

The assessment process for the level of risk at a facility is based on the Australian and New Zealand Standard AS/NZS ISO 31000:2009, Risk management - Principles and guidelines. There are three main steps involved in the assessment process:

  1. Risk identification - using the risk indicators
  2. Risk analysis - determining the consequences and likelihood of the risk
  3. Risk evaluation - determining the level of risk

Each facility is assessed using a risk assessment tool. Based on the result of the assessment process each facility is given a risk rating of 1 (high), 2 (substantial), 3 (moderate) or 4 (low).

Monitoring activity

All facilities have an initial assessment and a level of risk assigned. At least annual reviews are conducted in all facilities to assess the appropriateness of the risk rating. Reassessment of the risk rating for a facility may also be required at other times where there are changes to a risk indicator.

Monitoring activities for facilities are based on the risk rating for the facility and aimed to ensure that the regulatory burden is appropriate to the risk. Where a facility scores a risk rating of 1 (high) a management plan will be developed that includes the changes required to reduce the risk rating and an onsite visit to monitor improvements at least three months from the date of the assessment. As the level of risk decreases the frequency of onsite visits will be decreased to three to six monthly, and then six to nine monthly or annually.

In addition to onsite visits, monitoring activities include paper audits, telephone contact and written correspondence. The type of audit conducted may be routine or may focus on a particular area. Regardless of the risk rating all facilities receive regular visits to ensure compliance with the NSW licensing standards.

After each audit a report is sent to the facility. The report may ask for improvements to be made. The Regulation and Compliance Unit continues to monitor each facility to follow up on the progress of these improvements. The risk level is reassessed as improvements are implemented.


It should be noted that the COVID 19 pandemic had a significant impact on the Ministry's ability to achieve performance within approved timeframes and to undertake private health facilities onsite visits.

In 2020 the private health facilities that were allocated a risk rating of 1 – 3 were continued to be monitored to ensure that their management plan was implemented.

Day procedure centres

There are currently 110 licensed Day Procedure Centres in New South Wales.

Private hospitals

There are currently 98 licensed private hospitals in New South Wales.

Current as at: Monday 4 March 2024
Contact page owner: Private Health Care