The Canberra Hospital has passed its accreditation after managing to turn around 33 core criteria it failed during an audit in March.
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The Australian Council on Healthcare Standards accredited ACT Health for the next three years.
In April, the council produced an at-times scathing interim accreditation report which identified 33 of 209 core criteria where standards were not met.
Some of these failed criteria were classified as "extreme risks", with particular concern about the hospital's ability to protect mental health patients.
It also outlined systemic problems around the governance system of the hospital.
The agency conducted a further survey at Canberra Hospital between July 3 and 5, reassessing the failed core actions.
"ACT Health has for some time been going through a significant churn at executive level with many in their roles less than 15 months," the final report read.
"There has been what the staff would consider a revolving door at senior levels and this has created a great deal of instability, turmoil and fragmentation of leadership."
But the assessors noted the "dramatic" changes that have happened within ACT Health in the three months after the interim report.
"They have moved from a fragmented divided organisation to one of cohesion, teamwork, focused on what is best for the patient and the organisation to achieve great outcomes for all Canberrans," it read.
"The engagement and ownership of the problems and solutions to the recommendations by staff at all levels was clearly demonstrated to the surveyors.
"This has been no mean feat and everyone needs to recognise this achievement in a positive productive light.
"This work will need to be sustained but the surveying team felt the systems and processes put in place over the last few months, will assist staff and the leader’s confidence to drive towards excellence and safety in all patient care services."
The final report outlined three "not mets" within the "developmental" criteria, which are separate from the 209 core criteria which must be met.
The "not mets" were related to the need for an open disclosure program following an internal investigation and the lack of evidence of consumers and/or carers participating in the governance of the organisation.
Minister for Health and Wellbeing Meegan Fitzharris said the decision to re-accredit ACT Health for a further three years was a strong endorsement of the culture and values demonstrated by the organisation in recent months.
“Developing a high performing culture where people feel valued and are able to contribute and build effective partnerships is a high priority for ACT Health’s leadership,” she said.
“As it moves towards its transition into two organisations on 1 October, ACT Health is focused on building a cohesive, values-based environment where collaboration can thrive."
Minister for Mental Health Shane Rattenbury noted that the report found that the Mental Health Division had “demonstrated outstanding improvements,” and were “applauded for adopting, innovative approaches to creating a sustainable system of the production of timely patient discharge summaries.”
“These efforts demonstrate the enduring commitment and dedication of our mental health staff in delivering quality patient care,” he said.
Both Ms Fitzharris and Mr Rattenbury acknowledged the significant work of ACT Health staff to achieve accreditation.
“Staff have stepped up to this challenge, demonstrating outstanding commitment to the delivery of safe and effective care to the Canberra community,” Ms Fitzharris said.
