Preparing for an assessment to the NSQHS Standards

There are four major steps when preparing for an assessment which include:

  • Getting to know the NSQHS Standards
  • Allocating resources and coordinating implementation
  • Selecting an accrediting agency
  • Conducting a self-assessment and gathering evidence.

Step 1: Getting to know the NSQHS Standards

Health service organisations should familiarise themselves with the NSQHS Standards and how they will be applied.

Not applicable criteria or actions

For some health service organisations, criterion or action from the NSQHS Standards may be classified as not applicable. Not applicable actions are those that are inappropriate in a specific service context or for which assessment would be meaningless. An Advisory has been issued to clarify not applicable actions for health service organisations, which covers the following service areas: 

  • Hospitals
  • Day procedure services
  • Multi-purpose services
  • Bush nursing services
  • Patient transport services
  • Public dental services.

Related links:

Step 2: Allocating resources and coordinating implementation

Implementing the NSQHS Standards requires a whole-of-organisation approach with engagement from the workforce across the health service organisation. Effective implementation requires:

  • Organisations to take a risk management and quality improvement approach to all aspects of the health services and standards implementation. For example, using the COVID-19 infection prevention and control risk management.

  • Robust clinical governance systems to be in place
  • The involvement of leaders at the governance, management and clinical levels
  • Patient safety and quality of care to be considered in all relevant business decision making
  • Regular safety and quality reporting to the governing body, management, clinicians and consumers 
  • Partnerships with consumers in their own care and the governance of the organisation. 

Step 3: Selecting an accrediting agency

Health services organisations need to engage an approved accrediting agency to conduct their assessment to the NSQHS Standards.

The Commission approves accrediting agencies to assess health service organisations to the NSQHS Standards. These approved accrediting agencies are accredited by an internationally recognised body, such as the International Society for Quality in Health Care (ISQua) or the Joint Accreditation Scheme of Australia and New Zealand (JAS-ANZ).

Step 4: Conducting a self-assessment and gathering evidence

Health service organisations should complete a self-assessment of their current safety and quality systems and processes using the NSQHS Standards. Information gathered during the self-assessment process can be used to inform a plan or pathway to implement the NSQHS Standards. The process should include:

  • Identification of sources of evidence available to demonstrate actions have been met
  • Identification of areas where actions are not met and where improvements are required
  • Action plans to cover any identified gaps, allocate responsibilities and set timeframes for improvement

Health service organisations should conduct periodic self-assessments throughout their accreditation cycle to ensure quality improvement activities are targeted in the required areas. The NSQHS Standards monitoring tools allows health service organisations to track their progress in implementing the NSQHS Standards, including PICMoRS assessment methodology.

NSQHS Standards monitoring tools

These monitoring tools allow health service organisations to track their progress in implementing the NSQHS Standards. It should be used together with the relevant NSQHS Standards guide and the accreditation workbook

Audit, monitoring or reporting tool
Audit, monitoring or reporting tool
Audit, monitoring or reporting tool

Video tutorials for the monitoring tools

Two video tutorials are available to assist health service organisations with using the tool.

Episode 1 covers the features and functionalities of the tool (approx. 16 minutes)

Episode 2 provides tips on how health service organisations can use the information in the monitoring tool (approx. 14 minutes)

Health service organisations are required to participate in an external assessment by an approved accrediting agency to verify that they have met each of the actions in the NSQHS Standards. The timing and requirements of the assessment will be determined by the selected accrediting agency but usually include the submission of a self-assessment followed by an onsite survey or audit.

All hospitals and day procedure services are required to undergo external assessment. They should be implementing strategies to ensure they comply with the requirements in the NSQHS Standards. Assessments should occur at least four months before their current accreditation expires. This will allow sufficient time for remediation if it is required.