NSQHS Standards: Lessons learnt

Lessons learnt from the assessment of health service organisations to the National Safety and Quality Health Service (NSQHS) Standards.

NSQHS Standards assessment outcomes

The figures below provide information on the number and percentage of Australian hospitals and day procedure services that have completed assessments to the second edition of the National Safety and Quality Health Service (NSQHS) Standards. The reporting period commenced in January 2019.  

The following data includes finalised assessments for all Australian hospitals and day procedure services up to October 2021.

Data includes finalised assessments for all Australian hospitals and day procedure services.

Number of assessments to the NSQHS Standards by state and territory, by sector and facility type.

Sector and facility type NSW Vic Qld SA WA Tas NT ACT Other1 Total
Public hospitals 58 98 80 68 33 8 5 2 2 354
Private hospitals 62 43 35 13 17 3 2 3 - 178
Day procedure services 69 64 37 27 21 8 1 8 - 235
Total 189 205 152 108 71 19 8 13 2 767

1Other: Indian Ocean Territories Health Service

mandatory re-assessment is required when the outcome of the initial assessment shows a large number of actions in the NSQHS Standards require improvements. Health service organisations must implement improvements to comply with the NSQHS Standards to be awarded accreditation. There is a further assessment to ensure the changes are embedded in the organisation’s daily practice.

Significant risks are notified to the Australian Commission on Safety and Quality in Health Care (the Commission) when an assessor identifies a situation that could result in significant harm to patients. These risks must be reported and addressed within 48 hours.

Number of mandatory re-assessments and significant risks

Assessment data by standard

The graph below shows the outcome of the initial assessment by standard. For each standard, the percentage is calculated as the proportion of assessments per rating over total number of assessments.

Outcome at initial assessment by standard

*Preventing and Controlling Infections   **Recognising and Responding to Acute Deterioration

What is the rating scale used by assessors?

The NSQHS Standards are made up of 148 actions across the eight Standards. Each action is awarded a rating after assessment. The rating scale is as follows:

  • Met - The action was fully met. These actions are represented in dark blue on the bar graphs.
  • Improvements were recommended - The requirements of the action were largely met, with minor improvement recommended. These actions are represented in medium blue on the bar graphs.
  • Improvements required - Part or all of the requirements of the action were not met. Improvements had to be completed before accreditation was awarded. These actions are represented in light blue on the bar graphs.
  • Not applicable - The action was not relevant to the organisation. These actions are represented in light grey on the bar graphs.
  • Not assessed - The action was not assessed. This can occur in short-notice assessments when only three or four Standards are assessed at a time. These actions are represented in dark grey on the bar graphs.

Actions most frequently rated as improvements were required or recommended

Actions most frequently rated as improvements were required or recommended

Lessons learnt

Amendments to the Preventing and Controlling Infections Standard

The 2021 Preventing and Controlling Infections Standard was developed to further support health service organisations to prevent, control and respond to infections that cause outbreaks, epidemics or pandemics, including novel and emerging infections.

The key driver for revision of the 2017 standard was gaps and uncertainties that arose during the response to COVID-19. Issues identified by clinicians and health service
organisations included better support to respond to airborne transmission of COVID-19, particularly the concerns of healthcare workers; the importance of a precautionary
approach to infection prevention and control, based on risk assessment and management; and guidance regarding management of infections in healthcare workers, and outbreak response and planning.

The intention of 2021 Preventing and Controlling Infections Standard is to:

  • Reduce the risk of patients acquiring preventable infections in healthcare settings
  • Effectively manage infections if they occur; and
  • Limit the development of antimicrobial resistance through the appropriate use of antimicrobials, as part of antimicrobial stewardship.

The Commission anticipates that most health service organisations will find they are already meeting the requirements of the 2021 Preventing and Controlling Infections
Standard.

A mapping factsheet and other resources and guides are available. Accreditation assessment against the revised standard will commence in January 2022.