NSQHS Standards assessment outcomes

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

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 2022.

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 189 146 139 77 39 20 7 6 2 625
Private hospitals 98 73 68 20 24 7 3 6 0 299
Day procedure services 118 107 55 36 20 14 1 12 0 363
Total 405 326 262 133 83 41 11 24 2 1,287

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