Resources for the NSQHS Standards

The Australian Commission on Safety and Quality in Health Care (the Commission) has developed resources to assist health service organisations align their patient safety and quality improvement programs using the framework of the National Safety and Quality Health Service (NSQHS) Standards.

NSQHS Standards

The second edition of the NSQHS Standards was endorsed by Health Ministers in June 2017 and released in November 2017. This document contains the NSQHS Standards, criteria and actions. The Commission has not printed hard copies of this booklet. Files for commercial printing are available upon request.

Addendum and amendments

Clarification of the use of the term ‘cultural competency’

Updated 12 November 2020

Action 1.21 in the NSQHS Standards refers to improving cultural competency. It should be noted that the use of the term ‘cultural competency’ is not at the exclusion of the term ‘cultural safety’. The two terms complement each other rather than being mutually exclusive. The Commission uses the following definitions for the terms:

  • Cultural competency: A set of congruent behaviours, attitudes and policies that come together in a system, agency or among professionals to enable that system, agency or those professionals to work effectively in cross-cultural situations.1
  • Cultural safety: Identifies that health consumers are safest when health professionals have considered power relations, cultural differences and patients’ rights. Part of this process requires health professionals to examine their own realities, beliefs and attitudes. Cultural safety is not defined by the health professional, but is defined by the health consumer’s experience—the individual’s experience of care they are given, ability to access services and to raise concerns. The essential features of cultural safety are: a) An understanding of one’s culture b) An acknowledgment of difference, and a requirement that caregivers are actively mindful and respectful of difference(s) c) It is informed by the theory of power relations; any attempt to depoliticise cultural safety is to miss the point d) An appreciation of the historical context of colonisation, the practices of racism at individual and institutional levels, and their impact on First Nations people’s living and wellbeing, both in the present and past e) Its presence or absence is determined by the experience of the recipient of care and not defined by the caregiver.1

In the next iteration of the NSQHS Standards and guides this language will be amended in partnership with the Aboriginal and Torres Strait Islander communities.

1National Aboriginal and Torres Strait Islander Health Standing Committee of the Australian Health Ministers' Advisory Council (2016). Cultural respect framework 2016-2026 for Aboriginal and Torres Strait Islander health. Canberra, AHMAC.

Definition of diversity

Superseded: The varying social, economic and geographic circumstances of consumers who use, or may use, the services of a health service organisation, as well as their cultural backgrounds, religions, beliefs, practices, languages spoken and sexualities (diversity in sexualities is currently referred to as lesbian, gay, bisexual, transgender and intersex, or LGBTI). 

Updated 14 April 2020: The varying social, economic and geographic circumstances of consumers who use, or may use, the services of a health service organisation, as well as their cultural backgrounds, disability status, religions, beliefs and practices, languages spoken, sexual orientation, gender identity and gender expression, and sex characteristics.

Definition of My Health Record

Superseded: My Health Record (formerly known as a personally controlled electronic device): the secure online summary of a consumer’s health information, managed by the System Operator of the national My Health Record system (the Australian Digital Health Agency). Clinicians are able to share health clinical documents to a consumer’s My Health Record, according to the consumer’s access controls. These may include information on medical history and treatments, diagnoses, medicines and allergies.

Updated 14 April 2020: My Health Record: the secure online summary of a consumer’s health information, managed by the System Operator of the national My Health Record system (the Australian Digital Health Agency). Clinicians are able to share health clinical documents to a consumer’s My Health Record, according to the consumer’s access controls. These may include information on medical history and treatments, diagnoses, medicines and allergies.

User guides for the NSQHS Standards

The user guides are designed to support health service organisations improve the safety and quality of care they provide by using the NSQHS Standards as a framework for improvement. The Commission has not printed hard copies of these user guides . Files for commercial printing are available upon request.

2018
Guide, user guide or guidelines

2017
Guide, user guide or guidelines

2017
Guide, user guide or guidelines

2019
Guide, user guide or guidelines

Workbooks, risk matrices and monitoring tools

Accreditation workbook

This workbook contains examples of evidence and reflective questions for each of the actions in the NSQHS Standards to help health service organisations prepare for an assessment.

2017
Audit, monitoring or reporting tool

Risk matrices

These matrices are designed to provide health service organisations with a framework to assess and address risks in their organisation.

2014
Guide, user guide or guidelines

2018
Guide, user guide or guidelines

2018
Guide, user guide or guidelines

Monitoring tools

These monitoring tools allow health service organisations to assess current status of implementation of the NSQHS Standards and then track their progress towards full implementation. These tools should be used together with the relevant NSQHS Standards guide, fact sheets and the accreditation workbook.

2017
Audit, monitoring or reporting tool

2017
Audit, monitoring or reporting tool

Video tutorials for the monitoring tools

Two video tutorials are available to assist health service organisations with using the monitoring 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)

NSQHS Standards advisories

An NSQHS Standards advisory is a formal communication from the Commission to accrediting agencies to provide guidance and direction on the interpretation and/or assessment of the NSQHS Standards. The NSQHS Standards advisories are routinely reviewed to ensure they remain current. Any changes to any advisory are summarised in the notes section of the advisory’s cover sheet.

Rescinded advisory for the NSQHS Standards 

  • AS18/03Assessments from October 2018 to the second edition of the National Safety and Quality Health Service Standards

NSQHS Standard fact sheets

Fact sheets have been developed to provide health service organisations with more information relating to specific topic areas in the NSQHS Standards.

2017
Fact sheet or brochure

Fact sheets about the AHSSQA Scheme

These fact sheets outline the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme processes for health service organisations:

2020
Fact sheet or brochure

2020
Fact sheet or brochure

Rescinded fact sheet for the AHSSQA Scheme

  • Fact Sheet 2: Transition Arrangements for Assessments in 2019
  • Fact Sheet 13: Implementing the Aboriginal and Torres Strait Islander specific actions (superseded by Advisory AS18/04)

Fact sheets for consumers

These fact sheets are designed to provide consumers with an overview of the NSQHS Standards, accreditation and the Partnering with Consumers Standard.

The National Model Clinical Governance Framework and fact sheets

This guide provides a consistent national framework for clinical governance that is based on the NSQHS Standards. The Commission has not printed hard copies of this booklet. Files for commercial printing are available upon request.

2017
Publication, report or update

2019
Guide, user guide or guidelines

These two-page fact sheets identify the clinical governance roles and responsibilities of doctors, managers and clinician managers, and nurses and midwives:

2017
Fact sheet or brochure

2017
Fact sheet or brochure

Resources for medication management in cancer care

NSQHS Standards User Guide for Medication Management in Cancer Care was developed to support health service organisations involved in any part of the medication management of anticancer medicines to implement the National Safety and Quality Health Service (NSQHS) Standards.

User guides

Fact sheets for clinicians

Monitoring tool

2020
Audit, monitoring or reporting tool

Fact sheets for consumers

NSQHS Standards logo and icons

Health service organisations may brand locally developed resources with the NSQHS Standards logo and icons. The images are available upon request.

AHSSQA Scheme report and literature reviews

The Commission developed six strategies to improve the AHSSQA Scheme’s reliability and to more accurately assess an organisation’s compliance with the NSQHS Standards. The changes are detailed in this document.

As part of identifying strategy to improve the veracity of health service organisation assessments, the Commission contracted four literature, including:

2017
Publication, report or update

2017
Publication, report or update

The impact of the NSQHS Standards

The Commission produced the National Safety and Quality Health Service (NSQHS) Standards Impact Report to provide an overview of the changes associated with implementation of the first edition of the NSQHS Standards; a ground-breaking initiative that has improved the safety and quality of health care across Australia. The report  identifies areas where improvements have been made, as well as where further work is needed. It also documents associations between the implementation of the NSQHS Standards and improvements in healthcare processes and outcomes, and demonstrates that the scale and range of the associated improvements are significant. 

Mapping of the first and second editions

This document maps the actions from the first edition of the NSQHS Standards to the second edition. Some actions from the first edition map to more than one action in the second edition, and some second edition actions have new components and actions from the first edition. There are 50 new actions in the second edition.

Live literature searches

The live literature searches can be used to find evidence to support best practice in line with Australian National Safety and Quality Health Service Standards.

NSQHS Standards (first edition) resources for private dental practices

Private dental practices are currently assessed against the first edition of the NSQHS Standards. This arrangement will continue until the National Safety and Quality Primary Healthcare (NSQPH) Standards become available.

NSQHS Standards (first edition) fact sheets

Safety and quality improvement guides for private dental practices

Guides for private dental practices

2013
Guide, user guide or guidelines

2015
Guide, user guide or guidelines

Monitoring tool for private dental practices

NSQHS Standards (first edition) advisories

Superseded advisories 

  • Advisory A13/01: Notification of significant risk (superseded by Advisory AS18/09)
  • Advisory A15/01: Transitioning between accrediting agencies (superseded by Advisory AS18/05)
  • Advisory A16/01: Accreditation assessment requirements of health service organisations post significant clinical or governance review (superseded by Advisory AS18/06)
  • Advisory A16/03: Reprocessing of reusable medical devices in health service organisations (superseded by Advisory AS18/07)
  • Advisory A17/01: Antimicrobial stewardship (superseded by Advisory AS18/08)

Rescinded advisories

  • Advisory A12/01: Hand hygiene programs
  • Advisory A13/02: Interim accreditation of new health services
  • Advisory A13/04: Collection and reporting of accreditation evidence by accrediting agencies
  • Advisory A13/05: Assessment of training requirements for credentialed medical and other clinical practitioners and visiting medical officers
  • Advisory A13/07: Advice provided to accrediting agencies on not applicable actions
  • Advisory A13/08: Transition arrangements from 2014
  • Advisory A14/01: Assessment of developmental actions in the National Safety and Quality Health Service Standards
  • Advisory A14/02: Pre-admission requirements and responding to patient deterioration in small health facilities
  • Advisory A15/02: Advance care directive assessment requirements in low risk environments
  • Advisory A16/02: Application of the requirements for general observation charts
  • Advisory A16/04: Medication management plan

Other resources for private dental practices