Understanding Clinical Care Standards in conjunction with your NSQHS Standards requirements 

The Clinical Care Standards developed by the Australian Commission on Safety and Quality in Health Care (the Commission) provide consistent guidance on best practice for specific conditions, or health pathways. They aim to reduce any unwarranted variation to support safer, high-quality care by describing the care that people can expect to be offered for a specific clinical condition, treatment, procedure or clinical pathway wherever they are treated in Australia.

Each Clinical Care Standard includes a small number of key quality statements that describe what care should be provided and the indicators to monitor performance. They support patients in understanding care options, clinicians in the application of evidence-based practice, and health services in monitoring and improving care.

How do the Clinical Care Standards relate to NSQHS Standards?

During the NSQHS Standards accreditation process, assessors evaluate how your health service is implementing the Clinical Care Standards to support compliance with the NSQHS Standards.

Although Clinical Care Standards are not accreditation standards, their implementation is used as a supporting tool to demonstrate how health services are meeting several actions within the NSQHS Standards:

• Action 1.01c – Setting clinical priorities and monitoring outcomes
• Action 1.27b – Supporting evidence-based clinical care
• Action 1.28 – Monitoring and addressing variation in care

There are also three mandatory Clinical Care Standards that apply to specific services which include:

• Antimicrobial Stewardship (Action 3.18d)
• Delirium (Action 5.29a)
• Colonoscopy (per Advisory AS18/12)

Health services should also implement other relevant Clinical Care Standards based on risk factors, service scope, and quality improvement priorities.

How assessors evaluate the implementation of Clinical Care Standards during your NSQHS Standards assessment 

When your health service undergoes the NSQHS Standards accreditation process, your assessment team will look for a range of evidence that demonstrates how the service is incorporating Clinical Care Standards into your practice. According to the Commission’s guidance, assessors will review the following:

• Implementation of mandatory Clinical Care Standards as designated by the Commission (Antimicrobial Stewardship, Delirium, and Colonoscopy): by complying with these mandatory Clinical Care Standards, you are also addressing corresponding NSQHS Standards actions.
• Identification and application any other relevant standards to your services: besides the mandated Clinical Care Standards, assessors expect your service to have considered other Clinical Care Standards that might be relevant to the scope of care you provide. In practice, it means you should review the list published by the Commission, determine which ones apply to your clinical services and patient population, and incorporate their recommendations into your practice to improve quality and safety.
• Development of protocols aligned with Clinical Care Standards’ quality statements: assessors will look for evidence that your internal policies, protocols, or care pathways are aligned with the relevant quality statements of the Clinical Care Standards.
• Access to standards and supporting resources: assessors will expect clinicians to have easy access to the Clinical Care Standards and any other supporting resources and tools.
• Use of Clinical Care Standards indicators to monitor care and drive improvement: assessors will expect your service to use data to monitor how effectively you’re implementing the Clinical Care Standards to support ongoing improvement. Each Clinical Care Standard includes indicators that reflect whether the care described in the quality statement is being delivered. The use of these indicators is not mandatory, but it is recommended by the Commission.
• Regular review and governance oversight: assessors will expect that the implementation of Clinical Care Standards is regularly reviewed as part of your clinical governance process. Health service organisations should periodically assess their progress in implementing these standards.

It’s important to note that although the Clinical Care Standards are not assessed as a standalone requirement, they are evaluated as part of broader compliance with relevant actions under the NSQHS Standards. By embedding Clinical Care Standards into your practices, the services are better positioned to meet the NSQHS Standards accreditation requirements.

Tips to support you in preparing for your accreditation assessment 

We know there’s numerous moving parts when preparing for accreditation. Here’s a few suggestions to support your health service with implementing the key requirements of the Clinical Care Standards:

• Map which Clinical Care Standards apply or are relevant to your services
• Review internal protocols against mandatory standards
• Engage with your clinicians early to help them with implementation and feedback
• Document any necessary implementation actions and monitor progress

For detailed guidance on Clinical Care Standards please refer to the Commission’s website

If you have any questions or need support regarding the Clinical Care Standards in conjunction with your NSQHS Standards accreditation, please reach out to our Client Liaison Team via email info@qip.com.au or by calling 1300 362 111 – they’re more than happy to assist.