Assessment in action: what an NSQHS Standards assessment looks like on the ground

For health services preparing for assessment against the National Safety and Quality Health Service (NSQHS) Standards, there can be a natural tendency to focus on the assessment itself: the evidence to prepare, the timetable to organise and the questions staff might be asked.

But what does an assessment actually look and feel like once the assessment team arrives?

During Tasmania Health Service – Southern Region’s QIP assessment from 10-14 August 2026, the assessment team spent five days seeing how the health service’s quality and safety systems translated into everyday practice.

For Mary Jane Emmerton, Executive Director Quality and Patient Safety at Tasmania Health Service – Southern Region, the experience reinforced a simple message for other health services: assessment doesn’t need to become something separate from the quality and safety work happening every day.

She described the assessment as a ‘pulse check’ on business as usual, encouraging health services to tell assessors about the good things they are doing and allow the teams to shine.

The focus on showcasing quality and safety in everyday practice was evident throughout the week.

 

About Tasmania Health Service – Southern region

Tasmania Health Service – Southern Region operates across eight sites in and around Hobart, including the Royal Hobart Hospital, Peacock Building, J W Whittle Palliative Care Unit, Aged and Rehabilitation Services, Nephrology South at St Johns New Town, Midlands Multi-Purpose Health Centre, Cambridge Food Services and New Norfolk District Hospital.

Across these settings, services range from acute hospital and emergency care to specialist medical and surgical services, mental health, palliative and aged care, rehabilitation, renal and community health services, allied health, child and family health, diagnostic imaging, outpatient clinics, and patient food and nutrition services.

The Southern Region has around 500 inpatient beds and an estimated 88,000-92,000 hospital admissions each year.

The five-day assessment covered a broad range of services and settings, providing insight into how quality and safety systems were understood and applied across the health service. Moving across such a broad range of services and settings gave the assessment team the opportunity to see how quality and safety systems were understood and applied across the health service.

 

Preparing without over-preparing

Preparation matters, but Mary Jane’s advice is to keep it simple.

“Don’t overcomplicate for the team. Assessors are just a fresh set of eyes,” Mary Jane said.

The focus can instead be on helping people understand the Standards and feel confident talking about the systems and processes they work with every day. That can also make the experience less stressful.

“The more you normalise the process, the less stressful it is for staff.”

As a result of being well prepared, Mary Jane added that the health service team responded positively to the assessment and noted that staff particularly appreciated hearing from an assessor that their openness was valued.

Mary Jane’s advice to another health service preparing for assessment is: “Embrace the experience and welcome the assessor team. Value the opportunity to have a fresh set of eyes and keep the relationship between QIP and your health service collegial and collaborative.”

 

What assessors are looking for

That ‘fresh set of eyes’ becomes particularly useful when we look at the assessment from the assessor side.

For QIP Assessment Team Leader Stuart MacKinnon, consistency in how quality and safety are understood, applied and reflected in everyday practice is one of the clearest signs that they are truly embedded across an organisation.

Evidence is part of establishing that picture, and preparation before the assessment helps set the organisation and assessment team up for a productive week. Stuart highlights three important elements of effective preparation: uploading evidence against the relevant Standards and actions, ensuring staff across the health service understand and are engaged in the accreditation process, and working with the Assessment Team Leader to develop a timetable that reflects the organisation’s needs.

But the assessment goes beyond that preparation and the evidence submitted. Once on site, assessors seek to understand how the systems and processes described in the evidence are understood and applied in everyday practice.

Assessors talk with staff about what they do, their roles and responsibilities around quality and safety, and the processes that support their work. They look at areas such as audits and mandatory training, observe practice and ask people to demonstrate how systems actually operate.

Stuart sums it up simply by asking, “Show me what you do.” And his advice about preparing is similarly uncomplicated. Stuart advises that QIP is assessing the NSQHS Standards – nothing more, so you should prepare accordingly and educate staff on how the Standards apply to their job.

The objective isn’t for every staff member to memorise an answer for assessment week. It is for the systems and processes being assessed to be understood and consistently applied, so people can talk about what they do and demonstrate it in practice.

 

Seeing quality and safety in practice

At Tasmania Health Service – Southern Region, the assessment team spent much of the assessment in clinical areas, observing quality and safety systems in practice

The assessment included conversations with consumers and staff, high-risk scenarios and patient journeys, as well as visits to wards, departments and sites. Assessors also met with the Executive Group to discuss clinical governance recognising that quality and safety are shared responsibilities across the health service.

These activities gave the assessment team opportunities to see examples of quality and patient safety in practice across the health service.

One example of patient safety in practice was the Jack Jumper Clinic, where venom desensitisation is used for people with anaphylactic reactions to jack jumper ant venom. Treatment takes place over an extended period, with the clinic also working with honeybee and yellow jacket wasp allergies.

The consumer perspective was also incorporated into the process through a consumer walk-through, which identified opportunities for improvement.

Together, these activities show why an NSQHS Standards assessment involves more than checking that the right documents are in place. Through conversations, observations and evidence, assessors gain an understanding of how systems and processes are applied and experienced across the health service.

 

Seeing the assessment team at work

While the health service and assessment team were at the centre of the week, two QIP team members also had the opportunity to observe the assessment process: Shirlee Nichols, National Manager, Clinical Services Accreditation, and Lachlan Martin, Client Relationship Officer (pictured above on assessment).

One of the things that stood out to Shirlee and Lachlan was the collaboration within the assessment team.

Assessors came from different locations and brought different skills and knowledge but worked cohesively as a team. They reviewed evidence, liaised with the health service and complemented one another when interviewing staff and consumers.

They also valued the way the assessment process was managed, with activities progressing smoothly and evidence reviewed responsively throughout the assessment.

For the health service, that means assessment is not simply a sequence of separate interviews or observations. Together, these activities help the assessment team build a broader picture of how the organisation is performing against the Standards.

The assessors are also highly visible while they are on site. As Shirlee and Lachlan noted, during an assessment they become the ‘face of QIP’ for the people they meet.

 

What other health services can take from the experience

The NSQHS Standards provide the framework. Assessment is where that framework meets the everyday work of a health service.

Documents and evidence matter. So do governance arrangements, audits, training and communication. But assessment also gives assessors an opportunity to understand what happens in practice – what staff understand, what consumers experience and how consistently systems and processes are applied across the organisation.

For health services approaching their own assessment, the experience at Tasmania Health Service – Southern Region offers some practical lessons:

• Know the Standards.
• Help staff understand how they connect with their roles.
• Prepare evidence that relates to the relevant Standards and actions.
• Communicate about accreditation across the organisation.
• Work with your QIP Client Relationship Officer to develop a timetable that works for your service.

And, as Mary Jane advises, “embrace the experience.”

Rather than treating assessment as something separate from quality and patient safety, it can be an opportunity to let your teams shine, talk openly about the work they do and welcome a fresh set of eyes.

Find out more about QIP accreditation against the NSQHS Standards.