Emerging trends in NSQHS Standards assessments

The Australian Commission on Safety and Quality in Health Care (the Commission) has recently published assessment outcomes data for hospitals and day procedures.

The findings show that most health services continue to meet the National Safety and Quality Health Service (NSQHS) Standards, reinforcing the important role accreditation plays in supporting high quality and safe care. The findings also highlight common areas where services experience challenges, providing valuable insight into opportunities for improvement across governance, infection control and medication safety systems.

The published outcomes reflect a strong national focus on transparency, accountability and continuous quality improvement across the health sector.

Areas of strong performance

Services continue to demonstrate strong performance across several standards including:

• Blood Management
• Partnering with Consumers
• Recognising and Responding to Acute Deterioration

These areas reflect well-established systems and processes that are embedded into routine care, safety and quality improvement.

Common challenges and non-compliances in NSQHS Standards assessments

Across assessments, diverse standards are identified as common challenges, showing up as consistent areas where gaps are identified:

Clinical Governance
Clinical Governance underpins all NSQHS Standards and requires organisation-wide systems to ensure safe and high-quality care. Common non-compliances relate to the following criteria:

• Clinical performance and effectiveness – relating to effective workforce performance and oversight processes
• Safe environment for the delivery of care – related to design environment and infrastructure that is fit for purpose

Infection Prevention and Control
The Preventing and Controlling Infections Standard requires health service organisations to have systems in place to reduce the risk of healthcare-associated infections and support antimicrobial stewardship. In this standard, most non-compliances are:

• Infection prevention and control systems
  • Demonstrating a risk-based workforce screening and immunisation program for vaccine-preventable diseases
  • Providing evidence for an effective hand hygiene program integrated within the broader infection prevention and control program
• Reprocessing reusable equipment and devices – presenting sufficient evidence that there are processes in place that are consistent with Australian and international standards as well as a traceability process for equipment, instruments and devices

Medication Safety
The Medication Safety Standard focuses on ensuring safe and effective use of medicines, recognising the complexity of medication management across prescribing, dispensing and administration. Non-compliances for this standard focus on these criteria:

• Medication management processes
  • Relating to managing high-risk medications and evidence of how they are stored, prescribed and dispensed
  • Complying with requirements for safe storage, temperature monitoring, cold chain management and disposal of medicines
• Documentation of patient information
  • Showing adequate medication history documentation in healthcare records
  • Presenting evidence of a structured process to ensure that patients receive accurate and timely medication reconciliation on admission, at transfer of care and on discharge

Key recurring themes

There are various themes that are recurring in assessment outcomes, including:

• Gaps in governance oversight and documentation
• Variability in risk management and reporting systems
• Inconsistencies in medication management processes
• Ongoing challenges in infection control practices

These themes reflect the importance of organisation-wide systems that support safety and quality, as outlined in the NSQHS Standards.

What this means for services

For health service organisations, these findings reinforce the importance of moving beyond documented policies to demonstrated practice. Key areas of focus include:

• Strengthening governance frameworks, including clear roles, responsibilities and committee effectiveness
• Ensuring infection prevention and control systems are consistently applied and supported by surveillance and risk management processes
• Reviewing medication safety systems to ensure safe, standardised practices across medication management systems
• Providing clear, accessible evidence that shows how systems are implemented, monitored and continuously improved

A strong performance against the NSQHS Standards relies on systems that are consistently implemented across the organisation. By addressing these common areas of non-compliance and strengthening governance, infection control and medication safety systems, services can improve both accreditation outcomes and the quality of patient care. As we continue reviewing the Commission’s assessment outcomes data, we’ll share further insights and practical strategies to help health services address recurring challenges and strengthen compliance.