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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 November 2024.

Almost all of the 1,312 hospitals and day procedure services have been assessed to the second edition of the NSQHS Standards. 65% of assessments resulted to requirements met at initial assessment.

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	299	252	230	147	125	41	13	8	4	1,119
Private hospitals	184	116	107	24	42	9	5	13	-	500
Day procedure services	217	174	110	68	34	25	2	21	-	651
Total	700	542	447	239	201	75	20	42	4	2,270

¹Other: Indian Ocean Territories Health Service

A 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.

Not awarded accreditation: 1; mandatory repeat assessments: 72; significant risks: 24

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.

The Clinical Governance Standard has the lowest proportion of assessments that fully complied with the standard at 39%.

*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 151 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.

Actions most frequently rated as improvements were required or recommended

Safety and quality training is the action that was most frequently rated not met or met with recommendations.

Find more in our resource library

NSQHS Standards (second edition)