Summary of advisories, fact sheets and guides
The Commission develops resources to support implementation and assessment of Safety and Quality Standards as part of the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme.
This page summaries links between NSQHS Standards advisories, fact sheets and primary NSQHS Standards actions. It outlines the intent, timeframes and requirements for health service organisations. The referenced dates relate to the most current published versions. Version control cannot be guaranteed when this document is printed.
NSQHS Standards advisories provide formal guidance and direction on the interpretation and/or assessment of the National Safety and Quality Health Service (NSQHS) Standards. Fact sheets provide health service organisations with information relating to specific topic areas in the NSQHS Standards and guidance on accreditation assessment under the requirements of the AHSSQA Scheme.
Clinical Governance Standard
| Action(s) | Advisory | Fact sheet | Guide | Intent | Requirements |
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| 1.01 | NSQHS Standards Roles and responsibilities for governing bodies (Published 2019) |
National Model Clinical Governance Framework (Published 2017)
NSQHS Standards User guide for governing bodies (Published 2019) |
The National Model Clinical Governance Framework provides a consistent national framework for clinical governance that is based on the National Safety and Quality Health Service Standards |
The Governing body must endorse and monitor the organisation’s clinical governance framework | |
| 1.01 | National Clinical Trials Governance Framework and User Guide (Published 2022) | The National Clinical Trials Governance Framework and user guide for health service organisations conducting clinical trials builds on the National Model Clinical Governance Framework and the National Safety and Quality Health Service (NSQHS) Standards, in particular, the Clinical Governance Standard and the Partnering with Consumers Standard. | The National Clinical Trials Governance Framework provides information about each component and relevant action within the NSQHS Standards and the roles and functions of identified positions relating to clinical trial service provision. | ||
| 1.01 1.02 |
Fact Sheet 7: Governing body attestation statement (Published 2024) | NSQHS Standards User guide for governing bodies (Published 2019) | The Governing body provides leadership and must assure itself that a culture of safety and quality improvement, exists within the organisation. Attesting is a formal process. It involves authorised officers of a health service organisation confirming compliance, in this case to the NSQHS Standards. |
Attestation statements must be submitted annually between July and September | |
| 1.01 | NSQHS Standards Checklist for assessors - Reviewing information accessed and actioned by the governing body (Published 2021) | It is a responsibility of management to ensure that the governing body is provided with the information it requires to be assured of the safety and quality of its health services. Governing bodies must have regular access to data that are timely, reliable, comprehensive and suitable to their use |
This checklist will assist assessors when reviewing meeting minutes and other documentation during an assessment of clinical governance in a health service organisation. It provides a guide to the types of data that governing bodies should be reviewing. |
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AS18/04: Advice on Aboriginal and Torres Strait Islander specific actions (Version 3.0. April 2020) AS18/01: Advice on not applicable actions (Version 9.0. July 2021) |
NSQHS Standards Identifying Aboriginal and Torres Strait Islander people (Published 2019) | NSQHS Standards User guide for Aboriginal and Torres Strait Islander health (Published 2017) |
The NSQHS Standards include six defined actions that specifically address the needs of Aboriginal and Torres Strait Islander peoples.
The implementation of these actions will support the provision of culturally appropriate care to Aboriginal and Torres Strait Islander peoples across the health system. |
Links with the submission of the annual attestation statement. Organisations seeking exemption for any of these actions must demonstrate that a
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| 1.12 |
The Australian Open Disclosure Framework (Published 2014)
Open Disclosure - Templates and tools for clinicians and health service organisations (Published 2019) |
The Australian Open Disclosure Framework provides a nationally consistent basis for communication following unexpected health outcomes and harm. | The Clinical Governance Standard requires health service organisations to use an open disclosure program that is consistent with the Framework; and monitor and act to improve the effectiveness of open disclosure processes. | ||
| 1.17 1.18 |
Advisory AS18/11: Implementing systems that can provide clinical information into the My Health Record system (Version 6.0. February 2024) | This advisory describes the minimum requirements for health service organisation compliance with Actions 1.17 and 1.18 working towards implementing the My Health Record system. |
To comply with Actions 1.17 and 1.18, health service organisations must: By June 2024, have developed a detailed plan that complies with:
By December 2024, have ongoing monitoring and evaluation of compliance with the requirements of Action 1.17 and 1.18. Accrediting agencies are required to review evidence that:
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| 1.21 | National Survey on Cultural Safety Training (Published 2022) | This fact sheet outlines the outcomes of the national survey conducted by the Australian Commission on Quality and Safety in Health Care. | Health services organisation should implement strategies to improve cultural safety and cultural competency of the workforce to meet the needs of Aboriginal and Torres Strait Islander patients | ||
| 1.23 1.24 |
NSQHS Standards Training requirements for credentialed practitioners (Published 2019) | Draft Credentialing and Defining Scope of Clinical Practice: A guide for managers and clinicians (In draft 2021) | The purpose of this document is to provide practical guidance for managers and clinicians responsible for credentialing, and for determining and managing a clinician’s scope of clinical practice. This guide supports but does not replace or supersede state, territory or organisational policies, by-laws or rules on credentialing. | Credentialed practitioners are part of a health service organisation's clinical workforce and as such are subject to the requirements of the National Safety and Quality Health Service Standards. | |
| 1.23 1.24 1.27b 1.28a |
AS18/12: Implementing the Colonoscopy Clinical Care Standard (Version 2.0. March 2019) |
NSQHS Standards Implementing the colonoscopy clinical care standard – informed consent (Published 2020) NSQHS Standards Certification and Re-certification of practising colonoscopists (Published 2019) |
This advisory describes assessment requirements for Actions 1.23, 1.24, 1.27b, and 1.28a for health service organisations implementing the Colonoscopy Clinical Care Standard | Health service organisations providing colonoscopy services are required to implement the Colonoscopy Clinical Care Standard taking into consideration the services provided and the patient risks associated with those services. |
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| 1.27 | Fact Sheet 11: Applicability of Clinical Care Standards (Published 2023) |
can play an important role in delivering appropriate care and reducing unwarranted variation, as they identify and define the care people should expect to be offered or receive, regardless of where they are treated in Australia.
NSQHS Standards User Guide for the Review of Clinical Variation in Health Care (Published 2021) |
The purpose of this fact sheet is to provide advice to health service organisations implementing Clinical Care Standards and assessors reviewing compliance with these actions. |
The NSQHS Standards (second edition) refer to
To comply with Action 1.27b, health service organisations are expected to identify relevant clinical care standards and implement those that will reduce risk to patients, improve quality, and address areas of unwarranted variation from best practice, according to their local quality improvement priorities.
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Partnering with Consumers Standard
| Action(s) | Advisory | Fact sheet | Guide | Intent | Requirements |
|---|---|---|---|---|---|
| 2.04 | AS18/10: Informed financial consent (Version 3.0 November 2021) | Informed Consent - Fact sheet for clinicians (Published 2020) | The purpose of this advisory is to describe assessment requirements for informed financial consent in health service organisations. The Australian Government, states and territories have signed the National Health Reform Agreement to improve health outcomes for all Australians. This Agreement reaffirms the commitment by states and territories to ensure that eligible persons who have elected to be treated as private patients have done so on the basis of informed financial consent. |
A health service organisation’s compliance with the requirement of this Advisory for informed financial consent will contribute to overall compliance with Action 2.04 |
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| 2.03 |
Australian Charter of Healthcare Rights (Published 2020)
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The Charter describes rights that consumers, or someone they care for, can expect when receiving health care. These rights apply to all people in all places where health care is provided in Australia. This includes public and private hospitals, day procedure services, general practice and other community health services. | The National Safety and Quality Health Service (NSQHS) Standards require health service organisations to use a charter of rights that is consistent with the Charter. This means that health services may adopt the Charter, or develop their own charter. Health service organisations need to ensure that any charter that they develop aligns with the Charter and is accessible for patients, carers, families and consumers. | ||
| 2.11 | NSQHS Standards - Involving consumers in governance, design and performance-monitoring activities (Published 2020) | NSQHS Standards User Guide for Measuring and Evaluating Partnering with Consumers (Published 2018) | The purpose of this fact sheet is to describe how day procedure services can enhance consumers’ involvement in governance, design and performance-monitoring activities. |
Providing care that responds to consumers’ needs aligns with the requirements of the Clinical Governance Standard and Partnering with Consumers Standard.
This fact sheet provides some suggested strategies for engaging with consumers. |
Preventing and Controlling Infections Standard
| Action(s) | Advisory | Fact sheet | Guide | Intent | Requirements |
|---|---|---|---|---|---|
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3.02 Links with |
AS22/02: Advice on organisational training requirements for hand hygiene and infection prevention and control (Version 1.0. August 2022) |
Hand hygiene and infection prevention and control eLearning modules | This advisory provides health service organisations and accrediting agencies with information on the scope and assessment of workforce training requirements related to infection prevention and control and hand hygiene | Health service organisations implementing the NSQHS Standards are required to provide their workforce with access to theoretical and practical training that promotes infection prevention and control and hand hygiene |
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| 3.10 | AS21/05: Advice on the submission of hand hygiene compliance audit data for Audit 3, 2021, Audit 1, 2022, and Audit 2, 2022 (Rescinded June 2024) | National Hand Hygiene Initiative (NHHI) User Manual (Published 2019) | This advisory outlined requirements for submission of data for national hand hygiene Audit 3, 2021, Audit 1, 2022, and Audit 2, 2022, and assessment of Action 3.10 | During the COVID-19 pandemic, health service organisations were required to collect hand hygiene compliance audit data for national hand hygiene Audit 3, 2021, Audit 1, 2022, and Audit 2, 2022, unless exempted by the state and territory regulator. |
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| 3.13 |
Fact sheet: Action 3.13 Clean and safe environment
Fact sheet: Principles of environmental cleaning product selection |
These fact sheets provide updated advice regarding Action 3.13: Clean and safe environment and guidance on selecting suitable cleaning products for environmental cleaning. |
Health service organisations are required to establish systems and processes to maintain a clean, safe and hygienic environment, in line with the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare and jurisdictional requirements. |
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| 3.10 | AS 23/01Advice on national hand hygiene audit period 2 (Version 1.0 June 2023) | To advise of changes to data submission requirements for national hand hygiene audit period 2 |
Health service organisations should use the results of audits to inform quality improvement interventions to improve hand hygiene compliance.
National audit period 2 will become a voluntary audit period from 1 April 2023 |
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| 3.15 | NSQHS Standards Workforce Immunisation Risk Matrix (Published 2023) | The NSQHS Standards Workforce Immunisation Risk Matrix can be used by health service organisations to assess their workforce for risks associated with vaccine preventable disease transmission and develop actions to mitigate these risks. |
Action 3.15 requires health service organisations to have a risk-based workforce immunisation program that:
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| 3.17 |
Advisory AS24/01: National Safety and Quality Health Service Standards requirements for reprocessing of reusable medical devices in health service organisations. (Version 1.0 November 2024)
Advisory AS18/07: Reprocessing of reusable medical devices in health service organisations (Version 10.0. Rescinded November 2024) |
This advisory describes the minimum requirements for health service organisations’ compliance with Action 3.17, for health service organisations that reprocess reusable medical devices (RMDs). This advisory replaces advisory AS18/07 and provides advice regarding AS/NZS 5369:2023, which supersedes both AS/NZS 4187:2014 and AS/NZS 4815:2006
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Health service organisations using critical and semi-critical RMDs and other devices that require reprocessing are to update their gap analysis for AS4187 against AS 5369:2023 by 30 June 2025 Where risks are identified, risk mitigation strategies must be implemented and routinely monitored and reported to the relevant clinical governance body or individual.
An extension supports Action 3.17 to be rated ‘met with recommendations’ across assessment cycles. |
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| 3.18 3.19 |
AS18/08: Antimicrobial stewardship and surgical prophylaxis (Version 2.0 July 2021)
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Antimicrobial Stewardship Clinical Care Standard (Published 2020) | This advisory provided advice relating to antimicrobial stewardship, specifically in relation to surgical antimicrobial prophylaxis. | Accrediting agencies are to rate actions in the antimicrobial stewardship criterion of the Preventing and Controlling Infections Standard in the Antimicrobial as met, where the health service organisation has complied with the requirements set out in this Advisory. |
Medication Safety Standard
| Action(s) | Advisory | Fact sheet | Guide | Intent | Requirements |
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Fact Sheet: National Inpatient Medication Chart (NIMC) for Day Procedure Services. July 2024
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This fact sheet describes the requirements for documenting medicines-related information in line with the intent of the National Safety and Quality Health Service (NSQHS) Standards
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Action 4.01 requires clinicians to use the organisation’s policies and procedures to ensure safe and effective medication management. This action also requires clinicians to manage risks and develop or maintain skills for the effective and safe management of medicines. Action 4.06 requires organisations to document a patient’s medication history, treatment plan and reconciliation. Action 4.07 and 4.08 require documentation of allergies, adverse events and drug reactions.
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Comprehensive Care Standard
| Action(s) | Advisory | Fact sheet | Guide | Intent | Requirements |
|---|---|---|---|---|---|
| 5.08 | NSQHS Standards Identifying Aboriginal and Torres Strait Islander people (Published 2020) | The purpose of this fact sheet is to provide guidance to health service organisations when establishing processes to accurately identify and record Aboriginal and/or Torres Strait Islander status. | Health service organisations are required to establish processes to accurately identify and record Aboriginal and/or Torres Strait Islander status | ||
| 5.04 5.07 5.13 5.14 |
Oral health care for adult inpatients (Published 2023) | Oral health care for adult inpatients: Recommendations (Published 2023) | These resources identify key actions for health service organisations to reduce risks and support oral health care for adult inpatients. | Implementing the actions in these guides are based upon the best available evidence and can improve oral health care when implemented. | |
| 5.07 5.10 |
Advisory AS18/14: Comprehensive Care Standard: Screening and assessment for risk of harm (Version 4.0. December 2022)
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Essential element 1: Clinical assessment and diagnosis (Published 2019)
Essential element 3: Risk screening and assessment (Published 2019)
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This advisory describes the minimum requirements for Actions 5.07 and 5.10 for health service organisations to demonstrate planning for and conducting screening for comprehensive care. | By 31 December 2023, Health service organisations are to consider the risk of patient harm relevant to their context and have implemented of an organisation-wide approach to risk screening | |
| 5.13 | Advisory AS18/15: Comprehensive Care Standard: Developing the comprehensive care plan (Version 6.0. June 2024) | NSQHS Standards Identifying patient goals of care in day procedure services (Published 2019) |
Essential element 2: Identifying goals of care (Published 2019)
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This advisory describes the minimum requirements for Action 5.13 for health service organisations establishing comprehensive care plans. | This advisory contains updated advice for health service organisations and assessors regarding comprehensive care planning |
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National Consensus Statement: Essential elements for safe and high-quality end-of-life care (Under review Published 2015)
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The Consensus Statement contains 10 essential elements. Elements 1–5 relate to the way in which end-of-life care should be approached and delivered. Elements 6–10 relate to structural and organisational prerequisites for the effective delivery of safe and high-quality end-of-life care. |
The Comprehensive Care Standard outlines strategies for the delivery of comprehensive care for all patients. It includes specific actions about providing care to those at the end of life.
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AS22/01: Advice on implementing the updated Delirium Clinical Care Standard (released September 2021) (Version 1.0. Rescinded June 2024) | NSQHS Standards user guide for health service organisations providing care for patients with cognitive impairment or at risk of delirium (Published 2019) | This advisory clarified the requirements for health service organisations to transition from the 2016 to the 2021 Delirium Clinical Care Standard. | All health service organisations implementing the NSQHS Standards and providing care to people over the age of 18 are required to implement the Delirium Clinical Care Standard. | |
| 5.21a 5.22 5.23 |
NSQHS Standards - Preventing pressure injuries and wound management (Published 2020) | This resource provides guidance for organisations developing policies, procedures and protocols for preventing, screening, assessing, treating, monitoring and documenting pressure injuries. | Health service organisations implementing the National Safety and Quality Health Service (NSQHS) Standards are required to establish systems and processes for pressure injury prevention and wound management that are consistent with best-practice guidelines. |
Blood Management Standard
| Action(s) | Advisory | Fact sheet | Guide | Intent | Requirements |
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7.04 7.05 7.06 |
Implementing a Single Unit Blood Transfusion Policy (Published June 2024) |
The aim of this fact sheet is to align clinical practice with the National Safety and Quality Health Service (NSQHS) Blood Management Standard and national Patient Blood Management (PBM) Guidelines for single unit transfusion. |
Health service organisations should implement a policy for Single Unit Blood Transfusion. The policy should identify and document the roles, responsibilities and systems for managing adult acute non‑bleeding patients |
Recognising and Responding to Acute Deterioration Standard
| Action(s) | Advisory | Fact sheet | Guide | Intent | Requirements |
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| 8.05 8.06 b, c, d and e, 8.12 |
AS19/01: Recognising and Responding to Acute Deterioration Standard: Recognising deterioration in a person's mental state (Version 3.0. Rescinded June 2024) |
NSQHS Standards User guide for health services providing care for people with mental health issues (Published 2018)
National Consensus Statement: Essential elements for recognising and responding to acute physiological deterioration (third edition) (Published 2021)
National Consensus Statement: Essential elements for recognising and responding to deterioration in a person's mental state (Published 2017)
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This advisory described the minimum requirements for Actions 8.05, 8.06 b, c, d and e and 8.12 that health service organisations must undertake to demonstrate work towards establishing effective processes for recognising and responding to deterioration in a person’s mental state. |
From 1 January 2022 health service organisations must have completed implementation of their 2019 action plan |