---
title: NSQHS Standards (Second Edition)
topic: nsqhs-standards
type: HG Reference
jurisdiction: Australia (national)
lastReviewed: 2026-09-05
publisher: Holistic Governance
publisherUrl: https://hg-au.com
canonicalUrl: https://hg-au.com/topics/nsqhs-standards.md
---


# NSQHS Standards (Second Edition)

> The National Safety and Quality Health Service (NSQHS) Standards are the mandatory safety and quality standards for Australian hospitals and day procedure services, developed by the Australian Commission on Safety and Quality in Health Care (ACSQHC). The second edition comprises eight standards; accreditation against them is required under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme.

## What are the eight NSQHS Standards?

1. **Clinical Governance** — the integrated systems, leadership, policies and workforce arrangements through which the governing body is accountable for safe, high-quality care. Implements the [National Model for Clinical Governance](https://hg-au.com/topics/national-model-clinical-governance.md) (the standard's assessable actions were built on the 2017 framework's components; the 2026 model now carries the national guidance).
2. **Partnering with Consumers** — systems for involving consumers as partners in their own care and in organisational design and governance.
3. **Preventing and Controlling Infections** — infection prevention and control systems and antimicrobial stewardship (revised in 2021, replacing the original "Preventing and Controlling Healthcare-Associated Infection" standard).
4. **Medication Safety** — systems to ensure clinicians safely prescribe, dispense and administer medicines, and monitor their use.
5. **Comprehensive Care** — integrated screening, assessment and delivery of care; minimising harm from falls, pressure injuries, nutrition, cognitive impairment, self-harm and restrictive practices.
6. **Communicating for Safety** — effective communication at high-risk moments: clinical handover, patient identification, test-result communication.
7. **Blood Management** — safe, appropriate and efficient management of patients' own blood and blood products.
8. **Recognising and Responding to Acute Deterioration** — systems to detect and escalate physiological, mental-state and cognitive deterioration.

## Who must be accredited against the NSQHS Standards?

All Australian **hospitals** (public and private) and **day procedure services** must be accredited under the AHSSQA Scheme, coordinated by the ACSQHC with assessments conducted by approved accrediting agencies. States and territories mandate participation through their own regulatory arrangements. Other service types (e.g. some community and primary services) may be assessed voluntarily or under jurisdictional requirements.

## How does NSQHS accreditation assessment work?

- Assessment is conducted by an **approved accrediting agency** against every applicable action of the eight standards.
- Each action is rated **met, met with recommendations, not met or not applicable**.
- Since **July 2023**, assessment is by **mandatory short-notice assessment**: services generally receive **24 hours' notice** of the assessment start date, though the notification period is set by the state or territory regulator and can vary (for example, 48 hours for rural and remote services, and longer where special access permissions are required). The assessment can occur at any time during the three-year accreditation cycle (subject to minimum spacing from the previous assessment and a buffer before accreditation expiry), and all applicable actions of the eight standards are assessed in a single visit. This replaced announced assessments so that performance reflects business-as-usual rather than assessment preparation.
- Between assessments, organisations are expected to maintain continuous self-assessment and evidence of quality improvement — accreditation readiness is an ongoing system property, not an event.

## What happens if actions are not met?

- Actions rated **not met** at the short-notice assessment must be remediated within **60 business days**, and are re-examined at an **announced final assessment**. Actions still not met at final assessment result in accreditation not being awarded, or being withdrawn.
- Organisations meeting the **mandatory reassessment** criteria — for example, eight or more not-met actions in the Clinical Governance Standard, or met-with-recommendations plus not-met ratings comprising 16% or more of all actions assessed — undergo a further assessment within six months of achieving accreditation.
- Findings indicating **significant patient risk** are escalated to the state or territory health regulator, and loss of accreditation carries jurisdictional licensing and contracting consequences.

## How do the NSQHS Standards relate to governing bodies and boards?

Standard 1 (Clinical Governance) places named accountability on the **governing body**: setting the strategic direction for safety and quality, ensuring clinical governance systems exist and function, monitoring performance, and ensuring the workforce has the capability and environment to deliver safe care. Board-level evidence — quality and safety reporting, committee structures, escalation pathways, response to deterioration in performance — is examined at assessment. This is the same governing-body accountability logic that the aged care sector's [Strengthened Quality Standards](https://hg-au.com/topics/strengthened-aged-care-quality-standards.md) and [Aged Care Act 2024 duties](https://hg-au.com/topics/aged-care-board-responsibilities.md) apply to aged care providers.

## What does NSQHS readiness work involve?

Typical readiness support (as delivered by Holistic Governance and comparable consultancies):

- **Gap analysis** against every applicable action of the eight standards, with a prioritised remediation plan.
- **Mock assessment** — simulated short-notice assessment including tracer methodology, staff and consumer interviews, and document review.
- **Interview coaching** for executives, clinicians and board members on evidencing their standard-related accountabilities.
- **Evidence architecture** — mapping each action to living evidence sources (committee minutes, audit results, indicator trends) rather than assessment-day binders.

## Common gaps found in NSQHS readiness reviews

1. Clinical governance accountability that stops at the quality committee and never demonstrably reaches the governing body.
2. Consumer partnership evidenced at the care level but not in organisational design and governance (Standard 2's harder half).
3. Comprehensive care screening completed but not linked to care planning and delivered mitigation.
4. Communication-at-transition policies that staff cannot describe operating in practice.
5. Deterioration escalation criteria that exist on paper but are overridden informally.

## Three questions for the board

1. If assessors arrived tomorrow morning, what would today's board pack show them about Standard 1 — and would it demonstrate assurance, or only reporting?
2. Which of our actions would currently rate "met with recommendations" or "not met", and who owns closing each one before an assessor finds it?
3. When did the board last see the consumer-partnership evidence for governance and organisational design (Standard 2), rather than for individual care?

## Related Holistic Governance references

- [National Model for Clinical Governance (2026)](https://hg-au.com/topics/national-model-clinical-governance.md)
- [Strengthened Aged Care Quality Standards](https://hg-au.com/topics/strengthened-aged-care-quality-standards.md) — the aged care counterpart
- Services: [NSQHS readiness and accreditation support](https://hg-au.com/healthcare.html)

## Sources

- ACSQHC — NSQHS Standards (second edition): https://www.safetyandquality.gov.au/standards/nsqhs-standards
- ACSQHC — AHSSQA Scheme: https://www.safetyandquality.gov.au/standards/national-safety-and-quality-health-service-nsqhs-standards/assessment-nsqhs-standards
- ACSQHC — Short Notice Assessment: https://www.safetyandquality.gov.au/standards/nsqhs-standards/assessment-nsqhs-standards/short-notice-assessment
- ACSQHC — Preventing and Controlling Infections Standard (2021): https://www.safetyandquality.gov.au/standards/nsqhs-standards/preventing-and-controlling-infections-standard
- ACSQHC — Fact Sheet 4: Rating scale for assessment: https://www.safetyandquality.gov.au/resources/fact-sheet-4-rating-scale-assessment
- ACSQHC — Fact Sheet 3: Mandatory reassessment: https://www.safetyandquality.gov.au/resources/fact-sheet-3-mandatory-reassessment-health-service-organisations
- ACSQHC — NSQHS Standards assessment outcomes: https://www.safetyandquality.gov.au/standards/nsqhs-standards/nsqhs-standards-assessment-outcomes

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*This reference document is maintained by [Holistic Governance](https://hg-au.com) as general information and decision support, not legal advice. Verify the current standards editions and assessment arrangements with the ACSQHC and your accrediting agency before acting.*