NATIONAL SAFETY AND QUALITY
HEALTH SERVICE STANDARDS
Does your health service
need NSQHS accreditation?
IHCA Certification is committed to working closely with
Health Service Organisations in planning their assessment
and achieving accreditation.
The National Safety and Quality Health Service Standards (NSQHS)
accreditation program operates over a three-year cycle with no
mid-cycle assessment required. From 1 July 2023, health service
organisations will undergo assessment through a mandatory
short notice assessment program. This assessment may occur
at any time over a three-year accreditation cycle.
ACCREDITATION ASSESSMENT PROCESS
Formal accreditation decision and registration
IHCA Certification will provide a written report to your organisation and issue a Certificate of Accreditation against the Standards if there are no outstanding actions that are not met. Upon accreditation, your organisation will be issued with a certificate confirming your organisation’s conformance to the Standards and the right to use IHCA Certification’s distinctive symbol in promotional activities. The outcomes of your assessment are provided to the Australian Commission on Safety and Quality in Health Care (the Commission).
Annual Attestation Statement
Between July and September every year, your governing body will be required to complete an annual attestation statement (self-reporting on past performance) and provide this to IHCA Certification, we will then report this to the Commission.
Other Standards
NSQHS Standards assessment is not to be conducted at the same time as assessment to another standard e.g. ISO 9001:2015. Other assessments may be conducted immediately following your NSQHS assessment.
More Information
For more information about the NSQHS, please visit the Australian Commission on Safety and Quality in Healthcare website
Self-Assessment
While optional, it is recommended that your organisation completes a self-assessment against the NSQHS Standards to ensure you are fully prepared for your mandatory short notice on-site assessment.
The self-assessment will guide you in preparing necessary evidence to satisfy all of the requirements of the NSQHS Standards. We will review your completed self-assessment and development plans prior to commencing the on-site assessment.
Accreditation Assessment
The assessment team will consist of qualified assessors with relevant clinical, health service and assessment experience.
The assessment will commence with an entry meeting with the person in charge or their delegate. The assessment team will provide information regarding the conduct, length and scope of the assessment. The assessment must align to the PICMoRS (process, improvement, consumer participation, monitoring, reporting and systems) methodology. The assessment team are required to spend at least 75% of the assessment time spent at the point of care, observing and asking questions of the workforce, patients and consumers.
At the conclusion of the on-site assessment, the findings will be presented to your organisation’s management and other interested parties in relation to conformity with the Standard’s requirements.
Remediation Period and Final Assessment
The Lead Assessor will explain what follow-up action is required to remediate any actions that are found to be ‘not met’ or ‘met with recommendations’ during the assessment. You will have 60 business days to resolve these and they will be reviewed in a Final Assessment, to occur within 65 business days of the last day of the Accreditation Assessment.
NSQHS Resources
From Near Miss to Learning Opportunity: How to Build a Strong Incident Reporting Culture
One of the biggest indicators of a high performing health service isn’t a low number of incidents, it’s how the organisation responds when things go wrong. NSQHS Standard 1 (Clinical Governance) and Standard 6 (Communicating for Safety) both require a strong incident...
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