The National Safety and Quality Health Service (NSQHS) Standards aim to protect the public from harm and improve the quality of health care delivered across Australia. Accreditation against these standards is a requirement for all public and private hospitals and day procedure services.

However, many organisations face challenges when it comes to demonstrating compliance during an assessment. Understanding the most common difficulties can help health services proactively strengthen their systems and avoid pitfalls.

1. Lack of Documented Evidence

   One of the most frequently observed challenges is the absence of clear and up to date documentation. While many organisations are doing the right thing, they struggle to show it effectively.

   Examples:

   • Missing or outdated policies and procedures.
   • Inadequate records of risk assessments or audits.
   • Staff unable to locate required documents during assessment interviews.

   What to do instead: Ensure key documents are not only developed and reviewed regularly, but also well organised and easily accessible to all relevant staff.

2. Tokenistic or Minimal Consumer Engagement

   NSQHS Standard 2 requires services to partner with consumers in planning, design, delivery, and evaluation of care. A common non-compliance is insufficient, tokenistic, or minimal involvement of consumers in service development.

   Examples:

   • Lack of evidence showing how feedback from patients and families is used to improve care.
   • No clear process for involving consumers in governance committees or quality initiatives.

   What to do instead: Move beyond satisfaction surveys!

   1. Create structured roles for consumers in decision making forums.
   2. Clearly document their contributions.
   3. Document planning, design and delivery service development including feedback from patients and families.
3. Poorly Documented Risk Management Systems

   Accredited services must demonstrate a robust system for identifying, managing, and reviewing clinical and corporate risks. Assessors often identify weaknesses in how risks are documented and managed.

   Examples:

   • Risk registers not reviewed or updated regularly.
   • Incomplete follow-up on adverse events or near misses.
   • No consistent process for escalating risks or sharing learnings.

   What to do instead:

   1. Make risk reviews a regular agenda item at leadership and quality meetings.
   2. Encourage staff at all levels to report issues and contribute to risk mitigation.
4. Inconsistent Infection Prevention Practices
   NSQHS Standard 3 focuses on preventing and controlling infections. Findings in this area are often related to inconsistent or outdated practices and poor staff compliance.

   Examples:

   • Inconsistent hand hygiene audits or low compliance rates.
   • Out-of-date infection control procedures.
   • Limited staff awareness of standard and transmission-based precautions.

   What to do instead:

   1. Run regular refresher training
   2. Incorporate spot checks into routine operations to ensure adherence to current guidelines.
5. Gaps in Clinical Communication and Handover

   Effective clinical communication is essential for safe care transitions, and NSQHS Standard 6 covers the systems that support this. Many assessors find problems in how handovers are conducted and documented.
   Examples:

   • Lack of structured handover tools like ISBAR (Identify, Situation, Background, Assessment, Recommendation).
   • No standardised discharge summaries or communication with GPs.
   • Inconsistent patient identification practices.

   What to do instead:

   1. Standardise handover tools across the service
   2. Embed regular training and assessment cycles to monitor compliance.
6. Staff Training is out of date or not aligned
   Assessments often reveal that staff training is out of date or not aligned with the required competencies of their roles. This is relevant to nearly all standards.

   Examples:

   • No evidence of completed mandatory training (e.g., basic life support, infection control).
   • Training records not maintained or centralised.
   • No formal process for assessing competency.

   What to do instead:

   1. Implement a centralised learning management system
   2. Ensure line managers are responsible for tracking team compliance.
7. Failure to Escalate and Investigate Incidents
   NSQHS Standards 1 and 5 require clear incident management systems. A failure to properly respond to and learn from incidents can result in serious breaches.

   Examples:

   • Delayed or inadequate investigation of incidents.
   • No structured method for learning from adverse events or complaints.
   • Staff unaware of how to report an incident or concern.

   What to do instead:

   1. Foster a culture of safety where incident reporting is seen as a learning opportunity.
   2. Ensure follow-up actions are documented and closed out.

Conclusion

NSQHS assessments are not just a box-ticking exercise. They’re an opportunity to drive real improvements in the safety and quality of patient care.

Understanding common pitfalls allows your organisation to be proactive, not reactive, and demonstrate a commitment to quality, safety, and continuous learning.

By addressing these areas early and embedding good practice across all levels of your organisation, health services can avoid costly, time consuming assessment follow ups and more importantly, deliver safer, better healthcare to every person, every time.

Need help preparing for your next NSQHS assessment?
Contact us to explore coaching and assessment readiness, policy development, or staff training to ensure your service meets the highest standards.