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Seeking NSQHS accreditation? Learn the top 5 areas you need to meet

Accreditation can be a daunting and complex experience, especially when it comes to understanding which set of standards apply to your medical practice.

For specialist medical practices, your practice processes are assessed against the National Safety and Quality Health Service (NSQHS) Standards.

These standards have similar aims to the RACGP Standards; both focus on protecting patients from harm by improving the quality of health services. And while there is some crossover between both, the NSQHS Standards are structured to suit a range of healthcare organisations including specialist practices and the types of procedures they perform.

We’ve previously shared tips on preparing for RACGP accreditation. Here, we’ll look at the eight NSQHS Standards and some strategies to improve your compliance and accreditation success. We’ll also look at the top five areas where specialist practices don’t meet the compliance criteria and how to improve your processes for each one.

The 8 NSQHS standards:

1. Clinical Governance

This standard aims to ensure practices have a governance framework in place so consumers receive safe, quality healthcare and staff receive the support and professional development to perform better. It covers things like policies and procedures, doctor credentialing, risk management and staff training.

2. Partnering with Consumers

Your practice exists to provide services to your patients, so it’s essential that they are involved in their care. Clear communication, consent and effective complaints management are at the heart of this.

3. Preventing and Controlling Healthcare-Associated Infection

Improving your infection prevention and control is especially critical during the COVID-19 pandemic – and this standard was updated to incorporate COVID specific criteria. There’s increased focus on robust pandemic planning, antimicrobial stewardship and sterilisation.

4. Medication Safety

This standard covers the safe prescribing, dispensing, administration and monitoring of appropriate medicines. It includes ensuring consumers understand their own medical needs and risks.

5. Comprehensive Care

The aims of this standard are coordinated delivery of a patient’s total healthcare, to align with their goals and needs. It integrates patient care processes to identify their needs and prevent harm, encompassing actions related to falls, pressure injuries, nutrition, mental health, cognitive impairment and end-of-life care.

6. Communicating for Safety

Effective communication in patients’ care are the goals here – the systems and processes you use at all stages of care. This includes correct patient identification and procedure matching, and ensuring essential information is documented in the patient’s healthcare record.

7. Blood Management

This standard aims to improve patient outcomes by identifying risks and using strategies to ensure that any blood products patients receive are safe, appropriate and to minimise wastage of these blood products.

8. Recognising and Responding to Acute Deterioration

Acute deterioration criteria include changes in physiological, cognitive and mental states and this standard aims to ensure that a person’s acute deterioration is recognised promptly and appropriate action is taken. Accreditation includes assessing practice staff life support training and emergency processes.

Clinical Governance

Non-compliance here is generally around inadequate risk management and quality improvement processes. In PracticeHub’s online practice management platform, you can keep your practice policies and procedures in one place, so they are easy to access and update. PracticeHub’s Ahpra Alerts and Certificate of Insurance apps also let you manage clinician registrations and insurance certificate compliance, as part of your risk management strategy.

With PracticeHub, you can also monitor and audit any policy updates and incident reports, keeping an audit trail as evidence of your processes. Compiling this information quickly then becomes easy ahead of accreditation.

Infection Control

For specialist practices doing invasive procedures, and especially during COVID, Standards assessors are targeting non-compliance here. To improve your compliance, review the quality of your processes around cleaning and sterilisation, and check if your staff are up to date with their immunisations. PracticeHub’s onboard policy templates include specific processes around infection control and have been written by an infection control expert.

You can also link these policies to their relevant standards, so you can reference them when preparing for accreditation, and to help staff understand the reasons for the processes they perform. 

Medication Safety

It’s concerning that medication safety is a common area of non-compliance, and to help practices improve their compliance with this standard, in PracticeHub, there’s a template for the safe and quality use of medicines you can easily adapt to your own practice’s needs. 

Comprehensive Care

One reason practices don’t meet this standard is because they don’t have evidence to demonstrate they have involved patients in their own care planning, while following risk management protocols. Again, documentation is important here, from detailed patient medical records to your clinical governance framework. 

Partnering with Consumers

Non-compliance with this Standard usually indicates a practice needs to improve its communication processes and involve their patients more in the planning, design, delivery and evaluation of its systems and services. In PracticeHub, you can create a complaints and compliments register and invite input from your patients for ways to improve your practice systems and services.

Ongoing team training is another important part of ensuring compliance with the standards, and to demonstrate your practice’s commitment to quality improvement – which is important for accreditation. With PracticeHub’s eight learning modules, you can assign training to staff based on their role and modules include health records, privacy, risk, infection control and work health and safety. You can also track staff completion of training, which provides evidence for you that they understand their role, and for assessors, that your practice has provided training.

Book a meeting

Learn how PracticeHub, and our customised NSQHS accreditation support package can simplify your accreditation. Phone us on 1300 469 866 or book a meeting with one of our helpful consultants.


This article is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on its content, and practise proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this article must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published. © Avant Mutual Group Limited 2024.

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