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Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition
Australia (all States and Territories)
vNSQHS Standards second edition, as updated May 2021 (incorporating the revised Preventing and Controlling Infections Standard assessed from 1 January 2022); fetched 2026-10-13 from the Australian Commission on Safety and Quality in Health Care
8 domains
48 controls
Australia's mandatory hospital and day procedure accreditation standards: the eight NSQHS Standards (second edition) and their 148 actions on clinical governance, partnering with consumers, infection prevention and control and antimicrobial stewardship, medication safety, comprehensive care including pressure injury, falls, nutrition, cognitive impairment, self-harm, aggression, restraint and end-of-life care, communicating for safety, blood management, and recognising and responding to acute deterioration.
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Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition is a compliance framework from Australia (all States and Territories) with 8 domains and 48 controls. The largest domains are Standard 1: Clinical Governance – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition (11 controls), Standard 5: Comprehensive Care – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition (9 controls), Standard 3: Preventing and Controlling Infections – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition (8 controls). Every control below carries what it requires and what an assessor expects to see.
Maintained by Gerard Blokdyk
Framework summaries on this platform are AI-assisted interpretations for educational and compliance planning purposes. They do not reproduce or replace the official standards. Refer to the authoritative source for the definitive text. Framework names and trademarks belong to their respective organisations.
Framework Domains (8)
Standard 1: Clinical Governance – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition
11 controls
| Code | Title |
|---|---|
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::1.01-1.02 | The governing body leads a safety and quality culture, partners with consumers, sets priorities and the clinical governance framework, defines roles, monitors incident action and performance, and addresses the health needs of Aboriginal and Torres Strait Islander people |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::1.03-1.06 | The organisation maintains a clinical governance framework that drives improvement, implements strategies for Aboriginal and Torres Strait Islander patients, weighs safety and quality in business decisions, and clinical leaders support clinicians to perform their safety and quality roles |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::1.07-1.09 | Policies, procedures and protocols are managed through a risk-based system with compliance monitoring, organisation-wide quality improvement systems measure and improve performance with consumers and workforce involved, and timely safety and quality reports reach the board, workforce, consumers and partner services |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::1.10 | Organisational risks are identified, documented, assessed with clinical and other data, reduced, reviewed, reported to workforce and consumers, and emergency and disaster plans are in place |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::1.11-1.12 | Organisation-wide incident management and investigation systems support reporting by workforce and patients, involve them in review, feed back analyses, drive improvement and the risk register, and open disclosure follows the Australian Open Disclosure Framework |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::1.13-1.14 | Feedback from patients, carers, families and the workforce is sought regularly and used to improve, and an organisation-wide complaints management system encourages complaints, involves workforce and consumers in review, resolves them promptly, feeds back analyses and informs improvement and the risk register |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::1.15-1.18 | The organisation knows the diversity and higher-risk groups among its consumers and plans care accordingly, keeps healthcare records available at the point of care, accurate, secure, auditable and integrated, and works towards and governs contributions to the My Health Record system |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::1.19-1.22 | Everyone, including board members, locums, agency, students and volunteers, is oriented to their safety and quality roles; training systems assess competency and needs, deliver mandatory training and monitor participation; cultural safety and competency for Aboriginal and Torres Strait Islander patients is improved; and performance reviews identify development needs |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::1.23-1.26 | Scope of clinical practice is defined, monitored and reviewed, clinicians are credentialed where relevant with the process monitored and improved, safety and quality roles are assigned and supported including for locums and agency staff, and clinicians are supervised with after-hours advice available |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::1.27-1.28 | Clinicians have ready access to best-practice guidelines, pathways, decision support and the Commission's clinical care standards, and systems monitor variation in practice and outcomes, feed back to clinicians, review external measures, support clinical review and use unwarranted variation to improve and manage risk |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::1.29-1.33 | The environment and infrastructure are designed and maintained to maximise safety, areas at high risk of unpredictable behaviour have risk-minimising strategies and calm spaces, signage aids access, overnight services allow flexible visiting when safe, and the environment welcomes Aboriginal and Torres Strait Islander people |
Standard 2: Partnering with Consumers – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition
5 controls
| Code | Title |
|---|---|
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::2.01-2.02 | Clinicians apply the clinical governance and quality improvement systems to partnering with consumers: policies, risks, training, monitoring, improvement and reporting |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::2.03-2.05 | A charter of rights consistent with the Australian Charter of Healthcare Rights is used and accessible, informed consent processes comply with law and best practice, and processes identify a patient's capacity to decide and a substitute decision-maker where needed |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::2.06-2.07 | Clinicians partner with patients and substitute decision-makers to plan, communicate, set goals and make decisions about current and future care, and the workforce is supported to form partnerships so patients are actively involved in their own care |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::2.08-2.10 | Communication is tailored to consumer diversity, consumers are involved in developing and reviewing patient information, and clinicians are supported to communicate so information meets needs, is easy to understand, addresses clinical needs during the stay and covers ongoing care at discharge |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::2.11-2.14 | Consumers partner in governance, planning, design, measurement and evaluation, reflecting the diversity of users, and receive orientation, support and education; the organisation partners with Aboriginal and Torres Strait Islander communities and uses consumers' views in workforce training |
Standard 3: Preventing and Controlling Infections – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition
8 controls
| Code | Title |
|---|---|
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::3.01-3.04 | The clinical governance, quality improvement and consumer partnership systems are applied to infection prevention and control and antimicrobial stewardship: multidisciplinary teams, hierarchy of controls, training, capacity and equipment, performance monitoring and reporting, resource sustainability and pandemic planning |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::3.05 | A surveillance strategy collects and uses data on healthcare-associated and other infections and on antimicrobial use and appropriateness, incorporates national and jurisdictional information, reports to the workforce, board and consumers, and tracks responsiveness to identified risks |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::3.06-3.09 | Standard and transmission-based precautions consistent with the national infection control guidelines are implemented, risk-assessed with patients and workforce, supported by PPE processes, monitored and audited, applied by the workforce considering patient risk, placement, environment, procedures and movement, and infectious status is communicated at transitions and to patients |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::3.10-3.11 | A hand hygiene program consistent with the National Hand Hygiene Initiative audits compliance, addresses non-compliance against benchmarks, reports results and actions, and improves compliance; aseptic technique processes identify where it applies, assess and train competence and monitor compliance |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::3.12-3.14 | Invasive medical devices are used and managed consistently with the national guidelines; the environment is kept clean, safe and hygienic with TGA-listed products, cleaning training, audits and improvement; and infection risks from equipment, areas, building works, linen and novel infections are evaluated and addressed |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::3.15-3.16 | A risk-based workforce screening and immunisation program follows the Australian Immunisation Handbook and jurisdictional requirements, and workforce infection risks are managed through screening, exclusion, non-attendance when unwell, movement control, support for isolation and quarantine, outbreak management and service continuity planning |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::3.17 | Reusable equipment and devices are reprocessed consistently with national and international standards and manufacturers' guidance, critical and semi-critical items are traceable to patient and procedure, and reprocessing requirements are planned with additional controls for novel infections |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::3.18-3.19 | An antimicrobial stewardship program has a policy, current Australian therapeutic guidelines, a formulary with restrictions and approvals and the Antimicrobial Stewardship Clinical Care Standard elements, acts on audit results, reviews prescribing and use, uses resistance and usage surveillance, evaluates itself and reports to clinicians and the governing body |
Standard 4: Medication Safety – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition
4 controls
| Code | Title |
|---|---|
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::4.01-4.04 | Governance, quality improvement and consumer partnership systems are applied to medication management, and the scope of clinical practice for prescribing, dispensing and administering medicines is defined and verified |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::4.05-4.09 | A best possible medication history is taken and documented early, current orders are reconciled against it at presentation and transitions, allergies and adverse drug reactions are documented on presentation and during care including in the incident system, and adverse reactions are reported to the Therapeutic Goods Administration |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::4.10-4.12 | Medication reviews are performed, prioritised by clinical need and documented with actions; patients receive information on their medicines needs and risks; and a current medicines list with reasons for changes is generated, given to receiving clinicians at transitions and to patients at discharge |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::4.13-4.15 | Medicines information and decision support tools are available to clinicians; medicines are stored, distributed, cold-chain managed and disposed of per manufacturers' directions, legislation and jurisdictional requirements; and high-risk medicines are identified with a system for their safe storage, prescribing, dispensing and administration |
Standard 5: Comprehensive Care – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition
9 controls
| Code | Title |
|---|---|
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::5.01-5.06 | Governance, quality improvement and consumer partnership systems are applied to comprehensive care; systems support clinicians to develop, document and communicate care plans, provide care in the right setting, refer specialist needs promptly and identify the accountable clinician; teamwork and roles are defined; and clinicians collaborate to plan and deliver care |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::5.07-5.13 | Integrated, timely screening and assessment identify risks of harm and social circumstances, Aboriginal and Torres Strait Islander status is routinely asked and recorded, advance care plans are supported, findings and alerts are documented, and shared decision making produces a comprehensive individualised plan with goals, support people, discharge planning from the start, referral and evidence-based care |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::5.14-5.20 | Care is delivered, monitored and updated against the comprehensive care plan in partnership with patients, carers and families, and end-of-life care follows the National Consensus Statement: patients at the end of life are identified, specialist palliative care advice is accessible, advance care plans are received and recorded, the workforce is supervised and supported, end-of-life care is reviewed against goals, and shared decisions are supported |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::5.21-5.23 | Pressure injury prevention and wound management systems follow best-practice guidelines, clinicians inspect skin of at-risk patients in best-practice time frames, patients and families receive prevention information, and equipment and products are used in line with the guidelines |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::5.24-5.26 | Falls systems consistent with best-practice guidelines cover prevention, minimising harm and post-fall management, equipment and tools promote safe mobility, and patients, carers and families receive information on reducing falls risk |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::5.27-5.28 | Overnight services have food and fluid preparation and distribution systems with evidence-based nutrition care plans, and the workforce uses them to meet nutritional needs, monitor at-risk patients, provide nutritional support and assist patients to eat and drink |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::5.29-5.30 | A system for caring for patients with cognitive impairment or at risk of delirium incorporates best-practice recognition, prevention, treatment and management including the Delirium Clinical Care Standard, manages antipsychotic and psychoactive medicines per best practice and legislation, and clinicians use it with patients, carers and families to individualise care and minimise distress |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::5.31-5.32 | Systems support collaboration with patients, carers and families to identify risk of self-harm and suicide and respond safely and effectively to distressed patients, and follow-up arrangements are developed, communicated and implemented for people who have self-harmed or reported suicidal thoughts |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::5.33-5.36 | Situations that may precipitate aggression are identified and mitigated, patients at risk of aggression or violence are identified with de-escalation and safe management in collaboration with patients, carers and families, and restraint and seclusion where clinically necessary and lawful are minimised and where possible eliminated, governed under legislation and reported to the governing body |
Standard 6: Communicating for Safety – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition
4 controls
| Code | Title |
|---|---|
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::6.01-6.04 | Governance, quality improvement and consumer partnership systems are applied to clinical communication, and clinical communication processes support effective communication at identification and procedure matching, at transfers of care within and between organisations and at discharge, and when critical information emerges or changes |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::6.05-6.06 | Approved patient identifiers are defined per best practice, at least three are required at registration and admission, when care, medicines, therapy and services are provided, and when handover, transfer or discharge documents are generated, and the processes and documentation for matching patients to their intended care are specified |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::6.07-6.08 | The organisation and clinicians define the minimum information content, service-specific risks and the clinicians involved in clinical handover, and clinicians use structured handover that is prepared and scheduled, has the relevant information, involves the right clinicians, reflects patient goals and preferences, involves patients, carers and families per the patient's wishes, and transfers responsibility and accountability |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::6.09-6.11 | Critical information, alerts and risks are communicated in a timely way when they emerge or change to decision-making clinicians and to patients, carers and families per the patient's wishes; patients, carers and families can communicate critical information directly to clinicians; and critical information, reassessments and care plan changes are documented contemporaneously |
Standard 7: Blood Management – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition
3 controls
| Code | Title |
|---|---|
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::7.01-7.03 | Governance, quality improvement and consumer partnership systems are applied to blood management: policies, risks, training, performance monitoring, improvement, outcome reporting, and patient involvement, information and shared decisions |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::7.04-7.08 | Clinicians optimise patients' own blood, identify and manage bleeding risk and determine clinical need; blood management decisions, transfusion history and details are documented; prescribing and administration follow national guidelines and criteria; transfusion-related adverse events are reported per national guidelines; and the organisation participates in haemovigilance |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::7.09-7.10 | Blood and blood products are stored, distributed and handled safely and securely per manufacturers' directions, legislation and jurisdictional requirements, traced from entry to transfusion, discard or transfer, and availability is managed to meet clinical need, eliminate avoidable wastage and respond to shortages |
Standard 8: Recognising and Responding to Acute Deterioration – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition
4 controls
| Code | Title |
|---|---|
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::8.01-8.03 | Governance, quality improvement and consumer partnership systems are applied to recognising and responding to acute deterioration: policies, risks, training, monitoring and improvement of recognition and response systems, outcome reporting, and patient involvement, information and shared decisions |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::8.04-8.05 | Clinicians document individualised vital sign monitoring plans, monitor patients accordingly and graphically track observations to detect physiological deterioration; and for deterioration in mental state they monitor at-risk patients including for delirium, record known early warning signs, assess causes when changes are observed or reported, determine observation levels, and document and communicate changes |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::8.06-8.09 | Escalation protocols specify agreed vital sign and mental state triggers, emergency assistance criteria, unmanaged pain or distress and the worry or concern of workforce, patients, carers and families; patients, carers and families can escalate care directly; the workforce has mechanisms to escalate and call for emergency assistance; and the workforce uses them |
| australia-national-safety-and-quality-health-service-nsqhs-standards-second-edition::8.10-8.13 | Response processes ensure timely attendance by clinicians skilled to manage acute deterioration, rapid access at all times to a clinician who can deliver advanced life support on site or nearby, rapid referral to mental health services for acute deterioration in mental state, and rapid referral to services that can provide definitive management of acute physical deterioration |
What is Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition and who does it apply to?
Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition is a compliance framework from Australia (all States and Territories) with 8 domains and 48 controls. Australia's mandatory hospital and day procedure accreditation standards: the eight NSQHS Standards (second edition) and their 148 actions on clinical governance, partnering with consumers, infection prevention and control and antimicrobial stewardship, medication safety, comprehensive care including pressure injury, falls, nutrition, cognitive impairment, self-harm, aggression, restraint and end-of-life care, communicating for safety, blood management, and recognising and responding to acute deterioration. It is used by organisations to establish and maintain compliance with industry standards and regulatory requirements.
What does Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition actually require?
Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition has 48 controls organised across 8 domains. The largest domains are Standard 1: Clinical Governance – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition (11 controls), Standard 5: Comprehensive Care – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition (9 controls), Standard 3: Preventing and Controlling Infections – Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition (8 controls). Each control defines specific requirements that organisations must implement to achieve compliance.
If I already comply with another framework, how much of Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition do I already cover?
Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition does not currently have cross-framework mappings in our system. Check back as we continuously expand our mapping database.
How do I implement Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition?
Start your Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition compliance journey by running a self-assessment on our platform to identify your current compliance posture. Our AI advisory can answer specific questions about Australia National Safety and Quality Health Service (NSQHS) Standards Second Edition requirements, and cross-framework mapping helps you leverage existing controls from other frameworks you may already comply with. Create a free account to access all 48 controls and track your progress.
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