National Safety and Quality Health Service Standards
The Australian Commission on Safety and Quality in Healthcare has developed the National Safety and Quality Health Service (NSQHS) Standards to protect the public from harm and to improve the quality of health service provision. The Standards describe the systems required to ensure the minimum standards of safety and quality are met, and a quality improvement mechanism that allows health services to realise aspirational and developmental goals.
- Standard 1 – Governance for Safety and Quality in Health Service Organisations
- Standard 2 - Partnering with Consumers
- Standard 3 - Preventing and Controlling Healthcare Associated Infections
- Standard 4 - Medication Safety
- Standard 5 - Patient identification and procedure matching
- Standard 6 - Clinical Handover
- Standard 7- Blood and Blood Products
- Standard 8 - Preventing and managing pressure injuries
- Standard 9 – Recognising and Responding to Clinical Deterioration
- Standard 10 - Preventing Falls and Harm from Falls
SA Health Accreditation Resource Guides and Audit Tools
A South Australian Health Accreditation Resource has been developed to support Health Services and provides examples of South Australian tools and resources that can be used to demonstrate an action and standard has been met. Audit tools have also been developed for some standards. See the individual standard pages below for a copy.
Standard 1 describes integrated systems that maintain and improve the reliability and quality of patient care, as well as improve patient outcomes, including the following five criteria:
- Governance and quality improvement systems - There are integrated systems of governance to actively manage patient safety and quality risks.
- Clinical practice - Care provided by the clinical workforce is guided by current best practice.
- Performance and skills management - Managers and the clinical workforce have the right qualifications, skills and approach to provide safe, high-quality health care.
- Incidents and complaints management - Patient safety and quality incidents are recognised, reported and analysed, and this information is used to improve safety systems.
- Patient rights and engagement - Patient rights are respected and their engagement in their care is supported.
Standard 2 describes the systems and strategies to create a consumer centred health system by including consumers in the development and design of quality health care. The standard provides the framework for active partnership with consumers by health service organisations.
- Consumer partnership in service planning – Governance structures are in place to form partnerships with consumers and/or carers.
- Consumer partnership in designing care – Consumers and/or carers are supported by the health service organisation to actively participate in the improvement of the patient experience and patient health outcomes.
- Consumer partnership in service measurement and evaluation – Consumers and/or carers receive information on the health service organisation’s performance and contribute to the ongoing monitoring, measurement and evaluation of performance for continuous quality improvement.
Standard 3 describes systems to prevent and manage healthcare associated infections and communicate these to the workforce to achieve appropriate outcomes.
- Governance and systems for infection prevention, control and surveillance - Effective governance and management systems for healthcare associated infections are implemented and maintained.
- Infection prevention and control strategies - Strategies for the prevention and control of healthcare associated infections are developed and implemented.
- Managing patients with infection or colonisation - Patients presenting with, or acquiring an infection or colonisation during their care are identified promptly and receive the necessary management and treatment.
- Antimicrobial stewardship - Safe and appropriate antimicrobial prescribing is a strategic goal of the clinical governance system.
- Cleaning, disinfection and sterilisation - Healthcare facilities and the associated environment are clean and hygienic. Reprocessing of equipment and instrumentation meets current best practice guidelines.
- Communicating with patients and carers - Information of healthcare associated infections is provided to patients, carers, consumers and service providers.
Standard 4 describes systems to reduce the occurrence of medication incidents, and improve the safety and quality of medicine use including:
- Governance and systems for medication safety - Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines.
- Documentation of patient information - The clinical workforce accurately records a patient’s medication history and this history is available throughout the episode of care.
- Medication management processes - The clinical workforce is supported for the prescribing, dispensing, administering, storing, manufacturing, compounding and monitoring of medicines.
- Continuity of medication management - The clinician provides a complete list of a patient’s medicines to the receiving clinician and patient when handing over care or changing medicines.
- Communicating with patients and carers - The clinical workforce informs patients about their options, risks and responsibilities for an agreed medication management plan.
Standard 5 describes systems to ensure the correct identification of all patients and correct matching of patients with their intended treatment. This includes:
- Identification of individual patients - At least three approved patient identifies are used when providing care, therapy or services.
- Processes to transfer care - A patient’s identity is confirmed using three approved patient identifiers when transferring responsibility of care.
- Processes to match patients and their care - Health service organisations have explicit processes to correctly match patients with their intended care.
Standard 6 describes systems for effective and structured clinical handover. Ensuring there is a timely, relevant and structured clinical handover that supports safe patient care. This includes:
- Governance and leadership for effective clinical handover - Health service organisations implement effective clinical handover systems.
- Clinical handover processes - Health service organisations have documented and structured clinical handover processes in place.
- Patient and carer involvement in clinical handover - Health service organisations establish mechanisms to include patients and carers in clinical handover processes.
Standard 7 was developed to ensure that patients receive blood and blood products appropriately and safely. This includes:
- Governance and systems for blood and blood product prescribing in clinical use - Health organisations have systems in place for the use and appropriate prescribing and clinical use of blood and blood products.
- Documenting patient information - The clinical workforce accurate records a patient’s blood and blood product transfusion history and indications for use of blood and blood products.
- Managing blood and blood products safety - Health service organisations have systems to receive, store, transport and monitor wastage of blood and blood products safely and efficiently.
- Communicating with patients and carers - Patients and carers are informed about the risks and benefits of using blood and blood products, and the available alternatives when a plan for treatment is developed.
Standard 8 describes evidence-based systems to prevent pressure injuries and manage them when they do occur. This includes:
- Governance and leadership for the prevention and management of pressure injuries - Health service organisations have governance structures and systems in place for the prevention and management of pressure injuries.
- Preventing pressure injuries - Patients are screened on presentation and pressure injury prevention strategies are implemented when clinical indicated.
- Managing pressure injuries - Patients who have pressure injuries are managed according to best practice guidelines.
- Communication with patients and carers - Patients and carers are informed of the risks, prevention strategies and management of pressure injuries.
Standard 9 describes systems for recognising and responding to clinical deterioration, and ensures a patient’s deterioration is recognised promptly, and appropriate action is taken. This includes:
- Establishing recognition and response systems - Organisation-wide systems consistent with the National Consensus Statement are used to support and promote recognition of, and respond to, patients whose condition deteriorates.
- Recognising clinical deterioration and escalating care - Patients whose condition is deteriorating are recognised and appropriate action is taken to escalate care.
- Responding to clinical deterioration - Appropriate and timely care is provided to patients whose condition is deteriorating.
- Communicating with patients and carers - Patients, families and carers are informed of recognition and response systems and can contribute to the processes of escalating care.
Standard 10 describes evidence-based systems to prevent patient falls and minimise harm. These include:
- Governance and systems for preventing falls - Health service organisations have governance structures and systems in place to reduce falls and minimise harm from falls.
- Screening and assessing risks of falls and harm from falling - Patients on presentation, during admission, and when clinical indicated, are screened for risk of a fall and the potential to be harmed from falls.
- Preventing falls and harm from falling - Prevention strategies are in place for patients at risk of falling.
- Communicating with patients and carers - Patients and carers are informed of the identified risks from falls and are engaged in the development of a falls prevention plan.
Director, Safety & Quality Unit
Telephone: (08) 8226 6971