How do the NSQHS Standards apply to a day procedure service?

Every private day procedure service must be accredited to the NSQHS Standards, second edition, assessed on site at 24 hours' notice by an approved accrediting agency. The state licenses the premises separately, and actions outside your scope can be agreed in advance as not applicable.

Who requires it

All public and private hospitals, day procedure services and most public dental practices are required by health regulators to be accredited to the NSQHS Standards.¹ The Commission develops the standards and approves accrediting agencies. The state or territory regulator decides which services must be assessed to which standards, and what happens if a service does not comply.¹

The premises are licensed separately. In Victoria, for example, the Department of Health registers day procedure centres under Part 4 of the Health Services Act 1988.² In Western Australia, private day hospitals are licensed in classes A to D under the Private Hospitals and Health Services Act 1927.³ In New South Wales, licensing runs under the Private Health Facilities Act 2007.⁴

How the assessment runs

Since 1 July 2023 every service assessed against the NSQHS Standards is assessed at short notice, with 24 hours' notice of the start date, so the outcome reflects day to day practice.⁵ NSQHS assessments are on site. Assessors review documents, inspect the facilities and interview key personnel, consumers and patients in person.¹

Accreditation is awarded when all relevant actions are rated Met or Met with recommendations, for two or three years depending on the assessment model.¹

Which actions apply to a day service

Actions that do not apply to your scope or clinical context may be rated not applicable, agreed with your accrediting agency well before the assessment.¹ The Blood Management Standard, for example, is not applicable to a service that does not use blood or blood products, which shows it does not use, receive, store, collect or transport them.⁶

The Commission's guide for day procedure services gives examples of evidence for every action. Its examples are not mandatory, and a service is not expected to hold them all.⁷

1. Confirm your scope. List your procedures, anaesthesia and sedation levels, and whether you use blood products. Agree not applicable actions with your agency.
2. Map every action to evidence. Use the day procedure guide and the monitoring tool. Point each action to the record, policy or report that shows it.
3. Trace five patients. Pick five patients. Trace booking, consent, identification, procedure, handover and follow-up through the record.
4. Check the handover. Every discharge letter carries the minimum information you defined, with three approved identifiers.
5. Rehearse the 24 hours. Ask who would be called, who would answer for each standard, and where the evidence is. Time it.
6. Review monthly. Short notice means the service must be ready every day. Put the evidence review on the governance agenda.

1. Patient record number ______ Procedure ______ Date ______
2. Identifiers checked at admission, procedure, discharge ______
3. Consent recorded, by whom, when ______
4. Handover letter sent to ______ on ______
5. Follow-up call or recall on ______ by ______
6. Gaps found ______ Action and owner ______

Copy template

A newly established day procedure service may be eligible for interim accreditation, with an assessment within 10 working days of starting to provide services.¹ The Commission's interim guide generally applies for the first 12 months of operation.⁸

The guide to preparing for an NSQHS accreditation assessment sets out the steps before notice arrives, and the guide to clinic AI in Perth covers day hospital licensing in Western Australia. The NSQHS and RACGP accreditation hub lists every state body.

Questions

Do day procedure services have to be accredited to the NSQHS Standards?

Yes. All public and private hospitals and day procedure services are required by health regulators to be accredited to them.

How much notice is given before an NSQHS assessment?

24 hours' notice of the start date. Every NSQHS assessment has been short notice since 1 July 2023.

Can actions be not applicable?

Yes, where they do not apply to your scope of practice or clinical context. Agree them with your accrediting agency well before the assessment, as the Commission's approval may be needed.

Who licenses the premises?

Your state or territory health department, under its own legislation. The NSQHS accreditation is separate from the licence.

Sources

1. 1Australian Commission on Safety and Quality in Health Care, 2026Accreditation to National Safety and Quality StandardsRead source
2. 2Victorian Department of Health, 2026Day procedure centresRead source
3. 3WA Department of Health, 2026How to obtain a licence for a private healthcare facilityRead source
4. 4NSW Health, 2026Private health facilitiesRead source
5. 5Australian Commission on Safety and Quality in Health Care, 2026Short notice assessmentsRead source
6. 6Australian Commission on Safety and Quality in Health Care, 2026Blood Management StandardRead source
7. 7Australian Commission on Safety and Quality in Health Care, 2017NSQHS Standards Guide for day procedure servicesRead source
8. 8Australian Commission on Safety and Quality in Health Care, 2022NSQHS Standards Guide for interim accreditationRead source

Written by the wai team from Australian Commission on Safety and Quality in Health Care and the RACGP guidance, checked on 15 October 2026. This is guidance, not legal advice. Neither ACSQHC nor the RACGP endorses wai or any software.