How do you prepare for an NSQHS accreditation assessment?

NSQHS assessments come with 24 hours' notice, assessors judge actual performance from observation, interviews and records, and every relevant action must end Met or Met with recommendations.

What the assessors are testing

Accreditation tests whether the systems that make care safe are in place.¹ The Commission's assessment framework uses a structured method, PICMoRS, so that assessments are based on evidence of actual performance from observations, interviews and records.² Short notice exists for the same reason, so that the outcome reflects day to day practice and services spend less time preparing.³

Before the notice arrives

1. Confirm your standards. Hospitals and day procedure services are accredited to the NSQHS Standards. Check whether any module, such as the Cosmetic Surgery Module, also applies.
2. Engage an approved agency. Only agencies the Commission approves can assess you. You can change agency between assessments, but not in the middle of one.
3. Agree not applicable actions. Settle with your agency, well before the assessment, which actions do not apply to your service. Some need the Commission's approval.
4. Use the workbook and monitoring tool. The standards, your setting's guide and the accreditation workbook set the baseline. The monitoring tool tracks progress action by action.
5. Test each system. For each action, ask what the policy is, whether it is used, how it is monitored, and what improved. That is how assessors look at it.
6. Rehearse the first morning. Decide who takes the call, who meets the assessors, and who answers for each standard. Then time how long evidence takes to produce.

1. Standard ______ Action ______ Applicable, yes or no ______
2. Policy or process ______
3. How it is implemented ______
4. How it is monitored and reported ______
5. What improved this year ______
6. Evidence lives in ______ Owner ______

Copy template

From the first day to the decision

Accreditation is awarded, with a certificate, when all relevant actions are rated Met or Met with recommendations, for two or three years. If it is not awarded, the agency tells the Commission and your regulator.¹

Common reasons actions are rated Not met

• A policy nobody uses, with no monitoring behind it.
• Healthcare records that are incomplete, or written long after the visit.
• Not applicable actions raised on the day instead of agreed in advance.
• Consumer feedback collected and never acted on.
• A governing body that cannot show what it reads, or what it did about it.

The Commission keeps the list of approved accrediting agencies and the standards each may assess.⁴ Its resource hub holds the guides, workbook and monitoring tools for hospitals and day procedure services.⁵

The guide to clinical handover documentation covers one of the most tested areas, and the NSQHS and RACGP accreditation hub lists what assessors ask. To see the evidence on your own records, request a demo of the NSQHS accreditation software.

Questions

How much notice do you get for an NSQHS assessment?

24 hours' notice of the start date. All NSQHS assessments are short notice.

What does Met with recommendations mean for accreditation?

The action still counts towards accreditation, but you have up to 60 business days to remediate it, and too many can trigger a mandatory reassessment.

Can we choose our accrediting agency?

Yes, from the agencies the Commission approves. You can change agency if your regulator allows it and you are not mid-assessment.

What is PICMoRS?

The structured method in the Commission's assessment framework, used to review the processes that make up the safety and quality systems in the NSQHS Standards.

Sources

1. 1Australian Commission on Safety and Quality in Health Care, 2026Accreditation to National Safety and Quality StandardsRead source
2. 2Australian Commission on Safety and Quality in Health Care, 2020Fact Sheet 12, Assessment framework for safety and quality systemsRead source
3. 3Australian Commission on Safety and Quality in Health Care, 2026Short notice assessmentsRead source
4. 4Australian Commission on Safety and Quality in Health Care, 2026Approved accrediting agenciesRead source
5. 5Australian Commission on Safety and Quality in Health Care, 2026NSQHS Standards resource hubRead 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.