Vic Management Interns' blog

Blog posts by Victorian Management Interns of the Australasian College of Health Service Management. Views are those of the individual authors and not those of ACHSM or management interns’ host organisations or employers.


HMIP Victoria Management Interns

National Safety and Quality Health Service Standards and the new Health Manager

By Jass Pannu

2nd Year Management Intern

Health care systems, as we all know, are highly specialised and complex organizations catering to the varying needs of its customers across acute, subacute and primary health settings. Ensuring the delivery of safe and high-quality patient care is the responsibility of everyone that work within the health service – including the patient themselves. Introduced in 2013, the National Safety and Quality Health Service (NSQHS) Standards stipulate the level of care consumers can expect to receive during their episode of care (Duckett & Willcox, 2015).All hospitals and day procedure services in Australia are required to implement and be accredited against the NSQHS Standards as per the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme (ACSQHC, 2019a).

As an accreditation assessment tool, the NSQHS standards provide “quality assurance mechanisms to test whether relevant systems are in place to ensure that expected standards of safety and quality are met” (ACSQHC, 2019b). The 2nd edition of NSQHS standards evaluate health services against the 8 standards comprising of 148 actions (Department of Health and Human Services, 2017). The 8 standards are as follow:

What do these 8 standards mean for me as a future health manager?

As a new graduate in clinical setting, my desire to better understand the accreditation process was often overridden by learning how to do my job well, and when I could do my job well, I was often teaching the new graduates the tricks of the trade. Accreditation was an event that came every 3 years and was often accompanied by information overload about how we need to dot the i’s and cross the t’s which some have queried the value this adds to patient care. Studies have shown that accreditation has led to increased bureaucracy and a ‘control and checklist culture’ though standardization of policies and procedures (Simonsen, Hertzum & Scheuer, 2018).

In my role as a future health manager, I believe that the 4 points listed below will be fundamental of the basis of the accreditation journey.

  1. Don’t make it an ‘event’

I think when we put too much emphasis on accreditation once every three years, it becomes an event that everyone needs to get ready for. I think providing ongoing support and information to staff in regards to accreditation and what our organization is continually doing in the process will make the even less overwhelming and more meaningful to staff as accreditation gets closer.

  1. Take my staff on the journey with me.

Actively engage and inform staff the true purpose of evaluation. During one of my placements, I was told accreditation is an audit of the services we provide to the consumers of health care at one given point in time, and it made sense to me. It’s not about providing evidence that we meet the minimum standards for service provision as I have been previously told. Because as health professionals, we thrive on ensuring our patients are getting better and receiving the best care possible. The struggle for most of us, as health professionals, is that even though we do provide excellent patient care, it is often not documented. After all, how do I document that I held a patient’s hand as they were being anaesthetised because they were so nervous?

  1. Ownership and support

Get staff involved and localise the 8 standards within the work environment and ensure it blends in with the bigger picture of what the health service is aiming for. Empower and trust staff to initiate quality improvement projects within the clinical settings. Provide them with the necessary tools and knowledge to improve their work environment. As front-line staff, they have constant interactions with patients, and often have wonderful ideas which can enhance patient experience.

  1. Leadership and organizational culture.

As a leader, I would create a culture where staff feel nurtured and supported to provide safe high-quality care which is normalized into their everyday work. I would encourage staff to collaborate with other units to improve patient experience and care. I would love to embed a stronger ‘just’culture with a focus on learning and feedback from our incidents and working together to improve our complex work environment.

Having learnt much about accreditation during the various placements in the internship, I think I will nudge myself to be a more proactive participant at my next accreditation process, and hopefully inspire my colleagues to do the same.


Australian Commission on Safety and Quality in Health Care. (2019a). The state of patient safety and quality in Australian hospitals 2019.

Australian Commission on Safety and Quality in Health Care (2019b). Implementation of NSQHS Standards.

Department of Health and Human Services. (2017). National Safety and Quality Health Service Standards (second edition).

Duckett, S., & Willcox, S. (2015). The Australian health care system (5th ed.). Oxford University Press.

Simonsen, J., Hertzum, M., & Scheuer, J.D. (2018). Quality development in health care: Participation vs. Accreditation. Nordic Journal of Working Life Studies. 8, 49-69.

The Royal Victorian Eye and Ear Hospital. (2014).

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