What do the NSQHS Standards require for workforce training?

The NSQHS Standards are eight national standards, set by the Australian Commission on Safety and Quality in Health Care (ACSQHC), that describe the level of care consumers can expect from health services. All public and private hospitals, day procedure services and most public dental practices are required by health regulators to be accredited to them, as at September 2026.

The eight standards are Clinical Governance, Partnering with Consumers, Preventing and Controlling Infections, Medication Safety, Comprehensive Care, Communicating for Safety, Blood Management, and Recognizing and Responding to Acute Deterioration. Each contains criteria, explanatory notes and numbered actions that describe what is required (ACSQHC, NSQHS Standards).

The ACSQHC does not assess services itself. Under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme, approved accrediting agencies assess services against the actions, and state, territory and Australian Government regulators decide which services must be assessed and what happens if a service does not comply (ACSQHC, accreditation).

The Clinical Governance Standard sets the organization wide training duty in the criterion "Clinical performance and effectiveness", whose stated outcome is that "the workforce has the right qualifications, skills and supervision to provide safe, high-quality health care to patients" (ACSQHC, Clinical Governance Standard). Seven actions carry the load.

Action 1.20 is the one most organizations point to. Its four parts form a loop: find the gap, close it with a mandatory training program, make training accessible, and check that people actually complete it. The stated intent is that "the workforce is appropriately trained to meet the need of the organisation to provide safe and high-quality care". The ACSQHC's reflective questions ask how the organization tests the skills level of the workforce and how it keeps skills current, which is a question about competence, not attendance.

Standards 2 and 4 to 8 each open with an action requiring clinicians to use the Clinical Governance systems when identifying training requirements for that topic, the Preventing and Controlling Infections Standard sets its training requirements in Action 3.02, and several standards go further by requiring assessed competence. The mandatory training program under Action 1.20 therefore has to cover all eight standards, not just the first.

• Partnering with Consumers: Action 2.01 requires identifying training requirements for partnering with consumers, and Action 2.14 requires consumers' views and experiences to be incorporated into workforce training and education.
• Preventing and Controlling Infections: Action 3.02 requires the organization to identify requirements for, and provide access to, training on infection prevention and antimicrobial stewardship. Action 3.07 covers training, testing and fitting of personal protective equipment and assessing competence in standard and transmission based precautions. Action 3.11 requires assessing competence in aseptic technique and training to address gaps. Action 3.13 requires access to training on cleaning for routine and outbreak situations.
• Medication Safety: Action 4.01 covers training requirements for medication management, and Action 4.04 requires processes to define and verify the scope of clinical practice for prescribing, dispensing and administering medicines.
• Comprehensive Care: Action 5.01 covers training requirements for comprehensive care. The restraint actions (from Action 5.35) ask whether the workforce is competent to implement restraint safely.
• Communicating for Safety and Blood Management: Actions 6.01 and 7.01 cover training requirements for clinical communication and blood management respectively.
• Recognizing and Responding to Acute Deterioration: Action 8.01 covers training requirements, Action 8.10 requires timely response by clinicians with the skills to manage acute deterioration, and Action 8.11 requires rapid access at all times to at least one clinician who can deliver advanced life support.

Action numbers and wording above are from the ACSQHC's online version of the second edition, for example the Preventing and Controlling Infections Standard and the Recognizing and Responding to Acute Deterioration Standard. Check the current accreditation workbook and its 2025 addendum before an assessment.

Each training related action can be turned into a learning outcome for a defined role and a piece of evidence an assessor can inspect. The table below is an illustrative mapping written by Knowledge Foundry, not ACSQHC guidance; it shows how a training matrix can tie roles to actions.

The ACSQHC's own examples of evidence for Action 3.02 include certificates of completion, records of competency assessment, training logs and calendars, training curriculums in use, and evidence of processes to monitor workforce competency. That list is a useful template for the other standards too.

Training is assessed on site, at short notice, by an approved accrediting agency. The ACSQHC states that all services assessed against the NSQHS Standards are assessed at short notice with 24 hours' notice of the start date, and must complete on site assessments (ACSQHC, accreditation).

Assessors review documents, inspect facilities, and interview key personnel, consumers and patients. For training, that means records alone are not enough: a nurse asked how they would escalate a deteriorating patient, or a new agency worker asked who is responsible for infection control on the ward, is testing whether orientation and training produced the intended understanding. Assessments generally occur every two or three years, and the ACSQHC publishes assessment outcomes data.

A health service should be able to show, for any role, what training is required, why, who has completed it, and whether competence was assessed. This checklist follows the actions above.

1. Orientation content covers governing body members and every worker category named in Action 1.19, and completion is recorded for contractors, locums, agency staff, students and volunteers.
2. A documented training needs analysis links each role to the NSQHS actions it affects.
3. The mandatory training program covers all eight standards, not only the Clinical Governance Standard.
4. Competency assessments, not just completions, exist where the Standards ask for competence: PPE and precautions (3.07), aseptic technique (3.11), medicines scope (4.04), restraint, and response to deterioration (8.10).
5. Performance reviews generate training needs that flow back into the training system (Action 1.22).
6. Scope of clinical practice is reviewed when a new service, procedure or technology is introduced (Action 1.23), and the training content is updated at the same time.
7. Consumers are involved in the design or delivery of workforce training (Action 2.14).
8. Participation and overdue training are reported regularly to managers and the governing body, as described in how to prepare training records for an audit.

Yes, but the second edition is still the one to use. As at September 2026 the ACSQHC says it is revising the Standards and asks services to "continue using the second edition of the NSQHS Standards" in the meantime (ACSQHC, NSQHS Standards).

The second public consultation on the draft third edition ran from July 20 to September 25, 2026, with an extension to October 2, 2026 for First Nations peoples (ACSQHC, third edition engagement hub). The ACSQHC states that feedback will inform the next draft, "which will be piloted by health services in 2027, ahead of final release in 2028 and assessment commencing in 2030" (ACSQHC, third edition consultation). Action numbers may change in the third edition, so training maps built today should reference actions in a way that can be remapped, a problem covered in how to update training when regulations change.

Knowledge Foundry models each NSQHS action as an obligation linked to the concepts, roles, learning outcomes and assessment points that address it, before any content is written. That gives a health service a traceable line from Action 1.20 or 3.11 to the evidence an assessor will ask for, and a single place to remap training when the third edition changes action numbers. See how this applies in healthcare and life sciences.