Since 1 July 2023, accreditation to the National Safety and Quality Health Service (NSQHS) Standards has been carried out at short notice. Public and private hospitals and day procedure services now generally receive around 24 hours’ notice that assessors are on their way, and some services receive 48 hours or longer, as determined by state and territory regulators.
The intent is simple: the assessment should reflect how your organisation operates on an ordinary Tuesday, not how it looks after a month of preparation. For infection prevention and control (IPC), that shift changes everything. You can no longer assemble a folder of evidence the week before an announced visit. Assessors want to see a living system, and they have a good eye for the difference between a program that runs every day and one that was tidied up for show. This article sets out what assessors are really looking for under Standard 3, and how to evidence it with confidence.
The standard behind the assessment
Standard 3, the Preventing and Controlling Infections Standard, is one of the eight NSQHS Standards (second edition). Its purpose is to reduce the risk of patients, consumers and workers acquiring preventable infections, to manage infections effectively when they do occur, and to prevent and contain antimicrobial resistance through appropriate prescribing and use of antimicrobials. The standard is built around four areas: clinical governance and quality improvement systems for IPC and antimicrobial stewardship; infection prevention and control systems; reprocessing of reusable medical devices; and antimicrobial stewardship. The stakes are not abstract. A systematic review of the literature estimated that healthcare-associated infections may affect around 165,000 patients in Australian hospitals each year, and many are considered potentially preventable. Standard 3 exists because good IPC systems demonstrably reduce that harm.
What short-notice assessment really tests
Under short notice, assessors review all applicable actions across the eight standards in a single visit, and rate each action as met, met with recommendations, or not met. What matters for IPC is the underlying question they are asking: is this system real, and is it working? That question gets answered less by your documents and more by what assessors observe and hear. Assessors spend at least 75 per cent of their time in clinical areas. They walk the floor. They watch practice. They talk to frontline staff, including agency and locum workers, new starters, cleaners and, increasingly, consumers. A polished policy counts for little if the ward tells a different story. The gap between the two is exactly what an assessor is trained to find.
What assessors actually look for
- A risk-based program, not a generic one.
The second edition strengthened the expectation that IPC systems are evidence-based and account for risk: the individual patient’s risk factors, the risk of the clinical intervention, and the risk of the setting in which care is delivered. Assessors want to see a current IPC plan that reflects your organisation’s actual risks, along with a precautionary approach where the evidence is still evolving. A generic plan lifted from a template is a red flag.
- Governance that connects the floor to the board.
Assessors follow the thread. They look for an IPC committee with genuine clinical leadership, surveillance data flowing up into governance, and decisions and actions flowing back down. Terms of reference and meeting minutes should show issues being raised, decisions being made, and follow-through actually happening. Minutes that record discussion but never resolution are a common weakness.
- Practice that matches the policy.
This is where most findings are made. If your hand hygiene policy, your use of personal protective equipment, or your transmission-based precautions look one way on paper and another on the ward, the difference becomes the recommendation. Observation audits, competency records and simple consistency between the written and the witnessed are what hold up here.
- Surveillance that drives improvement.
Collecting data on hand hygiene compliance, Staphylococcus aureus bloodstream infections or surgical site infections is expected. What assessors reward is the loop: data gathered, analysed, acted on, and re-measured to confirm the action worked. Dashboards that no one acts on demonstrate monitoring, not improvement.
- A workforce that is trained, competent and credentialled.
Everyone who touches a patient should understand their IPC responsibilities and be able to describe them when asked. That includes your permanent staff and, critically, your contingent workforce. Orientation records, role-specific competencies, training completion and IPC checks built into credentialling are the evidence that matters.
- Reprocessing done to the current standard.
AS 5369:2023 has replaced AS/NZS 4187:2014 as the standard for reprocessing reusable medical devices. Action 3.17a requires reprocessing consistent with relevant standards, so assessors expect to see a gap analysis against AS 5369, an asset management plan where upgrades are needed, traceability, and demonstrated staff competency.
- Antimicrobial stewardship that functions.
Assessors look for a working stewardship program: prescribing guidelines in use, monitoring of antimicrobial use, and feedback to prescribers that changes behaviour. Evidence of point-prevalence surveys or audits, with resulting action, shows the program is more than a policy.
- Environmental cleaning to a defined standard.
Cleaning should be delivered to a recognised standard, audited, and owned by someone accountable. Cleaning schedules, audit results and clear lines of responsibility all support this.
- Consumers as partners.
IPC is not purely a clinical matter. Assessors may speak with consumers, and they look for consumer input into IPC governance and accessible IPC information. This is easy to overlook and simple to evidence once it is in place.
The gaps that trip organisations up
Five recurring weaknesses account for a large share of IPC findings:
- The policy-practice gap.
The system is documented but not lived.
- Stale documents.
An IPC plan or risk assessment last reviewed years ago signals a system that has stopped moving.
- Data without action.
Surveillance is collected but never converted into improvement.
- Contingent workforce blind spots.
Agency and locum staff are not oriented to your IPC systems, so their practice, and their answers to assessors, do not match your policies.
- Governance that never closes the loop.
Issues are raised but not resolved, and the minutes prove it.
How to be ready before the call
Preparation for short-notice assessment is really just good practice made continuous. A few priorities make the difference:
- Keep the IPC plan current and genuinely risk-based, with a scheduled review that actually happens.
- Walk your own wards the way an assessor would, and ask your own staff the questions they will be asked.
- Make sure every set of surveillance data has a visible action trail attached to it.
- Bring your contingent workforce fully into your IPC system, with proper orientation, competency checks and credentialling, so agency and locum staff represent your standards as well as your own team.
- Know who owns each Standard 3 criterion, and rehearse the entry and exit meetings so nobody is caught cold.
The real test
The organisations that move through short-notice assessment without drama are rarely the ones with the thickest folders. They are the ones where infection prevention is simply how the work is done, on every shift, by every person on the floor. Under short notice, that is the only version of a system worth having. At Healthcare Australia, we help organisations close the gaps that assessors find: supplying experienced IPC clinicians, building infection-prevention capability across permanent and contingent workforces, and making sure the people we place arrive credentialled, compliant and ready to uphold your standards from day one. Contact us today, we’re here to support your IPC challenges.
