Hospital and Health Care
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Clinical Governance

You answer for Standard 1, but your evidence sits in paper, spreadsheets, and an LMS.

For directors of clinical governance, quality and safety managers and directors of nursing. Ausmed holds each clinician's training, competency sign-offs, policy acknowledgements and performance reviews on one record. You answer the workforce actions from it, and the committee and the assessor read the same figures.

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Disparate systems result in inaccurate records.

A committee reviewing an incident relies on the training and competency record being right. In Ausmed the assessor writes the record where the work happens, on the unit, and Ausmed keeps every result and its date.

The record shows the admin as the assessor

Paper competency forms go to an administrator to key in, and the system shows one administrator assessing basic life support across a ward.

In Ausmed

The approved assessor records the result on the unit in the Ausmed Competency™ assessor app. Their name, a date and time stamp and comments go on the record.

Digitising paper-based competencies

Nobody wrote down Not Yet Competent

When a clinician doesn't meet the standard, the assessor reassesses them later and records only the pass.

In Ausmed

Ausmed Competency™ records Not Yet Competent like any other result and keeps it beside the later attempt. The action log tracks the follow-up, and the committee sees the whole history.

Quality and safety

The request names a date years ago

Coroners, workers' compensation claims and legal teams ask what a clinician had completed at a point in time, sometimes five or more years back.

In Ausmed

Every completion and sign-off carries its date and stays with the person after they leave. The Audit Report filters to the clinician.

Audit preparedness

Every question you answer for has a record behind it in Ausmed.

Standard 1 evidence

Compliance reports by NSQHS Standard answer the workforce actions under Clinical performance and effectiveness at short notice.

Incident review

The Audit Report shows what the clinicians involved had completed and been assessed on when it happened.

Assessor governance

You choose which assessors can sign off each competency, and the record names the one who did.

Scope of practice

When a scope expands, you assign the new assessment to the role, and the dashboard shows who is signed off.

Records on request

Training and competency history stays with each person after they leave, ready for coroners, claims and legal teams.

Content recency

Ausmed Library™ resources carry review dates under the T.R.U.S.T.E.D. framework. Swap an outdated in-house module for a current one.

NSQHS Standards, second edition

Report Action 1.20 to the committee from the training system.

Assessing competency and training needs is the first of the action's four parts, and monitoring participation is the last. Ausmed produces both from the same record.

Action 1.20

The health service organisation uses its training systems to:
a. Assess the competency and training needs of its workforce
b. Implement a mandatory training program to meet its requirements arising from these standards
c. Provide access to training to meet its safety and quality training needs
d. Monitor the workforce’s participation in training

Assessors sign off competency in Ausmed Competency™ against your own tools, with Competent and Not Yet Competent results by role. Knowledge Verification results show which clinicians already know an eligible topic.

Participation goes to the clinical governance committee in the Board Report: compliance percentage, overdue items by Standard or risk area, and the quarter-on-quarter trend. It exports as PDF or CSV.

Compliance reporting by NSQHS Standard

See who signed it off.

In Ausmed Competency™, the assessor records the sign-off on the unit in the assessor app. The record holds their name, a date and time stamp and their comments, with an optional co-signer.

You choose which assessors can assess which competencies. The name on the record belongs to someone you approved for that skill.

Results are Competent or Not Yet Competent, and dashboards show both by team, role and location. The assessments are your hospital's own, and you build them in Ausmed from your existing procedures and forms.

How Ausmed Competency works
Procedure sign-off in Ausmed Competency
Audit report in Ausmed Analytics

Show what a clinician had done, on the date that matters.

The Audit Report in Ausmed Analytics™ shows status per person and per requirement, with timestamps, version history and links to the evidence. When an incident review or a legal request names a clinician and a date, the answer comes from the record.

The record only reaches back as far as it starts, so the sooner the history sits in one place, the further back you can answer.

After an incident, record the follow-up and see who has read the revised procedure.

Where an incident involves a staff member's practice, their manager records it in a private Ausmed Perform™ note, with the date it happened and evidence attached. Only managers see Perform notes, and each one sits on the same staff record as the person's training and competency history, ready for the next review.

Ausmed Policy™ sends the revised policy or procedure to the people it applies to and records each acknowledgement against the version they read. Reminders follow up anyone who hasn't acknowledged it, and the committee sees acknowledgement of the new version by team and role.

Discover Ausmed Perform™
Post-incident policy rollout in Ausmed Policy

Ausmed produces a record for each workforce action.

For Actions 1.19 to 1.24, Ausmed holds evidence for the training and performance actions, and the competency history behind scope decisions. Credentials holds registrations and clearances for Action 1.24. Scope of practice and credentialing decisions stay with your committees. The same criterion, Clinical performance and effectiveness, also covers roles, supervision, evidence-based care and clinical variation (Actions 1.25 to 1.28).

Action 1.19

The health service organisation provides orientation to the organisation that describes roles and responsibilities for safety and quality for:
a. Members of the governing body
b. Clinicians, and any other employed, contracted, locum, agency, student or volunteer members of the organisation

Assign induction by role from your HR data when someone starts, give casual and agency staff separate onboarding plans, and assign policy acknowledgements at onboarding.

Action 1.20

The health service organisation uses its training systems to:
a. Assess the competency and training needs of its workforce
b. Implement a mandatory training program to meet its requirements arising from these standards
c. Provide access to training to meet its safety and quality training needs
d. Monitor the workforce’s participation in training

Training plans by role with recurring assignment, competency sign-offs by approved assessors, and participation reports by NSQHS Standard, team, role and location.

Action 1.21

The health service organisation has strategies to improve the cultural safety and cultural competency of the workforce to meet the needs of its Aboriginal and Torres Strait Islander patients

Assign your cultural safety program by role, deliver it online or as in-person Events, and see it in the same reports as every other requirement.

Action 1.22

The health service organisation has valid and reliable performance review processes that:
a. Require members of the workforce to regularly take part in a review of their performance
b. Identify needs for training and development in safety and quality
c. Incorporate information on training requirements into the organisation’s training system

Appraisals, probation reviews and catch-ups in Ausmed Perform™, with notes and evidence, held beside the training record.

Action 1.23

The health service organisation has processes to:
a. Define the scope of clinical practice for clinicians, considering the clinical service capacity of the organisation and clinical services plan
b. Monitor clinicians’ practices to ensure that they are operating within their designated scope of clinical practice
c. Review the scope of clinical practice of clinicians periodically and whenever a new clinical service, procedure or technology is introduced or substantially altered

Competency results by procedure and assessor show what assessors have signed a clinician off to do. Defining and approving scope stays with your committee.

Action 1.24

The health service organisation:
a. Conducts processes to ensure that clinicians are credentialed, where relevant
b. Monitors and improves the effectiveness of the credentialing process

Ausmed does not credential clinicians. Credentials holds the registrations and clearances a credentialing committee checks, tracked to expiry, beside the training and competency history.

Where to start

Governance evidence starts with the mandatory program and the sign-offs behind it.

Training Library

Map mandatory training to the NSQHS Standards and report it by Standard, with CPD alongside.

Training Library

NSQHS Re-accreditation

Have workforce evidence ready for an assessment that comes with a day's notice.

NSQHS Re-accreditation

Learning Management

Run graduate, transition and education programs, and record assessments as they happen.

Learning Management

“When somebody's doing a worker's compensation claim, they'll want to know what training the staff did at that point in time, and they'll give us a date of 2012.”

Manager of Organisational Development, private hospital group

Let’s talk

Bring a recent incident review, and we'll show you which parts of the workforce question Ausmed would have answered from the record.

Frequently asked questions

Does Ausmed limit us to using competency templates?

No. Your hospital's assessments are your own and stay that way. You build them in Ausmed Competency™ from your own procedures and forms, with your criteria and your choice of assessors.

Can someone sign off a skill they aren't competent in themselves?

Only if you allow it. You assign assessors per competency, so only the people you have approved for a skill can sign it off.

Does Ausmed handle credentialing or scope of practice?

Not yet. Credentialing and defining scope of practice stay with your credentialing committee. Ausmed holds the training and competency history that committee may want to see.

Which edition of the NSQHS Standards does Ausmed map to?

The second edition, which accrediting agencies assess hospitals against today. The Commission has consulted on a draft third edition, and assessment against it is not expected to start until 2030.