Advisory details
| Item | Details |
|---|---|
| Advisory number | AS18/01 |
| Version number | 10.0 |
| Publication date | 26 July 2021 |
| Replaces | AS18/01 version 9.0 published on March 2021 |
| Compliance with this advisory | It is mandatory for approved accrediting agencies to implement this Advisory |
| Information in this advisory applies to |
|
| Key relationship | All NSQHS Standards |
| Attachment | Summary tables of not applicable actions |
| Notes |
Updated actions for cosmetic surgery Services implementing the Cosmetic Surgery Module Updated actions for MPS implementing the MPS Aged Care Module Following release of the amended 2021 Preventing and Controlling Infections Standard, changes to this advisory are related to:
|
| Responsible officer | Margaret Banks Director, National Standards Phone: 1800 304 056 Email: AdviceCentre@safetyandquality.gov.au |
| To be reviewed | December 2022 |
Purpose
To clarify not applicable actions for hospitals, day procedure services, multi-purpose services, bush nursing services, patient transport services and public dental services.
Issue
In some exceptional circumstances, actions from the NSQHS Standards may not be applicable to a health service organisation. The Commission has issued this advisory to ensure the consistent application of not applicable status to actions within the NSQHS Standards.
Requirements
The attached summary tables detail the actions which may be awarded not applicable rating, subject to supporting evidence being provided by the health service organisation.
Where a health service organisation considers that an action is not applicable, evidence must be supplied to demonstrate that the action is associated with little or no risk of patient harm in their service context. Applications should be submitted to the approved accrediting agency well in advance of the assessment. Accrediting agencies are to provide an initial determination of the health service organisation’s submission before undertaking the scheduled assessment. At assessment, assessors are to verify that the decision to award these actions not applicable status is justified.
Accrediting agencies are required to refer to the below tables when considering applications from health service organisations for non-applicability of actions within the NSQHS Standards.
In large organisations, there may be specific units or departments where an action does not apply, while remaining applicable elsewhere in the organisation. For example, Action 3.12 regarding invasive devices may not be relevant in a sleep lab or rehabilitation unit. In these cases, the action will apply for the health service organisation but is not required to be assessed for units where it is demonstrated as not applicable.
Infrequent application of an action, such as applying Action 3.05 Surveillance strategies for antimicrobial use in patient transport services or Action 7.06 Prescribing and administering blood and blood products, is not sufficient reason for awarding not applicable status. Where an action is infrequently applied, strategies to implement the action are likely to be a simple monitoring and review process by the health service organisation.
Where there is a dispute concerning an award of not applicable status that is not resolved following discussions between the health service organisation and the accrediting agency, application can be made by either the accrediting agency or health service organisations to the Commission for mediation.
Bush nursing services
Bush nursing services generally operate in geographically isolated or small rural communities.
Bush nurses are generally the sole local public provider of services and report through a governance structure to a locally elected volunteer committee.
Bush nurses provide primary health care, home-based nursing and personal care, social support groups, health screening and education, accident and trauma stabilisation and may coordinate with visiting medical and allied health practitioners.
In Victoria, the bush nursing service is a recognisable service provider group.
Aboriginal and Torres Strait Islander specific actions
Please refer to Advisory AS18/04: Advice on the applicability of Aboriginal and Torres Strait Islander specific actions for further details on applying for not applicable status.
Multi-Purpose Services Aged Care Module
The MPS Aged Care Module describes in six actions the requirements of the Aged Care Quality Standards not covered by the NSQHS Standards and applies only to MPS that are part of the Commonwealth MPS program. The MPS Aged Care Module was endorsed by the former Australian Health Minister’s Advisory Council in February 2020.
Cosmetic Surgery Module
The Cosmetic Surgery Module outlines 20 actions that Services are required to implement in addition to the NSQHS Standards, allowing them to comply with both the NSQHS Standards (2nd Edition) and the Cosmetic Surgery Standards. Services seeking accreditation to only the Cosmetic Surgery Standards should refer to, Advisory AS24/XX: Advice on not applicable actions for the Cosmetic Surgery Standards.