Advisory AS18/04: Advice on the applicability of Aboriginal and Torres Strait Islander actions

Advisory details

Purpose

To clarify the applicability of Aboriginal and Torres Strait Islander actions in the National Safety and Quality Health Service (NSQHS) Standards.
 

Context

The Commission is committed to improving health outcomes for Aboriginal and Torres Strait Islander Peoples and are looking to a future state where cultural safety is visible in leadership, policy, practice and workforce culture.
 

Issue

The NSQHS Standards include six defined actions that address the needs of Aboriginal and Torres Strait Islander peoples. The implementation of these actions will support the provision of culturally safe, high-quality care to Aboriginal and Torres Strait Islander peoples across the health system.

States and territories have committed to Closing the Gap through successive national agreements and reforms. Implementing the Aboriginal and Torres Strait Islander actions is one mechanism to support improved health outcomes and experiences for Aboriginal and Torres Strait Islander peoples.
 

Requirements

Mandatory Actions

Health services must implement the following two actions, with no exclusions:

• Action 1.21 – the health service organisation has strategies to improve the cultural awareness and cultural competency of the workforce to meet the needs of its Aboriginal and Torres Strait Islander patients
• Action 5.08 – the health service organisation has processes to routinely ask patients if they identify as being of Aboriginal and/or Torres Strait Islander origin, and to record this information in administrative and clinical information systems.

Actions Eligible for Not Applicable Status

The Commission recommends that health services implement all six actions. However, the status of an action may depend on the organisation’s patient population, service scope and identified risks of harm. 

Health services that meet the criteria, may be eligible to receive an exemption for some of these actions. This only applies where a health service can demonstrate that the risk of harm for Aboriginal and Torres Strait Islander peoples is the same as for the organisation’s general patient population. Please refer to Advisory AS18/01 for advice on not applicable status. This includes:

• Action 1.02 – the governing body setting safety and quality priorities for Aboriginal and Torres Strait Islander peoples
• Action 1.04 – the health service organisation implementing strategies and monitoring safety and quality priorities for Aboriginal and Torres Strait Islander peoples
• Action 1.33 – the health service organisation demonstrating a welcoming environment
• Action 2.13 – partnering with the Aboriginal and Torres Strait Islander community.

Risk analysis for actions eligible for not applicable status

Health services seeking exemption for any of these actions must demonstrate that a comprehensive risk analysis has been undertaken that examines the:

• risk profile of the organisation’s general patient population
• risk profile of the organisation’s Aboriginal and Torres Strait Islander patient population.

The risk profile can be determined by comparing the following information on Aboriginal and Torres Strait Islander patients to non-Indigenous patients:

• number and age of Aboriginal and Torres Strait Islander patients
• diagnosis and/or reason for admission
• rate of complications
• length of stay
• type, severity and rate of incidents
• frequency of discharge against medical advice
• feedback or complaints from Aboriginal and Torres Strait Islander patients

This data could be collected from a range of sources, including:

• clinical and administrative data sets
• audit of patient records
• incident management systems
• feedback and complaints systems
• demographic information about the organisation’s patient catchment area
• risk register

Not applicable status for Actions 1.02, 1.04, 1.33 and 2.13 will only be granted where there is evidence of a comprehensive risk analysis.

Care Delivery

All health services are required to continue to monitor and manage risks of harm and provide culturally safe and high-quality care for all Aboriginal and Torres Strait Islander patients through the safety and quality improvement systems.

Attestation Statements

All health services are required to submit an Attestation Statement annually, see Fact Sheet 7: Governing body attestation statement.

Health services granted not applicable status for Action 1.02 may cross through or remove point two of the Attestation Statement and initial the change. In this way, the health service is reporting the not applicable status has been confirmed ahead of their assessment.