Advisory AS22/03: Advice on not applicable actions for BreastScreen Australia Services
To clarify not applicable actions for BreastScreen Australia (BSA) Services implementing the National Safety and Quality Health Service (NSQHS) Standards.
Advisory details
| Item | Details |
|---|---|
| Advisory number | AS 22/03 |
| Version number | 1.0 |
| Publication date | August 2022 |
| Replaces | - |
| 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 | |
| Responsible officer | Director, National Standards Phone: 1800 304 056 Email: AdviceCentre@safetyandquality.gov.au |
| To be reviewed | December 2027 |
Purpose
To clarify not applicable actions for BreastScreen Australia (BSA) Services implementing the National Safety and Quality Health Service (NSQHS) Standards.
Issue
There are actions in the NSQHS Standards that do not apply to BreastScreen Australia (BSA) Services, because of the scope of services they provide and the context in which they operate. The Australian Commission on Safety and Quality in Health Care (the Commission) has issued this advisory to ensure the consistent application of not applicable status to actions from the NSQHS Standards across BSA Services.
BSA Services have worked with the Commission to identify and provide evidence of actions that are not applicable. The evidence supplied demonstrates that the actions identified as not applicable present little or no risk of patient harm.
BSA Services should confirm the not applicable actions with their accrediting agency well in advance of their assessment.
Requirements
The actions that have been agreed as not applicable for BSA Services are listed at Attachment 1.
Accrediting agencies are required to refer to the Attachment 1 prior to assessing BSA services.
Where additional not applicable actions are sought, or there are differences in opinion between the BSA service and its accrediting agency that cannot be resolved, application can be made by either the accrediting agency or the BSA Service to the Commission for resolution.
Attachment: Summary tables of not applicable actions
Clinical Governance Standard
| Action | Applicability to BSA Services |
|---|---|
| 1.01 | No exclusion |
| 1.02 | No exclusion |
| 1.03 | No exclusion |
| 1.04 | No exclusion |
| 1.05 | No exclusion |
| 1.06 | No exclusion |
| 1.07 | No exclusion |
| 1.08 | No exclusion |
| 1.09 | No exclusion |
| 1.10 | No exclusion |
| 1.11 | No exclusion |
| 1.12 | No exclusion |
| 1.13 | No exclusion |
| 1.14 | No exclusion |
| 1.15 | No exclusion |
| 1.16 | No exclusion |
| 1.17 | No exclusion |
| 1.18 | Not applicable when evidence is provided that the My Health Records system is not in use. |
| 1.19 | No exclusion |
| 1.20 | No exclusion |
| 1.21 | No exclusion |
| 1.22 | No exclusion |
| 1.23 | No exclusion |
| 1.24 | No exclusion |
| 1.25 | No exclusion |
| 1.26 | No exclusion |
| 1.27 | No exclusion |
| 1.28 | No exclusion |
| 1.29 | No exclusion |
| 1.30 | No exclusion |
| 1.31 | No exclusion |
| 1.32 | Not applicable |
| 1.33 | No exclusion |
Partnering with Consumers Standard
| Action | Applicability to BSA Services |
|---|---|
| 2.01 | No exclusion |
| 2.02 | No exclusion |
| 2.03 | No exclusion |
| 2.04 | No exclusion |
| 2.05 | No exclusion |
| 2.06 | No exclusion |
| 2.07 | No exclusion |
| 2.08 | No exclusion |
| 2.09 | No exclusion |
| 2.10 | No exclusion |
| 2.11 | No exclusion |
| 2.12 | No exclusion |
| 2.13 | No exclusion |
| 2.14 | No exclusion |
Preventing and Controlling Infections Standard
| Action | Applicability to BSA Services |
|---|---|
| 3.01 |
|
| 3.02 |
|
| 3.03 |
|
| 3.04 |
|
| 3.05 |
|
| 3.06 |
|
| 3.07 |
|
| 3.08 |
|
| 3.09 | No exclusion |
| 3.10 | No exclusion |
| 3.11 | Not applicable when evidence is provided that Aseptic technique is not performed |
| 3.12 | Not applicable when evidence is provided that invasive devices are not in use |
| 3.13 | No exclusion |
| 3.14 | No exclusion |
| 3.15 | No exclusion |
| 3.16 | No exclusion |
| 3.17 |
|
| 3.18 | Not applicable |
| 3.19 | Not applicable |
Medication Management Standard
| Action | Applicability to BSA Services |
|---|---|
| 4.01 | No exclusion |
| 4.02 | No exclusion |
| 4.03 | No exclusion |
| 4.04 | No exclusion |
| 4.05 | No exclusion |
| 4.06 | Not Applicable |
| 4.07 | No exclusion |
| 4.08 | No exclusion |
| 4.09 | No exclusion |
| 4.10 | No exclusion |
| 4.11 | No exclusion |
| 4.12 | Not Applicable |
| 4.13 | No exclusion |
| 4.14 | No exclusion |
| 4.15 | No exclusion |
Comprehensive Care Standard
| Action | Applicability to BSA Services |
|---|---|
| 5.01 | No exclusion |
| 5.02 | No exclusion |
| 5.03 | No exclusion |
| 5.04 | No exclusion |
| 5.05 | No exclusion |
| 5.06 | No exclusion |
| 5.07 | No exclusion |
| 5.08 | No exclusion |
| 5.09 | Not applicable |
| 5.10 | No exclusion |
| 5.11 | No exclusion |
| 5.12 | No exclusion |
5.13
| No exclusion
|
| 5.15 | Not applicable |
| 5.16 | Not applicable |
| 5.17 | Not applicable |
| 5.18 | Not applicable |
| 5.19 | Not applicable |
| 5.20 | Not applicable |
| 5.21 | Not applicable |
| 5.22 | Not applicable |
| 5.23 | Not applicable |
| 5.24 | Not applicable when evidence is provided by the BSA service that they have had no incidents of falls over the preceding 12 months |
| 5.25 | No exclusion |
| 5.26 | No exclusion |
| 5.27 | Not applicable |
| 5.28 | Not applicable |
| 5.29 | No exclusion |
| 5.30 | No exclusion |
| 5.31 | No exclusion |
| 5.32 | Not Applicable |
| 5.33 | No exclusion |
| 5.34 | No exclusion |
| 5.35 | Not Applicable |
| 5.36 | Not Applicable |
Communicating for Safety Standard
| Action | Applicability to BSA Services |
|---|---|
| 6.01 | No exclusion |
| 6.02 | No exclusion |
| 6.03 | No exclusion |
| 6.04 | No exclusion |
| 6.05 | No exclusion |
| 6.06 | No exclusion |
| 6.07 | No exclusion |
| 6.08 | No exclusion |
| 6.09 | No exclusion |
| 6.10 | No exclusion |
| 6.11 | No exclusion |
Blood Management Standard
| Action | Applicability to BSA Services |
|---|---|
| 7.01 | Not applicable |
| 7.02 | Not applicable |
| 7.03 | Not applicable |
| 7.04 | Not applicable |
| 7.05 | Not applicable |
| 7.06 | |
| 7.07 | Not applicable |
| 7.08 | Not applicable |
| 7.09 | Not applicable |
| 7.10 | Not applicable |
Recognising and Responding to Acute Deterioration Standard
| Action | Applicability to BSA Services |
|---|---|
| 8.01 | No exclusion |
| 8.02 | No exclusion |
| 8.03 | Not Applicable |
| 8.04 | Not Applicable |
| 8.05 | Not Applicable |
| 8.06 | Not Applicable |
| 8.07 | Not Applicable |
| 8.08 | Not Applicable |
| 8.09 | Not Applicable |
| 8.10 | Not Applicable |
| 8.11 | Not Applicable |
| 8.12 | Not Applicable |
| 8.13 | Not Applicable |