Advisory PCHS26/02: Advice on not applicable actions for the National Safety and Quality Primary and Community Healthcare Standard
To describe the Australian Commission on Safety and Quality in Health Care’s (the Commission) requirements for awarding a ‘Not applicable’ rating for actions in the National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards).
Advisory details
| Item | Details |
|---|---|
| Advisory number | PCHS26/02 |
| Version number | 1.0 |
| Publication date | March 2026 |
| Replaces | Nil |
| Compliance | It is mandatory for approved accrediting agencies to implement this Advisory |
| Applicable to |
|
| Key relationship | Advisory PCHS25/01: Advice on not applicable actions for private dental practices |
| Attachment(s) | |
| Note(s) | |
| Responsible officer | Christina Lane Manager for Primary Health Care and National Standards Email: AdviceCentre@safetyandquality.gov.au |
| Review date | March 2028 |
Purpose
To describe the Australian Commission on Safety and Quality in Health Care’s (the Commission) requirements for awarding a ‘Not applicable’ rating for actions in the National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards).
Issue
Not all actions in the Primary and Community Healthcare Standards will be applicable to every healthcare service. The Commission has issued this advisory to ensure the consistent application of not applicable status to actions within the Primary and Community Healthcare Standards.
Requirements
Healthcare services implementing the Primary and Community Healthcare Standards should consider their individual circumstances in determining whether specific actions are not applicable. It is not intended that actions be implemented where they are beyond the scope of clinical practice of healthcare providers.
Large healthcare services, with multiple healthcare providers operating from different locations and delivering different levels of health care, may find that an action is not applicable in an area of service while remaining relevant in other parts of its service. In these cases, the action should be implemented in areas of the service where it is relevant, but not to the particular area of service where the action does not apply.
Requirements for private dental practices are stipulated in Advisory PCHS25/01: Advice on not applicable actions for private dental practices.
Where a healthcare service considers that an action is not applicable, the following steps must be taken.
- The healthcare service must provide evidence to the accrediting agency conducting the assessment to demonstrate that the action is associated with little or no risk of patient harm in its service context. Applications should be submitted to the accrediting agency well in advance of the assessment.
- The accrediting agency must provide an initial determination of the healthcare service’s submission before undertaking the scheduled assessment. Accrediting agencies are required to refer to Attachment 1 when considering applications from the healthcare service for non-applicability of actions within the Primary and Community Healthcare Standards.
- At assessment, assessors are to verify that the decision to award these actions not applicable status is justified.
- Where there is a dispute concerning an award of a 'not applicable' rating that is not resolved following discussions between the healthcare service and the accrediting agency, the accrediting agency may submit a written request to the Commission for mediation. The application may take 10 to 20 business days to be processed, dependent on the type and number of actions, the evidence provided, and whether additional information is needed.
Attachment 1. Potential not applicable actions for healthcare services
Patient safety and quality systems
| Item | Action | Circumstances where actions are not applicable |
|---|---|---|
| Healthcare records | 1.13 | Not applicable when My Health Record system is not in use. |
1.14 |
Preventing and controlling infection
| Item | Action | Circumstances where actions are not applicable |
|---|---|---|
| Antiseptic technique | 3.07 | Not applicable where aseptic technique is not required in the delivery of health care. |
| Invasive medical devices | 3.08 | Not applicable when invasive medical devices are not used in the delivery of health care. |
| Reprocessing of reusable medical devices | 3.13 | Not applicable when sterile reusable critical medical instruments, equipment and devices are not used in the delivery of health care. |
| Antimicrobial stewardship | 3.14 | Not applicable when prescribing, supplying and/or administering antimicrobial medicines does not form part of a service’s delivery of health care. |
Medication safety
| Item | Action | Circumstances where actions are not applicable |
|---|---|---|
| Documentation, provision and access to medicines-related information | 3.15 | Not applicable when prescribing, supplying and/or administering medicines does not form part of a service’s delivery of health care. |
| Safe and secure storage and supply of medicines | 3.17 | |
| High-risk medicines | 3.18 |
Comprehensive care
| Item | Action | Circumstances where actions are not applicable |
|---|---|---|
| Comprehensive care at the end of life | 3.24 | Not applicable when end-of-life care does not form part of a service’s delivery of health care. |