Advisory details
| Item | Details |
|---|---|
| Advisory number | AS18/01 |
| Version number | 11.1 |
| Publication date | 5 June 2025 (with minor update on 24 June 2025) |
| Replaces | AS18/01 version 10.0 published on July 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 |
Update from 5 June 2025 (Version 11.0) Updated not applicable actions for Community Healthcare Services implementing the NSQHS Standards. Update to Actions 4.10 and 4.12 for Day Procedure Services. Removal of:
For other National Safety and Quality Standards:
Update from 24 June 2025 (Version 11.1) Addition of:
|
| Responsible officer | Margaret Banks Director, National Standards Phone: 1800 304 056 Email: AdviceCentre@safetyandquality.gov.au |
| To be reviewed | December 2027 |
Purpose
To clarify not applicable actions for hospitals, day procedure services, multi-purpose services, community healthcare 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 tables below 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.
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 remains in effect until 1 November 2025.
Integrated Health and Aged Care Services Module
The IHACS Module describes in fourteen actions the requirements of the strengthened Aged Care Quality Standards not covered by the NSQHS Standards and applies only to providers of the Multi-Purpose Services Program from 1 November 2025.
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.