Advisory AS18/01: Advice on not applicable actions

Advisory details

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.

National Clinical Trials Governance Framework 

The National Clinical Trials Governance Framework (NCTGF) outlines 27 actions that Services are required to implement in relation to clinical trial services. The above advice clarifies the process for applying for not applicable actions for services implementing the NCTGF. Refer to the service type (i.e., hospital, day procedure service, community healthcare service) when considering a request for actions to be rated as not applicable. 

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.

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. 
 

Attachment: Summary tables of not applicable actions