Advisory details
| Item | Details |
|---|---|
| Advisory number | AS18/12 |
| Version number | 3.0 |
| Publication date | September 2025 |
| Replaces | 2.0 March 2019, titled: Implementing the Colonoscopy Clinical Care Standard |
| Compliance with this advisory | It is mandatory for approved accrediting agencies to implement this Advisory |
| Information in this advisory applies to |
|
| Key relationship |
|
| Attachment | Providers and responsibilities for Quality Statement |
| Notes | Version 3.0 of this advisory clarifies the requirements for the transition between the 2020 and 2025 Colonoscopy Clinical Care Standards |
| Responsible officer | Margaret Banks Director, National Standards Phone: 1800 304 056 Email: AdviceCentre@safetyandquality.gov.au |
| To be reviewed | December 2027 |
Purpose
To describe assessment requirements for Actions 1.23, 1.24, 1.27b, and 1.28a of the National Safety and Quality Health Service (NSQHS) Standards for health service organisations implementing the Colonoscopy Clinical Care Standard.
Issue
The Australian Commission on Safety and Quality in Health Care has updated the Colonoscopy Clinical Care Standard. This Clinical Care Standard was originally published in 2018 as part of a safety and quality model for colonoscopy, supported by funding from the Australian Government Department of Health, Disability and Aged Care.
The Colonoscopy Clinical Care Standard relates to the care of adult patients undergoing colonoscopy for screening, diagnosis, treatment or surveillance. It covers the period from when a patient is referred for consideration of colonoscopy through to discharge, including planning for follow-up care. It is relevant to the care provided in primary and acute healthcare settings including general practice, private hospitals, public hospitals and day procedure services. All patients undergoing a colonoscopy should be offered the care set out in the Colonoscopy Clinical Care Standard.
The NSQHS Standards require all healthcare services providing colonoscopy services to implement the Colonoscopy Clinical Care Standard. As care spans primary and acute healthcare services, implementing the Quality Statements may be the responsibility of more than one provider. This Advisory applies to all health service organisations providing colonoscopy services.
Requirements
Implementing the Colonoscopy Clinical Care Standard aligns with the following requirements in the NSQHS Standards:
| Action 1.23 | define the scope of clinical practice for clinicians, monitor clinician’s practices and review scope of clinical practice periodically |
|---|---|
| Action 1.24 | conduct credentialing processes |
| Action 1.27b | have processes that support clinicians to use the best available evidence, including relevant clinical care standards developed by the Australian Commission on Safety and Quality in Health Care |
| Action 1.28a,b | monitor variation in practice against expected health outcomes and provide feedback to clinicians on variation in practice and health outcomes. |
Requirements
Health service organisations implementing the Colonoscopy Clinical Care Standard are required to:
- Define the scope of clinical practice and credential clinicians providing colonoscopy services
- Review the Quality Statements against the services provided and the risks of providing services
- Document in a policy or procedure:
- the Quality Statements (or part of a quality statement) that are its responsibility, in line with the guidance provided at Attachment 1
- the processes for collection and monitoring of the Clinical Care Standard indicator data
- the data and reports including gaps and areas for quality improvement to be provided to procedural specialists, the governing body, managers, the workforce and where relevant, consumers
- processes for acting on variation identified as required
- processes for informed consent discussions and signed consent according to the Clinical Care Standard (see Colonoscopy Clinical Care Standard Informed Consent fact sheet)
- the requirement for procedural specialists to provide evidence of certification and recertification as part of the credentialing process and how this will be monitored
- Provide relevant clinicians including proceduralists (medical and surgical, generalist, endoscopy unit staff, nursing endoscopists), anaesthetists or other clinicians providing sedation for colonoscopy, with access to the Colonoscopy Clinical Care Standard
- Provide proceduralist clinicians with a copy of the policy or procedure relating to implementation of the Quality Statements and the indicators being monitored
- Implement the Quality Statements that are its responsibility
- Implement systems for the collection of agreed the Colonoscopy Clinical Care Standard indicators and other data to monitor variations in practice against expected health outcomes.
Assessors are required to review evidence that the health service organisation has:
- Implemented the Colonoscopy Clinical Care Standard, where relevant
- Defined the scope of clinical practice for all clinicians providing colonoscopy services and credentialed relevant clinicians
- Provided clinicians with access to the Colonoscopy Clinical Care Standard
- Provided procedural specialist clinicians with written advice of the Quality Statements for which the organisation is responsible from the Colonoscopy Clinical Care Standard
- Applied the requirements set out in the Quality Statements and monitored indicators relevant to the service setting for the Colonoscopy Clinical Care Standard
- Continually monitored variation in practice and provided clinicians with feedback.
Where the health service organisation has met these requirements, this supports compliance with elements of Actions 1.23, 1.24, 1.27b, 1.28a,b.