VERSION
Version 3.0
DATE OF
PUBLICATION
REPLACES
STATUS
8 September 2015
Version 2.0 issued on 18 June 2013
Active
COMPLIANCE
Mandatory
APPROVED FOR
DISTRIBUTION BY
REVIEW DUE
DATE
INFORMATION IN
THIS ADVISORY
APPLIES TO:
KEY
RELATIONSHIP
COO
September 2017
All approved accrediting agencies
All health service organisations with credentialed medical and other clinical practitioners and VMOs
All NSQHS Standards
RESPONSIBLE
OFFICER
CONTACT
DETAILS
TRIM NO.
Margaret Banks
Senior Program Director
Phone: 1800 304 056
Email: accreditation@safetyandquality.gov.au
D15-15339
LINKAGES TO
OTHER
ADVISORIES and/or
DOCUMENTATION

Basic Life Support Training: Sample Risk Analysis

Aseptic Technique Risk Assessment Matrix
ATTACHMENTS n/a
NOTES
(if applicable)
Amended July 2015
Advisory No: A13/05 1 Version 3.0 September 2015

PURPOSE:
To describe assessment requirements for training of clinicians providing care in a health service where there is no employment relationship.
ISSUE:
Stakeholders have raised with the Commission the issue of the interpretation of the term
‘ clinical workforce ’ and the application of the NSQHS Standards training requirement to credentialed medical and other clinical practitioners and visiting medical officers.
The Clinical Workforce in the NSQHS Standards is defined as “ the nursing, medical and allied health staff who provide patient care and students who provide care under supervision. This may also include laboratory scientists.”
The Commission intended that the definition of Clinical Workforce in the NSQHS
Standards include credentialed medical and other clinical practitioners and visiting medical officers. Stakeholders have identified issues for health service organisations with the
Commission applying this definition. Where credentialed medical and other clinical practitioners (CMPs) and visiting medical officers are not employed by health services, the mechanism and responsibility for training will vary from the employed clinical workforce.
Concern focuses on two actions where training is required in the NSQHS Standards, namely:

Standard 3: Preventing and Controlling Healthcare Associated Infections
Action 3.10.1: The clinical workforce is trained in aseptic technique

Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health
Care
Action 9.6.1: The clinical workforce is trained and proficient in basic life support.
The Commission has considered training requirements for credentialed medical and other clinical practitioners and visiting medical officers as part of the review of and changes made in version 2 of the NSQHS Standards. These changes are being tested through an extensive consultation process.
REQUIREMENTS:
Surveyors from approved accrediting agencies assessing compliance with Actions 3.10.1 and 9.6.1 of the NSQHS Standards are to apply the following arrangements until 31
December 2017, or otherwise advised by the Commission.
Advisory No: A13/05 2 Version 3.0 September 2015

1. For Action 3.10.1, health service organisations are required to provide evidence that:

a comprehensive organisational risk analysis of aseptic technique competencies has been undertaken

a plan has been developed to assess the clinical practice of aseptic technique for clinicians working in high risk areas

a training package for the clinical workforce in aseptic technique is available. It is anticipated the initial focus will be on employed nursing, allied health and medical staff.
2. For Action 9.6.1 health service organisations are required to provide evidence that:

a comprehensive organisational risk analysis of basic life support training needs has been undertaken

a plan has been developed to ensure that the clinical workforce can initiate appropriate early interventions and respond with life-sustaining measures in the event of severe or rapid deterioration

training in basic life support is available for the clinical workforce. It is anticipated the initial focus will be on employed nursing, allied health and medical staff.
A sample risk analysis: training needs regarding basic life support is available on the
Commission’s website: http://www.safetyandquality.gov.au/publications/sample-risk-analysis-training-needs-forbasic-life-support/
Advisory No: A13/05 3 Version 3.0 September 2015