Advisory No: A13/08 (Amended)
TITLE
Transition arrangements from 2014
VERSION
Version 2.1
DATE OF PUBLICATION
1 October 2015
REPLACES
2.0 issued 8 September 2015
STATUS
Active
COMPLIANCE
Mandatory
APPROVED FOR
DISTRIBUTION BY
COO
REVIEW DUE DATE
September 2017
INFORMATION IN THIS
ADVISORY APPLIES TO:
Health service organisations, approved accrediting agencies and
regulators
KEY RELATIONSHIP
All NSQHS Standards
RESPONSIBLE
OFFICER
Margaret Banks
Senior Program Director
CONTACT DETAILS
Phone: 1800 304 056
Email: accreditation@safetyandquality.gov.au
TRIM NO.
D15-34238
LINKAGES TO OTHER
ADVISORIES and/or
DOCUMENTATION
A13/05 Assessment of training requirements for credentialed
medical practitioners and visiting medical officers
ATTACHMENTS
NOTES
(if applicable)
Advisory No: A13/08
1. Developmental actions for hospitals and day procedure
services
2. Flexible arrangements from 2014 for hospitals and day
procedures services
October 2015:
Updated Attachment 2 – replaced “31 December 2015” with “31
December 2017, or otherwise advised by the Commission.”
1
Version 2.1 October 2015
Advisory No: A13/08 (Amended)
Transition arrangements from 2014
PURPOSE:
To notify approved accrediting agencies and health service organisations of the end of
flexible transition arrangements for the National Safety and Quality Health Service (NSQHS)
Standards which were put in place by the Australian Commission on Safety and Quality in
Health Care from 1 January 2013 to 31 December 2013.
ISSUE:
The Commission introduced the flexible transition arrangements to support the first wave of
health service organisations undertaking accreditation in 2013 to the NSQHS Standards.
The arrangements recognised that health services undergoing accreditation in 2013 had less
time to prepare for assessment, and that both surveyors and health services were new to the
NSQHS Standards. These flexible arrangements ceased on 31 December 2013.
IMPLEMENTATION:
From 1 January 2014:
1. The remediation period for a health service organisation to address any ‘not met’
actions following an accreditation assessment will revert from 120 days to 90 days.
2. The prescribed requirements will be removed for six actions: 2.4.2; 2.6.1; 3.10.2;
3.10.3; 6.1.3; and 6.3.1. This requires that health services fully implement the actions
described in the NSQHS Standards document.
The following arrangements will remain in place until reviewed as part of the implementation
of version 2 of the NSQHS Standard in 2017/2018, or otherwise advised by the Commission:
1. Actions classified as developmental will remain developmental. The Commission has
evaluated the classification of core and developmental actions and all current
developmental actions will remain in place, until the introduction of version 2 of the
NSQHS Standards. Developmental actions are listed at Attachment 1.
2. Two of the prescribed actions will remain in place – 3.10.1: Training in Aseptic
Technique and 9.6.1: Training in Basic Life Support. These actions will also remain in
place until the introduction of version 2 of the NSQHS Standards. (as per Advisory
A13/05). The prescribed actions are listed at Attachment 2.
REQUIREMENTS:
Regulators, accrediting agencies and health service organisations note flexible transition
arrangements ceased on 31 December 2013.
Advisory No: A13/08
2
Version 2.1 October 2015
ATTACHMENT 1
National Safety and Quality Health Service Standards
Developmental actions for hospitals and day procedure services
Standard
Hospital
Developmental Actions
Day Procedure
Developmental Actions
1. Governance for
Safety and Quality in
Health Service
Organisations
1.4.1
1.4.2
1.4.3
1.4.4
1.16.1
1.16.2
1.17.3
1.18.3
1.18.4
Hospital Actions
2. Partnering with
Consumers
2.1.1
2.1.2
2.2.1
2.2.2
2.3.1
2.5.1
2.6.2
2.8.1
2.8.2
2.9.1
2.9.2
Hospital Actions
3. Preventing and
Controlling
Healthcare
Associated Infections
3.4.3
3.19.2
Hospital Actions plus
4. Medication Safety
4.8.1
4.13.1
4.13.2
5. Patient Identification
and Procedure
Matching
3.1.4
4.14.1
4.15.1
4.15.2
Nil
Hospital Actions
Nil
6. Clinical Handover
6.3.2
6.5.1
Hospital Actions
7. Blood and Blood
Products
7.9.2
7.10.1
7.11.1
Hospital Actions
8. Preventing and
Managing Pressure
Injuries
8.7.3
8.7.4
8.9.1
8.10.1
Hospital Actions
9. Recognising and
Responding to
Clinical Deterioration
in Acute Health Care
9.3.1
9.7.1
9.8.1
9.8.2
9.9.1
9.9.2
9.9.3
9.9.4
Hospital Actions
10. Preventing Falls and
Harm from Falls
10.9.1
10.10.1
Hospital Actions
Advisory No: A13/08
3
Version 2.1 October 2015
ATTACHMENT 2
Transition arrangements from 2014
for hospitals and day procedure services
Action
3.10.1
Requirements to satisfactorily meet
Description
the action from 2014
Clinical workforce is trained in aseptic
technique
NB: See Advisory A13/05: Assessment of
training requirements for credentialed
medical and other clinical practitioners
and visiting medical officers
9.6.1
The clinical workforce is trained and
proficient in basic life support.
NB: See Advisory A13/05: Assessment of
training requirements for credentialed
medical and other clinical practitioners
and visiting medical officers
Advisory No: A13/08
4
Health service organisations 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 clinicians on aseptic
technique is available. It is anticipated the
initial focus will be on employed nursing,
allied health and medical staff.

This action is in place until 31 December
2017, or otherwise advised by the
Commission.
Health service organisations provide evidence
that:

a comprehensive organisational risk
assessment 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.

This action is in place until 31 December
2017, or otherwise advised by the
Commission.
Version 2.1 October 2015