Advisory no: A13/08 | Transition arrangements from 2014

Advisory no: A13/08

TITLE / Transition arrangements from 2014
VERSION / 3.0
DATE OF PUBLICATION / 22 May 2017
REPLACES / Version 2.1 issued on 1 October 2015
STATUS / ACTIVE
COMPLIANCE WITH THIS ADVISORY / Mandatory for accrediting agencies
APPROVED FOR DISTRIBUTION BY / Chief Operating Officer
REVIEW DUE DATE / 31 December 2018
INFORMATION IN THIS ADVISORY APPLIES TO /
  • Health service organisations
  • Approve accrediting agencies
  • Regulators

KEY RELATIONSHIP / All NSQHS Standards
RESPONSIBLE OFFICER / Margaret Banks
Senior Program Director
CONTACT DETAILS / Phone:1800 304 056
Email:
TRIM NO. / D15-34238
LINKAGES TO OTHER ADVISORIES and/or DOCUMENTATION / Advisory A13/05: Assessment of training requirements for credentialed medical and other clinical practitioners and visiting medical officers
ATTACHMENT /
  1. Developmental actions for hospitals and day procedure services
  2. Flexible arrangements from 2014 for hospitals and day procedure services

NOTES
(if applicable) / n/a

Version 3.0|22 May 20171

Advisory no: A13/08 | Transition arrangements from 2014

Advisory no: A13/08

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 (the Commission) 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 service organisations 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 the NSQHS Standards (second edition) 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 the NSQHS Standards (second edition). Developmental actions are listed at Attachment 1.
  1. 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 the NSQHS Standards (second edition) 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.

Attachment 1: NSQHS Standards developmental actions for hospitals and day procedure services

Standard / Hospital
developmental actions / Day procedure service
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
  1. 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
  1. Preventing and controlling healthcare associated infections
/ 3.4.3 / 3.19.2 / Hospital actions plus
3.1.4
  1. Medication safety
/ 4.8.1
4.13.1
4.13.2 / 4.14.1
4.15.1
4.15.2 / Hospital actions
  1. Patient identification and procedure matching
/ Nil / Nil
  1. Clinical handover
/ 6.3.2 / 6.5.1 / Hospital actions
  1. Blood and blood products
/ 7.9.2
7.10.1 / 7.11.1 / Hospital actions
  1. Preventing and managing pressure injuries
/ 8.7.3
8.7.4 / 8.9.1
8.10.1 / Hospital actions
  1. 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
  1. Preventing falls and harm from falls
/ 10.9.1 / 10.10.1 / Hospital actions

Attachment 2: Transition arrangements from 2014 for hospitals and day procedure services

Action / Description / Requirements to satisfactorily meet the action from 2014
3.10.1 / 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 / 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 2018, or otherwise advised by the Commission

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 / 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 2018, or otherwise advised by the Commission.

Version 3.0|22 May 20171