for service providers
‘Not applicable’ actions in the NSQDMH Standards
In some circumstances, actions in the National Safety and Quality Digital Mental Health (NSQDMH) Standards may not be applicable to a service provider. This fact sheet clarifies potential ‘not applicable’ actions for digital mental health service providers under the NSQDMH Standards.
Process to apply for a ‘not applicable’ rating
The summary table below details the actions that may be awarded a ‘not applicable’ rating, subject to satisfactory supporting evidence being provided by the service provider.
Where a service provider considers that an action(s) is not applicable, it should submit an application for ‘not applicable’ status to its accrediting agency well in advance of the accreditation assessment. All applications should provide evidence that there is little or no risk of harm to service users in relation to the action(s) in the submission. Accrediting agencies are to provide an initial determination of the service provider’s submission before undertaking the scheduled desktop review. At the verification assessment, assessors are to verify that the decision to award these actions ‘not applicable’ status is justified.
When does ‘not applicable’ apply
An action may be applicable to a service provider yet only apply to some of the service provider’s digital mental health services. For example, Action 3.10 regarding recognising acute deterioration may not be relevant to an information-only digital mental health service. However, it would be relevant to a digital mental health counselling service made available by the same service provider. In this case, the action will be applicable to the service provider, but assessment will be limited to consideration of the digital mental health services to which the action is applicable.
An action may also apply in part. For example, an action may have four subcomponents, but a service provider may submit an application for not applicable status for one or more subcomponents of that action. In this case, the accrediting agency may determine that the action remains applicable to the service provider with the exception of the agreed subcomponents, which are determined as not applicable.
Infrequent application of an action 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 service provider.
Where there is a dispute concerning an award of not applicable status that is not resolved following discussions between the service provider and the accrediting agency, application can be made by either the accrediting agency or the service provider to the Commission for mediation.
Further information
Further information on the NSQDMH Standards and accreditation can be found at:
www.safetyandquality.gov.au/dmhs
Email: Advice.Centre@safetyandquality.gov.au
Phone: 1800 304 056.
Applicable and potential ‘not applicable’ actions
Clinical and Technical Governance Standard
Action |
Advice |
|---|---|
1.01 |
No exclusion. |
1.02 |
No exclusion. |
1.03 |
Exclusion may apply. Given the targeted nature of many digital mental health services, not all service providers will make a decision to prioritise diverse population groups as their target audience. However, where they do so (e.g. developing an app for Aboriginal and Torres Strait Islander adolescents), the service provider is expected to demonstrate inclusion of service users and support people from the prioritised demographic in their strategies for implementing and monitoring the digital mental health services. |
1.04 |
No exclusion. |
1.05 |
No exclusion. |
1.06 |
No exclusion. May have limited applicability for solo service providers who do not employ or engage a workforce. |
1.07 |
No exclusion. |
1.08 |
No exclusion. |
1.09 |
No exclusion. Solo service providers may not have a governing body or a workforce but should provide reports to service users and their support people. |
1.10 |
No exclusion. |
1.11 |
No exclusion. |
1.12 |
No exclusion. |
1.13 |
No exclusion. |
1.14 |
No exclusion. |
1.15 |
Exclusion may apply where the service provider’s digital mental health services do not include collection of any information that allow them to identify the diversity of service users/support people and/or their level of risk (e.g. a self-help service that collects no information on the service user). |
1.16 |
Exclusion may apply. Not applicable if a healthcare record is not maintained. |
1.17 |
Exclusion will apply where clinical information is not provided into the My Health Record system. |
1.18 |
Exclusion may apply for solo service providers that do not have a governing body or a workforce. Where there is a governing board of more than one (e.g. two directors) and no other workforce, Action 1.18a applies as the governing board are required to have clearly articulated the roles and responsibilities that apply to each board member, but 1.18b will be not applicable. |
1.19 |
No exclusion. Solo service providers with no workforce must still consider their own training needs. |
1.20 |
No exclusion. Solo service providers with no workforce must still consider strategies to improve their own cultural awareness and cultural competency. |
1.21 |
Exclusion may apply for service providers that do not have a workforce (e.g. a solo service provider or a service provider run only by a small board with no other workforce) |
1.22 |
Exclusion may apply for service providers that do not have a workforce. Where a service provider has no workforce but the clinical/peer input is from a board member(s) or a contractor, then Action 1.22a applies to the board member(s) or contractor(s) but Action 1.22b may be not applicable. |
1.23 |
Exclusion may apply for service providers that do not have a workforce. Where a service provider has no workforce but the technical input is from a board member(s) or a contractor, Action 1.23 applies to the board member(s) or contractor(s). |
1.24 |
Exclusion may apply for service providers that do not have a workforce (e.g. a solo service provider or a service provider with a governing body only but no other workforce). |
1.25 |
No exclusion. |
1.26 |
No exclusion. |
1.27 |
No exclusion. |
1.28 |
No exclusion. |
1.29 |
No exclusion. |
1.30 |
No exclusion. |
1.31 |
No exclusion. |
1.32 |
Exclusion may apply where no personal data is collected. |
1.33 |
Exclusion may apply where there are no direct costs and there is no data usage. |
1.34 |
Exclusion may apply where there is no in-product sales or advertising. |
1.35 |
No exclusion. |
1.36 |
No exclusion. |
Partnering with Consumers Standard
Action |
Advice |
|---|---|
2.01 |
No exclusion. |
2.02 |
Exclusion may apply where consent is not required (e.g. information-only service or self‑help service). |
2.03 |
Exclusion may apply where consent is not required (e.g. information-only service or self‑help service). |
2.04 |
Exclusion may apply where the service provided does not include decisions about current and future care (e.g. information-only service or self-help service). |
2.05 |
No exclusion. |
2.06 |
No exclusion. |
2.07 |
No exclusion. |
2.08 |
No exclusion. |
2.09 |
Exclusion may apply where the service provider has no workforce (e.g. solo service provider or service provider with a small board but no workforce). |
2.10 |
No exclusion. |
2.11 |
No exclusion. |
Model of Care Standard
Action |
Advice |
|---|---|
3.01 |
No exclusion. |
3.02 |
No exclusion. |
3.03 |
No exclusion. |
3.04 |
No exclusion. |
3.05 |
Exclusion may apply, depending on the type of service delivered (e.g. a non-interactive service such as an information-only service or a self-help service will not be expected to conduct screening for risk). |
3.06 |
No exclusion. Information-only services may provide information on services available for those in distress or with thoughts/actions of self-harm or suicide. |
3.07 |
Exclusion may apply to Action 3.7, in part or in whole. Action 3.7a may not apply where the service provider does not collect identifying information. Action 3.7b may not apply where the model of care does not require matching a service user to their previous care (e.g. an information-only service). Action 3.7c may not apply where anonymity is not part of the model of care. Action 3.7d may not apply where there is no process for identification of service users (including for example, IP address or telephone number). |
3.08 |
Exclusion may apply, depending on the type of service delivered (e.g. a non-interactive service such as an information-only service or a self-help service will not be expected to communicate critical information). |
3.09 |
Exclusion may apply in services where the model of care does not include the transfer of care (e.g. an information-only service or a self-help service). |
3.10 |
Exclusion may apply in services where the model of care does not include the ability to recognise acute deterioration (e.g. an information-only service or a self-help service). |
3.11 |
Exclusion may apply in services where the model of care does not include the ability to recognise acute deterioration and escalate care (e.g. an information-only service or a self‑help service). |
3.12 |
Exclusion may apply in services where the model of care does not include the ability to recognise and respond to acute deterioration (e.g. an information-only service or a self‑help service). Notwithstanding that Action 3.12 may be not applicable, all services are encouraged where practicable to provide advice to service users that can assist them to access emergency care if required. |
© Australian Commission on
Safety and Quality in Health Care 2023