Accreditation Bulletin: 13 May

Accreditation Bulletin: 13 May

This is a weekly communication to keep you up to date with what you need to know and do in the lead up to accreditation (7-11 June).

Preparing for accreditation is about ensuring you feel confident and comfortable when you meet with the assessors in June, to convey the great work that you do every day to deliver high-quality care and a positive patient experience.

Over the following weeks, we’ll be providing you with updates, resources, top tips, access to events and more directly to your inbox. You can view and download previous Bulletins here.

Focus of the week

Here are the top things you can do this week to ensure we remain on track for accreditation:

  1. All employees, book in a Give Me Five or Annual Performance discussion and remember to document it in ESS.
  2. Managers, ensure your Quality Improvement Plans (QIP) are up to date and discuss the content with your teams.
  3. Clinicians, log in to Latte and complete or check your Basic Life Support (BLS) training and Aseptic technique training is up to date.

Safety, compliance and cleaning

Providing safe patient care and high-quality outcomes for our patients, families and carers is one of the most important things we do as a health service. In this edition, you’ll find advice and resources to ensure we continue to deliver safe, timely, effective and person-centred care in the lead up to accreditation.

Used a device? Keep it nice!

Please ensure that you are in the habit of cleaning your ward devices regularly and that Workstations on Wheels (WOWs) are free of clutter.

A helpful factsheet for cleaning your electronic devices has been created to show how and when they are to be cleaned.

Templates for daily and weekly cleaning schedules for (WOWs) have also been created so that you can regularly record your WOW cleaning.

For more information, please refer to the Clinical Equipment Cleaning Procedure on PROMPT.

Get pumped for hand hygiene – the importance of hand hygiene practice

Hand hygiene is an integral part of keeping you, your colleagues and your patients safe. When performed correctly, hand hygiene results in a reduction of microorganisms on your hands and contributes to the prevention of healthcare-associated infection and improved patient safety.

Over the next few weeks, we will provide reminders of the five moments of hand hygiene to clearly outline the critical times that hand hygiene should be completed. Each moment has a specific purpose and is an essential step in protecting both patients and healthcare workers from the transmission of pathogens.

To refresh your hand hygiene practice, you can review the Monash Health Hand Hygiene guidelines on PROMPT and download a poster for clinical and non-clinical areas. Don’t forget to complete your hand hygiene training on LATTE.

We all need to observe hand hygiene. If you observe someone not following the principles of hand hygiene, politely remind them to wash their hands or use the gel. If someone reminds you, thank them.

Resuscitation trolleys

To ensure equipment and medications are available to code blue and emergency response teams, please ensure resuscitation trolleys are set up in the standardised way, and that daily and weekly checks (as outlined in the procedure below) are completed. The latest Point of Care Audit results shows that daily checks are not always completed.

% of areas with completed checks

  • Bed-based areas – 78%
  • Mental Health areas – 82%
  • Specialist Consulting areas – 60%
  • Day patient areas – 69%
  • Newborn areas – 100%

You can find more information, including the trolley equipment list and checking requirements, here:

Medication Safety

During Accreditation week, assessors will want to see clinicians safely prescribing, dispensing and administering appropriate medicines, as well as monitoring medicine use. Here are some key areas of focus:

Medication refrigerators

  • Check and document the CURRENT, MINIMUM and MAXIMUM temperature once a day for all medication fridges and twice a day for all medication fridges storing vaccines
  • In the event of a temperature excursion (fridge outside the range of 2° to 8°C), document and take the corrective action steps outlined in the ‘Medication and Vaccine Refrigerator Temperature Monitoring Form’.
  • If your clinical area stores vaccines or does not have 24-hour staff presence, a data logger (or centralised monitoring) must be used. Check the data every week.

Insulin storage and labelling

  • Once you open an insulin vial/pen, label it with the patient’s name, UR number and date of opening
  • Do not return insulin to the refrigerator once opened. Store it in a locked medication storage facility (WOW/trolley).

Medication allergies

  • All prescribers, nurses/midwives and pharmacists are responsible for ensuring medication allergies and adverse drug reactions information are documented.

Important changes to our medication administration procedure

We have recently changed the way we check and administer high-risk medicines at Monash Health. This change ensures high-risk medicines are managed safely, reduces variation in practice, and reduces the risk of medication administration errors.

You can read more about this important change here.

Have you completed your deteriorating patient training?

The target for deteriorating patient training has been set at 90%. Please ensure you and your teams are up to date with your Deteriorating Patient training.

Up to 31 May, completion of the online courses for deteriorating patient training (excluding neonatal courses) will be considered as full completion of the course. Log in to Latte, search for “deteriorating patient” in the course catalogue, and open the deteriorating patient training specific to your area/speciality.

Help improve our care of deteriorating patients – fill out a brief survey

Medical emergency recognition and response systems, such as MET teams, are a crucial part of our care for deteriorating patients. To ensure we maintain the most effective approach, please take a few minutes to fill out our brief Medical emergency recognition and response teams survey.

The information gained will help us plan and improve care for these vulnerable patients.

All managers are requested to share these updates with their teams and discuss them at meetings and handovers. View and download previous Bulletins here. Please print a copy and display it in communication books and on employee noticeboards.

For accreditation information and resources, visit our employee Accreditation website. If you have any questions or concerns, please contact us.



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