Accreditation Bulletin: 20 May

Accreditation Bulletin: 20 May

Accreditation Bulletin

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)…only 17 days away.

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. You can view and download previous Bulletins here.

Focus of the week: Performance appraisals and training requirements

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

  1. All employees, book in a Give Me Five or Annual Performance discussion.
  2. Managers, use our new ‘Power BI Targeted Training Dashboard’ Quick Reference Guide (QRG) to pull reports and monitor training compliance (more information below).
  3. Clinicians, log in to Latte and check your training is up to date, and if not, please complete it.


Training is a critical part of delivering safe and effective care to our community. You must complete your targeted and mandatory training as soon as possible. In this edition, you’ll find statistics, guides, calls to action and answers to frequently asked questions around training.

Training in numbers

Monash Health has set a target of 90% for mandatory and targeted training. With our National Standards accreditation assessment less than three weeks away, here’s how our training completion rates look (as of Thursday, 20 May). The courses in bold indicate where we need to improve and where we need you to concentrate your efforts.

Mandatory training

CourseCompletion rate (%)
Cultural Awareness89.3%
Fire Training90.6%
Managing Challenging Behaviour (OVA)88.7%
Health and Safety (OHS)96.7%
Privacy Training65.9%
Using Social Media97.2%
Unconscious Bias94.2%

Targeted training

CourseCompletion rate (%)
Allergies and ADR88%
Aseptic Technique87%
Cultural Awareness for Managers79%
Blood Safe Clinical Transfusion70%
Clinical Handover80%
Delirium: Suspect it, spot it, stop it52%
Deteriorating Patient81%
Hand Hygiene83%
Intro to high-risk medications66%
Medication Safety61%
Open discussion training71%
Partnering with consumers81%
Patient ID Procedure Mat66%
PPE transmissions based precautions84%
Preventing falls81%
Prevent & Mng Pressure Injuries68%
Quality, safety and managing risk for SMS72%


Take aim with our Targeted Training BI Dashboard guide

Do you need help accessing and using Power BI to find, monitor and report on targeted training? We’ve developed a new and easy to follow ‘Power BI Targeted Training Dashboard’ Quick Reference Guide (QRG).

From how to access Power BI to filtering by course, program, cost centre and/or occupational groups, the new QRG will help you and your teams find reports, dashboards and data analysis to monitor performance and compliance.

You can read more about the guide and answers to some of your frequently asked questions 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. Overall, 81% (9,748) of employees have completed this training in the last 12 months, however not all disciplines have the same completion rates.

  • 66% Doctors
  • 85% Nurses and Midwives
  • 88% Allied Health
  • 92% Pharmacists

Doctors, make sure you have completed your Deteriorating Patient training.

Up to May 31, completion of the online deteriorating patient courses (excluding neonatal courses) will be considered as full completion of the course.

Medication Safety & Administration training for Nurses and Midwives

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.

‘Delirium: Suspect it, Spot it, Stop it’ training

The Delirium and Dementia e-module, ‘Delirium: Suspect it, Spot it, Stop it’, is available via Latte for clinicians. The module only takes 15-20 minutes to complete, so log in to Latte and complete your training today.

Mandatory and targeted training FAQ

Mandatory v targeted training – what’s the difference?

All Monash Health employees are required to complete their mandatory training, such as iBelong and fire training, regardless of role.

Targeted training is specific to your role, and you must complete the courses that have been allocated to you.

How do I know which training courses I need to complete?

Completing your training is now easier than ever. All you need to do is log in to Latte, and the targeted and mandatory training courses you are required to complete will be automatically assigned to you and featured under “My Required Learning” on the Latte homepage.

How are training courses allocated?

Every employee is allocated an occupational category, specialty and management level in our Position Management database. We use this information to create audience groups. Targeted training courses are then allocated to the relevant audience group(s).

  • Employees – If you believe you haven’t been assigned the correct training, please speak to your line manager.
  • Managers – if you have any concerns regarding the correct occupational category, specialty or management level details for your teams, please refer to the Position Management intranet page or email

What do I need to know about completing my training?

Overall, and for most employees, the training takes less than 90 minutes per year. Many of the course modules are short and can be completed in bursts (you can pause and return to your training if required).

Latte will send you notifications via email as a reminder when there is something new or when you are due to redo a course. If you are completing your training before the due date, remember to click on the ‘Reset Completion’ button on the course page prior to doing your training (so that a new completion date is recorded).

Don’t forget that Latte can be accessed on-site or remotely via your laptop/computer, tablet or mobile device, via

Have some of the course names in the BI reports changed?

Some of the names of Latte courses were not consistent with the names used in the Targeted Training reports and dashboards on Power BI.

It’s important to note that the course codes won’t change, but to improve reporting consistency, the names/descriptions of four courses (outlined below) to align with the course names in Latte.

Course codePrevious course description in BINew course description in BI
IQCP01Consumer ParticipationPartnering with Consumers
NMMP01Preventing Managing PresPrevent & Mng Pressure Injuries
NMTV01WEB-Fam Violence Workplace Response 1hrFamily Violence – Managers
PHMS01Medication SafetyIntro to High Risk Meds


Where can I get more information on Mandatory and Targeted training and LATTE?

The process and requirements for mandatory and targeted training are outlined in the Mandatory and Targeted Training procedure on PROMPT. The procedure includes:

  • details of mandatory training courses applicable to employees
  • details of targeted training courses
  • the criteria for defining which employees are required to complete the courses
  • the approval process for course and audience group changes

If you have any queries about LATTE, please email

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

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

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