Accreditation Bulletin: 27 May

Accreditation Bulletin: 27 May

Accreditation Bulletin

Accreditation (7-11 June) is only 10 days away.

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

In the lead up to accreditation, we’re providing you with updates, resources, top tips, access to events and more. You can view and download previous Bulletins here.

Focus of the week:

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

  • Clinicians, download and familiarise yourself with our EMR and Comprehensive Care QRGs (more information below).
  • Ensure your work and communal areas are clean and free of clutter (more information below).
  • Log in to Latte and check your mandatory and targeted training is up to date, and if not, please complete it.

Key Messages

EMR and comprehensive care Quick Reference Guides (QRGs)

When speaking with assessors, you may be asked to show how the EMR assists in providing comprehensive care.

Our ‘EMR and Comprehensive Care’ QRGs have been created for medical, nursing and midwifery, pharmacy, allied health and administrative employees, and assist with EMR workflows and how they facilitate comprehensive care. Please ensure you have read and are familiar with each of these QRGs (not just your discipline).

New Care Plan view in the EMR

From today (Thursday, 27 May) a new Care Plan view is available to all disciplines in the EMR.

The new Care Plan view will be available from the Inpatient Doctor workflow, Inpatient Pharmacy workflow, Neonatal workflow, Neonatologist workflow, Nurse Handover workflow and Allied Health Nutrition workflow.

The new Care Plan view will provide higher visibility and easy access to your patient’s Care Plans while improving clinical review and documenting.

Please ensure you are familiar with the updated Quick Reference Guides (QRGs) and key workflow resources on the homepage of the EMR website to understand how these changes will benefit you.

Accreditation (7-11 June) gives us the opportunity to showcase the collaborative clinical work we do to deliver high-quality care and a positive patient experience.

  • Most of our patients will have between 2 to 5 Care Plans. Please make sure you are familiar with them, and they are current and complete
  • View and discuss Care Plans during handover to make sure everyone is familiar with them.

For more information, visit the EMR website. If you have a technical question, please call the IT Helpdesk (option 2) or ‘log an EMR issue’ on your desktop. Remember, the usual escalation pathways for help and support still apply.

Communicating for Safety

The completion of patient identification and handover processes are crucial steps in ensuring timely, purpose-driven and effective communication and documentation that supports our delivery of safe patient care.

During Accreditation week (7-11 June), assessors will be observing and want to see clinicians following these processes as part of the Communicating for Safety Standard.

Patient identification

Both clinical and patient-facing administrative staff need to complete patient identification processes.

  • The “ask and look” method is used to confirm three approved identifiers.
  • Identifiers must be verbally stated by the patient, not read aloud by staff for confirmation by the patient.
  • Only white or red identification bands are to be utilised.
  • A red identification band is to be applied to communicate a patient having a known allergy or Adverse Drug Reaction (ADR).

For more information, refer to the Patient Identification procedure on PROMPT.

Positive Patient Identification scanning in the EMR Medication Administration Wizard (MAW) is an additional identification measure. It does not replace the requirement for clinical staff to physically check a patient’s identification band for identifiers and allergies prior to providing medication.

Handover at transitions of care

Clinical handover is the transfer of professional responsibility and accountability for some or all aspects of care for a patient (or group of patients) to another person or professional group on a temporary or permanent basis.

  • The pneumonic used at Monash Health to structure and support a minimum data set for standardised clinical handover is ISBAR (identity of patient, situation, background, assessment and action, response, rationale and recommendation).
  • Ensure you are aware of your patient’s critical information, as displayed on the EMR banner bar.
  • Electronic tools are utilised by EMR sites for handover and huddles e.g. ISBAR handover tab, iPASS handover tool,  Clinical Leader Organiser (CLO).
  • Printed handover sheets are no longer required.

For more information, enter “handover” into the PROMPT search and download your specialty-specific document from the handover policy/procedure suite.

Cleaning and decluttering your areas

Part of preparing and being ready for accreditation is ensuring our work and communal areas are kept clean and free of clutter.

As our Quality Manager for Standards, Audits and PROMPT, Rachel Vogelsang likes to say, “Accreditation is similar to preparing your house for auction, we want to showcase and present it in the best possible way.”

Our General Services team work tirelessly to deliver a clean environment for our patients, visitors and employees, but keeping our areas and facilities clean and free of clutter is everyone’s responsibility.

Find out how to request the removal of any excess, broken or unused equipment on your ward and some tips about keeping your areas clean and free of clutter here.

Speaking with assessors guide and sample questions and answers

So that you feel prepared when you meet with the assessors, don’t forget to check out our ‘Speaking with Assessors’ guide, as well as our sample question and answer factsheets for doctors, clinicians, food service employees and environmental services assistants, here.

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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