Accreditation Bulletin: 17 June

Accreditation Bulletin: 17 June

Rescheduled Accreditation assessment – Save the date!

Monash Health’s National Standards accreditation survey rescheduled for 13-17 September 2021.

With your commitment to quality and safety, and with systems and processes in place, we continue to deliver high quality, safe care to our community.

We will continue to support you with regular updates on maintaining best practice in your day-to-day work, and to ensure you feel confident and comfortable when you meet with the assessors to convey the great work you do each and every day to deliver high-quality care and great patient experience.

If you have any questions or would like more information about our National Standards accreditation assessment, please contact us.

Key Messages

Here are the things to do to remain on track for accreditation.

Don’t defer your Deteriorating Patient training

While Accreditation has been deferred for a few weeks, it is no reason to defer your Deteriorating Patient training.

Due to the ongoing impact of COVID-19, completion of the online component of your deteriorating patient training before September 30, 2021 will be considered as full completion of the course.

The target for deteriorating patient training is 90%. As of today, 86% (10,368) of employees have completed this training in the last 12 months, however not all disciplines have the same completion rates.

  • 73% Doctors
  • 89% Nurses and Midwives
  • 91% Allied Health
  • 95% Pharmacists
  • 76% Clinical Support (Imaging and Pathology)
  • 86% Dental
  • 89% Psychology

As a clinician, you must complete your Deteriorating Patient training. Successful completion ensures you have the skills and confidence to accurately recognise clinical deterioration and provide an appropriate and timely response. It is a requirement for all patient-facing employees.

More information about deteriorating patient training, including FAQs can be found here. If you have any questions about the training program, please speak to your manager or contact

Now is the time for a Give Me Five

Give Me Five or performance appraisal discussions are important conversations between you and your manager. They provide an opportunity to clarify expectations, ensure a shared understanding of your goals and aspirations, highlight your progress from previous conversations, identify growth opportunities and plan for the year ahead.

Here’s what you can do…

  • If you have not had a recent Give Me Five or performance appraisal, please book one in with your manager.
  • Book in a convenient time with your manager for your Give Me Five conversation (top tip: ensure it is clear of other meetings so you can have a relaxed conversation without looking at the clock).
  • Visit the Give Me Five page of the COVID-19 employee website for some useful resources, guides for these conversations
  • Download the Give Me Five template and complete it ahead of your conversation. Don’t worry if there are gaps; the conversation is what’s important, not the piece of paper!  Please note: support services and security employees should download the Give Me Five template for support services and security.
  • Once agreed with your manager, a record of a completed Give Me Five/Performance appraisal conversation can be added directly to HR 21/Employee Self Service by individual employees.
  • Book in a follow-up Give Me Five or performance appraisal within the next 12 months so that you are always up to date.

Family Escalation of Care posters

It is important that Family Escalation of Care posters displayed in clinical areas are up-to-date.

The hospital/site-specific posters have recently been updated, so please ensure you have downloaded the relevant and updated poster(s) and translations from PROMPT.

These can also be found on the Family Escalation of Care translations page on the Monash Health website.

Monash Health moving to quiet MET calls

From 8am Monday, 21 June Monash Health will move to quiet MET calls for adult, paediatric and neonatal Medical Emergency Team (MET) calls. This change will apply to Monash Medical Centre, Monash Children’s Hospital, Casey Hospital, Dandenong Hospital, Moorabbin Hospital and Kingston Centre.

The change will improve patient experience by reducing the environmental noise in clinical areas and, crucially, ensure messaging is received as a priority by the first responders and medical and nursing teams caring for the patient.

It is important to note:

  • MET call and Code Blue teams remain unchanged.
  • If there is no response to a MET call within 10 minutes, an overhead MET call will be announced.
  • All Adult and Paediatric Code Blues will remain as overhead announcements. Neonatal Code Blues (previously quiet) will now ALSO be overhead announcements.

This change will be evaluated and re-assessed in three months. If you have any questions or would like to provide feedback, please contact the Deteriorating patient governance committee.

You can read more about our move to quiet MET calls and the tiered approach to messaging employees here.

Mandatory Privacy Training on Latte

Protecting the privacy of others is a vital part of our roles.

Breaches of privacy can result in a disciplinary process, and sadly, we have terminated employees due to privacy breaches. To help you better understand your legal responsibilities about access, disclosure and handling of personal information, we launched a new Privacy Training module in April.

It is vital that you Log onto Latte and complete the Privacy Training as soon as possible. The training will only take 15 minutes and is automatically assigned to you under “My Required Learning” on LATTE.

Mandatory and Targeted training

Monash Health has set a target of 90% for mandatory and targeted training. Training is a critical part of delivering safe and effective care to our community. Please ensure you have completed the training that has been allocated to you in LATTE.

Below are our current completion rates. The courses in bold indicate where we need to improve and where we need you to concentrate your efforts.

Mandatory training

CourseCompletion rate (%)
Cultural Awareness92.3%
Fire Training93%
Managing Challenging Behaviour (OVA)91.6%
Health and Safety (OHS)97.7%
Privacy Training82.2%
Using Social Media98%
Unconscious Bias95.7%

Targeted training

Targeted training is specific to your role. Every employee is allocated an occupational category, specialty and management level in our Position Management database. We use this information to create audience groups and assign targeted training.

The percentages below are based on the total number of employees assigned to each training course.  Completion rates for most targeted training packages are falling short of target. Please attend to these as a priority.

CourseCompletion rate (%)
Allergies and ADR91%
Aseptic Technique90%
Cultural Awareness for Managers87%
Blood Safe Clinical Transfusion75%
Clinical Handover83%
Delirium: Suspect it, spot it, stop it75%
Deteriorating Patient 86%
Hand Hygiene86%
Intro to high-risk medications73%
Medication Safety 73%
Open discussion training79%
Partnering with consumers85%
Patient ID Procedure Mat69%
PPE transmissions based precautions 85%
Preventing falls86%
Prevent & Mng Pressure Injuries84%
Quality, safety and managing risk for SMS79%

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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