Accreditation Bulletin: 30 July

Accreditation Bulletin: 30 July

Monash Health’s rescheduled accreditation assessment (13-17 September) is in seven (7) weeks.

A look at Jessie McPherson’s accreditation assessment

Earlier this month (13 -15 July), Jessie McPherson Private Hospital had its accreditation assessment against the National Standards. The final report is still a few weeks away, however the feedback received from the assessors was extremely favourable, with Jessie McPherson on-track for a successful accreditation.

It’s important to recognise and thank all our Jessie McPherson employees and, of course, the teams behind the scenes for their hard work and dedication in ensuring we remain accreditation-ready at all times.

Hybrid accreditation model

Jessie McPherson’s accreditation assessment was conducted using a new hybrid assessment methodology with some assessors on site, and others reviewing the organisation and evidence remotely.

Monash Health will likely undergo a similar assessment and will work closely with the Australian Council on Healthcare Standards (ACHS) to ensure a COVID-safe assessment in September.

Areas of interest and praise from Jessie McPherson’s assessors

Some of the key areas assessors were interested in and impressed by were:

  • The COVID-19 response and how the workforce and our Models of Care changed and adapted to meet patients’ needs
  • How the EMR successfully facilitates and supports comprehensive care
  • Vaccination data
  • Medication management, and how the EMR supports this
  • Cleaning processes, especially around microfiber practice, having separate cloths for cleaning areas, and UV marking audits
  • Huddles and handovers sharing critical information
  • Point of care audits
  • Monash Health support for MET Calls and Infection Prevention is evident and favourable
  • Strong Governance – an involved Board with proactive oversight


As with any survey or review, there are valuable and helpful suggestions on where there is room for improvement. Jessie McPherson received no official recommendations, but assessors suggested the following could be targeted for improvement in the future:

  • Allied Health huddles to be conducted with patients at the bedside
  • Ensuring Workstations on Wheels (WOWs) are not a barrier between employees and patients during handover as this doesn’t facilitate patient-centred care.
  • Ensuring the patient is involved in bedside handover if appropriate.
  • Journey/Communication boards at the bedside – positioning of boards to be reviewed to ensure patients can see the boards easily.

Staying focused for September

With Monash Health’s accreditation assessment scheduled for 13 – 17 September 2021, it’s important we stay focused, keep the momentum going, take note of suggestions for improvement and continue to deliver high-quality care and a positive patient experience.

Here are some of the things you can focus on to ensure we remain accreditation-ready at all times:

  • Ensure your Welcome to Ward Boards, Quality Boards, Journey Boards and New Ideas Boards are all up-to-date.
  • Log in to Latte and check your mandatory and targeted training is up to date, and if not, please complete it.
  • Clinicians, download and familiarise yourself with our EMR and Comprehensive Care QRGs.
  • Ensure your Quality Improvement Plans (QIP) are up to date and discuss the content with your teams.
  • Communicate and correctly document the care we provide so team members, and other clinicians associated with your patients’ care get the complete picture.

News, updates, resources and presentations for accreditation

Don’t forget to visit our employee accreditation website for the latest accreditation news and updates, preparation resources and National Standards information.

Earlier this week, Rachel Vogelsang, the Quality Manager for Standards, Audits, and PROMPT, gave an excellent presentation at our Employment Forum on the positives and learnings we can take from Jessie McPherson’s accreditation assessment. If you missed it, you can download the slide deck and watch the recording via the following links:

Throughout the year, Rachel has been delivering tailored accreditation webinars to teams and departments throughout the organisation. If your team would like to organise an ‘accreditation planning’ session via Webex, please contact us.

In the lead up to September, 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.

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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