Accreditation Bulletin: 20 August

Accreditation Bulletin: 20 August

Monash Health’s rescheduled accreditation assessment (13-17 September) is in four (4) weeks.

In the lead-up to our accreditation assessment, we will support you with regular updates on maintaining best practice in your day-to-day work and ensure you feel confident and comfortable when you meet with the assessors.

Focus of the week

Here are the things to do to keep us on track:

  • Please ensure electrical equipment in your area is tested and tagged (more information below).
  • Log in to Latte and check your mandatory and targeted training is up to date, and if not, please complete it.
    • All employees – please take 15 minutes to complete your ‘Privacy Training‘.
    • Managers – if you haven’t already, please complete the ‘Family Violence – Managers’ module on Latte.
    • Clinicians – there are several targeted training courses that require your attention. Please check the ‘My Required Learning’ section on your Latte dashboard.
  • Clinical area managers – please ensure your Point of Care audits have been completed (information and resources below).

Key Messages

Continual improvement

Embedding continual quality improvement in our practice is an important part of ensuring we consistently provide safe, high-quality and timely care to our community.

Naturally, assessors will be observing how you provide great patient care, but they will also be interested in your efforts to continually improve.

Follow the steps outlined in the Continuous Improvement Process Wheel and listed below.

1.       Evaluate services and care

Meeting best-practice standards requires that our services and care are regularly monitored and evaluated. This includes:

  • conducting audits, assessments and reviews (such as Point of Care audits, Infection Prevention Risk Assessment, Incident reviews, Morbidity and Mortality reviews, etc.)
  • monitoring clinical indicators
  • learning from consumer and employee feedback.

2.       Set clear goals

Set clear goals for how you intend to improve services and care using the SMART (specific, measurable, achievable, relevant, timely) goals method.

3.       Action improvement

This is the fun part! You’ve evaluated, found room for improvement and set your goals. Now it’s time to act and implement.

4.       Measure effectiveness

Did you reach your goals? How effective were your actions? Much like step one, measuring effectiveness is about reviewing, assessing, monitoring and consolidating feedback on how your actions improved a particular service or care.

5.       Document improvement activities

It’s important to celebrate successes, and it’s equally important to understand where there is room for improvement. Document your goals, actions, improvements and evaluations on your Quality Improvement Plans and Quality Boards. Discuss these with your ward governance teams, and don’t forget to show and discuss them with the assessors as well.

Point Of Care audits

Why we audit!

Auditing ensures:

  • we are meeting best practice standards
  • we are following the official processes described in procedures, guidelines, and medication profiles
  • our strategies for continual improvement are effective.

We conduct Point of Care audits to identify where our practices might fall short of best practice standards and identify opportunities for improvement.

Audit compliance

Clinical area managers (or their delegates) are required to conduct 11 Point of Care audits each month:

  • Part 1 – 10 audits, including patient questions and a medical record review.
  • Part 2 – 1 audit, including employee questions and a check of environmental safety.

The Point of Care audit tools are customised for specialty areas, including: bed-based services, day patient areas, specialist consulting, mental health, ICU, newborn, cath lab, Monash Children’s,  endoscopy, theatre, diagnostic imaging, the Sleep Centre, Aboriginal Health, and several areas in Community. This customisation is to ensure the audit is relevant to your particular area.

Top tip: Make sure you select the correct audit, correct entity, and ensure all tabs are completed. Click ‘save’ and then ‘submit’ when you are ready to finalise.

Audit results

Review and celebrate your positive areas and/or discuss areas that are outliers and require improvement. So that our strategies for continual improvement are effective, follow these steps:

Latest results:

  • In June, 90% of QIPs were updated and uploaded to the intranet.
  • In July 2021, 80% of areas completed the 11 audits in the Point of Care audit.

For August, we have set a target of 90% for audit completion compliance and Quality Improvement Plans uploaded to the intranet.

For more information, refer to the Point of Care audit procedure and the Quality Improvement Plan procedure. If you have any questions, please contact:

Has your electrical equipment been tested and tagged?

Please check your areas to ensure your electrical equipment is appropriately tested and tagged. Here are three simple practices for your area:

  1. Check for tags – all electrical equipment must have a tag.  If a piece of equipment doesn’t have a tag, it needs to be reported (using the contact information below).
  2. Check the date – tags will indicate that the electrical equipment has been tested and when it is due for a retest. If the equipment is due to be retested, report it.
  3. Check for damage – if electrical equipment is showing signs of damage or unreasonable wear and tear, it needs to be reported, even if it falls within the date on the tag.

Last month, Jessie McPherson Private Hospital had its accreditation assessment against the National Standards. While on track for a successful accreditation, assessors noted some equipment was overdue for testing. In the lead up to our accreditation assessment in September (13-17), it’s important that all our electrical equipment is in good condition, has been tested, tagged and is within its retest date.

If you require equipment to be tested and tagged, you can contact:

More information, including general retest intervals, can be found in the Electrical Testing and Tagging PROMPT procedure.

Targeted training reminders

Keeping yourself up to date with training and education is a critical part of delivering safe and effective care to our community.

That’s why we have introduced targeted training email reminders. Similar to your mandatory training reminders, you will now receive an email from Latte with a reminder to complete your targeted training as it becomes due.

The training target (which includes both mandatory and targeted training) for all cost centres has been set at 90%.

  • All Monash Health employees are required to complete their mandatory training, such as Cultural Awareness, OHS, OVA and Fire training, regardless of their role.
  • Targeted training is specific to your role, and you must complete the courses that have been allocated to you. These will be automatically assigned to you under ‘My Required Learning’ on your Latte homepage.

The process and requirements for mandatory and targeted training is outlined in the Mandatory and Targeted Training procedure on PROMPT. If you have any questions, please direct them to

Quality Care Newsletter

Lastly, this month’s Quality Care Newsletter has several key messages to assist you in continuing to perform at the standard that Monash Health expects. It’s good reading, so be sure to look out for it.

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.

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