Accreditation Bulletin: 31 August

Accreditation Bulletin: 31 August

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

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

Hybrid assessment model

To ensure a COVID-safe assessment in September, Monash Health will undergo a new hybrid model accreditation assessment.

Similar to Jessie McPherson’s accreditation assessment in July, some assessors will be on-site, and others will review the organisation and evidence remotely.

We are currently working with the Australian Council on Healthcare Standards (ACHS) to ensure a safe and efficient assessment and will keep you updated as soon as details and logistics have been confirmed.

Focus of the week

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

  • Ward boards – Ensure your Welcome to Ward Boards, Quality Boards, Journey Boards and New Ideas Boards are all up-to-date (more information below).
  • Decluttering – Please take some time and ensure your work and communal areas are clean and free of clutter in the lead up to accreditation (more information below).
  • Mandatory and Targeted training – Log in to Latte and check your mandatory and targeted training is up to date, and if not, please complete it.

Key messages and reminders

Speaking with assessors

Remember, assessors are not there to test or trick you. They genuinely want to know how you provide patients with safe, appropriate and effective care. Be calm and confident. Talk about the great work you do (see the brag list section below for examples)!

The assessors are likely to ask you about some of the challenges in your area/space. Make the most of the opportunity to discuss the ongoing improvement work you are doing to address those challenges.

If you haven’t already, 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.

Brag lists

To ensure you feel comfortable talking with the assessors, create a brag list so that you can talk about all the great work you do! Your brag list should be specific to your team, but can also include your team’s involvement with projects that Monash Health has rolled out. Here are just some examples you might want to add to your brag list:

  • COVID-19
  • EMR
  • Vaccination project
  • Monash Health Experience surveys
  • Smart pumps
  • Resuscitation trolley standardisation
  • ED emotional experience workshop
  • Patient experience week
  • Pressure injury projects in community and ICU
  • Falls champion program
  • Patient Clinical Alerts improvements
  • Bedside communication boards
  • Children’s admission activity book
  • Telehealth
  • Staggered admission times
  • Welcome to ward videos
  • Online exercise program – Aged and community care

Ward and local 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.

Ward boards

Ensuring your ward and quality boards are up-to-date is crucial to our day-to-day work and commitment to safety and quality.  It’s also an important part of being accreditation ready.

Your unit’s Welcome to Ward board is often the first thing patients, their loved ones , and other visitors see when entering your area and helps orient them when they feel nervous or have questions. It’s essential that this information is up-to-date, accurate, and reflects the great work happening on your ward.

Likewise, your Quality board is an important tool in maintaining the visibility of your practice and ensuring you are continuing to deliver safe and high-quality care to our community. It’s also a great place to attach a print out of the latest Quality Care newsletter for your team’s reference.

More information is available in our Welcome to Ward and Quality Boards on PROMPT.

Hand Hygiene

As part of our efforts to ensure hand hygiene stays front of mind, auditors continue to complete hand hygiene audits and promote feedback in wards and clinical areas across Monash Health.

But what does a Hand Hygiene Auditor do? What do they look for? How can you work with one to get the best results for your area? To get some answers to these questions, we spoke to Monash Health Hand Hygiene Auditor, Loulou Ibrahim on “Looking out for ‘before and after’”.

Key messages from the National Standards Committees

The eight National Safety and Quality Health Service (NSQHS) Standards provide a nationally consistent framework for the level of care consumers can expect from health services.

More information about the National Standards, including factsheets and guides, are available on our National Standards accreditation page. Below you’ll find some key items/messages for each standard to show and discuss with the assessors.

Clinical Governance

  • Ensure your team know the resources available to support patients who identify as Aboriginal or Torres Strait islander.
  • Safe work environment:
    • workplace inspections are up to date and actioned
    • signage is accurate and clear
    • emergency management procedures are known
    • electrical equipment is tagged and tested
  • Ward Governance – outcomes (scorecards) are monitored and improvements implemented.

Partnering with Consumers

  • Know the consumer feedback results for your area (available via the Manager BI portal)
  • What improvement has occurred as a result of consumer and/or employee feedback?
  • Are you confident patients are receiving the necessary and up-to-date information?
  • Discuss how our consumers partner with us at all levels of our organisation (more info and resources below).

Infection Prevention

  • Ensure you are familiar with the before and after of Hand Hygiene:
    • Before and after contact with our patients
    • Before and after procedures
    • Before and after touching equipment
  • Cleaning schedules – clinical equipment cleaning, WOWs
  • Linen – storage and transporting
  • Employee health – vaccination records

Medication Safety

  • Fridges – checks are done as per the procedure: Medication and Vaccine Refrigerator and Medication Freezer Temperature Management
  • High-risk drugs – storage – (refer to article in the upcoming QC newsletter)
  • Medication management plans

Comprehensive Care

Check that:

  • All patients have a care plan in place that reflects completed risk assessments
  • Care plans have a goal/intervention
  • Discharge planning commences early
  • Care provided is documented
  • Goals of Care are updated when needed

Communicating for Safety

Check that:

  • Patient identification checks are done with all transfers of care and prior to  medication administration
  • Your area has a process for ensuring correct meal is provided to the correct patient
  • Handovers follow the ISBAR format, assessors will watch and listen, including medical handovers
  • Critical Information – Alerts

Blood Management

  • Consent
  • Conserving blood, wastage reports
  • Observations align with protocols

Recognising and Responding to Acute Deterioration

  • Ensure resus trolley checks are done and documented
  • Training and compliance – deteriorating patient training
  • Family escalation of care – posters/handouts and translations available (see below for info and links).

Accreditation resources

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

Accreditation checklists

Our Accreditation checklists have been designed to help you get accreditation ready. Use the checklists to embed the ‘small’ things in your everyday work to ensure we continue delivering outstanding health care to our community.

EMR and comprehensive care Quick Reference Guides (QRGs)

Providing high-quality, comprehensive care is one of the most important things we can do as a health service. Use our ‘EMR, Documentation and Comprehensive Care’ Quick Reference Guides (QRGs) to help you demonstrate how the EMR facilitates comprehensive care.

Family Escalation of Care posters and translations

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

The hospital/site-specific posters and translations are available via PROMPT, and can also be found on the Family Escalation of Care translations page on the Monash Health website.

Partnering with consumers and patient information

It’s important to remember that the delivery of safe, timely, effective and person-centred care is only possible by working together with patients, consumers, carers and our community.

You can find consumer advisor brochures on the patient information resources page. The partnering with consumers page on our Monash Health website is another fantastic resource for those wanting more information on how we partner with consumers, carers and community members at all levels of our organisation.

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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