Accreditation Bulletin: 5 May 2022

Accreditation Bulletin: 5 May 2022

Thursday, 5 May 2022

Save the date for an August Accreditation

Monash Health is set to undergo a National Standards accreditation assessment from Monday 15 August to Friday 19 August 2022. 

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

Over the following months, we’ll be providing you with updates, resources, top tips, access to events and more, directly to your inbox. We’ve also relaunched our Employee Accreditation website, with all the latest information, resources and tools you need to be Accreditation-ready.  

Of course, if you have any questions or would like more information about our National Standards Accreditation assessment, please contact us. 

Focus points 

Here are the top things you can do to ensure we remain on track for Accreditation:  

  • Download resources and guides to help you prepare and plan for Accreditation 
  • Complete your mandatory and targeted training via LATTE as soon as possible  
  • Completion of patient identification and handover to support our delivery of safe patient care 
  • Ensure your ward and quality boards are up-to-date 

Key messages and reminders  

Mandatory and Targeted training

Monash Health has set a target of 90% for mandatory and targeted training. Ensuring everyone is up to date with their training requirements is critical to us delivering safe and effective care to our community. It is also an Accreditation requirement. 

Please ensure you have completed the targeted and mandatory training that has been allocated to you in LATTE as soon as possible. 

If you’re wondering what the difference between mandatory and targeted training is, read our FAQs here. 

Communicating for safety 

Patient identification and adequate transfer of information at handover are crucial steps in our delivery of safe patient care and ensure timely, purpose-driven and effective communication and documentation.

During Accreditation week, assessors will be observing handovers to see clinicians following these processes as part of the Communicating for Safety Standard. You can find more information and top tips on patient identification and handover at transitions of care here.

Ward boards 

Ensuring your Welcome to Ward and Quality boards are up-to-date is crucial to our day-to-day work and commitment to safety and quality. It is 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 demonstrating to our community that your ward delivers safe and high-quality care. It’s also a great place to attach a printout of the latest Quality Care newsletter for your team’s reference. 

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

Used a device? Keep it nice! 

Please ensure that you are in the habit of cleaning your ward devices regularly and that Workstations on Wheels (WOWs) are free of clutter.  

You can find a helpful factsheet for cleaning your electronic devices that shows how and when they need to be cleaned. 

Templates for daily and weekly cleaning schedules for (WOWs) have also been created so that you can regularly record your WOW cleaning. 

For more information, please refer to the Clinical Equipment Cleaning Procedure on PROMPT. 

Accreditation Resources

In this edition, you’ll find resources and guides to help you prepare and plan for accreditation. Download them, print them out, discuss them with your teams and put them on your employee noticeboards. 

EMR, documenting and comprehensive care Quick Reference Guides (QRGs) 

Providing high-quality, comprehensive care is one of the most important things we do as a health service. It’s critical we communicate and correctly document the care we provide so that the rest of the team members and other clinicians associated with the patient have the complete picture for decision- making.  

Accreditation gives us the opportunity to showcase the collaborative clinical work we do in caring for patients. To help prepare, we’ve created QRGs, which show how the EMR facilitates comprehensive care.

The ‘EMR and Comprehensive Care’ QRGs are available on the employee resources page and have been created for medical, nursing and midwifery, pharmacy, allied health and administrative employees. 

Assessors may ask you to show them how the EMR facilitates comprehensive care, so please ensure you have read and are familiar with these QRGs.   

Accreditation checklists 

Accreditation checklists are available for doctors, clinicians, non-clinical employees and managers. Many of the actions in the checklists are to be undertaken every day as part of delivering safe, timely, effective and person-centred care. 

You can find the new checklists here. 

Speaking with assessors guide and sample questions and answers  

Remember, assessors are not trying to test or trick you. They are offering you the opportunity to show them how you provide patients with safe and effective care. So take the time to talk about the great work you do!  

So that you feel prepared when you meet with the assessors in August, we’ve developed a helpful guide, and a series of factsheets covering some of the questions assessors may ask. 

The ‘Speaking with Assessors’ guide, as well as factsheets for doctors, clinicians, food service employees and environmental services assistants, are available here. 


Visit the events page on our employee accreditation website for a list of upcoming accreditation-related presentations. As they become available, we’ll add recordings and slide decks from previous events to the Accreditation website. 

Your Quality and Safety Business Partners 

If you have any enquiries or require any assistance in preparation for Accreditation in August, please reach out to your program’s Quality Partner via the Quality Partners Intranet page. 

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.

Previous Next
Test Caption
Test Description goes like this