Accreditation Bulletin: 19 May 2022

Accreditation Bulletin: 19 May 2022

Thursday, 19 May 2022 

Our Accreditation assessment is in 13 weeks; less than 100 days away.

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.

For all the latest information, resources and tools you need to be Accreditation-ready, including guides on how to speak with assessors, visit the employee Accreditation website.

Focus points 

Here are the top things you can do this week:

  • Deteriorating Patient Training is currently at 72% completion, please check LATTE and if you are not up-to-date, complete your training
  • Clinical area managers complete your Point of Care Audits and ensure the results are reviewed and any items ‘not met’ are actioned
  • Review your last Infection Prevention Risk Assessment and ensure all ‘not mets’ have been actioned and closed or escalated to your manager
  • Ensure your Welcome to Ward and Quality Boards are accurate, up-to-date and reflect the great work happening on your ward.

Key messages

Safety, compliance, and training

Providing safe patient care and high-quality outcomes for our patients, families and carers is one of the most important things we do as a health service.

In this edition, you’ll find advice and resources to ensure we continue to deliver safe, timely, effective and person-centred care every time.

Complete your targeted training

Ensuring we are all up to date with our training is critical to us delivering safe and effective care to our community.

Targeted training is specific to your role, and we have a target of 90% completion for all targeted training courses, to allow for people on leave.

The percentages below are based on the total number of employees assigned to each training course.

Please ensure you have completed the training that has been allocated to you in LATTE as soon as possible, and be sure to check in regularly to see if there are any updates.

For those targeted training packages that are following short of target, please attend to these as a priority.


Completion rate (%)
Allergies and ADR94%
Aseptic Technique90%
Cultural Awareness for Managers93%
Blood Safe Clinical Transfusion73%
Clinical Handover86%
Delirium: Suspect it, spot it, stop it86%
Deteriorating Patient (BLS)71%
Hand Hygiene85%
Intro to high-risk medications79%
Medication Safety87%
Open discussion training80%
Partnering with consumers83%
Patient ID Procedure Mat85%
PPE transmissions-based precautions86%
Preventing falls90%
Prevent & Manage Pressure Injuries92%
Quality, safety and managing risk for SMS81%


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

Have you completed your deteriorating patient training? 

For all clinicians, your Deteriorating Patient Training ensures you have the skills and confidence to accurately recognise clinical deterioration and provide an appropriate and timely response.

Deteriorating Patient Training is a requirement for all patient-facing employees.

Overall, 72% (9219) of employees have completed their training in the last 12 months, however not all disciplines have the same completion rates. Please ensure you and your teams are up to date with your Deteriorating Patient Training.

  • 46% (1212) Doctors
  • 80% (6301) Nurses and Midwives
  • 71% (962) Allied Health
  • 79% (249) Pharmacists
  • 72% (116) Clinical Support

Find out more information about Deteriorating Patient Training read our FAQs here. If you have any questions about the training program, please speak to your manager or contact

Audits for ongoing quality improvement

Ensuring your audits are up-to-date and accurate is a crucial step in ongoing quality improvement.

Of course, conducting an audit is only one step in successful quality improvement. It’s what you do with your results, and how you fix things, that really counts.

Point of Care Audits

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

  • 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.

Read more information about point of care audits, audit compliance, results and responsibilities for clinical area managers here.

If you have any further questions or enquiries, please refer to the Point of Care audit procedure or contact

Infection Prevention Risk assessments

It’s important to review the last assessment undertaken in your unit.

Ask yourself: What did the last risk assessment show? Have any ‘not mets’ been actioned or escalated?

If you need a copy of the last audit undertaken in your area, contact Infection Prevention.

Quality Improvement Plans

Each month, review all your audit results and themes from incidents and complaints. Celebrate your positive areas and discuss areas that are outliers and:

You can read more on the Quality Improvement Plan procedure on PROMPT.

Welcome to Ward and Quality Boards

Ensuring your Welcome to Ward and Quality boards are up to date is crucial to your everyday work and ongoing commitment to safety and quality.

Your unit’s Welcome to Ward board is often the first thing patients, their loved ones, and visitors see when entering your area and helps orient them when they feel nervous or have questions. It’s essential that this information is accurate and current.

Likewise, your Quality board is an important tool in demonstrating to our community the safe and high-quality care that your ward delivers every time. It’s also a great place to attach a printout of the latest Quality Care newsletter for your team’s reference.

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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