Accreditation Bulletin: 30 June 2022

Accreditation Bulletin: 30 June 2022

Thursday 30 June 2022

Our Accreditation assessment is in 6 weeks; less than 45 days away.

Over the past couple of months, we have been helping you to get Accreditation-ready with some helpful resources and guides.

In this edition of the Accreditation Bulletin, we focus on audits, knowing your data, and the important steps in ongoing quality improvement.

For all the latest information, resources, and tools you need to be Accreditation-ready, visit the employee Accreditation website.

Focus points  

Here are the top things you can do this week:

  • 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 Quality Improvement Plans (QIP) are up to date and discuss the content with your teams

Key messages

Why we audit  

Audits are an important part of our everyday practice to ensure

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

Point of Care Audits 

Conducting your Point of Care audits isn’t just about identifying key risks in your area, it’s also about actioning those key risks for further improvement and keeping a close eye on progress.

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.

Remember, conducting an audit is only one step in successful quality improvement. It’s what we do with your results, and how we continue to improve, that really counts.

What do I need to do?

  • Ensure this month’s audits have been completed,
  • Discuss with your team and record actions in your Quality Improvement Plan,
  • Implement the key actions, and
  • Review effectiveness of the actions on your next audit.

Top Tips:

  1. Make sure you select the correct audit, correct entity, and ensure all tabs are completed.
  2. When you are ready to finalise click ‘save’ and then ‘submit’.

Infection Control Risk Assessments   

The second audit your teams should be focusing on is the Infection Control Risk Assessment actions.

The first step to this audit is reviewing the last assessment undertaken in your unit (which must be within the last 12 months).

The next step is to ensure all results and actions have been closed off. Ask yourself the following two questions:

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

If you are new to your role and 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, discuss areas that are outliers and complete the following:

  1. Develop an action plan to address any shortcomings,
  2. Make sure your QIP uses the current Quality Improvement Plan template,
  3. Document the action plan in your Quality Improvement Plan and then upload your QIP to the intranet, and
  4. Discuss results and strategies at ward governance, huddles, committees and involve all disciplines, including non-clinical areas, to assist in improvements.

For further enquiries, refer to the Quality Improvement Plan procedure or contact your Quality Partner or email

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.

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

Continuous improvement can be achieved by following the steps outlined in the Continuous Improvement Process Wheel, as discussed and pictured below.

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, through consumer surveys, complaints, compliments, and patient experience forms

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.

Action improvement

Having completed the evaluation, identified room for improvement and set goals, the next step is to make sure improvement plans are implemented.

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.

Document improvement activities

The last step in the Continuous Improvement Process Wheel is documenting improvement activities for your area, by reflecting on all your documentation and what you have learnt from the previous steps. It is important to celebrate successes, and it is 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.

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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