Accreditation Bulletin – 7 July 2022

Thursday 7 July 2022

With our Accreditation assessment just 6 weeks away, now is the time to ensure your local area is ready to shine. In this bulletin, we will focus on some of the high-risk areas the assessors are likely to observe when they visit your ward or service.

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.”

Earlier this week, Rachel joined our Employee Forum to give us some practical tips on how to prepare and maintain local areas, as well as some of the high-risk activities that assessors will be looking out for in August. If you missed Rachel’s presentation you can watch the recording or view the slide deck here.

All the latest information, resources, and tools you need to be Accreditation-ready, can be found on our employee Accreditation website.

Focus points 

Here are the top things you can do this week to ensure we remain Accreditation-ready:

• Update your Welcome to Ward and Quality Boards and check that all the information is accurate, up-to-date and reflects the great work happening on your ward.
• Remove any clutter and tidy up your work and communal areas.
• Check that the resuscitation trolleys on your ward are set up in the standardised way, and that you are completing the daily and weekly checks.
• Check your areas to ensure your electrical equipment is appropriately tested and tagged. See below for more information.
• Check LATTE to stay up to date with all your training.

Key messages

Understanding high risk activities  

Assessors are not there to test or trick you, but they will be interested in how you provide patients with safe, appropriate, and effective care.

It is about making sure the roles and responsibilities you undertake as part of your everyday work, are well maintained and you can demonstrate our practices to the assessors.

Some of these include:

• Patient identification checks
  • Before meal delivery
  • Prior to medication administration
  • Between transfers of care
• Handovers
  • Include your patient when and where possible
  • Ensure you are consistent with your documentation, and you are using ISBAR for your clinical handovers
  • Make sure you can tell the patient’s story and journey
• Care planning
  • All of our inpatients need to have a care plan
  • Know how to access the care plans and update them daily
  • Have risk assessments been completed, documented, and actioned?
• Hand hygiene
  • All employees need to be performing hand hygiene at critical moments (before and after contact with our patients, before and after procedures, before and after touching equipment)

Read more about additional high-risk activities and what you can do to prepare your local area below.

Updating your Welcome to Ward and Quality Boards   

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. Take some time and check that the information on your Welcome to Ward board is accurate and current.

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

Remember all the information on your boards needs to be laminated, no paper!

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

Cleaning and decluttering your areas 

Part of preparing and being Accreditation-ready is ensuring our work and communal areas are kept clean and free of clutter.

Our General Services team work 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 tips for keeping your areas clean and free of clutter here.

Used a device? Keep it nice! 

We should all be in the habit of cleaning devices regularly and making sure Workstations on Wheels (WOWs) are free of clutter. We know the Accreditation assessors will be checking WOWs so if you need a refresher, download our factsheet for cleaning your electronic devices, showing you how and when to clean WOWs.

Templates for daily and weekly cleaning schedules have also been created so you can record your WOW cleaning.

• Daily Cleaning Schedule for WOWs
• Weekly Cleaning Schedule for WOWs

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

Set up and checks for resuscitation trolleys 

To ensure equipment and medications are available for code blue and emergency response teams, resuscitation trolleys must be set up in the standardised way, and daily and weekly checks (as outlined in the procedures below) must be completed.

You can find more information, including the trolley equipment list and checking requirements here:

• Adult and Paediatric Resuscitation trolley procedure on PROMPT
• Resuscitation equipment (Neonatal, Monash Newborn, Maternity)

Has your electrical equipment been tested and tagged? 

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.

In the lead up to our Accreditation assessment in August, it is 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:

• Medical equipment – contact Clinical Engineering on 8541 6400 (or internal ext. 16400) or email: clinicalengineering@monashhealth.org
• Non-medical equipment – place a BEIMS request

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