Employee Resources

Read, download and share the most up-to-date Accreditation resources for employees.

Key messages

Monash Health frameworks

Monash Health frameworks describe the systems in place to ensure that we continue to deliver high-quality care and exceptional patient experience. It is important to familiarise yourself with frameworks, such as:

  • Clinical Governance framework
  • Enterprise Risk Management framework
  • Health Literacy framework
  • Policy, Procedure and Guideline Framework
  • Consumer, Carer and Community Participation framework

The frameworks are easily accessible via Prompt or the Quality and Safety Unity resources intranet page (below).

Visit the Quality and Safety Resources Intranet page

Access via Citrix if working remotely

Accreditation Bulletins

The Accreditation Bulletin is a weekly communication to keep you up to date with what you need to know and do in the lead up to accreditation. You can view and download previous Bulletins below.

31 August 2021Accreditation Bulletin #9


In this edition of the Accreditation Bulletin, we look at our hybrid assessment model, speaking with assessors, brag lists, hand hygiene, ward and local area preparedness, key messages from the National Standards Committees and accreditation resources.

20 August 2021Accreditation Bulletin #8


In this edition of the Accreditation Bulletin, we look at continual improvement, Point of Care audits, testing and tagging and targeted training reminders.

30 July 2021Accreditation Bulletin #7


In this edition of the Accreditation Bulletin, we look at the positives and learnings we can take from Jessie McPherson’s accreditation assessment.

16 July 2021Accreditation Bulletin #6


In this edition of the Accreditation Bulletin, we cover accreditation brag lists, your mandatory privacy training, mobility charts, clinical cleaning schedules, and Give Me Five or Annual Performance discussions.

17 June 2021Accreditation Bulletin #5


In this edition of the Accreditation Bulletin, we cover our rescheduled accreditation dates and key messages such as completing your mandatory and targeted training, booking in a Give Me Five discussion, Family Escalation of Care posters and more.

27 May 2021Accreditation Bulletin #4


In this edition of the Accreditation Bulletin, we cover the new Care Plan view in the EMR, cleaning and decluttering your areas, patient identification, handover at transitions of care, and more.

20 May 2021Accreditation Bulletin #3


In this edition of the Accreditation Bulletin (May 20), you’ll find statistics, guides, calls to action and answers to frequently asked questions around training. Updates include: targeted training BI dashboard guide, deteriorating patient training, medication safety & administration training for Nurses and Midwives, ‘Delirium: Suspect it, Spot it, Stop it’ training, and a mandatory and targeted training FAQ.

13 May 2021Accreditation Bulletin #2


In this edition of the Accreditation Bulletin (May 13), you’ll find updates, resources and guides on safety, compliance and cleaning. Updates include: cleaning your ward devices, hand hygiene, resuscitation trolleys, medication safety, changes to our medication administration procedure, and deteriorating patient training.

7 May 2021Accreditation Bulletin #1


In this edition of the Accreditation Bulletin (May 7), you’ll find updates, resources and guides to help you prepare and plan for accreditation. Updates and resources include: accreditation checklists, speaking with assessors guide and sample questions and answers, ‘EMR, documenting and comprehensive care’ Quick Reference Guides (QRGs), partnering with consumers and patient information resources.

Speaking with assessors

Preparing for accreditation is about ensuring you feel confident and comfortable when you meet with the 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! It’s ok to mention challenges if you think it’s warranted but also discuss the ongoing improvement work to address them.

Below are guides, factsheets and area-specific sample questions for doctors, clinicians, food service employees and environmental services assistants. Download them, print them out, discuss them with your teams and put them on your employee noticeboards.

‘EMR, Documentation 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. It’s critical we communicate and correctly document the care we provide so your team members, and other clinicians associated with your patients’ care get the complete picture.

Accreditation gives us the opportunity to showcase the collaborative clinical work we do in caring for patients. To help you prepare, we’ve created Quick Reference Guides (QRGs) to help you connect and demonstrate how the EMR facilitates comprehensive care.

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

Evidence lists


Audits are an ongoing piece of work and something that we need to continue as part of our everyday practice.

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.

There are two audits your teams should be focusing on:

  1. Point of Care Audit
    • Please ensure this month’s audit has been completed
    • Record actions in your Quality Plan
    • Start closing off actions and document as appropriate
    • Prepare to review at your next audit
  2. Infection Control Risk Assessment actions
    • Review the last assessment undertaken in your unit (must be within the last 12 months)
    • Ensure all results and actions have been closed off

Many areas have their own specialised audits. Please make sure you have actioned and documented the results.

Ensuring this work is up-to-date, accurate and specific to your area means that meaningful and ongoing quality improvement can occur and that we can continue to deliver safe and high-quality care.

Ward boards

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

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 orientate them when they might be feeling nervous or have questions. It’s essential that this information is up-to-date, accurate, and reflects the great work happening in 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.

The procedure for Welcome to Ward and Quality Boards is available on PROMPT.

Accreditation checklists

Checklists have been specifically designed to help you get accreditation ready and are available at the links below.

Remember – many of the actions in the checklists should be undertaken every day. There’s no such thing as ‘set and forget’ in delivering excellent patient care. Embed the ‘small’ things in your everyday work to ensure we continue delivering outstanding health care to our community.

Print them out, discuss with your teams and put them on your noticeboards.

Manager checklist

PDF document

Clinical checklist

PDF document

PICMoRS (Process; Improvement; Consumer participation; Monitoring; Reporting and Systems)

PICMoRS is a quality improvement and assessment preparation pneumonic that was designed to help assessors of the National Safety and Quality Health Service (NSQHS) Standards to undertake assessment for accreditation.

PICMoRS stands for: Process; Improvement; Consumer participation; Monitoring; Reporting and Systems.

During accreditation, assessors may use the PICMoRS method to determine Monash Health’s quality systems and clinical
governance operations in regards to the NSQHS Standards.

PICMoRS Methodology

  • Examination of information and data available on the process
  • Identification of improvement strategy applied
  • Review of consumer participation in the processes
  • Determine what ongoing monitoring is in place
  • Identification of where the information is reported
  • Examine how process is linked to other safety and quality systems

PICMoRS Factsheet

PDF document

PICMoRS example

Microsoft Excel spreadsheet

Targeted and Mandatory Training

It’s now easier than ever to log in, locate and complete your mandatory and targeted training via LATTE.

Now, when you log in to LATTE, the targeted training packages (as well as the mandatory packages) you are required to complete will be automatically assigned to you and be featured under “My Required Learning” on the Latte homepage. 

Mandatory v targeted training – what’s the difference?

All Monash Health employees are required to complete their mandatory training, such as iBelong and fire training, regardless of role.

Targeted training is specific to your role, and you must complete the courses that have been allocated to you.

How do I know which training courses I need to complete?

Completing your training is now easier than ever. All you need to do is log in to Latte, and the targeted and mandatory training courses you are required to complete will be automatically assigned to you and featured under “My Required Learning” on the Latte homepage.

How are training courses allocated?

Every employee is allocated an occupational category, specialty and management level in our Position Management database. We use this information to create audience groups. Targeted training courses are then allocated to the relevant audience group(s).

  • Employees – If you believe you haven’t been assigned the correct training, please speak to your line manager.
  • Managers – if you have any concerns regarding the correct occupational category, specialty or management level details for your teams, please refer to the Position Management intranet page or email positionmanagement@monashhealth.org

What do I need to know about completing my training?

Overall, and for most employees, the training takes less than 90 minutes per year. Many of the course modules are short and can be completed in bursts (you can pause and return to your training if required).

Latte will send you notifications via email as a reminder when there is something new or when you are due to redo a course. If you are completing your training before the due date, remember to click on the ‘Reset Completion’ button on the course page prior to doing your training (so that a new completion date is recorded).

Don’t forget that Latte can be accessed on-site or remotely via your laptop/computer, tablet or mobile device, via learning.monashhealth.org/

Have some of the course names in the BI reports changed?

Some of the names of Latte courses were not consistent with the names used in the Targeted Training reports and dashboards on Power BI.

It’s important to note that the course codes won’t change, but to improve reporting consistency, the BI team have updated the names/descriptions of a handful of courses (outlined below) to align with the course names in Latte.

Course codePrevious course description in BINew course description in BI
IQCP01Consumer ParticipationPartnering with Consumers
NMMP01Preventing Managing PresPrevent & Mng Pressure Injuries
NMTV01WEB-Fam Violence Workplace Response 1hrFamily Violence – Managers
PHMS01Medication SafetyIntro to High Risk Meds

Where can I get more information on Mandatory and Targeted training and LATTE?

The process and requirements for mandatory and targeted training are outlined in the Mandatory and Targeted Training procedure on PROMPT. The procedure includes:

  • details of mandatory training courses applicable to employees
  • details of targeted training courses
  • the criteria for defining which employees are required to complete the courses
  • the approval process for course and audience group changes

If you have any queries about LATTE, please email lmsadmin@monashhealth.org.

Power BI Targeted Training Dashboard QRG

Need some help accessing and using Power BI to find, monitor and report on targeted training? We’ve developed a new and easy to follow ‘Power BI Targeted Training Dashboard’ Quick Reference Guide (QRG).

From how to access Power BI to filtering by course, program, cost centre and/or occupational groups, this QRG will help you and your teams find reports, dashboards and data analysis to monitor performance and compliance.

Accreditation Coaching Tool (for DCOs and Managers)

National Standards training for medical employees

As an employee of Monash Health, you are required to complete mandatory and targeted Quality and Safety training.

National Standards training is available on the Monash Health Learning platform, Latte.

Download the relevant factsheet below to discover which mandatory and targeted training courses you need to complete.

Previous Next
Test Caption
Test Description goes like this