Accreditation Planning

Manager Briefing | Wed, 24 March

Evidence Lists

National Safety and Quality Health Service (NSQHS) Standards

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Comprehensive Care

Communicating for Safety

Preventing and Controlling Healthcare-Associated Infection

Medication Safety

Recognising and Responding to Acute Deterioration

Partnering with Consumers

Clinical Governance

Blood Management

Clinical Governance Standard

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Intent• This standard aims to ensure that there are

systems in place within health service organisations to maintain and improve the reliability, safety and quality of health care.

• The Clinical Governance Standard recognises the importance of governance, leadership, culture, patient safety systems, clinical performance and the patient care environment in delivering high quality care.

• This standard, together with the Partnering with Consumers Standard, set the overarching requirements for the effective implementation of all other standards.

Clinical Governance Standard

Evidence (1/2)• Communication distributed to the workforce – how is this performed• Training - mandatory and targeted training • Education and training across the workforce – credentialing and scope of practice• People and Culture – all HR, On-board process, performance appraisals, contracts, PD’s,

orientation manuals etc. • Quality Boards, Welcome boards, OHS boards current and present data• QIP (actions for audit outliers, improvement activities)• Ward/unit meeting minutes and Terms of Reference where

quality/risk/audit/feedback/complaints is discussed• Risk – incident reporting, example of recent investigation and actions/outcomes, e.g. SKIRT• Consent process• Awareness of Clinical Governance framework

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Clinical Governance Standard

Evidence (2/2)• Workplace inspections OHS, safe environment, OVA strategy• Patients health record – correct documentation, privacy, record available at point of

care• How to report broken equipment or hazard• What to do in EMR downtime• Orientation manual process• Equipment maintenance schedule• Daily checks in EMR documented (o2/suction)• Evacuation plans/maps/posters current• OHS workplace inspections• Declutter – old folders, hazards, corridoors, equipment

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Partnering with Consumers Standard

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Intent• The Partnering with Consumers Standard

aims to create health service organisations in which there are mutually beneficial outcomes by having:

• Consumers as partners in planning, design, delivery, measurement and evaluation of systems and services

• Patients as partners in their own care, to the extent that they choose.

Partnering with Consumer Standard

Evidence (1/2)• Patient Information

• How to access, what's available, ensuring patients/carers receive• Developing and reviewing, consumer review

• Rights and Responsibilities – available in different languages, visible and accessible in all areas

• Welcome packs – current and relevant• Welcome to Ward boards – “You said, We did”• Ensure patients have consented and are involved in decisions about their care

(Shared Decision Making)• Awareness of Health Literacy framework

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Partnering with Consumer Standard

Evidence (2/2)• Consumer engagement framework and consumer participation procedure• Consumer representatives on all standards committees and subcommittees• Engagement of patient in EMR, being involved in care e.g.- goals documented, care

plans in place• Complaints and compliments – responding, service recovery, data• Example of improvement activity with consumer involvement• Teach back method – staff to use and demonstrate, this confirms consumers

understanding information• Patient experience data e.g. VHES survey, MHES (BI portal), patient questions in point

of care audits• Interpreter services how to access• Understand cultural considerations/how to access aboriginal liaison officer

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Preventing and Controlling Healthcare Associated Infections Standard

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Intent• The Preventing and Controlling

Healthcare-Associated Infection Standard aims to improve infection prevention and control measures to help prevent infections, and the spread of antimicrobial resistance through the appropriate prescribing and use of antimicrobials.

Preventing and Controlling Healthcare Associated Infections Standard Evidence

• Latest hand hygiene audit results• Cleaning schedules (including ice machine)• Clean equipment schedule, e.g. clinical, EMR device• Infection Control risk assessments (check dates and actions)• Staff health – flu vax rate and immunisation process• Infection data reports (if relevant)• Isolation protocols and signage• Clinical waste correct management• Aseptic technique training statistics• Aseptic technique and transmission based audit results• Invasive device documentation including labelling lines, dates, changing PIVC every 72hrs• PPE – COVID-19 intranet site• Spillkits – accessibility and know how and when to use• 5 moments - discuss with staff, as assessors will be watching• Cleaning equipment between Patients – WOWS’s

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Medication Safety Standard

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Intent• The Medication Safety Standard aims to

ensure that clinicians safely prescribe, dispense and administer appropriate medicines, and monitor medicine use. It also aims to ensure that consumers are informed about medicines, and understand their own medicine needs and risks.

Medication Safety Standard

Evidence• Be familiar with some of the Medication Safety initiatives and processes implemented across

Monash Health:• Smart pumps with error reduction software to improve patient safety (for which data libraries are updated

regularly)• Medication related Procedures, Clinical Guidelines and Medication Profiles available via PROMPT• Where to find medicines information (Pharmacist, Medicines information Service, online resources –

AMH, MIMs online, Australian Injectable Drugs Handbook etc)• Medication Safety training package via LATTE• Medication Safety initiatives implemented for management of high risk medicines (PINCH)

• Safe storage of medicines in clinical areas (locked medication storage facilities, sealed bags for storage of patients own Schedule 8 and 4D medicines)

• Provision of a discharge summary and discharge medication list to patients (also communicated to the GP)

• Labelling of injectable medicines, fluids and lines in accordance with the National Standard • Clinical staff obtaining a best possible medication history• Clinical staff completing a Medication Management Plan

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Medication Safety Standard

Ensure• Medication related in-services provided• Management of look-alike sound-alike medicines (labelling of hydromorphone oral

liquid)• Medicine related incident reports are available and regularly discussed with clinical

staff• Temperature monitoring of medication and vaccine refrigerators is up to date and

documented on the correct monitoring form• Lock codes for medication storage facilities are changed annually (at a minimum) • Staff are aware of how to report and document an adverse drug reaction• Staff are aware of medicines related quality improvement projects applicable to your

area

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Comprehensive Care Standard

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Intent• The Comprehensive Care Standard aims

to ensure that patients receive comprehensive health care that meets their individual needs, and considers the impact of their health issues on their life and wellbeing.

• The Comprehensive Care Standard integrates patient care processes to identify patient needs and prevent harm. It includes actions related to falls, pressure injuries, nutrition, mental health, cognitive impairment and end-of-life care.

Comprehensive Care Standard

Evidence (1/2)• Demonstrate the flow of care in EMR from admission to discharge inclusive of

referrals, all disciplines notes (assessors may pick a patient)• Targeted training LMS packages, e.g. falls, delirium, nutrition, pressure injury• Demonstrate completing care plans in EMR • Complete risk assessments – not just on admission (PI, falls, MUST, 4AT, skin

assessments)• Show strategies in place appropriate to risk assessment rating• Mental state of patient in acute setting –referral process• Point of care audit results, ward scorecards what have you done with the results• EMR reports/dashboards care plan usage and risk assessment completion show

assessors

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Comprehensive Care Standard

Evidence (2/2)• MDT meetings define patient goals• End of life care/Advance care planning referral process• Equipment registry, e.g. falls, pressure injury prevention stock, ordering,

maintenance process• Pressure injury (hospital acquired) incident report data • Falls incident report data• Post falls management and expert wound management• Nutrition Meal supervision, dietary requirements including cultural, how to access

food afterhours• FBC documentation in EMR• Rounding checks• Restraint and seclusion – how is this managed, escalated and documented

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Communicating for Safety Standard

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Intent• The Communicating for Safety Standard

aims to ensure timely, purpose-driven and effective communication and documentation that support continuous, coordinated and safe care for patients.

• This standard recognises that effective communication is needed throughout patients’ care and identifies high-risk times when effective communication is critical.

Communicating for Safety Standard

Evidence • All patients wearing identification band• Staff checking 3 identifiers when required– Assessors will observe • Communication Board – correct template, up to date, involve patient/carer• Clinical alerts – how identified, what are they (PROMPT Document)• Patient discharge information – Teachback method used with patients• Point of care audit results - identification and handover

Observational• Handover with EMR – assessors will watch, involve patient• Clinical Alerts in EMR ensure handed over as critical information• ISBAR framework used when handing over care• Transporting of patients, e.g. to x-ray, ensure checks occur• Theatre Timeout process and audits – Assessors will observe a timeout in progress • Demonstrate multidisciplinary team meetings and huddles– invite assessor to meeting

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Blood Management Standard

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Intent• The Blood Management Standard aims

to improve outcomes for patients by identifying risks and using strategies that optimise and conserve a patient's own blood, as well as ensuring that any blood and blood products that patients receive are safe and appropriate.

Blood Management Standard

Evidence• Administration checklist completion in EMR• All patients receive information on blood products before transfusion –know how to access• Blood and blood products training (BloodSafe) completion• Transporting of blood PSA’s training statistics• Blood administration protocols, observations documented and completed• Completed consent forms at point of care – check SMR for any annual consents• Smart pump – show assessors blood protocol built into pump for administration, great

safety initiative• Blood audit results• Riskman transfusion incidents examples if relevant• Understanding and awareness of the massive transfusion protocol• Transfusion Reactions – how to manage, escalate, report/document• Transfusion Services Intranet page – resources for blood management

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Recognising and Responding to Clinical Deterioration Standard

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Intent• The Recognising and Responding to

Acute Deterioration Standard aims to ensure that a person's acute deterioration is recognised promptly and appropriate action is taken. Acute deterioration includes physiological changes, as well as acute changes in cognition and mental state.

Recognising and Responding to Clinical Deterioration StandardEvidence

• Vitals completed as per individualised monitoring plan• Adult - Adult Clinical Observation and response procedure• Paediatric and Neonates – Clinical Observations – Paediatrics procedure• Altered

• Monitoring of mental state in EMR• Conscious state• 4AT / CAM-ICU

• Safety checks completed and documented every shift in EMR• Escalation of care process for physiological deterioration• Resuscitation trolley checks up to date• BLS and ALS training up to date • Evidence of workforce attendance at any acute deterioration management workshops / in-services e.g. S.O.U.P• MET call/Code Blue data and clinical incident investigations (delayed METs, equipment issues, communication

failures)• Goals of care completion in EMR all patients• Family escalation of care posters visible (new template)• EMR alerts – observation charts, clinician review and MET call criteria• Point of care results deteriorating patient questions• SCIRT – serious event example, learnings in place

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If there are any issues during survey week…

Contact Quality for assistance

Stay calm and say very little until you understand exactly what is being saidConfirm with the lead assessor if they think there is an issueResearch the standard action that they are referring toEngage with the Commission if neededAct on the issue and come up with a plan to eliminate it during the assessment develop a planManage key stakeholders and manage expectation if it is a serious issue

To ensure there are no misunderstandings, all communication will be with the lead assessor.

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Resources

• Accreditation website (accreditation.monashhealth.org) • Accreditation forums and webinars • Prompt – how to access, search function• Monash Health Frameworks – strategic, quality, procedures, clinical governance, RAP,

health literacy, consumer engagement• National Standards committees and sub committees• Accreditation Checklists • Quality Boards, Welcome Boards, New Ideas Boards• Quality and Risk Unit, Quality Partners and Managers• Power BI, EMR dashboards• www.safetyandquality.gov.au – factsheets, workbooks• www.achs.org.au (The Australian Council on Healthcare standards)

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Employee accreditation website

• Our new accreditation website has:• The latest accreditation news• Upcoming and past forums/webinars• Planning and preparation resources• National Standards information

• Easily accessible via the intranet homepage

• The site can be accessed at home, work, or on your device

• The site will be updated regularly with news, events and resources

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Visit: accreditation.monashhealth.org/