Accreditation Bulletin – 21 July 2022

Thursday 21 July 2022

Communication is key

With our Accreditation assessment 25 days away, it’s important you feel confident and comfortable when you meet with the assessors in August.

As we detailed in last week’s Accreditation Bulletin, comprehensive care involves teams of health care professionals working together with patients to effectively plan, manage, and coordinate care from admission to discharge.

Communicating openly, effectively, and consistently with our patients, carers, families, and each other is key. In this edition of the Accreditation Bulletin, we take a closer look at the systems and processes we have in place to support effective communication and how best to describe and demonstrate them to assessors.

Focus points

• Understand how comprehensive care and clinical handover work together to tell the patient’s story.
• Know how to show assessors the ISBAR tab and Inpatient workflow pages in the EMR and how they support comprehensive care and handover, including:
  • Nurses/Allied Health/Ward Clerks – ISBAR handover tab
  • Doctors – Inpatient workflow
  • Pharmacist – Pharmacist workflow
• Familiarise yourself with how we partner with our consumers, where to find patient information, and how you would access an interpreter when required.

Key messages

Patient identification

Checking patient identification is crucial to ensuring the correct patient receives the correct treatment. Assessors will be observing our processes around patient identification, so make sure you follow the following steps:

• The ‘ask and look’ method is used to confirm three approved identifiers (full name, date of birth, UR Number, or the patient’s address).
• Identifiers are to be verbally stated by the patient, not read aloud by team members for confirmation by the patient.
• Only white or red identification bands are to be utilised.
• A red identification band is applied to communicate a patient having a known allergy or Adverse Drug Reaction (ADR).

For more information, refer to the Patient Identification procedure on PROMPT.

The EMR

The EMR is the tool we use for communicating and documenting the care we provide to our patients. It gives team members and other clinicians associated with your patients’ care the complete picture across the patients’ journey.

If the assessors ask or show interest, run them through the EMR workflows you’re using to communicate with your colleagues and deliver comprehensive care for your patients.

You can read more about how we use the EMR to communicate and document the care we provide, here. We’ve also developed one-page, area/speciality-specific Quick Reference Guides (QRGs) to help you connect and demonstrate how the EMR facilitates comprehensive care.

Assessors will ask how you communicate with your colleagues and patients, particularly the critical processes of handover, referral, and discharge.

Handovers at transitions of care 

Handovers are critical for continuity of care and patient safety and are essential to the daily work of our patient-facing teams.

The framework we use to structure and support clinical handovers is ISBAR:

• Identify
• Situation
• Background
• Assessment (and action)
• Response, rationale, and recommendation

During handovers, ensure you:

• Have access to patient records (electronically via the EMR or paper-based).
• Follow the ISBAR framework to communicate your patient’s critical information.
• Utilise electronic tools (at EMR sites) e.g., ISBAR handover tab, iPASS handover tool, Clinical Leader Organiser (CLO).
• If appropriate, involve the patient/family/carer in handover and offer them the opportunity to be involved in shared decision-making about their care.

Assessors will watch and listen in on clinical handovers as part of our assessment. You don’t need to do anything differently. In fact, you should invite them in and involve them. Show the assessors how you effectively communicate and structure your handovers.

For more information, enter ‘handover’ into the PROMPT search and download your specialty-specific document from the handover policy/procedure suite.

Referral management 

Referral management ensures ongoing assessment and care of a patient’s illness or condition, enabling continuity of care through access to speciality or community-based services.

Timely and accurate referrals ensure a positive patient experience, allowing our patients to access the right services at the right time for the management and recovery from their illness or condition.

A suite of documents relating to referrals can be found by searching ‘referrals’ on PROMPT.

Discharge planning  

Start planning your patient’s discharge from the day of their admission. It will establish open and effective lines of communication, goals of care, address any barriers and ensure a clear plan for the patient, their family and carers, and your colleagues.

You can read more about our multidisciplinary team approach to discharge planning via our Discharge Planning procedure on PROMPT.

Communicating with patients, carers, and families 

Partnering with consumers 

We are committed to involving our consumers, carers, and community members at all levels of our organisation.

We understand that the delivery of effective, timely and quality healthcare is only possible by working together with patients and their families.

At an individual level, that means listening to patients and families when we are caring for them. At the organisational level, it means involving consumers in our hospitals and community health centres and providing opportunities for them to give advice and feedback on how we do things. In this way, consumer participation at Monash Health is embedded at all levels of the organisation.

The partnering with consumers page on our Monash Health website is a fantastic resource for those wanting more information on how we partner with consumers, carers and community members at all levels of our organisation.

Welcome to ward and bedside communication boards 

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 orient them when they feel nervous or have questions.

Make sure the information on your Welcome to Ward board is up-to-date, accurate, and reflects the great work happening on your ward. You can find more information via PROMPT: Welcome to Ward and Quality Boards.

Patient’s communication boards are there to complement verbal communication. They are not for clinical information and should be used to facilitate information sharing between clinicians, patients, and their families.

Interpreters and language services 

Monash Health Language Services (MHLS) facilitates communication between employees and patients whose preferred language is not English or whose primary mode of communication is Auslan/Australian Sign Language.

Use the following resources to help you access and book interpreters and language services:

• Access interpreter services (PROMPT document)
• Access translations services (PROMPT document)
• On-site interpreter booking form

For more information about our interpreter services, patients can access the Interpreter services page on the Monash Health website.

Patient information  

You can find information, flyers and posters for our patients on PROMPT, and via the patient information page of the Monash Health intranet. If you have any questions about patient information resources, you can reach out to patientinfo@monashhealth.org.

Below are some of the key patient resources you need to know about, have access to and be able to provide your patients.

Rights and Responsibilities brochures and translations 

Our ‘Rights and Responsibilities’ brochure outlines what patients can expect from us and what we expect from them when they use our services. Find the brochure, as well as translations into 14 languages, on the rights and responsibilities page of the Monash Health website.

Family escalation of care posters and translations 

In some episodes of care, a family member or carer may notice signs that the patient is getting worse before we do.

If a patient is feeling worse, a family member or carer notices a change or there are any concerns, we encourage our patients and their loved ones to tell their treating nurse or doctor immediately. If they are still concerned, family members or carers can speak to the nurse in charge at the desk.

If family members or carers are still worried, there is a process they can follow to further raise their concerns. There are site-specific posters and translations available on the Family Escalation of Care Translations page on the Monash Health website that outlines the process.

Staying safe to prevent falls and pressure injuries  

Flyers are available for patients, families and carers about preventing falls and pressure injuries on the employee resources page of the Accreditation website.

Patient feedback forms

Our patients’ feedback matters and is important to us. We welcome all feedback about the services we provide and the way they are delivered. Patients’ feedback allows us to improve the quality and consistency of our care and services.

Patients can access the compliments, complaints and comments page on the Monash Health website, which outlines the different ways to provide feedback to us, including translated feedback forms.