Thursday 28 July 2022
Accreditation – now only 18 days away!
In this week’s Accreditation Bulletin, we look at potential areas of interest for assessors, including how we address challenges and areas of improvement, how the EMR supports comprehensive care and clinical handovers, our family escalation of care process, and the important role our consumer advisors have at Monash Health.
In these last couple of weeks before Accreditation, we are making a final push to ensure we have completed all mandatory and targeted training, and completed, or scheduled a time for a Give Me Five or Annual Performance conversation.
Remember, preparing for Accreditation is about ensuring you feel confident and comfortable when you meet with the assessors and sharing the great work you do each and every day. There are lots of resources to help you which are easily available on the employee Accreditation website.
Focus points
Here are the things you can do this week to ensure we remain on track for Accreditation:
- Review our speaking with assessors guides and understand how to address challenges and areas of improvement if asked by an assessor.
- Practice discussing and demonstrating how the EMR, and paper-based workflows facilitate comprehensive care.
- Ensure the Family Escalation of Care posters in your clinical areas are up to date, and you are familiar with the escalation process.
- Understand the roles and responsibilities of our consumer advisors in the delivery of safe patient care.
- Make sure you have had and recorded (or booked) a Give Me Five or Annual Performance conversation in the last 12 months.
Key messages
Speaking with assessors
Assessors aren’t there to test or trick you. What they want to know and see is how you provide your patients with safe, appropriate, timely and effective care.
If the assessors approach you, be calm and confident. Talk about the great work you do. While the work you do may feel like second nature, when discussing or demonstrating your work to the assessors, think about three key elements:
- Structure – talk about the structures and systems you have in place and the skills and knowledge you have that help you provide safe and appropriate care.
- Process – discuss the techniques and practices, and how you use them.
- Outcomes – demonstrate your achievements and how you know that you’re delivering safe, appropriate, and effective care to your patients.
If you haven’t already, check out our ‘Speaking with Assessors’ guide, as well as our sample question and answer factsheets for doctors, clinicians, food service employees and environmental services assistants.
Discussing challenges and areas of improvement
During Accreditation week, the assessors may also ask about some of the challenges you face in your area. When talking about challenges, it is important to remember to discuss the ongoing improvement work and actions to address them.
There are many examples you can use to discuss with assessors how we address challenges. For example:
- Implementing targeted education sessions and data monitoring to address medication errors in your area.
- Ensuring patients’ food allergies are considered prior to providing them with any meal, snack or drink through the introduction and integration of Delegate within the EMR.
The EMR, comprehensive care and handover workflows
The comprehensive care and handover workflows in the EMR link together and help tell the patient’s care story and describe their journey, which assessors will be interested in and may ask you to demonstrate.
At this week’s Employee Forum, Associate Professor Michael Franco gave a fantastic presentation on how the EMR assists in providing coordinated and comprehensive patient care.
The interactive views and workflows in the EMR allow us to view and share the same patient information, across disciplines, in real-time.
To ensure you feel confident discussing and demonstrating how the EMR facilitates comprehensive care and clinical handover, download our one-page Quick Reference Guides (QRGs) for your area/speciality.
If you missed Michael’s presentation earlier this week, you can watch the recording and/or view the slide deck here.
Assessors may also want to watch and listen in on clinical handovers. You don’t need to do anything differently. In fact, feel free to invite them in and involve them, after first asking your patient if they can join.
Show the assessors how you use the EMR to communicate and structure your handovers effectively.
Delivery of comprehensive care outside the EMR
Some of our teams, including oncology, anaesthesia, maternity, and mental health use a hybrid model including the EMR, paper-based workflows and other systems.
If your team uses a hybrid model, demonstrate this to the assessors, and talk about the systems you use, the processes you have in place and how they work together to deliver patient-centred care and facilitate safe and informed decision-making.
Where the EMR is not available, be confident to demonstrate to assessors the paper-based practices or processes you use to deliver comprehensive care.
To ensure you feel confident and comfortable conveying your great work, review the hybrid model resources available on the Accreditation website.
Focusing on our consumers
Family Escalation of Care
Sometimes a family member or carer may be the first to notice signs that a patient is getting worse.
Carers and families are valuable members of the care team, and it is important that,
- we make it easy for them to raise concerns,
- we listen, and
- we address those concerns.
Assessors may ask about family-initiated escalation of care, so it is important you are familiar with our process and have the latest hospital/site-specific posters displayed in your area.
You can learn more about how family escalation of care is initiated and find the posters and translations (in over 10 languages) via the Family Escalation of Care Translations page on the Monash Health website or PROMPT (type in ‘Family Escalation of Care’).
Our consumer advisors
Assessors may ask about our consumer advisors and how they help us improve our care and service delivery. Our consumer advisors have experience with our services and provide us with advice through their involvement on committees, working groups and project teams.
If you were asked, could you describe some of the projects our consumer advisors are engaged in? Some examples include:
- Consumers advisors were engaged in,
- the design of the new Monash Medical Centre Emergency Department.
- the design of information provided to patients when they are discharged.
- reviewing the discharge process to ensure it is efficient and patient centred.
- the implementation of ward communication boards.
- Consumer advisors provide feedback on every patient information brochure on PROMPT.
- Consumer advisors are members of committees across the organisation.
Our consumer advisors are integral to helping us improve our patient care and experience. Learn more about the responsibilities of our consumer advisors and how they are engaged in work that directly impacts our care and service delivery.
Brag lists
A great way to ensure you feel confident and comfortable when discussing challenges and improvement activities with assessors is to create a brag list.
This list should be specific to your team and can include your team’s involvement with projects that Monash Health has rolled out. Here are just some examples:
- EMR Monash Health Experience surveys
- Consumer participation competition
- Smart pumps
- Resuscitation trolley standardisation
- ED emotional experience workshop
- Patient Experience Week
- Pressure injury projects in community and ICU
- Falls champion program
- Patient Clinical Alerts improvements
- Bedside communication boards
- Children’s activity book
- Paediatric weekend allied health service
- Telehealth
- Health and wellbeing programs, resources, and support
Now is the time for a Give me Five
If you haven’t had a Give Me Five or performance appraisal in the last 12 months, book one in with your manager now. Currently our performance appraisals compliance is at 69% and is steadily increasing. Managers, prioritise these conversations with your team members over the next few weeks.
If you’ve recently had a performance appraisal, ensure you have recorded it on HR 21/Employee Self Service. > 1. My Details > ‘Performance Enhancement [APR]’.
Here’s what you can do
- Visit the Give Me Five webpage for useful resources and guides for these conversations.
- Once completed, record your completed Give Me Five/Performance appraisal conversation directly on HR 21/Employee Self Service. > 1. My Details > ‘Performance Enhancement [APR]’.
Employees can check when they last had this conversation by logging into the HR 21/Employee Self Service > 1. My Details > ‘Performance Enhancement [APR]’.
Managers can find helpful resources for completing these conversations on the Give Me Five page of the COVID-19 employee website and check their team’s status via the ‘Mandatory training’ or ‘Performance Appraisal’ tab in the BI Portal.
Accreditation resources
Don’t forget to visit the employee Accreditation website for the latest Accreditation news, updates, preparation resources, and National Standards information.
Download them, print them out, discuss them with your teams and put them on your employee noticeboards. Directly access some of our resources below.
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.