Quality Care June 2019 – Ward Governance Update

Welcome to Quality Care, a monthly update with important information for Ward Governance Committees to implement in their ward and then share with their team by email, huddles, posting on your noticeboard or in your communications book.

We know that most people like to get information face-to-face, but we also know that the nature of shift work means that this isn’t always possible. The important part is to share the information so please, refer to these important items in your Ward Governance meetings, link to the newsletter in your emails and pop a copy on the noticeboard.

And if you have any suggestions for content or how we can help you communicate better, please email our Public Affairs and Communications team, or call or email me.

Carlos Scheinkestel
Executive Director, Quality, Safety and Patient Experience


Serious Clinical Incident Case Study

All Programs work with the Quality Unit to review adverse events. Once a month we will include an anonymised case study to highlight common themes we see in these reviews. Please review these learnings with your team and implement them to improve your clinical practice.

Case of the Month

A 79 year old lady, Mrs B was admitted for elective surgery. She had a past history that included open appendicectomy, hypertension, chronic back pain and ischaemic heart disease.

[The full, detailed Case Study, although anonymised does contains confidential information. A copy is available from your Ward Governance Committee or by contacting the Quality Team.]


What we want you to do and note:

  1. Ensure all craft groups enter adequate notes in the medical record, documenting name and unit, date and time of review, and where required a conclusion and plan
  2. Where unit specific ward round templates exist, that these are completed and the relevant sections are filled in.  Alerts in the EMR and pathways will not work if the triggers for these are not entered.
  3. Ensure all fluid balance charts are completed, that the volumes are entered and the nature of the drain fluid is entered
  4. Severe post-operative pain needs to make you think of an operative complication, particularly if associated with abnormal vital signs
  5. Order blood for the following day the evening prior to ensure bloods are taken first thing in the morning.  Ensure timely review of pathology tests and unusual /abnormal results are followed up promptly
  6. Vital signs may follow a pattern that should raise concern, even before they get into review or MET criteria, for example:
    1.   maintaining an acceptable saturation but requiring progressively increasing doses of oxygen to achieve these
    2. A drop in blood pressure in conjunction with a rise in pulse rate
  7. Remember to look at the patient as a whole not just the part of the body that is of concern to your specialty
  8. Escalate concerns to a more senior nurse, to the nurse manager, DCO, overnight co-ordinator and for doctors to a registrar or fellow and if not directly to the consultant


Revised Point of Care Audit

The Point of Care Audit and Self-Assessment Audit Schedule has been redesigned to make the process easier and more accessible. The MARS audit is being rolled out now. Please ensure 10 patients per month are audited in your area every month. It ensures:

  • A comprehensive audit program is available to inform ward governance teams;
  • A reduction in the duplication across audit tools;
  • Data informs improvement work;
  • Implementation of the revised National Standards (second edition)

The audit will continue to be completed on MARS with monthly reports available for your local areas.

A PROMPT procedure document is available. Please contact Standards Manager, Rachel Vogelsang (Rachel.vogelsang@monashhealth.org or extension 44072) if you have any questions or feedback regarding the implementation of the audit and schedule.


Employee Flu Vaccinations at 78%

Get your flu shot now – don’t wait, the flu this year is severe and starting early. 

Congratulations to the 12,388 Monash Health employees who have taken action against influenza! Thank you for taking this step and protecting yourself, your patients, your colleagues and your family.

This year there have been more than 26,000 influenza cases, which is a significantly higher number than in recent years and we want our organisation to be safe.

We know there are still 3,520 employees that haven’t had their vaccine yet. If this is your team, then they need to get their free vaccination as soon as possible. If they’ve already received the vaccination elsewhere or cannot receive a vaccination, then they must complete this simple online declaration form. Vaccinations are available at Dandenong, Casey, Cranbourne, Kingston, Monash Medical Centre, Moorabbin, Pakenham, and Thomas Street. The schedule is available on the intranet.


EMR Program Update

We have completed the Integration Testing phase of our EMR. This substantial body of work is vital to be able to produce a fit-for-purpose, safe and stable EMR. The work involved in completing this phase is impressive and moves us one step closer to Go-Live.

For all the latest news on EMR visit emrmonashhealth.org and create a shortcut on your smartphone. This website can be accessed from any device.


Mandatory training and performance appraisals

  • Completion of mandatory training (Fire, iBelong, Social Media and OH&S) is below 90%.
  • Completion of performance appraisals is at 48%.

 How is your team performing? All employee must ensure they are up to date with their mandatory training and performance reviews. Accreditation will take place next year- don’t leave it to the last moment.


The Medication Storage and Security Audit

This audit is undertaken every six months and focuses on the legislative requirements related to medication storage and security. This includes medication refrigerators, trolleys, bedside lockers, imprest cupboards and documentation in Schedule 8 and 11 registers. In most cases, a pharmacist completes the audit in conjunction with the nurse/midwife manager (or delegate) in each area to improve awareness and timely actioning of areas for improvement.

Suboptimal results were noted in the following areas:

  • Only 64% of medication trolleys not in use were locked — a 25% decrease on the last audit.
  • In 33% of areas the medication trolley key was NOT held by a nurse/midwife or in a key safe — a 29% decrease on the last audit.
  • Only 59% of areas had daily documentation (for the past 7 days) of the medication fridge temperature — a 5% decrease on the last audit.

Individual area results have been sent to Managers and Directors of Clinical Operations. Ensure actions to close all areas of non-compliance are documented on your Quality Improvement Plan. Note any deficiencies and ensure that these are corrected and if not escalated so that they can be resolved.


No eReferral means no specialist consulting appointment!

Doctors – once eReferral has been implemented in your unit an internal referral using eReferral in SMR is REQUIRED for a patient to receive a post discharge Specialist Consulting appointment. A discharge summary will no longer be accepted as a referral source.

An internal referral is quick and easy – complete the electronic referral via SMR! Click here for more information. Quick reference guides are available on Latte, the Monash Health Learning system. Search eReferral.

Remember, no e-referral, no appointment. If a patient needs review in outpatients following discharge, there must be an e-referral.


Policy, Procedure and Guideline update May 2019

Every month we release policy, procedure and guideline updates on Prompt. Review these updates and implement the changes to improve your clinical practice. Every month we will highlight key changes or new documents to prioritise across Monash Health:


Clinical Guideline: Pressure Injury: Prevention and Management

This document aims to standardise pressure injury prevention and management at Monash Health by amalgamating the existing pressure injury documents for various clinical settings into a clinical guideline. Pressure injuries are a frequently occurring, but largely preventable, health issue that cause significant physical, psychosocial and financial burden to individuals, families and healthcare organisations. A pressure injury can develop in as little as thirty minutes in an at-risk person. Early identification of an individual’s risk for pressure injury development is vital to determine care priorities and to ensure that pressure relieving strategies are implemented in a timely manner.

Procedure: Standard and Transmission Based Precautions are changing

Monash Health has new standard precautions from 1 July 2019 and they must be practiced at all times. Check the new procedures on Prompt and make sure you know what this means for your clinical practice: Transmission Based Precautions and Standard Precautions.

RED precautions will no longer be used:

        • Well patients, with VRE or MRSA, will not require isolation

YELLOW precautions will be used for all patients with:

        • Diarrhoea or uncontained stoma/faecal incontinence
        • Gastroenteritis
        • difficile, CRE  and other multidrug resistant organisms
        • Increased risk of infection transmission including scabies and extensive skin disease


Policy procedure and guideline update May 2019

Organisation-Wide Procedures

Pressure Injury: Prevention and ManagementStandardises pressure injury prevention and management by amalgamating documents for various clinical settings into one clinical guideline.


Daily Operating RhythmReflects the new flow of meetings to ensure patient access, timely decision making and escalation.


Ultrasound Transducers DisinfectionDescribes the high level disinfection required for all ultrasound transducers.


Management of Risk – Guidance for Risk and Action OwnersDescribes the steps to follow once a risk has been identified.


Template Checklist for Policy or Non-Clinical procedureNew checklist for non-clinical PROMPT documents.

Surgical and Interventional Services

Surgery for a Child or Baby with a Life-limiting ConditionDescribes the process for documenting procedurally – relevant goals of care when children with life-limiting conditions undergo surgical or procedural intervention.


Insulin Dose Adjustment (Paediatric)A framework for Diabetes Nurse Educators to provide advice to families of Monash Children’s outpatients requiring insulin dose adjustment.
Low Risk Febrile NeutropeniaNew model of care for Monash Health (already in place at Royal Children’s) linked to state-wide guideline.

Women’s and Newborn

Bougie use for intubation (Neonatal)Bougie use is increasing within Monash Newborn, and often forms part of an anaesthetic response in the setting of a difficult intubation. This procedure is intended to provide guidance on how to safely use (and/or assist others using) a bougie.
Inhaled nitric oxide use in pulmonary hypertension (Neonates)Inhaled nitric oxide (iNO) is proven therapy for pulmonary hypertension in late preterm and term infants. This provides guidance on the use of iNO in newborn infants with pulmonary hypertension.
Transition to Home (Parent/ Carer accommodation rooms) Monash NewbornProvides guidance for staff managing parent accommodation rooms.


Transition to Home Checklist – Monash Newborn
Glidescope use for intubation (Neonatal)Provides guidance on the use of video laryngoscopy (and specifically the Glidescope) in Monash Newborn.

Mental Health

Pathway for Mental Health Care for Refugees and Asylum SeekersTo guide staff to the correct referral pathway for refugees and asylum seekers for access to Mental Health Services.


Compounding Services – Aseptic and Cytotoxic Suite CleaningInternal pharmacy documents moved to PROMPT.
Compounding Services – General Principles of CleaningInternal pharmacy documents moved to PROMPT.
Compounding Services – Gowning and DegowningInternal pharmacy documents moved to PROMPT.

Medication profiles

Lisinopril (Oral) Monash Newborn Medication Profile
Vecuronium Monash Newborn/NeoMed Medication Profile

Medical Services

Junior Medical Staff (JMS) On-Call & Fatigue ManagementProvides guidance managing the rostering of junior medical staff when there is concern regarding fatigue.

Patient Information

Ward 44 Discharge information for Patients, Families and Carers
Cardiac Care Unit Important Discharge Information
Calcium intake in pregnancy
Pelvic Organ Prolapse
Patient Information Approval Checklist
My Passport Coronary Care Unit (CCU) (patient information)
My Passport Monash Newborn (SCN) (patient information)
My Passport Moorabbin
My Passport Refugee Clinic (patient information)
Charter of Aged Care Rights (external)

Specialist Consulting

Specialist Consulting Referrals

Health Information Services

iPM Discharge Date/ TimeCovers EMR implementation.
iPM Ward TransfersCovers EMR implementation.

People and Culture

Employee PrivacyDescribes the management of employee information, including the collection, use, disclosure and access.


Security Framework


 Revised Procedures and Guidelines

Clinical audit

Point of Care AuditRevised to reflect the 2nd edition of the National Standards and to reduce duplication.
Point of Care Audit and Self-Assessment Audit ScheduleRevised to reflect the 2nd edition of the National Standards and to reduce duplication.

Infection Prevention

Head LiceUseful resources section added to include link to consumer information.
Healthcare Workers with Infectious DiseasesUpdated to reflect new national guidelines for the management of healthcare workers living with blood borne viruses.
Staff ImmunisationRevised with minor changes. The staff immunisation implementation tool has been incorporated as Appendix 1 and 2.
Opportunistic patient influenza vaccinationRemoved statement regarding anaphylaxis to latex as all influenza vaccines on the National Immunisation Program are latex free. Removed brands of vaccines not in use in 2019.


Diabetes screening algorithm Inpatient and Pre-admission

Acute Medicine, Subacute & Community

Continuous Cardiac Monitoring on General Medicine WardsRevised to include Dandenong and Casey.


Asplenic/ Hyposplenic (Paediatric)Revised updates.
Clinical Observations (Paediatric)Updated to align with EMR and Paediatric Code/Met Procedure.  updated level of sedation and intravenous opioid infusion observations including Bromage score and epidural infusions.
Discharge Process for Infants with Chronic Neonatal Lung Disease on Home Oxygen TherapyRevised with minor updates.
Identification of Pleural Effusions (Paediatric)Title changed from ‘Pleural effusions paediatric management and document’ and changed from a procedure to a Clinical Guideline.


Monash Health Policy, Procedure and Guideline FrameworkUpdated to remove background documents implement a checklist for non-clinical procedures.
Template Checklist for Clinical Procedure or GuidelineNew format – easier to use and read
Template Clinical GuidelineNew format – easier to use and read
Template Implementation Tool (Landscape)New format – easier to use and read
Template Implementation Tool (Portrait)New format – easier to use and read
Template Policy (Operational or Strategic)New format – easier to use and read
Template ProcedureNew format – easier to use and read

Women’s and Newborn:

Admission to Monash Newborn Revised to include a flowchart for escalation when no capacity to accept PIPER referral.
Artificial rupture of amniotic membranes (ARM)Revised to align with EMR.
Assessment of the progress of labour – first and second stagesRevised to align with EMR and the maternity interim solution. Replaced pregnancy telephone triage with recording on the BOS.
Caesarean section (postnatal) assessment and careRevised to align with EMR.
Credentialing skills in resuscitation of the newly born (Paediatric/Neonatal medical staff)
Decreased fetal movementRevised to align with EMR.
Exchange Transfusion (Neonatal)
Female Genital Mutilation (FGM) counselling in pregnancyRevised to align with EMR.
Fetal (scalp) blood sampling (FBS)Revised to align with EMR.
Initial assessment and post birth examination of the newbornRevised to align with EMR.
Jaundice in healthy term and near term Infants (Neonatal)Revised to incorporate the introduction of transcutaneous bilirubin monitoring for infants who are >35 weeks in Monash Newborn neonatal units.
Maternal postnatal head to toe assessmentRevised to align with EMR.
Maternal vaginal birth (postnatal) assessment and careRevised to align with EMR.
Maternity – Infant safe sleepingRevised to align with EMR.
Naso/ oro gastric tubes (Neonatal)Revised to align with EMR.
Neonatal and Paediatric Medical Staff attendance at births (Resuscitation skill levels)The terminology updated to align with current neonatal resuscitation program as well as the retrieval service name change.
Neonatal Assessment and examinationRevised to align with EMR. Newborn observations are now documented on the Victorian Children’s Tool for Observation and Response (Birth suite/PN) and not the Neonatal Observation Chart (MRK01).
Ovarian Hyper stimulation Syndrome (Gynaecology) management
Planning for birth and parenting with women during pregnancyRevised to align with EMR.
Postnatal care in the first weekRevised to align with EMR.
Postpartum haemorrhage (PPH)Revised to align with EMR.
Private cord blood bankingRevised to align with EMR.
Third stage of labourRevised to align with EMR.
Transcutaneous jaundice meterRevised to incorporate the introduction of transcutaneous bilirubin monitoring for infants who are >35 weeks in Monash Newborn neonatal units.
Treatment threshold graphs for neonatal jaundice in babies ≥ 35 weeks gestationRevised to incorporate the introduction of transcutaneous bilirubin monitoring for infants who are >35 weeks in Monash Newborn neonatal units.
Vitamin D in pregnancy and the newbornRevised to align with EMR.

Mental Health

Accommodation for Patients Discharged from Youth and Adult Acute Psychiatric Units
Development of a Comprehensive Service Plan
Mental Health Advance StatementsClarifies roles in the development of an Advance Statements.
Mental Health Electroconvulsive Therapy Referral from Private Psychiatrist
Transport of a Mental Health Consumer/ Patient


Viral Haemorrhagic Fevers (VHF) packaging and Transporting Samples Emergency DepartmentRevised updated concentration of cleaning solution and requirement to pre-label all containers prior to contact with patient or specimen.


Adrenaline (epinephrine) (infusion) Monash Newborn/NeoMed Medication Profile
Adrenaline (epinephrine) (IV blous) Monash Newborn/NeoMed Medication Profile
Adrenaline (epinephrine) (nebulised) Monash Newborn/ NeoMed Medication Profile
Ceftriaxone (IM) Monash Newborn Medication Profile
Dobutamine Monash Newborn/ NeoMed Medication Profile
Dopamine Monash Newborn/ NeoMed Medication Profile
Flucloxacillin Monash Newborn / NeoMed Medication Profile
Insulin Subcutaneous administrationRevised to align with EMR.
Medical administrationRevised to align with EMR.
Medication initiation by Registered Nurses, Midwives and PharmacistsRevised update to align with EMR.
Medication prescribing telephone ordersRevised update to align with EMR.
Nystatin (cream) Monash Newborn Medication ProfileRevised update to align with EMR.
Template Medication ProfileNew layout.

Patient Information

Advocacy Poster – Mental Health
My Passport Casey (patient information)
My Passport Dandenong (patient information)
My Passport Monash Children’s (Patient information)
My Passport Monash Medical Centre (patient information)
My Passport Sub-Acute (patient information)

People and Culture

People and Culture Transition to retirement application form
People and Culture Transition to Retirement Arrangements
People and Culture – Long Term ill or Injured
People and Culture Secondment

Support Services

Ward food, fridge and freezer temperature monitoringRevised to include MCH fridges and freezers which are electronically monitored.


Security (Operational)


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