Accreditation Bulletin – 4 August 2022

Thursday 4 August 2022

Accreditation – now only 11 days away!

As our Quality Manager for Standards, Audits and PROMPT, Rachel Vogelsang likes to say, “Accreditation is similar to preparing your house for auction. We want to showcase and present it in the best possible way.”

It’s just about time for our “Open for inspection!”

In this week’s Accreditation Bulletin, we will look at what you can do to prepare your local areas to ensure your working environment and teams are ready to welcome the assessors.

We also want you to feel confident and proud to discuss all the wonderful work you do. Remember, all the latest news and resources you need to be Accreditation-ready can be found on our Accreditation website.

Focus points 

Here are the things you can do this week to ensure we remain on track for Accreditation:

• Correctly record your Give Me Five/ Performance Appraisal or make sure you book a time with your manager.
• Ensure you are familiar with and are following our employee uniform requirements.
• Check your areas are clean, free of clutter, testing and tagging of electrical equipment is up to date, and hand hygiene stations are full.
• Familiarise yourself with our family escalation of care process and ensure the posters in your area are up to date.

Key messages 

Preparing and supporting each other  

Recording your Give Me Five/ Performance Appraisal 

If you’ve recently had a performance appraisal, ensure you have recorded it on HR 21/ Employee Self Service.

Employees

• Once completed, record your completed Give Me Five/Performance appraisal conversation directly on HR 21/Employee Self Service
• > 1. My Details > ‘Performance Enhancement [APR]’

Managers

1. Download and complete the Performance Review Record spreadsheet. The spreadsheet is available on the GM5 webpage, under ‘Manager Resources’
2. Email the completed spreadsheet to: performancereviews@monashhealth.org

Managers, you can check your team’s status via the ‘Mandatory training’ or ‘Performance Appraisal’ tab in the BI Portal.

If you’re having trouble viewing your team’s data or are receiving an error message, please use the ‘Reset to default’ button in the top right-hand corner of the navigation bar. You can then filter your search to view your team’s data.

Book in a Give Me Five / Performance appraisal 

To check when you had your last Give Me Five/Performance appraisal, log on to HR 21/Employee Self Service (> 1. My Details > ‘Performance Enhancement [APR]’).

If you haven’t had a Give Me Five / Performance appraisal in the last 12 months, book one in with your manager now. Our performance appraisal compliance is currently at 72%, and we are making a final push to reach our target of 90%.

Managers, prioritise these conversations with your team members over the next week. Visit the Give Me Five webpage for useful resources and guides for these conversations.

Employee uniform requirements

Our uniforms create an inclusive and safe environment for our colleagues, patients, and visitors. Please ensure you are following our uniform requirements.

Uniform and professional presentation
Ensure you wear the designated uniform for your area or department and are professionally presented while at work.

Remember, if you work in a clinical setting, you must keep your arms bare below your elbow, which means long sleeve tops, jewellery and wrist watches (including smart watches) are not permitted. You must also keep your nails natural, short, clean, and tidy, and have no artificial nails.

Employee ID requirements
A reminder that lanyards and long ties are not permitted in our clinical areas. They pose a risk to both patients’ and team members’ safety.

Employees in clinical areas must attach their employee ID cards to a toggle, wear them on their clothing, and ensure both first name and surname are visible. In addition to our employee identification cards, all employees must also wear their name badges and display this in a prominent place.

Ordering name badges
If you require a new name badge, you can place an order through the standard iProc process.

For our nursing and midwifery teams, nurse and midwife managers can place bulk orders if required. Order processing and dispatch will be fast-tracked to ensure delivery ahead of Accreditation week.

For more information, visit PROMPT for our procedures on staff identification requirements and Uniforms and Professional Presentation Framework.

Preparing your areas 

Cleaning and decluttering your areas

Part of preparing and being Accreditation-ready is ensuring our work and communal areas are kept clean and free of clutter.

Our Environmental Services team work to deliver a clean environment for our patients, visitors, and employees, but keeping our areas and facilities clean and free of clutter is everyone’s responsibility.

Managers and DCOs, in the days before Accreditation, do a final walk in your area and check the following:

• Work and communal areas are clean, tidy, and free of obstacles and clutter.
• Hand hygiene stations are full (more info below).
• Remove any old posters.
• Make sure all posters in patient areas and wards are laminated (and wipeable).
• Ensure your Welcome to Ward and Quality Boards are relevant and up to date.
• Clinical items are all stored appropriately.

Top tip: Managers and DCOS help each other and consider swapping areas and doing a walk around of another team’s area, as a fresh set of eyes can help you identify anything that might need addressing.

Find out how to request the removal of any excess, broken or unused equipment on your ward and tips for keeping your areas clean and free of clutter here.

Used a device? Keep it nice!

We should all be in the habit of cleaning devices regularly and that Workstations on Wheels (WOWs) are free of clutter.

The Accreditation assessors will be checking WOWs so if you need a refresher, download our factsheet for cleaning your electronic devices, showing you how and when to clean WOWs.

Templates for daily and weekly cleaning schedules have also been created so you can record your WOW cleaning.

• Daily Cleaning Schedule for WOWs
• Weekly Cleaning Schedule for WOWs

For more information, refer to the Clinical Equipment Cleaning Procedure on PROMPT.

Has your electrical equipment been tested and tagged?

Check your areas to ensure all your electrical equipment is in good condition, has been tested, tagged and is within its retest date. Here are three simple practices for your area:

1. Check for tags – all electrical equipment must have a tag. If a piece of equipment doesn’t have a tag, it needs to be reported (using the contact information below).
2. Check the date – tags will indicate that the electrical equipment has been tested and when it is due for a retest. If the equipment is due to be retested, report it.
3. Check for damage – if electrical equipment is showing signs of damage or unreasonable wear and tear, it needs to be reported, even if it falls within the date on the tag.

If you require equipment to be tested and tagged, you can contact:

• Medical equipment – contact Clinical Engineering on 8541 6400 (or internal ext. 16400) or email: clinicalengineering@monashhealth.org
• Non-medical equipment – place a BEIMS request

For more information, including general retest intervals, can be found in the Electrical Testing and Tagging PROMPT procedure.

Are your patient beds due for a service?

Ensuring our patient beds are regularly serviced helps keep our patients safe and prevents bed breakdowns causing disruptions to our delivery of care. Find out more information about how to ensure your patient beds are within their service date.

Refill your hand hygiene stations

Look over your area and make sure that your hand hygiene stations are full and hand sanitiser is available for your team, patients, and visitors to use at key touch points. Assessors will be observing to see that we are completing hand hygiene at all critical moments.

Ensure you perform hand hygiene at critical moments, including before and after contact with our patients and their environment, before and after procedures, and before and after touching equipment.

For more information, visit the hand hygiene webpage to review our hand hygiene procedure and to download the most up-to-date posters for your area. If you require more soap dispensers for your area, keep an eye out for a supply alert with more information regarding the ordering of soap dispensers.   

OHS Accreditation checklist

A new OHS checklist for managers puts a focus on completing key OHS actions and activities in the lead-up to Accreditation.

Preparing and supporting our patients  

Family escalation of care posters and translations

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.

At this week’s Employee Forum, Maryse Dhanapala, Quality & Safety Officer, gave a presentation on Standard 8 and our family escalation of care process. If you missed Maryse’s presentation earlier this week, you can watch the recording and/or view the slide deck here.

Our Point of Care Audit results from Quarter 2 (April to June 2022) show:

• 97% of patients know how to ask for help if they were becoming more unwell.
• 99% of patients, family or carers know how to ask for help if the patient was becoming more unwell.
• 69% of patients, family or carers have seen the poster/ brochure outlining the process for family-initiated escalation of care.

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’).

Patient meal tray flyers during Accreditation week

To help keep our patients and visitors informed about our Accreditation assessment, information flyers will be distributed to patients on their breakfast meal tray.

These flyers will also be available at ward/clinic receptions for our patients, consumers, carers, and visitors, to support their understanding of our accreditation assessment and the presence of assessors across our hospitals and sites.