May 11, 2020

Accreditation ready any time

Before the COVID-19 pandemic started, Northern Health’s accreditation due date was scheduled for today, 11 May.

On 25 March, the Australian Commission for Quality and Safety ceased all accreditation in response to the coronavirus pandemic.

Maree Glynn, Director of Clinical Practice Improvement, explained the Commission understood the health services would be fully immersed preparing for the pandemic.

“The National Standards describe the minimum standard of care expected for any patient. Organisations often see and prepare for accreditation as an event,” she explained.

Dr Bill Shearer, Executive Director Quality and Safety, added that “event” is about showing that we do our daily work well – every day.

“Our goal is to be accreditation ready any time. That means that at Northern Health, quality and safety is our continuous work, and working towards a standard is part of our everyday role. We prove this to ourselves, and at accreditation, by regularly measuring our performance, auditing our practice, and making sure we are following procedures and best evidence practice,” he said.

The other way we monitor quality and safety is our reactive side. That includes learning from clinical incidents, adverse events and feedback to improve our care.

“The work of getting the organisation ready for accreditation, as well as the work of the clinical improvement committees has continued regardless of the pandemic. From the accreditation team point of view, we will be very ready once accreditation comes back. Once the decision is made, and the timeline is determined, we will probably get about five to six months to re-prepare,” Maree explained.

“The uncertainty is also an exciting opportunity to make Northern Health Ready Anytime – whether for accreditation or COVID-19,” Dr Shearer added.

Our approach to quality and safety is also built on the High Reliability Organisation transformation work we are doing.

“Our response to COVID-19, which has been an incredible effort, and really breaking barriers will be excellent to showcase once we have accreditation. If we take Standard 3, one of our big standards, which is preventing infection, our COVID-19 response is a case study of a resilient and learning organisation that has concentrated on things like hand hygiene, immunisations, screening, isolating patients, preventing the spread of virus and infection. Resilience means that an organisation can respond to new and unexpected challenges, and COVID-19 was exactly that,” Maree explained.

“It’s about responding to unexpected challenges quickly, effectively and with the minimal disruption of the organisation. Our response to COVID-19 is an example of how we are doing that well,” Dr Shearer added.

While some of our staff are very busy now, others have some down time so Maree is encouraging everyone to keep up with mandatory training, appraisals and things we always find hard to do and usually leave for the last minute.

“We need to make sure we continue to do audits where we can and do the improvement work where we need to. From an accreditation point of view, we already almost met every action that was required, so we should be positive and proud of what we have achieved and we need to keep up that work to be ready anytime,” she added.

Featured image (left to right): Maree Glynn and Marisa Argetto, Administrative Assistant and PROMPT Administrator, Quality & Service Improvement