March 3, 2021

Accreditation: Only 12 weeks left

Northern Health’s Accreditation is scheduled from 24 – 28 May 2021. Leading up to the date, we will be sharing communication from Standard Chairs, as well as initiatives and stories that relate to the Standard. Below, Maree Glynn, Director of Clinical Practice Improvement, talks about how to prepare, what to expect during the Accreditation Week and how we are going so far.

How are we going so far?

From the “back of house” point of view, there is a lot of work being done to prepare for our assessment. On the Intranet and in your work area, we have resources such as the Manager’s Checklist, which will help managers prepare their areas and their staff, along with Q&As about each Standard, so there is a lot of information to help you understand the requirements in each Standard. Each Standard has a page on the Intranet and all the Standard’s requirements are captured in our Policies and Procedures. If you follow these, you will meet the Standards. If you know the policies and procedures that guide your work, you will be ok.

What are some of the key messages staff should know?

Quality and safety is everyone’s responsibility and everyone has a role to make sure that care given to patients, families and people visiting our organisation is the best there can be, and that we have the right culture where quality and safety is valued.

Patients and families need to feel welcome, well looked after, safe and culturally safe as well. We have a very diverse community and we have to be respectful and inclusive of their needs. At an individual level, you need to understand what your role is and which Standards are relevant to your role. If you are unsure your manager will be able to help you.

At this point, it is essential that you are up to date with all your  mandatory training. We have to submit our training data to the survey team on April 9, and currently, all our mandatory training is sitting below our target of 95 per cent. It is really important to get that done in the next month. Performance appraisals are also very important.

Where can staff find more information?

There is a lot of information on the Intranet, but I think it’s important for staff to listen to the key messages we’ll be rolling out. We have 12 weeks to go and this is the first message to all staff. From Monday 8 March, each week will be focusing on a different Standard and staff will be able to hear from Standard Chairs, as well as read about initiatives and developments in the organisation that tie in to the Standard.

How does the survey team observe the organisation?

When the survey team of eight arrives, they will be here for five days and will visit all our campuses. They are here to assess how we meet each of the 8 Standards (148 Actions). We will provide information and the evidence to show that we are meeting the Standards. Much of their time, they will be out in the clinical areas where they will verify our evidence and observe our practise. This might include clinical handovers, ward rounds, multidisciplinary meetings and responding to MET calls. They will spend time talking to staff, patients and family members and reading health care records. Our survey begins on the first morning and often when the team is waiting in the foyer to be greeted, first impressions are very important. For example, quite a few years ago, a surveyor noticed we had some ripped chairs in the foyer, which sets the scene that there might be a problem here. On the other hand, we have received some very positive feedback about how welcoming the receptionist/ward clerk was when they arrived at a ward to meet with the staff. They will interpret this situation as “this must be what the patients and their families are experiencing”. Those are some examples of how they can observe the ways we do our work.

What can people who work in non-clinical areas expect?

That depends on your role, as many non-clinical roles have a very close connection to delivering patient care. For example, cleaning is a really important factor for preventing infections in hospital. Reception staff are essential for the patient experience and getting the right information. People who work ‘back of the house’ are less likely to be interviewed, but our survey team are welcome to meet with any of our staff. Talk to your manager if you need more information and I am also happy to provide advice. We don’t always know what they will be interested in, but we know they will visit all our clinical areas.

How is this different than the 2017 Accreditation?

Back in 2017, we were accredited against an earlier edition of the National Standards. This is now a new edition, and we’ve never been surveyed against this one. That makes things a bit harder as it makes it a bit unknown, as there are some new Standards. The Accreditation team and the Chairs of the Standards committees and some key personnel have been preparing all the evidence that might be requested. A really important message from me to staff is – the surveyors are here to talk about our everyday work. If a surveyor asks you for something, and you don’t know the answer, say ‘I will get back to you’ or ‘Could we please talk with my manager who may be able to help”. If you work in direct patient care, and you get asked how you involve patients in their care, just talk about how you are working with your patients every day. That is all you need to do.

Accreditation is about our quality and safety every day, but working up to an event such an assessment of this size means staff will be working to ensure they have everything in order, and be aware what is about to happen.