Northern Health has achieved successful Accreditation during the Short Notice Assessment, conducted from 6 – 10 May 2024.

The Accreditation assessment involved on-site visits by assessors, independent of the health service, who spent time at Northern Hospital Epping, Broadmeadows Hospital, Kilmore District Hospital, Bundoora Centre and Craigieburn Centre, along with all transitioned mental health services.

Surveyors experienced great hospitality throughout the week as they met with staff, spoke to patients and looked for evidence that each action in the National Standards has been implemented effectively. They looked for evidence of a culture where quality and safety are valued, and systems that provide the very best care to our patients and community. Surveyors said it was evident that safety and quality is firmly embedded into the organisation, and while there are some areas to improve upon, the feedback was very positive. They have also emphasised that the value of kindness is very evident throughout the health service, and were pleased to observe ‘very authentic patient centred care’ across Northern Health.

Northern Health has now received a detailed Assessment Report, which contains comments pertaining to the findings of the assessment team. All 151 actions were assessed as met across all Northern Health facilities. There were no recommendations that require remedial action.

Key feedback from the survey team included:

• Standard 1 Governance: There is strong Clinical Governance framework effectively applied by a visible executive and leadership team.
• Standard 2 Partnering with Consumers: Amazing and embedded, could be strengthened with central oversight/visibility of all the great work with consumers across the health service.
• Standard 3 Infection Prevention: Led by a credentialed and enthusiastic team.
• Standard 4 Medication Safety: Excellent management at all levels of the organisation.
• Standard 5 Comprehensive Care: Working together is apparent, care is patient centered and risk management and harm minimisation is a strength.
• Standard 6 Communicating for Safety: It is evident of how it is embedded across the organisation, with very good engagement with patients, families and carers
• Standard 7 Blood Management: Great framework
• Standards 8 Recognising and Responding to Clinical Deterioration: Strong governance

Reflecting on the Short Notice Assessment, some of the insights from Northern Health staff included:

• “I feel we were really well prepared for this assessment. The level of organisation-wide education and training about the standards and our quality and safety responsibilities was very effective. We need to ensure that despite the success of this assessment, we need to maintain a high level of quality and safety and clinical governance – especially as we grow and induct new staff into the organisation.” – Jason Cirone, Chief Allied Health Officer.
• “My overall experience was positive. The assessors I was aligned to were very approachable and thorough. They were very mindful of ensuring the Nurse Unit Manager or Head of Unit felt comfortable and was given time to talk and showcase their area.” – Paula Dimakos-Pugliese, Quality Coordinator.
• “It was a pleasant, respectful and professional experience. The assessors were very through and asked a number of questions after reviewing the evidence before our meetings. They were keen to understand processes and implementation on the floor at patient level.” – Vinod Chellaram, Operational Director of Medical Workforce.
• “I found the assessors to be personable, knowledgeable and genuinely interested in the work that we were doing across our craft groups and the division more broadly. They took the time to listen to us talk about what we do and recognised the passion we have for our work and the value it brings to our learners and in turn our patients. We have a great culture of improvement at Northern Health which is driven by the passion that staff have for their roles and those they work with (rather than the need to comply with any particular set of standards) and supported with great governance. I think this helps us to address those things the surveyors are interested in proactively as our motivation is coming from the right place.” – Peter Brack, Director Education – Allied Health.
• “It was a new experience for me, and also a milestone for the health service as Clinical Trials were incorporated into our survey week for the first time. Our team’s knowledge, as well as that of the governing body and the researchers, earned high praise from the assessor, as interviewees came prepared, often bringing along documentation to the interviews to further demonstrate transparency. Looking ahead, we are committed to streamlining research practices and hope to demonstrate even greater integration in future assessments of Clinical Trials.” – Belinda De Poi, Research Quality Manager, RDGU.

Siva Sivarajah, Chief Executive, Northern Health, said that he is proud of each of our staff for all of their work in the lead up to Accreditation, and for upholding our values each and every day.

“I would like to personally thank and acknowledge Maree Glynn and Marisa Argetto for their unwavering commitment and diligent efforts in preparing for accreditation, including the way they coordinated the schedule and provided staff to chaperone the surveyors across the week. I also acknowledge the work of the Chairs of the Standards Committees, our clinical and non-clinical leadership and Bill Shearer, our Executive Lead for Quality, Safety and Transformation,” Mr Sivarajah said.

“Congratulations to each and every one of you for the part you played in achieving this significant outcome.”

Staff can access the full Assessment Report and other assets here.