NSQHS Accreditation Survey FAQs and Tools

How are we going - daily Survey update

• Monday - day 1 Survey update

  Overall surveyors are very impressed with what they have been seeing, referring to innovative and high quality care.

  A big thank you to areas visited yesterday – the presentation of your areas and discussion on providing best care contributed significantly to Surveyors’ favourable comments.

  Please note the Surveyors are making constant changes to where they would like visit and when – it may not be possible to keep updating the timetable on this site to reflect these changes. We will try to do so however. We are giving areas advance knowledge of any unscheduled visits where we can.

  Notes for clinical areas to consider:

  • O2 cylinder storage: It has been noted that a few wards/departments have had oxygen cylinders untethered (mainly next to resus trolleys). Can you please ensure that all O2 cylinders are not on the floor or untethered – they need to be stored in a O2 cylinder rack or trolley. Any that cannot be appropriately stored need to be removed from the ward/department.
  • Testing and tagging: a couple of items have been found that were not in date for testing and tagging. Please check your area to minimise the risk of this reoccurring.

   

• Tuesday - day 2 Survey update

  After Day 2 a few additional items that need active management please after we have received feedback from the Lead Surveyor:

  • Testing and tagging: items have continued to be found that were not in date for testing and tagging. Any items that have been entered into BIEMS have been rectified, and Support Services will continue to support a rapid-response to address this issue. Please check your area, and enter in a BIEMS for Engineering to undertake testing and tagging for any out-of-date items as a priority.
  • Delirium: please ensure that all of your patients have had a 4AT risk assessment within the first 4 hours of their admission. For patients that are identified as being a high risk of delirium, we just need 4ATs done and the Comprehensive Care IPOC
  • Food fridges: there have been food items found in fridges that have been out of date. Please ensure that all food fridges are checked and any out-of-date items are disposed of. If items are not labels with a date, please dispose of them.
  • Medication stickers for high risk drugs: For our areas that store and use anaesthetic and paralysing agents (including theatres, ICUs and Eds) – please order stickers with the agent name (e.g. Propofol) from FMIS to support the clear labelling of syringes. These stickers should be used in addition to our hand-written additive labels, to minimise the risk of hard writing being misread. If you do not have stickers in place at the moment, please reach out to your colleagues for a temporary supply until your order is delivered.
  • Goals of Care on Communication Boards: Please work with the multidisciplinary team to ensure that goals of care are captured and written on the patient communication boards so that they are visible. Allied Health colleagues will be important contributors to this.

   

  As per yesterday, please remain vigilant to:

  • O2 cylinder storage: Please ensure that all O2 cylinders are not on the floor or untethered – they need to be stored in a O2 cylinder rack or trolley. Any that cannot be appropriately stored need to be removed from the ward/department.

   

  Whilst this is a bit of a list today, overall surveyors continue to be very impressed with what they have been seeing.

• Wednesday - day 3 Survey update

  After Day 3, the accreditation survey team today were incredibly complementary on the Western Health culture, stating that it was friendly, patient-centred, collaborative and really valued the multi-disciplinary team.

  They also stated that every patient that they have spoken to has been very complementary of the care being received, and their involvement in decision making and their own care.

  These are things that you should all feel incredibly proud of – well done all!

  The good news is only 1 additional element to actively manage after we have received feedback from the Lead Surveyor:

  • Patient curtains to be in-date: Please ensure that patient curtains are within date, and have not expired. If they have expired, please work with the PSAs to get these changed as quickly as possible.

  Ongoing items to monitor and manage please for the rest of the week:

  • Testing and tagging: you are aware that we have clinical equipment that moves around our service. So we need to remain vigilant to this. Please keep an eye out for equipment not in date for testing and tagging. Support Services will continue to support a rapid-response to address this issue. Please check your area, and enter in a BIEMS for Engineering to undertake testing and tagging for any out-of-date items as a priority.
  • Food fridges: Please ensure that all food fridges are checked and any out-of-date items are disposed of. If items are not labels with a date, please dispose of them.
  • Goals of Care on Communication Boards: Please work with the multidisciplinary team to ensure that goals of care are captured and written on the patient communication boards so that they are visible. Allied Health colleagues are important contributors to this.
  • O2 cylinder storage: Please ensure that all O2 cylinders are not on the floor or untethered – they need to be stored in a O2 cylinder rack or trolley. Any that cannot be appropriately stored need to be removed from the ward/department.

  Overwhelmingly the feedback has been incredibly positive, and you are all doing a remarkable job.

• Thursday - day 4 Survey update

  After Day 4, the accreditation survey team have been extremely positive about the standards of care, Western Health culture and focus on consumers.

  You should all feel incredibly proud of the work you have all put in, and the work undertaken every day by your teams. We have the Best People here at Western Health, that delivery Best Care.

  The 3 elements raised yesterday for action please:

  • Ensure that resus trolleys are checked every day, and that this is done comprehensively – including checking of expiry dates on equipment.
  • Please ensure that all food in fridges is labelled with a date, and thrown out when expired (or old).
  • Please ensure fire doors are not blocked with equipment.

  There are some administrative elements that have been raised by the surveyors, where we will likely need to do further work.

  Thanks for all of your continuing efforts and support.

• Friday - end of Survey update

  Well, we’ve reached the end of Survey!

  A full on week but Surveyors were full of praise for the commitment and passion of everyone, everywhere in Western Health to provide Best Care.

  They felt it was an honour and a privilege to spend a week here.

  We do have a couple of recommendations coming out of Survey but we will knock these over in no time.

  Congratulations to everyone! You should all be immensely proud of yourselves and the amazing health care services we provide for our community.

Meet the Surveyor Team

• Dianne Knight, Lead Assessor

  Dianne Knight is aligned to NSQHS Std 4 Medication Safety.

  Qualifications: General and Mental Health Nursing, Masters Public Health, Disaster Management Commenced assessing in 2004.

  Ms Knight is an experienced assessor and has led and reviewed large metropolitan health services through to small non government drug and alcohol services. Di has a background in nursing both in general and mental health, acute and community settings. As a clinician, experience has been diverse from theatre through to community mental health services. Di has held senior executive positions within government and nongovernment inclusive of primary health, and within private and public health services. Ms Knight has also led a regional health service clinical and corporate governance systems reform and been responsible for planning and information services.

  Ms Knight, throughout her career; has led reform agendas that required a redesign of service delivery systems. Di’s most recent appointment was as the regional director for mental health and drug and alcohol services where she was responsible for reform and redesign of services and the development of innovative service models.

• Jordan Kelly

  Jordan Kelly is aligned to NSQHS Standard 1 Clinical Governance.

  BScHIM(Curtin); PGradDipHlthAdmin(Curtin); MHSM(Curtin); FACHSM; GAICD

  Commenced assessing in 2012

  Jordan Kelly commenced with the North Metropolitan Health Service in June 2019 as Executive Director
  Business and Performance. For the past six years he held the position of Executive Director Business (Corporate) Services for the WA Country Health Service (WACHS) which oversees the Finance, Workforce, Information and Performance functions for the organisation. Prior to this, Jordan has undertaken a variety of roles with WACHS including Director Business Performance and Analysis, Director Corporate Services – Goldfields (based in Kalgoorlie) and Manager Organisational Performance. He holds a Bachelor of Science (Health Information Management) and commenced his health career in Geraldton as the Regional Health Information Manager – Midwest.

  Jordan is a member of the Health Information Management Association of Australia and is actively involved and interested in the latest developments in digital innovation and eHealth. Jordan is a Board Member of the Palmerston Association which provides alcohol and other drug services for communities across WA. He chairs the Palmerston Board Governance and Risk committee and is a Graduate of the Australian Institute of Company Directors. Jordan enjoys improving systems to support the delivery of services and has a strong background in governance and risk. He is a Fellow of the Australian College of Health Service Management. Jordan has expertise in Corporate Services, Performance, Health Information Management, Governance and Risk.

• Debra Cutler

  Debra Cutler is aligned with Clinical Trials Framework

  Adjunct Professor, MSc Health Mgt, BSc (Hons), Dip Leadership Coaching, RN, MACN, GAICD

  Commenced assessing in 2013

  Debra is a registered nurse and has enjoyed combining working clinically in 3 countries: Australia, the UK and the Bahamas with her passion for travel. She has enjoyed a successful career working in large, complex and diverse teaching hospitals in clinical, management and executive director of nursing and midwifery positions
  within England and Australia. She has extensive experience of strategic and change management, ensuring effective clinical and operational governance and providing professional leadership coaching and support to the many staff with whom she has been privileged to work.

  Debra has a special interest in improving the safety and quality of health services and is passionate about integrating research into clinical practice to improve patient outcomes and is an adjunct professor at UTS and JCU.

• Helen Chambers

  Helen Chambers is aligned to NSQHS Standard 1 Clinical Governance.

  Bachelor of Economics; Chartered Accountant

  Commenced assessing in 2013

  Since 2019 Helen has been an Executive Director of SA Health, with oversight of large operational services including Elective Surgery and outpatients (Planned care), Unplanned care and End of Life services including Voluntary Assisted Dying (reporting to the VAD Board) and Palliative Care. During the Covid pandemic she was the co stream leader for the Acute System. Prior to this role she was the Chief Operating Officer of Central Adelaide LHN encompassing the Royal Adelaide Hospital, the QEH, Glenside Campus, and Hampstead Rehabilitation Centre. In 2016 Helen was the Chief Executive of Mackay HHS and enjoyed working as an
  interim Executive CEO or COO for several years. She has also been the Chief Operating Officer of Country Health SA Local Health Network, a service of 60 acute sites, 30 aged care facilities, community health services and a number of GP practices spanning the State of South Australia.

  Until 2003, Helen worked in the UK national health system where her roles included Chief Executive of Kingston District Hospital (600 beds); Finance Director / Deputy CE of University College of London Hospitals, a group of nine hospitals in the middle of London including the development of a privately financed acute hospital and a private hospital acquisition. She has also been an Executive Director of London Ambulance Service for four years at a period that included the transition to Trust status during some challenging years for that organisation. Prior to that Helen has held various roles in the UK and Australia. Helen has also had a
  strong interest in the provision of emergency services throughout her career.

  Helen is a previous Counsellor with the Australian Health and Hospitals Association; spent 5 years as a nonexecutive
  Board Member of the SA Fire and Emergency Services Commission; is currently an independent health member of the SA Ambulance Service Finance Committee. She is interested in high operational performance and systems of operational and organisational governance. Areas of interest include governance, performance, acute services, ambulance services, rural services, and aged care. Helen has too many years to count as an Executive Director in a variety of health services and is greatly appreciative of the teams she works with.

• Rosyln Chataway

  Rosyln Chataway is aligned to NSQHS Standard Std 6 Communicating for Safety.

  RN, RM, Neonatal ICU, Bachelor of Laws and Legal Practice (Hons), Bachelor of Behavioural Science (Psychology), AFCHSM. Mrs Chataway is currently completing a Masters of Business Administration (MBA) at Flinders University.

  Commenced assessing in 2016

  Mrs Chataway qualified as a general nurse at The Royal Adelaide Hospital in 1981 before completing her midwifery training at The Queen Elizabeth Hospital in 1983 and Neonatal Intensive Care at Flinders Medical Centre in 1985. Further studies continued at Flinders University in Behavioural Science (Psychology) and Law & Legal Practice (Hons). Mrs Chataway commenced in the safety and quality field in 2004 when she started at the Queen Elizabeth Hospital as the Safety, Quality and Risk Management Coordinator, before being seconded into the Risk Manager role in 2005. Mrs Chataway was appointed as Manager, Safety Quality and Risk Management Unit at the Queen Elizabeth Hospital and Central Adelaide Local Health Network incorporating the Royal Adelaide Hospital, before her employment as Manager Safety and Quality for Country Health South Australia Local Health Network (CHSALHN) from 2013-2017.

  Mrs Chataway has extensive health care experience in both the public and private spheres, particularly working in Midwifery and Neonatal Intensive Care. Mrs Chataway’s corporate governance experience includes roles as a board member of the SA Health Consumers Alliance (HCA) 2012-2016, the National Rural Health Alliance (current) and the Australian College of Health Service Managers (ACHSM) South Australia, where she is the Immediate Past President and sits on the National ACHSM Board. Mrs Chataway was appointed to the Consumers Health Forum of Australia (CHF) in 2018, and was reelected in 2021. Mrs Chataway has undertaken a variety of roles and responsibilities and has substantial knowledge and skill in health service delivery, project and change management, senior management and leadership roles following over 30 years in healthcare. Mrs Chataway is acutely aware of the challenges faced delivering health care to rural and remote areas of Australia, issues with health literacy and marginalised groups and is passionate about safety and quality, always holding the consumer at the heart of healthcare provision.

• Glenise Coulthard

  Glenise Coulthard is aligned to NSQHS Std 2 Partnering with Consumers

  Certificate 4 – Community Development, 1996 Churchill Fellowship

  Commenced assessing in 2019

  Glenise recently retired from the position of the Director of Aboriginal Health for the Flinders and Upper North Local Health Network of South Australia in September 2022. Glenise had been in this position since 1995 moving through the ranks of Senior Project Officer, Manager of Aboriginal Health to Director of Aboriginal Health. Glenise has acted in the capacity of Executive Director, Aboriginal Health on numerous occasions for Country Health SA. Glenise has managed and led a number of Projects for the region/network during this time, the Child health project from 1995 – 1997, Otitis Media Project for Aboriginal Children 0-8 years from 2004 -2006 and the Connecting Mums, Babies, Family & Culture Advocating for Women’s Project in 2005-2008.
  Glenise is a recipient of a Churchill Fellowship which was awarded in 1996. Glenise travelled to New Zealand and the United States of America investigating Aboriginal Children’s health programs. In 1999 Glenise took time out of her career to help develop the families cultural tourism venture in the Northern Flinders Ranges where many students from schools and universities both domestic and international visit to gain cultural education, sharing, learning whilst living in an Aboriginal community embracing the lifestyle and the environment. Students from Medical and Allied Health have been amid these numbers. Glenise has led many
  cultural emersion programs for Midwives and Aboriginal Infant Care Workers providing a culturally safe environment to exchange and develop culturally appropriate tools to embed in their clinical and community practices. In 2001 – 2003 Glenise led the Aboriginal Children’s Renal Screening Program in partnership with the Women’s and Children Hospital in SA, visiting many remote Aboriginal communities raising awareness and providing education on child diabetes and renal health.

  Glenise is often called upon to provide expertise and leadership to both the State and Commonwealth Departments with contract management as well as key note speaker at conferences and forums throughout Australia. Glenise has extensive management within hospitals and at the community level with expertise in policy development, project management, leadership, quality and safety, consumer engagement and clinical and cultural governance. Glenise has a number of Directorships, The Royal flying Doctor Service Central Operations from 1995 – 2018 total of 23 years, SA Arid Lands Natural Resource Management, Australian
  Hearing and Ninti One Pty Ltd as the Deputy Chair for the past 9 years. Glenise is a strong advocate for quality and safety, embedding cultural respect frameworks and the principles of accreditation. Glenise has participated on strategic planning and quality improvement committees, providing cultural education which equips staff with tools to deliver respectful and culturally responsive services to consumers and the community. On Australia Day 2020, Glenise was appointed a member in the General Division AM for significant services to Aboriginal Health in South Australia and to emergency response organisation.

• Julianne Clift

  Julianne Clift is aligned to NSQHS Std 3 Infection Prevention.

  Registered Nurse, Non-practicing Midwife

  Commenced assessing in 2022

  Julianne Clift is currently the Board Chair of a Victorian Rural Health Service. Julianne has extensive experience in Governance, Strategic Planning, safety, quality, and risk management and has lead change through her various roles. Julianne has extensive experience in Health, with over 20 years’ experience in a range of leadership roles in the public sector, including Executive Director of Nursing and Midwifery at South West Healthcare, and Acting executive Director of Nursing and Midwifery for Murrumbidgee Local Health District. Julianne is a Registered Nurse, has practiced in Midwifery and Critical Care and has a Masters in Health Administration from the University of New South Wales. Julianne is passionate about outcomes for patients/clients and Residents. Julianne conducts volunteer work in Skin Checks, a way of giving back to the Community.

• Xin Nee Chua

  Xin Nee Chua is aligned to NSQHS Std 7 Blood Management

  MBBS, MHM, MPH

  Commenced assessing in 2022

  Xin is a medical administration trainee in her final year of training. Throughout the years, she has been involved in various roles including Medical Administration. In her current role as DDCS, Xin is actively involved in Executive functions and governance, including accreditation within her own organisation. Xin has previous experience as a trainee surveyor with the state PMCWA (post graduate medical council western Australia) who accredit all JMO positions in WA. Prior to undertaking Medical Administration roles, Xin was working clinically as a Medical Registrar, where her area of interest has always been in Rehabilitation and Aged Care specialities. Xin strongly believes that safety and quality in line with NSQHS is key to ensure safe clinical and patient care. Being in her medical administration role, Xin is a keen advocate for governance and safety, including safety of staff and the organisation-which in turn relates/translates to patient care to patients in her the organisation.

• Nadja Hartzenberg

  Nadja Hartzenberg is aligned to NSQHS Standard 5 Comprehensive Care.

  Registered Nurse (AHPRA) Member (AAQHC)

  Commenced assessing 2022

  Nadja is the Risk, Safety and Quality Manager with Calvary Central Districts and North Adelaide Hospitals.

  Having completed her training as a Registered Nurse, Mental Health Nurse and Midwife at Groote Schuur Hospital in Cape Town, South Africa, Nadja went on to complete post graduate studies in Neonatal Cardiac and Adult Intensive Care and completed a Masters in Health Administration.

  Nadja is an accomplished leader having worked in several senior operational management roles within both the public and private Healthcare sectors in Queensland, New South Wales and South Australia. Prior to joining the Calvary group Nadja worked with the Northern Adelaide Local Health Network as Critical Care Divisional Director and Director Clinical Governance and Risk.

  Besides working in the specialty area of Critical Care, Nadja has also held senior roles in the specialties of Medical Specialties, Aged Care, Rehabilitation and Palliative Care, as well as Demand and Access Management involving Outpatient and Theatre scheduling reform.

  Nadja enjoys developing and adding successful, high functioning teams to her proven record of accomplishment. She believes that by bringing people, ideas and inspiration together to foster learning, boosts organisational outcomes in a complex environment.
  When not working, Nadja enjoys travelling and spending time outdoors with friends and family.

• Sandra Polmear

  Sandra Polmear is aligned to NSQHS Standard 8 Deteriorating Patient.

  RN, B App. Sc., Diab Nr Ed., Post Dip Grad Business, Masters Health Mgt., Quality and Leadership, MACN

  Commenced assessing in 2013

  Sandra is a Registered Nurse who has been appointed to several executive health positions. Sandra has worked in various clinical positions including an appointment to support the National response to care for COVID positive patients in Melbourne. She has worked with a diverse range of people and has developed a strong appreciation for cultural differences.

  Sandra has been involved in the redesign of services at local and state levels for clinical services, human resources, patient support services, information systems and emergency response systems. Quality, patient safety and risk management have been the primary focus of her work practice since 1999. Sandra was recognised by WA Health for her creative clinical practice improvement programs to support patient safety, the advancement for quality patient care and was presented with the WA Health Award for Innovation for Patient Safety in 2009.

  Sandra has a keen interest in human error which has led to the development of expertise in the identification of systems and risks that weaken healthcare delivery. Sandra has skills to critically think through issues and articulate strategic direction. She can interpret and understand problems and information with the aim to apply logical and practical recommendations which has led to healthcare reform and changes to organisational culture. She has often been the pivotal person in the development of operational strategies, policies, and procedures. Sandra has a personal commitment to high-quality consumer service, facilitated by her ability to recognise and capitalise on opportunities to develop and implement effective change strategies.

  Current activities include ACHS education National and International programs, a Nurse Champion to support the Australian College of Nursing, Digital Health Agency Program and is appointed as an Approved Person for AHPRA hearing panels for the Nursing and Midwifery Board of Australia.

• Andrea Taylor

  Andrea Taylor is aligned to NSQHS Standard 5 Comprehensive Care.

  SEN, BSW, MOHS, MM, GAICD, CPRM

  Commenced assessing in 2001

  Ms Taylor is the Director, Mental Health Drug and Alcohol for Northern Sydney Local Health District (NSLHD) since 2008 providing inpatient (~360 beds) and community health services to a community of ~980,000 people from prenatal to end of life. This includes a considerable number of speciality services for NSLHD including: Eating Disorders, Intellectual Disability, Substance Use in Pregnancy Services, Involuntary Drug and Alcohol Treatment, Perinatal and Infant Mental Health Services, family admission unit, Aboriginal and Torres Strait Islander services, academic psychiatry – both medical and nursing, disaster portfolio etc. Prior to this she was the Director, Mental Health Drug and Alcohol for both the Northern Sydney and Central Coast Local Health Districts/Northern Sydney Central Coast Area Health Service. Ms Taylor has been previously employed in the following positions, Manager of Quality and Risk Management Unit at Royal North Shore and Ryde Health Services, as a director, manager and clinician in Mental Health, Drug and Alcohol and General Health Services, in non-government organisations including a women’s refuge, residential aged care facilities, and in for profit non-health organisations. Ms Taylor has previously taught at the University of NSW and Sydney University in undergraduate programs.

  Ms Taylor has led the health service teams in innovation and winning awards for this work including NSW Health Awards the most recent being in 2020 for Excellence in Mental Health Service Delivery for reducing seclusion and restraint in a Mental Health Intensive Care Unit, Highly Commended in the 2021 ACHS Awards for work completed alongside the local Aboriginal Communities and PHN to assist with the identification of people who are Aboriginal or Torres Strait Islander entering the health service, the NSW SiCorp/SunCorp/Treasury Managed Fund Risk Framework Award and two NSW Premiers Awards for services working in partnership. Ms Taylor has lead the team that have developed the award winning Enterprise Risk Management platform that is currently being utilised by Northern Sydney Local Health District and has been purchased by other services.

• Katherine Moore

  Katherine Moore is aligned with Clinical Trials Framework

  B.App.Sc.(Occ Therapy); M.App. Sc.(Occ Therapy); DHSM

  Commenced assessing in 2002

  Katherine Moore has recently retired and was the Executive Director of Clinical Governance and Risk for the Sydney Local Health District from 2011 till 2021. Her career started as an occupational therapist in aged care and rehabilitation, and she went on to be an Occupational Therapy Manager at Greenwich Hospital and RPAH, and as Director of Occupational Therapy for Central Sydney Area Health Service (CSAHS). In 1996 Katherine became Allied Health Director for CSAHS, and in 2006 after a restructure became Allied Health Director of Sydney South West Area Health Service (SSWAHS). In 2008 Katherine was appointed to the position of General Manager for Community Health, SSWAHS, responsible for a large and complex Community Health service with over 1,000 community staff including Early Childhood, Child and Family, Youth Health, District Nursing, Palliative Care, Sexual Health, and the Interpreter Service. Following another restructure in 2011.

  Katherine was appointed to the position of Executive Director Clinical Governance and Risk in SLHD where she
  remained until her retirement in March 2021. Katherine has expertise in clinical governance and risk management in a large complex metropolitan health district. She also has expertise in managing a community health service including a large district nursing team, child and family services and a range of specialist services including sexual health, youth health and child
  protection. She retains expertise in allied health management and service delivery.

Accreditation Survey Roles for Staff

• Front Line Staff
  • You will be informed when accreditation survey has been announced through a number of mechanisms including through your Manager, WH-everyone email, PA announcements and screen savers.
  • Remain Calm … we are already providing Best Care and living up to the requirements of NSQHS Standards Care in our everyday work! It is why we performed exceptionally in the 2020 Accreditation Survey. This Survey is simply a chance to show once again how well we support the NSQHS Standards at Western Health.
  • When advised it is available, Access the Accreditation Survey Timetable through the NSQHS Accreditation FAQs and Tools site to check if there is a specific day and time scheduled for the Surveyors to visit your area
  • If no specific day and time scheduled for a visit to your area, Surveyors will be on site for five days (Monday to Friday) and may still visit your area; you may also be asked questions by the Surveyor outside of their area.
  • Assist your Manager as requested to complete a visual walk through check of your unit/department on the Friday before Survey and each day of the Survey. Use the Clinical / Non-Clinical Checklist to assist you with this walk through.
  • Ensure Surveyors have the correct PPE when they come to your area
  • Note: Surveyors are to be granted access to all areas (unless a safety risk) and will ask to be shown information on the EMR or hard copy clinical record forms if area not on the EMR.
  • Debrief with your Manager following a Surveyor visit.
  • If you want to find out more, go to the home page of the Live Best Care site when accreditation survey announced and throughout the Survey and click on the banner at the top of the screen to go to a page with survey FAQs, Tools & Survey Updates.

   

• Managers
  • You will be informed when accreditation survey has been announced through a number of mechanisms including email, PA announcements and screen savers
  • Remain Calm … we are already providing Best Care and living up to the requirements of NSQHS Standards Care in our everyday work! It is why we performed exceptionally in the 2020 Accreditation Survey. This Survey is simply a chance to show once again how well we support the NSQHS Standards at Western Health.
  • Follow directions to go to the home page of the Live Best Care site when accreditation survey announced and click on the banner at the top of the screen to go to a page with survey FAQs and Tools. Read through this page.
  • Inform staff that 24 hour Announcement has occurred and Accreditation Surveyors will be on site from Monday to Friday of the following week. Pass on the ‘remain calm’ messaging above.
  • When advised it is available, Access the Accreditation Survey Timetable through the NSQHS Accreditation FAQs and Tools site to check if there is a specific day and time scheduled for the Surveyor to visit your area, and inform staff rostered for that day.
  • If no specific day and time scheduled for a visit to your area, inform staff Surveyor will be on site for five days (Monday to Friday) and may still visit their area; they may also be asked questions by the Surveyor outside of their area.
  • Remind staff where to access accreditation evidence eg systems such as PROMPT for PPGs and any local information
  • Complete a visual walk through check of your unit/department on the Friday before Survey and ensure completed each day of the Survey. Use the Clinical / Non-Clinical Checklist to assist you with this walk through.
  • Use the bestcare@wh.org.au email if you have any queries in the lead up to Surveyors visiting your area
  • Ensure Surveyors have the correct PPE when they come to your area
  • Seek consent from patients if Surveyors wish to speak to them
  • Note: Surveyors are to be granted access to all areas (unless a safety risk) and will ask to be shown information on the EMR or hard copy clinical record forms if area not on the EMR.
  • Text who you report to if you feel you need some assistance answering questions about organisation-wide process or strategy during a Surveyor visit
  • Use the bestcare@wh.org.au email if you have any queries or if Surveyors ask you to follow-up information for them.
  • Debrief with your staff following a Surveyor visit.
  • If you have time, check the Live Best Care site (click through banner on home page) to see summaries of how each day of the Survey has gone.

   

• Directors and Senior Clinicians
  • You will be informed when accreditation survey has been announced through a number of mechanisms including email, PA announcements and screen savers
  • Remain Calm … we are already providing Best Care and living up to the requirements of NSQHS Standards Care in our everyday work! It is why we performed exceptionally in the 2020 Accreditation Survey. This Survey is simply a chance to show once again how well we support the NSQHS Standards at Western Health.
  • Follow directions to go to the home page of the Live Best Care site when accreditation survey announced and click on the banner at the top of the screen to go to a page with survey FAQs and Tools. Read through this page.
  • Check with your direct reports they are aware 24 hour Announcement has occurred and Accreditation Surveyors will be on site from Monday to Friday of the following week. Pass on the ‘remain calm’ messaging above.
  • When advised it is available, access the Accreditation Survey Timetable through the NSQHS Accreditation FAQs and Tools site to check if there are specific days and times scheduled for the Surveyors to visit your areas – ensure managers are aware and have informed staff rostered for that day.
  • WH DONMs aligned with each NSQHS Standard will be the Guides for the Surveyors during Survey week.  Be available or identify a proxy if requested to attend at short-notice any meetings/discussions with Surveyors.
  • Where possible, ensure you or direct reports are available on site when Surveyors are visiting your areas in case they / the DONM Guides call out for assistance with any organisation-wide or strategy questions during the visit.
  • If no specific day and time scheduled for a visit to your areas, ensure your areas know Surveyors will be on site for five days (Monday to Friday) and may still visit their areas. They may also be asked questions by the Surveyor outside of their areas.
  • Ensure your areas are completing a visual walk through check of their units/departments on the Friday before Survey and ensure completed each day of the Survey. Use the Clinical / Non-Clinical Checklist to assist you with this walk through.
  • Use the bestcare@wh.org.au email if you have any queries in the lead up to Surveyors visiting your areas
  • Check in with areas surveyed if possible to let them debrief and give them positive messaging about their visit
  • Be available to trouble-shoot any issues raised following visits to your areas
  • Use the bestcare@wh.org.au email if you have any queries or if Surveyors ask you to follow-up information for them.
  • Check the Live Best Care site (click through banner on home page) to see summaries of how each day of the Survey has gone.

   

• Executive
  • You will be informed when accreditation survey has been announced through a number of mechanisms including email, PA announcements and screen savers. Note: Russell, John and Shane will receive an immediate text.
  • Remain Calm … we are already providing Best Care and living up to the requirements of NSQHS Standards Care in our everyday work! It is why we performed exceptionally in the 2020 Accreditation Survey. This Survey is simply a chance to show once again how well we support the NSQHS Standards at Western Health.
  • Follow directions to go to the home page of the Live Best Care site when accreditation survey announced and click on the banner at the top of the screen to go to a page with survey FAQs and Tools. Read through this page.
  • Check with your direct reports they are aware that 24 hour Announcement has occurred and Accreditation Surveyors will be on site from Monday to Friday of the following week. Pass on the ‘remain calm’ messaging above.
  • When advised it is available, Access the Accreditation Survey Timetable through the NSQHS Accreditation FAQs and Tools site to check where you may be involved in meetings/visits and if there are specific days and time scheduled for the Surveyors to visit your areas.
  • Be available if requested to attend at short-notice any meetings/discussions with Surveyors.
  • Check in with direct reports before and/or after their areas are surveyed if possible to let them debrief and give them positive messaging about their visit
  • Be available to trouble-shoot any issues raised following visits to your areas
  • Use the bestcare@wh.org.au email if you have any queries or if Surveyors ask you to follow-up information for them.
  • Check the Live Best Care site (click through banner on home page) to see summaries of how each day of the Survey has gone.

   

• Surveyor Guides

  The NSQHS Fab 5 Team Lead for each Standard (DONM) will be the Guide for the Surveyor assigned to their Standard for the week of Survey. Apart from exceptions noted below, they will collect the Surveyor for each timetabled session and take notes on any requests from Surveyors for additional information or areas that need immediate attention.

  There will also be two back up guides (back up 1, back up 2). Where there is more than one Surveyor for a single Standard, a second Guide has been nominated for this Standard.

  See following image of Guide Allocation.

  Guides will not be required to go with aligned Surveyors to our smaller sites (Williamstown, Sunbury, Bacchus Marsh, Melton) – Guides at these sites will be the campus DONMs, with back up 1 Standard Guides taking their places at Footscray and Sunshine when the smaller sites are visited.

  For any mental health site visited, Guides to liaise with Ryan Dube; back up Sharlin Berna re handing over guide duties.

  For JKWC sessions, Guides to liaise with Tanya Farrell re handing over guide duties.

  Timetabled events will be entered into a dedicated calendar supported by Kellie Tyson and BCGS Administration. Invitations will be sent to relevant staff as soon as timetable finalised.

  A Slack Channel has been created for Guides and other key Accreditation support staff to communicate during the Survey. Invites will be sent to relevant staff. The BestCare@wh.org.au email can also be used if any difficulties with Slack.

  

   

• Best Care Governance & Support Division
  Whole Team 

  • The Team will receive an email when 24 hour announcement occurs. This and all linked information in the email needs to be read;
  • Daily BCGS Huddle will be used to provide Survey updates and allocated additional tasks if required
  • Use the zoom meeting background for any online meetings attended between Announcement and end survey;
  • Assist anyone outside of division (or inside) if they have any questions about survey & guide staff to use the bestcare@wh.org.au email if required; to use this email address themselves if have any queries

   

  Belinda Bisignano 

  Co-ordinate the use of the Non-Clinical Checklist within the BCGS Division

   

  Admin Staff 

  • May be asked to assist with things like printing out information, sorting out room bookings, chasing information requested by Surveyors, adding/ revising items on Live Best Care site

   

  Alex, Mel 

  • Will be keeping a regular eye on the bestcare@wh.org.au inbox to ensure any Survey related queries or requests are addressed quickly
  • Will be part of Slack channel to process requests

   

  Fab 5 Quality Leads 

  • Help Fab 5 Team Leads trouble-shoot during the Survey if required
  • Will be part of Slack channel to process requests

   

  Best Care Co-ordinators 

  • Check in with areas aligned with their Divisions who have scheduled visits in the Survey timetable before visit (to see if they have any questions or just need reassurance they will be fine with Surveyors) and after visit to see how they went and check if Surveyors have asked for additional information
  • Put any Surveyor requests for additional information through bestcare@wh.org.au inbox

   

Frequently Asked Questions

• What are the NSQHS Standards?

  The Australian Commission on Safety and Quality in Health Care developed National, Safety and Quality Health Service (NSQHS) Standards to drive the implementation of safety and quality systems and to improve the quality of health care in Australia. The NSQHS Standards provide a nationally consistent statement about the level of care consumers can expect from health services.

  Health Services are required to be independently assessed for compliance against the NSQHS Standards.

  There are eight NSQHS Standards covering the following:

  1. Clinical Governance
  2. Partnering with Consumers
  3. Preventing and Controlling Healthcare-Associated Infection
  4. Medication Safety
  5. Comprehensive Care
  6. Communicating for Safety
  7. Blood Management
  8. Recognising and Responding to Acute Deterioration
• When is the Survey happening?

  The Survey is being held between 4-8 December 2023

• How many Surveyors are involved in the Survey?

  Twelve Accreditation Surveyors will be involved in the Survey.

• Will all Western Health campuses be visited during accreditation survey?

  Yes, all campuses and a sample of community sites will be visited during accreditation survey.

   

   

• Will the Accreditation Surveyor visit my area?

  Surveyors will be visiting all clinical and clinical support areas, and may visit a range of corporate areas as well.

  When Accreditation Survey is announced, the Timetable won’t be available immediately – WH will be asked to contact the Lead Accreditation Surveyor to access a draft copy and finalise it with them. It will then be added to this page as a link on the right hand side.

  Access the Accreditation Survey Timetable (link to be added when Timetable available) to check if there is specific day and time scheduled for the Surveyor to visit your area, and inform staff rostered for that day.

  If no specific day and time scheduled for a visit your area, the Surveyor may still visit other areas if time permits. Staff may also be asked questions by the Surveyor outside of their area.

   

• What if I don't know an answer to a Surveyor question?

  Be honest and tell the Surveyor you don’t know the answer to their question or that you are unsure what they are asking.

  Accreditation Surveyors aim to support staff to understand and answer questions by, for example, asking their question in a different way.

  It is okay to say you don’t know the answer but ideally you should add but I would ‘go and look at xx to find the answer’ or would ‘ask their manager’.

• Are there any last minute actions required to prepare for Accreditation Survey?

  Short checklists have been developed to support Managers inform staff about the  survey and check a few items to make sure our areas make a good first impression when visited by an Accreditation Surveyor.

  There is a checklist for clinical/support areas and one for non-clinical/corporate areas. Note: the clinical/support areas checklist is drawn from the larger Managers checklist staff have been using to prepare for accreditation survey. It contains those items that are suitable to be checked within 24 hours of survey and on each day of survey.

  Also remember the Live Best Care site is a great source of knowledge about our quality systems and practices supporting best care. Take a moment to become familiar with at least the home page of the Live Best Care site and feel free to show information on the site to the Accreditation Surveyor.

• Do I need to tell patients/consumers that the Survey is happening?

  A notification form for patients will be added by HSS staff to meal trays for inpatients.

  Surveyors will ask permission from the Unit Manager to talk to any patients/consumers.

• Best Care and Accreditation Surveys

  The best way you can be prepared for accreditation survey is to focus on living best care everyday, everywhere, every time.

  Every single staff member at Western Health — either directly or indirectly, whether clinical staff, non-clinical staff or volunteers — makes a contribution every day to supporting the provision of Best Care and the best experience for our patients.

  Best Care is care that is person-centred, co-ordinated, safe and right for each patient’s needs.

  Click here to learn more about our Best Care Framework and your role in living best care.

• Who can I contact if I have any queries about Survey?

  If you or your staff have specific questions about Accreditation Survey or need to pass on a request from the Accreditation Surveyor for additional information during Survey, email:

  BestCare@wh.org.au