June 24, 2013
MHS receives outstanding Accreditation Results
Moyne Health Services has had successful reviews of all of their services during the month of June. These reviews were conducted by three groups of external assessors on three different dates. The first was an unexpected review of the Residential Aged Care Services. The remaining assessments have been planned for some time and involved two areas, the Hospital and the Community and Primary Care Department.
The Aged Care Standards and Accreditation Agency were represented by two assessors on Wednesday 12th June. They each assessed one of our residential aged care homes. The focus of the assessment was Continuous improvement, medication management, activities and HR. The results were very pleasing with a report of “full compliance” achieved at the end of the day.
The “Hospital area” of Moyne Health Services has been one of the first Victorian Health services to undertake an assessment of the quality and safety of their care and services against the new National Safety and Quality Health Service Standards. These Standards were an initiative of the Australian Commission on Safety and Quality in Health care and became effective from the 1st January 2013. They reflect a change in approach for accreditation and involve a greater focus on processes and compliance rather than patient outcomes.
The Board of Management at Moyne Health Services made the decision early in 2012 to commit to maintaining accreditation through the Australian Council on Healthcare Standards (ACHS) and opted to join their most intensive program EQuIPNational – a combination of the National Standards and some ACHS Standards that broaden the scope of the assessment to cover any areas not assessed by the National Standards alone. This decision put us into the four year program with a Periodic Review scheduled for 2013.
On Wednesday 19th June we had two surveyors from the Australian Council on Healthcare Standards (ACHS) visit to assess MHS against National Standards 1 “Governance for Safety and Quality in Health Service Organisations”, Standard 2 “Partnering with Consumers”, Standard 3 “Preventing and Controlling Healthcare Associated Infections” and the mandatory criteria from Standard 11 “Service Delivery”, Standard 12 “Provision of Care”, Standard 13 “Workforce Planning and Management”, Standard 14 “Information Management” and Standard 15 “Corporate Systems and Safety”.
The day started with a tour of facilities followed by an interesting presentation about staff education by Nurse Educator – Jo Keane. The surveyor spent the remainder of the day interviewing staff and checking records and other documentation. The day progressed very well and we received an excellent report at the summation conference at 4:30 that afternoon. Some key comments made include:
- Excellent policies and procedures
- Strong governance processes
- Committed Staff
- Well maintained facilities
Some recommendations to continue our progress included:
- Further progress the Employee Assistance Package
- Continue to progress the electronic patient record to move forward from the current part hard copy / part electronic system
- Develop the Electronic observation chart so that it is compliant with Standard 9 prior to Organisation Wide Survey
- Work to maintain better consistency with Hand Hygiene results
- Continue to progress the involvement of consumers
The overall result was that accreditation was maintained. We maintained the ratings that we had allocated ourselves and had 3 ratings upgraded, including one associated with cleaning upgraded to “Met with Merit”. We were all very happy with the result.
On the following day 20th June 2013 one surveyor remained to conduct an assessment of the HACC services against the Community Care Common Standards. These involved the Community and Primary Care Department as well as the Governance, Quality, Risk, Infection Control and other generic standards that are Health Service wide.
The day included a visit to the Koroit campus and interviews with a number for Community and Primary Care staff. Client and Staff records were reviewed as well as policies and other documentation. Similarly to the previous day the visit culminated with a summary of the findings. The assessment also found that the standards were met and accreditation has been maintained. Staff in the Community and Primary Care area, were commended on their commitment and enthusiasm. There were some suggestions to assist with further improvement relating to records and documentation. This was another very successful assessment and staff are very proud of their achievements.
June, 2013 has been quite demanding and has the record for the most external reviews in a short period of time. Despite the drain on staff that this demands, the outcomes that were achieved were excellent and we are all very proud of the final outcome.