Our hospital accreditation survey is fast approaching, which is why I’m putting together a quick checklist and provide resources to help every staff prepare for accreditation. During survey week, an accreditation surveyor may approach you about any quality and safety matters relevant to your role.  It is therefore essential that you are familiar and prepared.

This is the biggest survey we have ever had, which will be conducted over five days, 27-31 Aug 2018, across all four hospitals.

Conducted by external surveyors, accreditation ensures that we maintain the highest standards of quality and safety, and deliver continuous service improvements. The standards ensure all health services have rigorous and consistent safety and quality systems.

There are 15 standards altogether but I would like to point out the top 5 standards that are relevant to all staff.

Know how to locate policies & procedures- This is available on the staff intranet. Speak to your manager if you are unsure how to.



Know what to do in an emergency- Your quickest reference is the back of your staff ID



Know how to report hazards and risk– Enter incidents on Riskman accessible through staff intranet.



Practice standard precautions towards infection prevention– E.g. always practice the 5 moments of hand hygiene, clean in and clean out.



Complete your annual mandatory training by 26 August– log on to Workday and check the courses assigned to you which must be completed.



Here are a few resources to help you and your team better prepare for accreditation:

If you ever do get approached, don’t be nervous. Be truthful and show the surveyors you are ‘Inspired to Care’ and ensuring our patients feel Welcome, Valued and Safe is your priority.

If you have any questions or should you need to speak to someone about accreditation, please feel free to contact the Clinical Safety & Quality team.

  • Fitzroy campus: Diana Smith, Kim White, Michelle Killick, Natalie Benn and Seamus Knight
  • East Melbourne & Kew campuses: Penny Hodge
  • Werribee campus: Victoria Downey