Short Notice Accreditation - Standard Operating Procedure (SOP) - May 2025
Introduction
Purpose
This document describes the plan for managing a Short Notice Assessment in St John of God Murdoch Hospital.
The Australian Commission on Safety and Quality in Health Care (“The Commission”) developed the National Safety and Quality Health Service Standards which set the mandatory minimum required standards to be met by all public and private hospitals.
From July 2023, mandatory short notice assessment to the NSQHS Standards replace existing announced and voluntary short notice assessments of hospital and day procedure services.
Short notice assessment for accreditation to the NSQHS Standards, ensures the outcome reflects day to day practices, identifies gaps and supports health service organisations to improve safety and quality systems and processes.
Communication Flow after phone-call received to advise of Short Notice Assessment
MQR receives phone call from ACHS confirming accreditation date
Accreditation Mobilisation Team (AMT) convened
Leadership Group comms and meeting
MQR informs CEO, DON, DDON SS
Group Services notified:
- CEO informs COO and EA to Group CEO
- DON informs CNO
- MQR informs Manager Patient Safety and Clinical Standards
Release of comms to:
• Caregivers
• VMOs
• External Providers
• Patients
AMT reconvened where required
Accreditation Mobilisation Team (AMT)
Role
Chief Executive Officer (CEO) AMT Lead
Director of Medical Services (DMS)
Director of Nursing (DON)
Director of Corporate Services (DCS)
Director Organisational Development & Improvement (DODI)
Deputy Director of Nursing Specialist Services (DDON SS)
Deputy Director of Nursing Inpatient Services (DDON IS)
Deputy Director of Nursing Procedural Services (DDON PS)
Manager Quality & Risk (MQR)
Infection Prevention & Control Manager (IPCM)
Learning and Development Coordinator (LDC)
Manager Public Relations & Marketing (MPRM)
HMC
HMC-Ops
HMC; Standard 2: Partnering with Consumers Lead
HMC-Ops Standard 7: Blood Management Lead
HMC-Ops Standard 8: Acute Deterioration Lead
HMC-Ops Standard 5: Comprehensive Care Lead
HMC-Ops Standard 6: Communicating for Safety Lead
Assessor Contact / Person in Charge
HMC-Ops Standard 3: Infection Prevention & Control Lead
Depending on current staffing and leave arrangements, the AMT Lead may call on representatives from other departments or subject matter experts to be coopted.
Operations Centre
The AMT will meet in the Executive Boardroom.
Action Card 2: Manager Quality & Risk
Responsibilities: Liaison person for ACHS Assessors
Reports to: Deputy Director Nursing – Specialist Services
Immediate Actions
• When phone call for notification is received, confirm:
o Assessor names
o Assessment start date and time
o Assessment duration
o Confirm timetable (arrange entry and exit meetings)
o Confirm assessor dietary requirements
• Notify CEO, Director of Nursing and DDON Specialist Services
• Notify SJGHC Senior Manager Quality Improvement
• Finalise assessment timetable with CEO, DON and DDON SS prior to circulation to Leadership Group
• Convene Quality & Risk team after AMT meeting to allocate tasks / roles / assessor contact persons
• Direct Quality & Risk Admin to send out meeting invites as per confirmed timetable
• Liaise with Executive Assistants to:
o WhatsApp Accreditation Group to go “live”
o Clear diaries for AMT (once draft timetable received from Lead Assessor)
o Clear Boardroom schedule
• Liaise with Functions Coordinator to :
o Clear Function Rooms schedule
o Deploy catering plan
o Boardroom set-up for Function Rooms
• Liaise with Q&R Team to:
o Allocate ‘buddy’ to each assessor
• Liaise with Learning & Development to clear Exam Room schedule adjacent to library and Tutorial Rooms if required
• Liaise with Librarian (or Director Corporate Services if not available) to close library services
• Contact D&T with final list of assessors for deployment of confirmed contractor numbers and ensure contact person is identified should any troubleshooting be required
• Send Accreditation Preparation Checklist to Managers
• Finalise security passes and locker keys with Learning & Development (MURTEC)
• Liaise with Security to confirm DSO to complete fire drill on the day
During Assessment
• Available on the day to :
o Meet Assessors at reception
o Attend entry meeting
o Attend exit meeting
o Attend any meetings as per Assessor request
• Orientate Assessors to:
o Assessor base
o Welcome packs
o Q&R contact person
o Share Point site
o My Policy
• Update WhatsApp and timetable where required
• Triage any requests by an assessor for additional evidence or access and discuss accordingly with DDON SS and DON
Action Card 5: Other HMC Members
Responsibilities: Manage and coordinate the preparation of their specific directorates
Reports to: CEO
Immediate Actions
• On notification, proceed to the Accreditation Mobilisation Team meeting
• Commence HMC walk-through and immediately escalate any concerns to Accreditation Mobilisation Team
• Advise AMT of any managers on leave under your directorates and identify and ensure proxy is identified and briefed
• Ensure Managers have received and commenced actioning Accreditation Checklists and advise if any concerns
• Ensure you and your managers have read/reviewed SJGHC Cheat Sheet: What to expect from assessors
During Assessment
• Keep up to date with WhatsApp updates
• Inform MQR if any Managers or relevant caregivers scheduled for interviews are not on site and arrange relevant proxy
Action Card 6: Clinical and Non-Clinical Managers
Responsibilities: Manage and coordinate the preparation of their specific areas
Reports to: DDON/Director
Immediate Actions
• On notification, proceed/attend the Leadership Group Meeting
• Inform DDON/Director if on leave for assessment period and identify and inform proxy (where relevant)
• Commence walk-through as per Manager Checklist and immediately escalate any concerns to the relevant DDON/Director
• Ensure you have reviewed SJGHC Short Notice Accreditation Cheat Sheet: What to expect from assessors
• Ensure you have reviewed and provided SCGHC Short Notice Accreditation Cheat Sheet: For Caregivers
During Assessment
• Ensure caregivers, VMOs and patients are aware of assessment occurring
• Identify patients that may be good candidates for assessor interview (as required)
• Keep up to date with WhatsApp updates.
• Inform MQR/DDON/Director immediately if any concerns raised at departmental visit
