Mind the Gap: What do you do when practice doesn’t meet Standards?

Anita Lovegrove 1, Jacky Meyer 1

Monash Health, Melbourne, VIC, Australia


Accreditation is an invaluable review process however the framework of National standards poses a considerable challenge in providing evidence to demonstrate currency and performance against protocols enshrined by the governance of an organisation. One of the salient points is to ensure this knowledge is held by practitioners at the clinical face. Monash Health decentralised clinical auditing processes to practitioner level. This promotes both reflective practice and educates staff on the current protocols.
An annual risk assessment measures compliance and identifies gaps. Results are reported to the Hospital Acquired Infection governing committee. The intensive care unit had significant gaps and required immediate action.

A short funded project led by infection control with a brief identifying aims and objectives. A multidisciplinary team was assembled. Weekly meetings promoted robust and open discussion with key stake holders around the issues, ideas and potential solutions. Minutes reflected progress.

Reinvigorated staff engagement with positive outcomes in each criteria. Strengthened relationships with medical staff on infection control issues. Positive outcomes for environmental cleaning including fluorescent marking assessment. Engaged executive team to facilitate financial requirements to meet capital expenditure.

Risk assessments were proven to be an effective tool in identifying the gaps between practice and standards, and the governing structure reflected the facilities ability to escalate the urgency of action. A collaborative approach proved effective in achieving immediate outcomes, and providing a framework to maintain infection control standards going forward.

Recent Comments