Mock Accreditation Survey

A mock accreditation survey was held from 19 - 22 November to support us to prepare for the real survey in March 2020. Watch the videos of staff taken directly after visits to their patient care areas and read about Accreditation expert Sandy Thomson's feedback on what she saw during her visit.


NSQHS Standard expert Sandy Thomson was onsite at Western Health from the afternoon of Tuesday 19th November until late morning Friday 22nd November. 

As 60% of surveyor time during a real accreditation survey will be spent where care is provided to our patients, a key focus of the mock assessment was what could be seen and described in our patient care areas of our practices against the NSQHS Standards.

Sandy undertook a whirlwind visit of patient care areas at Sunshine, Footscray and Williamstown and was most impressed by the welcome she received from staff and the enthusiasm of staff to discuss Best Care. She was especially complimentary of how staff have embraced the recent launch of Comprehensive Care tools to support the assessment of care planning for our patients.

Key areas arising from the mock survey for attention of staff in our preparation for accreditation are:

  • Reinforcing housekeeping … testing and tagging of equipment, appropriate storage of items in fridges and daily checks, removal of old information from noticeboards, removal of mortar and pestles from wards
  • Updating PPGs and completing PDPs & Mandatory training … ensuring staff are aware of how to locate policies, procedures and guidelines and that they are up-to-date.  Ensuring staff have completed their Performance Development Plans and mandatory training requirements
  • Ensuring daily risks, incidents, changes to policy or procedure are discussed and managed … the mock survey noted a lack of daily ward huddles that address areas such as risks, incidents and changes to policy or procedure.  Tier 0 huddles provide an opportunity to strengthen the focus on these areas
  • Knowledge of accreditation standards and Live Best Care … the mock survey reflected staff need to further enhance their knowledge of the accreditation standards, what care aligned with the standard looks like in practice, our Live Best Care approach and what Best Care looks like in practice.

Several videos were taken of staff directly after mock survey visits to their patient care areas.  We thank staff for sharing their experience during mock survey and the videos can be viewed below.

A lot of Sandy’s verbal feedback at the end of the mock survey related to the areas covered in the ‘Are you Ready for Accreditation Guides’ in the tips and guides section of the Live Best Care site . It is worthwhile accessing these  to familiarise yourself with the NSQHS Standards and associated practice at Western Health. They will also help you answer Surveyor questions in March when they visit your area.

Two new learning packages will also help you prepare for accreditation survey:

Complete the WeLearn module ‘Living Best Care’ to find out more about Best Care and what it means to be living it every day with/for our patients
Complete the WeLearn module ‘Accreditation – Know Your Standards’ to gain an understanding of the Standards and how they relate to Best Care


Mock Assessment Staff Feedback:

CSSD – Footscray Hospital


1 West – Surgical Ward –  Footscray Hospital


Theatre – Williamstown Hospital


Paediatrics – Childrens Ward – JKWC


Emergency Department – Sunshine Hospital


Medical Imaging – Sunshine Hospital


Westside Lodge – Sunshine Hospital