Mrs Ning An1
1Sydney Sydney Eye Hospital, Sydney, Australia
Biography:
During my 37 years of nursing I have circulated in difference areas. I obtained knowledge and advanced nursing skills through these rotations in a variety of nursing areas which I have been able to provide excellent nursing care in Infection Prevention and Control/ Staff Health Department interstate.
Abstract:
Background
Preparing for 24 hours short-notice accreditation requires sustained staff engagement and a strong understanding of infection prevention and control practices. To strengthen compliance with NSQHS Standard 3 and enhance accreditation readiness, two hospitals implemented a dedicated Standard 3 Focus Month in November 2025. Gap analysis identified improvement opportunities in four key areas: hand hygiene, intravenous access devices (IVADs), environmental and shared equipment cleaning, and transmission-based precautions.
Aim
To improve staff awareness, knowledge and engagement with Standard 3 requirements through a structured and month-long accreditation preparation program.
Methods
This multidisciplinary program was delivered across four themed weeks. Activities included newsletters, fact sheets, education sessions, interactive games, ward-based quizzes and staff recognition initiatives.
Week 1 – Hand Hygiene: Clean Hands, Safe Lives
Week 2 – Intravenous Access Devices: Right Line, Right Care
Week 3 – Cleaning: Clean Spaces, Clear Risks
Week 4 – Isolation and Precautions: Protect to Prevent
Results
The program achieved high levels of staff participation across two hospitals. The results of survey showed that staff improved understanding of NSQHS Standard 3 requirements, increased awareness of IPC principles and greater confidence in supporting accreditation readiness.
Conclusion
The Standard 3 Focus Month provided an effective and engaging approach to accreditation preparation. Combining targeted education, recognition programs and interactive activities strengthened staff knowledge and reinforced evidence-based IPC practices and fostered a culture of accreditation readiness and continuous quality improvement across two hospitals.