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Roles and Responsibilities - SHED - ANUM Quality, Safety & Clinical Improvement

Primary Roles

The Quality, Safety and Clinical Improvement ANUM will work in collaboration with the Nurse Unit Manager and Emergency Services Operations Manager to provide governance, and oversight to all quality and safety issues related to patient care and clinical improvement measures required to meet the NSQHS standards and KPI’s.

Secondary Roles

  • To be the primary support and escalation point for the Floor Co-Ordinator
  • To be the conjugate for change
  • Coach and support staff
  • Regular review and response of all risk reports around patient care and breaches of protocol
  • Regular review and response of all OH&S issues reported by staff with timely communication with affected staff
  • Regular review and response to patient and consumer feedback received
  • Regular reporting to the Nurse Unit Manager around key performance indicators
  • Work together with the senior leadership team to meet departmental objectives and key performance indicators
  • Work with AV Triage to achieve AV Offload within 40 minutes
  • Implement strategies to expedite safe and timely transfer of patients out of the department with strict adherence to the 24 hour escalation protocols
  • Auditing of key performance and quality measures and reporting of these to the senior leadership team
  • Provide updates at the Daily Operating Systems meetings at 0815 and 0830 to both local and divisional team, respectively
  • Contributions to the SHED Monthly Quality Newsletter
  • Escalate and assist in the management of any issues that will impact the efficiency and safety of the Emergency Department.

Primary Workspace

  • ED Administration Area
  • Emergency Department

Quality and Safety

  • Ensures the Safety of patients and the environment by conducting regular safety checks
  • Ensure all patients departing ED to the ward have modified criteria in place (if applicable)
  • Infections precautions are considered and documented for all admissions
  • Any high risk patients are identified prior to departure (high risk of pressure injuries, falls risk, behavioural specials)


  • Director of Emergency Medicine
  • Director of Paediatric Emergency Medicine
  • Divisional Director, Emergency Medicine and Access
  • Director of Operations, Emergency Medicine and Access
  • Clinical Service Director, Emergency Medicine and Access
  • ED Nurse Unit Manager
  • Short Stay Nurse Unit Manager
  • SHED Operations Manager
  • Morbidity and Mortality Members
  • Floor Co-ordinator
  • Nurse In Charge
  • EMA Quality Partners

Escalation Plan

Facilitate the management and escalation of any issues that impact on quality and safety processes of the Emergency Department via consultation and liaison with:

  • Internal: Nurse Unit Manager, Director of Emergency Medicine, Operations Manager – Emergency Services
  • External: Ambulance Victoria, Victoria Police & Emergency Mental Health Teams

Methods of Documentation and Reporting

  • Riskman
  • Tier 3 ED Leadership Meetings – held weekly
  • EMA Quality and Safety Meeting – held monthly
  • QP & QSCI ANUM Meeting – held weekly
  • ED DOS Meeting – held daily
  • EMA DOS Meeting – held daily

Measures of Success

  • Zero tolerance for any 24 hour total length of stay breaches within the Emergency Department (this excludes admitted patient in the Short Stay Unit)
  • Achieve a 65% NEAT total for the department
  • Achieve an 80% AV Offload Stretcher time within 40 minutes of arrival
  • Prompt review of all ISR 1 & 2 reports within 24 hours of notification, during business days
  • Sustained improvement in time to treatment times
  • Ensure auditing compliance metrics are met as per current WH policies and guidelines
  • Ensure there is a sustained reduction in the number of pressure injuries and falls in the Emergency Department
  • Ensure open Riskman items are kept to a minimum across a 30, 60 and 90 day period, with a response to all open items within 3 – 5 business days
  • Ensure all feedback items receive a response within 30 days
  • Improved delivery of quality and safety to ensure Best Care is delivered to all patients in the community who require our care