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)

Communication

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

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