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unitED Our Goals - 2021

In November 2019, the Emergency Medicine Leadership Team met to plan for the 2020 calendar year. The planning session led to the agreement on a set of goals to be achieved over the next twelve months. At a high level the team discussed a broad aim of reducing the incidents of avoidable patient harm and negative patient experience.

Then COVID happened.

In 2021, we are re-energising these plans. The development of the unitED microsite is one tool that we hope will support the achievement of the goals we first developed in 2019. We hope that the site will improve our communication practices, and encourage more staff collaboration. We also commit to keeping the content of the site user friendly, and managing the amount of new material that is circulated. The aim of the site is to:

  1. Create a single source of trusted and accurate communication material.
  2. Promote staff support activities, creating a forum for peer to peer encouragement and recognition.
  3. Create a central source of simplified information that details clinical and operational best practice in our emergency departments.

The activity and subsequent goals that the unitED site will support in 2021 are:


Goal: Morbidity and Mortality (Quality Review) recommendations will be implemented within 150 days.

To achieve this in 2021, we will:

  1. Review the Morbidity and Mortality (M&M) processes across the program.
  2. Develop and commence the use of a Morbidity and Mortality database that allows for the tracking of incident themes.
  3. Table and track Morbidity and Mortality meeting recommendations through monthly ED Leadership Meetings.
  4. Include Williamstown in Sunshine or Footscrays Morbidity and Mortality meetings.
  5. Regularly share the incident themes, and opportunities for improvement that come from the Morbidity and Mortality meetings.


Goal: 1000 – incidents of Peer to Peer Recognition will be recorded and shared across Emergency Medicine.

To achieve this in 2021, we will:

  1. Develop a peer recognition framework that outlines the traits Emergency Medicine staff value in a colleague.
  2. Develop electronic platform for submitting and sharing peer to peer recognition.
  3. Implement a quarterly Emergency Medicine reward and recognition meeting to review the peer to peer recognition program and to further reward incidents of staff excellence.

quality EDucation

Goal: 100% of Emergency Department staff will have easy access to simple education material about the Quality and Safety priorities of the departments. These priorities are aligned to the National Standards.

To achieve this we will:

  1. Develop a Quality and Safety staff education framework. The framework will be implemented through regular Theme of the Week (TOTW) updates, and easy access to associated Quick Reference Guides (QRGs).
  2. Implement the education framework that refreshes every six months, educating the staff on the department’s quality and safety priorities.
  3. Evaluate and report on staff opinion of the programs impact.
  4. Monitor the reduction of quality and safety incidents within the program.


Goal: The Emergency Medicine program will record over 500 patient experience feedback submissions. The information will be utilised, to improve the quality of care that we provide.

To achieve this we will:

  1. Develop and implement an easy to access patient experience survey.
  2. Commence theming all long form patient feedback that is provided.
  3. Regularly share survey results and feedback themes.
  4. Implement any recommendations that come from increased monitoring and measurement of the patient experience within 150 days.


Goal: > 65% of Emergency Department patients will be discharged or transferred to another point of care in less than 4-hours. This will be achieved consistently by Quarter 4 (October to December) of 2021.

  1. Each site to develop a twelve month access improvement plan
  2. Department Directors will work collaboratively with the Director of Access and Patient Flow to remove barriers to timely Ward transfers.
  3. Emergency Physicians and Senior Nursing staff to be engaged in the development of plans and effort to improve access.
  4. Twice yearly Access Forums to occur at each site to engage all staff on access improvement initiatives and current performance.
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Our Goals 2021:

  1. reviewED – all M&M (Quality) actions are implemented within 150 days of agreement
  2. recognisED – record 1000 incidents of peer to peer recognition
  3. quality EDucation – all staff have easy access to information about quality and safety priorities and performance.
  4. experienceED – record 500 patient experience feedback submissions.
  5. accessED – +65% NEAT cumulative for Western Health in the quarter September to December