1. Peter Freeman

2. Facilitate integration of quality activity into service delivery and to form the central hub for all quality activities within the Emergency Department. Provide communication about quality activities and initiatives for ED staff and provide integration with organisational quality improvement activities. Co-ordinate and drive quality activities within the Emergency Department. Work within the Quality framework domains of Clinical Profile, Education and Training, Administration, Professionalism and Research/Clinical Audit. Develop and maintain best practice initiatives and an evidence based culture for clinical practice. Monitor, report and evaluate professional and unit based quality activities. Maintain an overview of standards of practice, including clinical audit practice. Action outcomes and improvement initiatives from case reviews from critical incidents, complaints and mortality and morbidity meetings. Report to the Ambulatory Service Clinical Governance Group to enable and support strategic planning. Elevate any unresolved Quality issues to Service Clinical Governance Meeting.

3. Clinical Profile Clinical Indicators, Procedures, Imaging, Pathology, M&M meeting summaries, ED QA Senior Case Review, Medication errors, Whole hospital initiatives. Education & Training Profile Education meetings, Courses attended, Academic achievements, Teaching schedule, CPD compliance, Credentialing, Competencies Research Profile Publications/Presentations, Clinical Audits Administration Profile Waiting times, Trauma calls, Complaints/Feedback, PAGI Risk management, Finances/CAPEX, Workforce, Statistics Professional Profile Participation in hospital committees, Public health, Liaison.

4. Clinical ReportsFrequencyResponsibility of Core Clinical IndicatorsDefined by MOH in Suite of Quality MeasureMonthly ProceduresProcedural sedation logMonthly ImagingAudit of nurse X-ray requests and clinician activityMonthly PathologyHaemolysis rateMonthly M&M summariesMonthly report on learnings from cases discussedMonthly ED QA Senior Case ReviewSenior Doctor case reviews of near missesMonthly Medication errorsReport of medication errors identifiedMonthly Whole of hospital initiativesSmoking cessation, Family Violence, AlcoholMonthly Education & Training Education sessionsTeaching sessions, medical and nursingMonthly Courses attendedMedical & NursingMonthly Academic achievementsTemplates for both medical & nursingAs and when Teaching objectivesMedical & NursingAnnual CPD complianceAs part of medical credentialingAnnual CompetenciesNursingAnnual Research Publications/PresentationsAcademic publications or presentationsAs and when Clinical AuditsMedical auditsMonthly Administration Waiting timesArrival to Triage, Triage to seen, ED LOSMonthly Trauma callsNumber made with any delays or issues identifiedMonthly Complaints/FeedbackReport of numbers, types and trendsMonthly PAGIReport of numbers, types and learningsMonthly Risk managementOpen discussion about current risksMonthly Finances/CAPEXStanding reportMonthly WorkforceNew appointments and vacanciesMonthly StatisticsOpen forum for discussion about trendsMonthly Professional Hospital committeesList of hospital committee attendedMonthly Public HealthCurrent issuesAs and when LiaisonMedical and Nursing PortfoliosQuarterly

5. Allows Rotorua ED to respond to MOH Quality measures Formalises existing reports for Triage times and activity Provides a reference point for M&M meeting summaries, ED QA Senior Case Review and Medication error reports Profiles Whole of hospital initiatives. Education & Training activity is identified and recorded Education meetings, Courses attended, Academic achievements are recorded CPD compliance, Credentialing, Competencies are monitored Research is identified when active Publications/Presentations and Clinical Audits are shared and recorded Waiting times, Trauma calls, Complaints/Feedback, PAGI are discussed Risk management, Finances/CAPEX, Workforce, Statistics are discussed Participation in hospital committees, Public health activity and Liaison roles are acknowledged and recorded

6. CQI is a process and the ED Quality Group has focussed on identifying activity and responding to issues and trends A repository of Quality activity is being created that can form the basis of Clinical Governance and annual reports Issues are taken up by sub groups to investigate – such as Triage 2 non compliance (data entry/integrity) More structured discussion Less ad hoc administrative reporting – standardised reports Inputs from all professional groups in ED Feedback to staff