Quality Improvement (QI) Tool Kit

Quality improvement (QI) is nothing new, practices are doing it every day, probably without realising it. The key is to document QI activities so systems and processes can be reviewed to ensure continuing improvement in service delivery and patient outcomes.

The Royal Australian College of General Practitioners (RACGP) defines continuous quality improvement as an ongoing activity undertaken within a general practice with the primary purpose to monitor, evaluate or improve the quality of health care delivered to practice patients.

Put simply, QI is a process of regularly reviewing and refining your practice’s systems, structures and clinical care to improve patient outcomes and practice efficiency, underpinned by the Quintuple Aim for Health Care Improvement.

According to the RACGP Standards for general practices (5th edition), QI activities are important because making quality improvements to structures, systems and clinical care that are based on a practice’s information and data can lead to improvements in patient outcomes.

When QI activities are undertaken using a whole-of-team approach, the results can deliver positive change across one or more of the categories below:

• Safety – avoiding harm to patients and staff.
• Effectiveness – providing evidence-based care and services that are likely to be of benefit.
• Patient centredness – providing care that is responsive to each patient’s preferences, needs and values.
• Timeliness – reducing waiting times for care and avoiding harmful delays.
• Efficiency – avoiding and reducing waste.
• Equity and fairness – providing quality care regardless of a patient’s personal characteristics such as gender, ethnicity, location or socio-economic status.

Watch Dr Wally Jammal (general practitioner) and Learne Durrington, WA Primary Health Alliance CEO, discuss the concept of continuous quality improvement in general practice.

Whether your general practice is accredited or non-accredited, undertaking QI activities can deliver better outcomes for both the practice and patients by improving quality, safety, efficiency, productivity and sustainability.

QI activities also provide opportunities for your practice team to come together to share information and consider how the practice can improve. To achieve the best results, your team members should feel empowered to contribute towards the ongoing collaborative effort to improve patient safety and care.

By scheduling protected time to plan, implement, review and document QI activities that align with the Quintuple Aim for Health Care Improvement, your practice team can provide ongoing benefits in the following areas:

• Improving population health.
• Enhancing the care experience.
• Care team well-being.
• Reducing costs.
• Advancing health equity.

Undertaking QI activities is a mandatory requirement for practices wishing to achieve accreditation and receive the Practice Incentives Program Quality Improvement (PIP QI) Incentive payments.

Accreditation standards for general practice

In Australia, general practice accreditation is a voluntary process where practices are assessed against the Royal Australian College of General Practitioners (RACGP) Standards for general practices (5th edition) that were developed to provide assurance to the community that a general practice meets expected standards for safety and quality.

In terms of quality improvement, the RACGP Standards include a QI module with QI Standard 1 outlining the following Criterion QI1.1 for QI activities:

• QI1.1 A - Our practice has at least one team member who has the primary responsibility for leading our quality improvement systems and processes.
• QI1.1 B - Our practice team internally shares information about quality improvement and patient safety.
• QI1.1 C - Our practice seeks feedback from the team about our quality improvement systems and the performance of these systems.
• QI1.1 D - Our practice team can describe areas of our practice that we have improved in the past three years.

If you would like further information about general practice accreditation, visit the Practice Assist Accreditation for General Practice Tool Kit.

Practice Incentives Program Quality Improvement (PIP QI) Incentive

The Practice Incentives Program Quality Improvement (PIP QI) Incentive is a payment to general practices for undertaking continuous quality improvement activities in partnership with their local Primary Health Network (PHN). In Western Australia, WA Primary Health Alliance (WAPHA) is the operator of the state’s three PHNs – Perth North, Perth South and Country WA.

To be eligible for the PIP QI payment, practices in Western Australia must:

• be eligible for the PIP which includes being accredited or registered for accreditation against the RACGP Standards for general practices
• register for the PIP QI Incentive
• undertake continuous quality improvement activities in partnership with their local PHN (WAPHA)
• electronically submit the PIP Eligible Data Set to their local PHN (WAPHA) on a quarterly basis.

The PIP Eligible Data Set is de-identified patient data, aggregated at the practice level against the 10 PIP Quality Improvement Measures.

You can apply for the PIP QI Incentive online through HPOS using your PRODA account. After your practice has registered for the PIP QI Incentive, please notify your WAPHA practice support team member.

To find out more about the PIP QI Incentive, visit the links below:

• PIP QI Incentive guidance
• Practice Assist PIP QI FAQs
• Practice Assist PIP webpage

The first step on your QI journey is to establish a dedicated QI Team with members from different areas across your practice. The QI Team will work together to plan, implement, review and document QI activities while fostering a culture of quality throughout the wider practice team.

The responsibilities of your practice’s QI Team will include:

• sharing ideas and identifying focus areas
• planning, testing and implementing QI activities
• monitoring, reviewing and documenting progress
• providing feedback on outcomes and priorities
• developing internal progress reports
• sharing and celebrating successes.

It is important that your QI Team has protected time incorporated into its QI plans and activities, which will help ensure progress and send a message to the practice team about the importance of this type of work.

To find out more about assigning roles and responsibilities, refer to the QI Team Roles and Responsibilities Fact Sheet.

For further information about establishing a QI Team, refer to the How to build your QI Team resource.

After you have established your QI Team, the next step is to nominate a QI Team Lead who could be anyone in the QI Team that is enthusiastic about leading your practice’s quality improvement. The QI Team Lead does not have to be a manager or key decision maker, but it is important that they have the support of the leaders within your practice.

The responsibilities of your practice’s QI Team Lead will include:

• coordinating QI meetings and circulating agendas
• encouraging the views and opinions of the team
• taking and circulating QI meeting minutes
• ensuring appropriate resources, systems and support mechanisms are in place
• facilitating and assisting with implementing QI activities
• providing regular communication about QI activities
• reviewing the progress of QI activities
• collating/distributing practice data reports
• modelling enthusiasm for quality improvement
• fostering a culture of open communication.

Having a QI Team Lead will also help your practice meet the RACGP Standards for general practices (5th edition) QI Standard 1 indicator QI1.1 A that states:

• Our practice has at least one team member who has the primary responsibility for leading our quality improvement systems and processes.

​For further information about nominating a QI Team Lead, refer to the How to build your QI Team resource.

The RACGP Standards for general practices (5th edition) encourage quality improvement so that practice teams can identify opportunities to make changes that will improve patient safety and care.

To identify opportunities for focus areas within your QI activities, it can be helpful to clearly define the problem that you would like to improve and consider how the outcomes will align with the Quintuple Aim for Health Care Improvement.

Don’t forget to keep in mind that your general practice is a business and it will be easier to get support from the overall team if the focus areas for QI activities have a clear business case for change.

After you have identified and selected the focus areas for your QI activities, you should set SMART goals that are Specific, Measured, Achievable, Relevant and Timed. Setting SMART Goals provides a structured approach that outlines what you want to achieve and by when, which can prevent you feeling overwhelmed by the QI activities.

Once your practice has established a QI Team, nominated a QI Team Lead, identified focus areas and set SMART goals, you are ready to plan and implement your QI activities.

Throughout your QI activities, it is important to review and document the progress which will help to:

• inform and motivate your team
• see whether the changes are leading to improvement
• learn from the outcomes and celebrate successes
• provide evidence for accreditation and PIP QI
• identify unintended consequences
• improve patient safety and practice efficiency
• support sustainability and reduce waste
• recognise patterns and trends
• identify performance gaps and issues
• support decision making and planning.

The following tools can be used to assist your team with planning, undertaking, evaluating and documenting QI activities:

• QI PDSA Template
• QI PDSA Template (Word)
• Guide to documenting a QI activity as a PDSA
• Guide to documenting a QI activity as a PDSA (Word)
• Identifying and undertaking QI activities using PDSAs
• Identifying and undertaking QI activities using PDSAs (Word)
• QI PDSA Log
• QI PDSA Log (Word)
• Quarterly QI Plan
• Quarterly QI Plan (Word)
• QI Work Plan
• QI Register
• QI Register (Word)
• QI Activity Progress Report (Word)

​For further information about using these tools and templates, refer to the resources section of this webpage.

To help ensure that your QI activities are successful, you need to plan, implement, review and document thoroughly and systematically. By understanding the ‘what’ and the ‘why’ and using the resources in this QI Tool Kit, you will be more likely to achieve your goals and meet the Quintuple Aim for Health Care Improvement.

Set up your practice for success

• Ask one of our Practice QI Coaches about how we can help you.
• Identify and consider several ideas for improvement.
• Set SMART goals that are Specific, Measured, Achievable, Relevant and Timed.
• Consider whether the changes will align with the Quintuple Aim for Health Care Improvement.
• Implement small changes first and work up to large changes.

Collect useful, accurate and varied data

• Collect feedback from your patients and team members.
• Collect baseline data and progressive data.
• Collect qualitative and quantitative data.
• Keep stakeholders informed, involved and engaged.
• Involve your staff, keep them informed and acknowledge their contributions and successes.
• Involve some of your patients in QI activities.
• Display information visually (e.g. graphs, charts and tables).

Review and learn from the outcomes

• Review, monitor and assess the outcomes honestly, so you can improve your processes and achieve real improvement.
• Document your process and outcomes, including how the process could be improved, so you can learn from the outcomes.

If you have any questions or need assistance, get in touch with one of our helpful Practice QI Coaches by contacting Practice Assist.

Establishing a dedicated QI Team within your practice will make it easier to plan, implement, review and document QI activities. To help you establish your QI Team and nominate a QI Team Lead, we recommend downloading and completing the following resource:

• How to build your QI Team

Completing this resource will also assist you with:

• assigning roles and responsibilities
• setting the scene of what QI looks like in your practice
• scheduling protected time for quality improvement
• considering administration processes to embed QI into day-to-day tasks
• defining your communication method and frequency
• designing the review process for your practice.

For further information about assigning roles and responsibilities, refer to the QI Team Roles and Responsibilities Fact Sheet.

To help you develop, test and implement QI activities within your general practice, we recommend using the internationally recognised Model for Improvement (MFI) with Plan-Do-Study-Act (PDSA) cycles.

The MFI outlines a simple, two-part approach that is designed to guide your QI Team through the improvement process by breaking it into manageable, easy-to-follow sections.

The first part of the MFI approach is referred to as the ‘thinking’ part, which aims to focus QI activities by asking:

• what are we trying to accomplish?
• how will we know/measure that the proposed change will be an improvement?
• what changes can we make that will lead to an improvement?

The second part of the MFI approach is referred to as the ‘doing’ part, which includes the Plan-Do-Study-Act (PDSA) cycle that will help you:

• test the ideas from the ‘thinking’ part
• assess whether you are achieving your goal from the ‘thinking’ part
• determine which changes you want to adopt permanently.

For additional information, see the Model for Improvement (MFI) and PDSA Cheat Sheet.

To find out more about the Plan-Do-Study-Act (PDSA) cycles, refer to the next section below.

Plan-Do-Study-Act (PDSA) cycles provide a framework to help you develop, manage and test your QI activities.

Using the PDSA cycle framework is also a simple and effective way of documenting your QI activities, which can help you build a case for change and provide evidence for accreditation and PIP QI purposes.

As the name suggests, each PDSA cycle includes the following four stages:

• Plan – develop a plan and the steps involved.
• Do – implement the plan and record the observations.
• Study – analyse and learn from the results.
• Act – adopt if you achieved the planned results. Adapt if your results are not quite what you wanted, but could be tweaked. Abandon if you have tested the findings several times, but it’s just not working out.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963536

For further information about implementing and documenting PDSA cycles, refer to the resources below:

• Guide to documenting a QI activity as a PDSA
• Guide to documenting a QI activity as a PDSA (Word)
• Identifying and undertaking QI activities using PDSAs
• Identifying and undertaking QI activities using PDSAs (Word)
• QI PDSA Template
• QI PDSA Template (Word)
• QI PDSA Log
• QI PDSA Log (Word)
• QI Activity Progress Report (Word)

Setting a SMART goal is the first part of the Model for Improvement (MFI) and the Plan-Do-Study-Act (PDSA) cycle.

A goal is referred to as SMART when it is Specific, Measured, Achievable, Relevant and Timed. Using the SMART goal framework provides your QI Team with a structured approach that can help:

• clarify and prioritise focus areas
• focus effort and resources
• manage time productively
• monitor progress
• measure performance
• increase the likelihood of success.

For further information about setting SMART goals, refer to the resources below:

• SMART Goals Cheat Sheet
• Model for Improvement (MFI) and PDSA Cheat Sheet

Throughout your QI journey, it is important to measure improvement by monitoring and evaluating your progress against the measures that you decide upon during the planning stage.

Successful measurement is a corner stone of QI activities, but that does not mean measuring improvement has to be difficult or time consuming.

The key is to pick the right measures so that you are able to see results quickly and adapt your actions if necessary, which will put less strain on your resources and greater focus on outcomes.

For further information, refer to the Measuring Quality Improvement Fact Sheet.

Quality improvement plans and work plans are simple templates designed to help your QI Team plan and document your practice’s QI activities.

For further information, refer to the templates below:

• Quarterly QI Plan
• Quarterly QI Plan (Word)
• QI Work Plan

To help your QI Team track, monitor and document your practice’s QI activities, we recommend using a quality improvement register that can be easily updated throughout the process.

Maintaining a quality improvement register is an effective way of tracking your qualitative improvement, which relates to measuring, or being measured by, the quality of something rather than the quantity.

To see what information should be included in a quality improvement register, refer to the template below:

• QI Register
• QI Register (Word)

Your practice’s clinical information system can collect a large amount of information about your patients, which can provide a rich source of data for QI activities.

To ensure that your patients’ health records are accurate and current, it is essential to maintain your patient database with data cleansing and data quality improvement practices.

Data cleansing

Regular and opportunistic data cleansing activities are essential to maintain your patient database.  

Archiving inactive patients, in conjunction with identifying duplicate patient records, and maintaining a set number of ‘test patient’ are processes to assist in the maintenance of the practice patient data base enabling:  

• accurate practice level reporting and data analysis
• the understanding of the practice patient population and patient cohorts.

This may identify possible QI activities, and addresses multiple standards under the RACGP (Royal Australian College of General Practitioners) 5th edition standards for general practices.

For further support with data cleansing QI activities, including PDSA cycles, contact Practice Assist to be linked in with a Practice QI Coach in your area.
 
Baseline data collection

Baseline data collection includes:

• non-clinical patient demographic data (e.g. next of kin, email address, mobile number)
• clinical demographic data (e.g. allergies, etc)
• lifestyle risk factors (e.g. smoking status, etc).

It is encouraged that practices complete this activity as a 'baseline' QI activity to identify potential ‘targeted’ QI activities based on the results.
 

Primary Sense

WA Primary Health Alliance (WAPHA) provides general practices with Primary Sense, a population health management, clinical decision support and data extraction tool that helps general practice deliver the right care to patients at the right time.

For further information, refer to the Primary Sense Tool Kit and FAQs.

The Australian Government has introduced a new voluntary patient registration (VPR) model called MyMedicare to drive improvements in primary health care for all Australians and deliver new funding packages to primary care providers.

For information about preparing your practice for MyMedicare, refer to the MyMedicare QI Practice Readiness Fact Sheet.