Standards for general practices

Quality improvement module

Criterion QI1.1 – Quality improvement activities

        1. Criterion QI1.1 – Quality improvement activities

Last revised: 24 Feb 2023

Indicator


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 shares information internally 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.

Why this is important

Making quality improvements to the practice’s structures, systems and clinical care that are based on the practice’s information and data will lead to improvements in patient safety and care.

Practice team engagement with the practice’s safety and quality systems is essential to help the practice implement its quality improvement activities.

Meeting this Criterion

Roles and responsibilities

Having at least one team member responsible for leading quality improvement in the practice establishes clear lines of accountability. The responsibilities of this role must be agreed to and documented (eg in a position description).

Engaging the practice team

Quality improvement relates to many areas of a practice, so the collaborative effort of the entire practice team is necessary if you are to achieve improvements in quality and safety of patients. You could improve engagement by establishing a quality improvement team made up of members from all parts of the practice team (eg doctors, nurses and administrative staff).

Actively participating in quality improvement gives all members of the practice team an opportunity to come together to share information and consider how the practice can improve.

In order to improve engagement and obtain feedback from the practice team about quality improvement initiatives and performance, you could:

  • include quality improvement as a standing agenda item at team meetings
  • provide notice boards or suggestion boxes for the team to contribute their ideas
  • keep the team up to date with any system or process changes
  • create short surveys to get the team’s thoughts on initiatives.

Quality improvement activities

Activities to improve a general practice can involve examining the practice’s structures, systems and clinical care. Relevant patient and practice data can help you identify where quality improvements can be made (eg patient access, management of chronic disease, preventive health).

Quality improvement activities can include:

  • changes to the day-to-day operations of the practice, such as
    • scheduling of appointments
    • normal opening hours
    • record-keeping practices
    • how patient complaints are handled
    • systems and processes
  • responding to feedback or complaints from patients, carers or other relevant parties
  • responding to feedback from members of the practice team
  • auditing clinical databases
  • analysing near misses and errors.

Quality improvement plans

Your practice could maintain a quality improvement plan and a register of quality improvement activities showing which have been undertaken, and their outcomes.

Using a quality improvement plan and register means you can:

  • track quality improvement efforts
  • identify whether improvements were made or other efforts are required to address the quality issue
  • reduce duplication of effort and time
  • evaluate the plan and effect of the activities conducted
  • provide a learning tool for members of the practice team who want to be involved in improvement activities.

Meeting each Indicator

QI1.1 A Our practice has at least one team member who has the primary responsibility for leading our quality improvement systems and processes.

You must:

  • educate the team member with primary responsibility for quality improvement activities in the practice about their role.

You could:

  • document the responsibilities of this role in the position description
  • develop a quality improvement team made up of members of clinical and administrative staff.

QI1.1 B Our practice team shares information internally about quality improvement and patient safety.

You must:

  • have a system to identify quality improvement activities.

You could:

  • allocate time in each team meeting to discuss quality improvement systems with your practice team
  • keep a record of planning meetings where quality improvement activities are discussed.

QI1.1 C Our practice seeks feedback from the team about our quality improvement systems and the performance of these systems.

You must:

  • keep a record of feedback from the practice team about quality improvement systems.

You could:

  • have notice boards or suggestion boxes the team can use to contribute their ideas
  • create short surveys for the team to complete that are incorporated into a quality improvement plan.

QI1.1 D Our practice team can describe areas of our practice that we have improved in the past three years.

You must:

  • keep records of quality improvements made to the practice or practice systems in response to feedback, complaints or audits.

You could:

  • keep minutes of meetings where improvements to the practice are discussed
  • have a system for developing, mandating, implementing and reviewing policies and procedures
  • include quality improvement as a standing agenda item at team meetings.

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