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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 3.1 Safety and quality

Our practice is committed to quality improvement.

Criterion 3.1.1

Quality improvement activities

Our practice participates in quality improvement activities.

Indicators

► A. Our practice team can describe aspects of our practice that we have improved in the past three years.

► B. Our practice uses relevant patient and practice data for quality improvement (eg. patient access, chronic disease management, preventive health).

Explanation

Key points

  • Practices need to engage in quality improvement activities to improve quality and safety for patients in areas such as practice structures, systems and clinical care
  • Decisions on changes should be based on practice data
  • Achieving improvements requires the collaborative effort of the practice team and all members of the team should feel empowered to contribute
  • This criterion cross references to Criterion 2.1.2 Patient feedback and Criterion 1.3.1 Health promotion and preventive care.

Quality improvement is an essential business activity

Improvement in general practice can involve examining practice structures, systems and clinical care. Improvement needs to be based on evidence produced by the practice’s own data. This data can be gathered from patient or staff feedback, an audit of clinical databases, or the analysis of near misses and mistakes.

Examples of quality improvement

It is important that standards for general practices encourage quality improvement and identify opportunities to make changes that will increase quality and safety for patients.

It is critical the practice has a plan for carrying out any improvements it has identified as being necessary. Quality improvement activities can encompass changes to the day-to-day operations of the practice (eg. scheduling appointments, normal opening hours, improving patient health record keeping, changing the way patient complaints are handled, or altering systems in response to ‘near misses’). Quality improvement can also encompass activities specifically designed to improve clinical care or the health of the entire practice population (eg. improving rates of immunisation, improving the care of patients with diabetes or hypertension or altering the systems used to identify risk factors for illnesses that are particularly prevalent in the practice’s local community such as cardiovascular disease). For example, practices could undertake an internal assessment of their clinical handover processes by checking with randomly selected referral recipients whether the practice’s clinical handover processes are consistently satisfactory.

Patient experience feedback

Patient feedback is an essential component of quality improvement activities in both clinical and system domains (see Criterion 2.1.2 Patient feedback).

Practice accreditation as a driver of quality improvement

One of the most effective quality improvement activities is formal accreditation using these Standards; peer surveyors can provide extremely useful ideas about how a practice can improve in a range of areas.

Information management

Quality improvement activities are underpinned by effective information management techniques that allow practices to collect and analyse practice data and make decisions for service changes based on that data. Innovative use of information technology can assist practices in performing quality improvement activities to improve the health of their practice population. Ideally, practices need to review their own practice data for quality improvement purposes. Where such data is not easily accessible (eg. in non-computerised practices) national recall and reminder registers such as the Australian Childhood Immunisation Register can provide practice specific data for practices to use in quality improvement activities.

Data collection

Consistent data coding systems drive meaningful quality improvement activities. Coding is an effective means to address issues of having consistent clinical terminology. This can be readily addressed by means of a software system that uses ‘drop down box’ functionality in defining medical diagnoses. Coding can form the basis of chronic disease registers and avoids the confusion that can result from ‘free text’ style descriptions in the medical history.

It is preferable for the practice to use nationally recognised coding systems rather than a system which is idiosyncratic to the practice.

Quality improvement is a team activity

Engaging in quality improvement activities is an opportunity for the practice’s GPs and other staff members to come together as a team to consider quality improvement. Quality improvement can relate to many areas of a practice and achieving improvements will require the collaborative effort of the practice team as a whole.

Quality improvement tools and other resources

The National Prescribing Service offers free quality improvement activities that help GPs review their prescribing habits at www.nps.org.au/health_professionals/activities/ clinical_audits_for_gps/clinical_e-audits_for_gps.

Australian Primary Care Collaboratives offer subsidised learning workshops on a model for improvement at www.apcc.org.au.

The RACGP Quality Framework included in the January/February 2007 issue of Australian Family Physician discussed the theory of quality improvement in general practice and included an examination of the RACGP Quality Framework at www.racgp.org.au/afp/200701). 

RACGP QI&PD services offer a wealth of quality improvement tools and guides including clinical audit mechanisms. Visit http://qicpd.racgp.org.au.

The RACGP has produced and endorsed a wide range of guidelines to assist GPs and practice teams in their work. These resources are available at www.racgp.org.au/guidelines.

The Measurement for improvement toolkit is a tool produced by the Australian Commission on Safety and Quality in Healthcare and is available at www.safetyandquality.gov.au/internet/safety/publishing.nsf/content/publications-M.

Standard 3.1 Safety and quality

Our practice is committed to quality improvement.

Criterion 3.1.1

Quality improvement activities

Our practice participates in quality improvement activities.

In a nutshell

Quality improvement activities increase quality and safety for patients. The best quality improvements are the result of team efforts, and involve looking at your health service’s structures, systems and clinical care, and planning, implementing, reviewing and further improving what your service does in a regular and systematic way.

Key team members

  • Health service manager
  • CEO/director
  • Clinical and administrative staff
  • Board

Key organisational functions

  • Quality improvement plan
  • Quality improvement tools
  • Service planning and evaluation meetings
  • All related clinical and service delivery policies and protocols
  • Service delivery charter or principles
  • Patient feedback policy and processes
  • Clinical and health service data collection 
and use
  • Clinical audits

Indicators and what they mean

Table 3.1 explains each of the indicators for this criterion. Refer to Criterion 3.1.1 Quality improvement activities of the Standards for general practices for more information, resources and explanations of some of the concepts referred to in this criterion. 

Table 3.1 Criterion 3.1.1 Quality improvement activities
IndicatorWhat this means and handy hints
▶ A. Our practice team can describe aspects of our practice that we have improved in the past 3 years. Your health service undergoes regular quality improvement activities, and your staff know about these improvements. These activities could include regularly monitoring, reviewing and providing plans for action drawn from data in areas such as:
  • patient feedback
  • day-to-day operations (for example, appointments, opening hours, patient record keeping and patient complaints handling)
  • clinical care (for example, referral protocols, clinical handovers, immunisation rates, Pap smear rates, child and adult health checks, and identifying health risk factors based on your patient population)
  • health service data (for example, audit of clinical databases, analysis of near misses and mistakes)
  • complaints handling processes and results.
Reviewing, developing and implementing plans of action to improve clinical care and systems, when documented, are all evidence of quality improvement activities. It is recommended you conduct these activities on a regular basis, and as necessary in relation to clinical risk management. These activities are, ideally, collaborative efforts from all members of your health service team. They are most effective when they take place in a way that helps staff feel empowered, safe to contribute and confident of implementing change effectively.

In situations of near misses or mistakes, it is recommended that your health service undergo quality improvements to immediately address what has gone wrong, and ensure they don’t happen again.
▶ B. Our practice uses relevant patient and practice data for quality improvement (e.g. patient access, chronic disease management, preventative health). Data collection is crucial because it gives you a bird’s eye view of what has been happening in your health service. Using the appropriate data will help you to identify your service’s strengths and weaknesses and how to improve on them. It is important to collect data carefully so that it makes a reliable basis for quality improvement activities. See examples of data in Indicator A.

Some health services may not have sophisticated information technology. In these instances, data from immunisation records, recall systems, chronic health registers and the like are also useful to help identify quality improvement activities. It is vital that all data your health service relies on for quality improvement comes from your service.

Following the Council of Australian Governments’ (COAG) National Indigenous Reform Agreement, a set of 24 national key performance indicators (nKPIs) has been approved by the Australian Health Ministers’ Advisory Council (AHMAC) for reporting by Commonwealth and state and territory government-funded services that provide healthcare to Aboriginal and Torres Strait Islander peoples.

Commonwealth government-funded services commenced reporting 11 nKPIs (for 2011–12 data) in July 2012. Reports due in July 2013 (for 2012–13 data) will include a further eight nKPIs; reports due in July 2014 (2013–14 data) will include a further five nKPIs, using detailed specifications to be determined by AHMAC during 2012–13. Consistent with COAG agreements, it is anticipated that nKPI data for subsequent years will also be collected from state and territory government-funded services.

Services will be able to use the nKPIs to generate and view a wide range of reports and charts about their activities; these can also be used to participate in CQI programs, projects and other data quality initiatives.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can participate in quality improvement activities. Not all of these good practices are required by the Standards, but they illustrate the many practical and creative things that ACCHSs can do to ensure they deliver services of high safety and quality to their community.

The health service identifies areas for improvements at regular team meetings and annual planning meetings, based on data collected by the service itself. Priority topics are determined by adverse events, near misses and mistakes, patient feedback and staff feedback, as well as monitoring of issues arising from usual operations in reception, administration and clinical areas of the health service.

Some areas the health service has addressed – and improved on – were important to improving patients’ experience of the centre. These areas include scheduling appointments and catering for walk-in clients; changing opening hours; changing incident reporting; and handling of near misses and adverse events.

The health service prides itself on its public health activities and seeks to monitor these via, for example, immunisation rates in the under-5s, and flu vaccinations in the elderly and in patients with chronic diseases. The service keeps a database for each of its core programs, such as chronic disease, under-5s, women’s health, men’s health and antenatal care programs. Further, the service has reliable patient management software that is able to collate patient data into meaningful reports of their demographics, clinical presentations and how they were managed. This data helps the health service to make decisions about changes to its services.

The service’s GPs are encouraged to participate in clinical audits. Some are free, such as the National Prescribing Service’s clinical audits for GPs. Other clinical audits the service conducts on a regular basis include how it manages patients with diabetes, high cholesterol, high blood pressure and those with depression, to identify areas for clinical improvement.

The health service actively participates in more intensive quality improvement cycles, through the support and facilitation of external organisations such as One21Seventy and the Improvement Foundation. It shares information and learns from other participating ACCHSs, using collaborative learning processes and good use of information technology.

Clinical and administrative staff members are aware of the introduction of the nKPIs and their use in reporting to the Office for Aboriginal and Torres Strait Islander Health. The service plans to identify and implement a quality improvement activity for each of the first 11 indicators.

Showing how you meet Criterion 3.1.1

Below are some of the ways in which an Aboriginal community controlled health service might choose to demonstrate how it meets the requirements of this criterion for accreditation against the Standards. Please use the following as examples only, because your service may choose other, better-suited, forms of evidence to show how it meets the criterion.

  • Maintain a quality improvement plan based on collated patient feedback, clinical data and reports, incident reports and other data.
  • Keep clinical data and reports, including rates of childhood vaccinations, completed adult health checks and updated risk factors.
  • Maintain a quality improvement plan based on a clinical audit completed by staff.
  • Maintain a continuous improvement register.
  • Use patient management software.
  • Use a clinical program database.
  • Keep agenda and minutes for planning meetings.
  • Prepare reports to funding bodies.
  • Preapre reports on use of patient feedback, clinical audits and other improvement achievements.

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