RACGP aged care clinical guide (Silver Book)

Silver Book - Part C

Quality improvement

Silver Book - Part C
    5. Quality improvement

Last revised: 28 Jul 2023

Quality improvement is a systematic, ongoing activity to improve the quality of care and services. The RACGP Standards for general practices (5th edition) encourage quality improvement so that general practices can identify opportunities to make changes that will improve patient safety and care (see Standards for general practices: QI Standard 1). There is scope for improving the quality of medical care for people in aged care through the implementation of learning systems and tools over the short and medium term. This chapter outlines some structured and systematic approaches to quality improvement so that aged care settings can work towards implementing sustainable solutions for GPs working in aged care.

Many RACFs use a continuous quality improvement cycle to implement changes. Standard 8. Organisational governance of the Aged Care Quality and Safety Commission standards details strategic priorities to promote a culture of safety and quality in aged care facilities’ governance systems. It is expected that aged care facilities have governance systems in place to assess, monitor and drive improvement in the quality and safety of the care and services they provide.

It is important for aged care facilities to consider the importance of GPs in the clinical governance of their facility, and involve them in quality care discussions.

The RACGP encourages all services that provide primary healthcare to consider the Standards for general practices (5th edition) as a template for quality improvement and risk management. The Standards provide a standard of care for GPs to apply to all settings, including RACFs.

Accreditation against the Standards also enables general practices to access the Practice Incentives Program (PIP) and Workplace Incentive Program (WIP) – practice stream. These programs are managed by the Australian Department of Health and Aged Care, and payments are made directly to the participating practice.

Structured and systematic approaches to quality improvement are important in identifying areas of inefficiency or suboptimal performance within an organisation and take systematic actions to address them. These systems provide a structured framework for organisations to continuously learn, adapt and evolve in response to change. 

Quality improvement activities may include:

  • models of improvement (eg plan–do–study–act (PDSA) cycles, plans for continuous improvement)
  • feedback from consumers/patients
  • feedback from the general practice/RACF team
  • audits of clinical data
  • knowledge sharing and collaboration. 

Models for improvement

The model for improvement entails three main concepts to consider when undertaking improvement:

  1. Aim: What are you trying to accomplish?
  2. Measures: How will you know that a change is an improvement?
  3. Changes: What changes can you test that will result in an improvement?1 

Plan–do–study–act

Changes identified as part of the model of improvement can be tested using small-cycle testing called PDSA cycles. These small changes can build into larger improvements in practice through successive quick cycles of change, as shown in Table 1. 

Table 1. Plan–do–study–act cycle
Step 1. Plan to test a selected improvement or change
Once the actual change to be introduced has been agreed, consider the following questions:
  • What would we expect to see as a result of this change?
  • What data do we need to collect to check the outcome of the change?
  • How will we know whether the change has ‘worked’ or not?
  • Who, what, where, when, why?
Step 2. Do the test and collect the data for analysis
Keep the ‘do’ stage short and record any outcomes, unexpected events, problems and other observations.
Step 3. Study the results/analysis of your data
  • Has there been an improvement?
  • Did your expectations match the reality of what happened?
  • What could be done differently?
Step 4. Act on the result
Do an ‘amended’ version of what happened during the ‘do’ stage, and measure and study any differences in results.
  • What changes do you need to make next?
  • What will the change be?
 

Once you have achieved success in a PDSA cycle, the change can be implemented as part of usual practice and mechanisms established to sustain the improvement. These mechanisms may include:

  • training and education of staff
  • standardisation of systems and processes
  • documentation of associated policies and guidelines
  • measurement and review to ensure that the change is incorporated into routine practice. 

Over the long term, there are further challenges for enhancing the quality of medical care in the residential setting. There is a need for:

  • the inclusion of residents in clinical studies of the effectiveness of interventions
  • systematic data collection to build an information base about the epidemiology and current medical treatment of the residential aged care population
  • processes to establish agreed and evidence-based treatment guidelines specific to the needs of this population.

GPs could help meet these challenges by working with other professional groups (eg nurses, allied health, geriatricians and aged care facilities) to:

  • collect agreed objective data that can be used comparatively as a starting point for quality enhancement
  • examine and understand reasons for suboptimal care
  • establish agreed clinical indicators that reflect good care
  • establish agreed evidence-based benchmarks
  • develop agreed strategies for translating evidence into practice.

Collecting and responding to feedback about patients’ experiences has been shown to improve:

  • clinical effectiveness and patient safety
  • adherence to recommended medication and treatments
  • preventive care, such as the use of screening services and immunisations.2

Criterion QI1.2 of the RACGP Standards for general practices (5th edition) requires practices to:

  • collect feedback from patients, carers and other relevant parties in accordance with the RACGP’s Patient feedback guide
  • analyse, consider and respond to feedback
  • inform patients, carers and other relevant parties about how the practice has responded to feedback and used feedback to improve quality.

Patients appreciate knowing that their feedback is taken seriously and acted on where possible. 

Resident engagement is also of particular importance in the development, delivery and evaluation of care and services in the Aged care quality standards:

  • Standard 6. Feedback and complaints: Aged care facilities are expected to demonstrate that they encourage and support consumers and their representatives to provide feedback or complain about the care and services they receive.
  • Standard 8. Organisational governance: Aged care facilities are expected to ask for input from a wide range of consumers about their experience and the quality of the care and services they have received. 

Quality improvement tools and guides

The RACGP’s continuing professional development (CPD) program offers a wealth of quality improvement tools and guides, including clinical audit mechanisms. Further information is available here. 

  1. Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: A practical approach to enhancing organizational performance. 2nd edn. Jossey-Bass Publishers, 2009.
  2. Epstein RM, Franks P, Fiscella K, et al. Measuring patient-centered communication in patient–physician consultations: Theoretical and practical issues. Soc Sci Med 2005;61(7):1516–28.
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