Continuous quality improvement standard

CQI1 – Continuous quality improvement activities

Standards for general practices (6th edition)
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      2. CQI1 – Continuous quality improvement activities

CQI1 | Continuous quality improvement activities

Consumer expectation statement: I expect that this practice continuously monitors the services and care provided and makes improvements to enhance patient care.

CQI1.A The practice team undertakes continuous quality improvement activities. 

The practice:
  • trains member/s of the practice team who have the primary responsibility for quality improvement activities in the practice about their role
  • has a system to identify quality improvement activities
  • undertakes at least one quality improvement activity every 12 months, one of which includes the use of coded clinical data
  • keeps a record of feedback from the practice team about quality improvement systems
  • documents quality improvements made to the practice or practice systems in response to feedback, complaints, or audits
  • has processes to report performance data and quality improvement activities to the practice’s leadership.

CQI1.B The practice assesses and acts on its environmental performance to track progress toward sustainability goals and compliance with its documented strategies to reduce direct and indirect carbon greenhouse gas emissions.

The practice:

  • assesses progress toward sustainability goals and compliance and reports it to the practice’s leadership
  • implements actions based on the practice’s assessment that reduce direct and indirect carbon greenhouse gas emissions.

Aspirational criterion

CQI1.C  The practice measures environmental-impact metrics to assess and manage its overall environmental footprint.

The practice:

  • assesses and manages its overall environmental footprint.


Continuous Quality Improvement (CQI) results in service improvements through continuous cycles of change led by the practice team. Using practice information and data to make quality improvements to practice structures, systems and clinical care will lead to improvements in patient safety and care. 

Meeting these criteria contributes to the delivery of safe and high-quality healthcare. Improvements in environmental performance can:

  • reduce exposure to pollutants
  • support healthier indoor environments
  • enhance the practice’s resilience during climate-related disruptions.

These outcomes help safeguard vulnerable populations, reduce operational risks, and align the practice with public health and safety objectives.


Having at least one member of the practice team who leads CQI in the practice establishes clear lines of accountability. The responsibilities of this role need to be agreed to and documented and included in a position description or process document.


Giving all members of the practice team an opportunity to come together to share information and consider how the practice can improve, means that they are all actively participating in quality improvement. To do this, the practice could:

  • provide training for staff on quality improvement methodologies
  • establish a quality improvement team that:
    • includes members from all parts of the practice
    • meets regularly to discuss practice and performance data
    • leads improvements that are shared with the practice team
  • include quality improvement as a standing agenda item at team meetings 
  • keep a record of quality improvement discussions at planning meetings
  • provide virtual or physical noticeboards or suggestion boxes where the team can contribute their ideas 
  • have a system for developing, mandating, implementing and reviewing policies and procedures and keeping the team up to date with any changes 
  • create short surveys for the team to complete and incorporate feedback and ideas into a quality improvement plan.

The practice needs to report performance data and quality improvement activities to the practice leadership team which could include the practice owner, practice manager and clinical leads. The report could be based on:

  • structured or coded clinical data extracted from clinical software
  • clinical audits of a particular treatment or service
  • data reported to PHNs, such as Practice Incentives Program (PIP) and Quality Improvement (QI)
  • activities undertaken by the practice quality improvement team
  • activities that are informed by validated patient feedback.  

Because formal reporting of performance data and quality improvement to the practice leadership is not necessary to meet this criterion, the practice could:

  • provide verbal updates in team meetings
  • produce short summaries of data to share and discuss in team meetings
  • include data and quality improvement as a standing item on the team meeting agenda.

Analysing and sharing data with the practice team and leaders helps build a culture of continuous quality improvement.


The practice needs to set performance indicators and use them to determine how well they have or have not performed against the practice’s quality benchmarks. Elements of quality to be evaluated could include effectiveness, safety, timeliness, person-centeredness, efficiency, and equity. The practice could:

  • use patient feedback to determine performance indicators
  • use the Practice Incentives Program Quality Improvement (PIP QI) improvement measures to determine performance indicators
  • establish its own performance indicators and justify them
  • keep the same performance indicator for an accreditation cycle to see trends over time.


Analysis of coded data can be used to identify actions that will improve clinical care for the practice’s patient population. This data could be:

  • rates of immunisation
  • chronic disease management and preventive health
  • identifying patients with health/lifestyle risk factors such as smoking, alcohol consumption, physical activity
  • the use of antimicrobials in the practice.

The practice could encourage clinicians to complete CPD that includes the use of coded clinical data Through this process, the practice could also identify processes to improve data accuracy and completeness.

The RACGP’s CPD activities in your practice provides information about how GPs could meet CPD requirements that can also help them meet the requirements of criterion CQI1.A.


Appropriate aspects of a practice’s performance data need to be made publicly available. For example:

  • improvements in a service’s response to feedback
  • achievements made through a health campaign such as immunisation targets

The Practice could display this information in the waiting area, or on its website.


The practice’s quality improvement activities need to include an assessment of its environmental performance to track progress towards its environmental sustainability goals and strategies See F3 – Environmental sustainability and responsibility).

To assess its environmental performance, the practice could:
  • agree on measures to review the practice's environmental impact over time, such as energy consumption, waste generation, recycling practices, water usage
  • set specific, measurable, and time-bound improvement targets for reducing environmental impact (for example, improving resource efficiency)
  • inform patients about the practice's commitment to environmental responsibility and the progress that has been made
  • regularly review the actions taken to reduce the environmental impact and the effects of those actions.

The practice needs to report its progress towards its sustainability goals to the practice leadership teams. This could be done by including summaries of key environmental actions and outcomes as a standing agenda item of team meetings.


As criterion CQI1.C is aspirational, the practice could measure its environmental impact so that it can assess and manage its overall environmental footprint. This could include measuring, over time, of:

  • water and electricity use
  • waste reduction and recycling
  • environmental outcomes of procurement choices
  • the energy efficiency of practice equipment and appliances.

Many of the actions listed in Tables 1, 2 and 3 under F3 – Environmental sustainability and responsibility can be measured and assessed over time.

To achieve this, the practice could:

  • define a set of relevant performance indicators for:
    • the sourcing of materials and products from sustainable suppliers
    • indoor air quality
    • the generation and correct disposal of clinical waste
    • energy consumption from renewable sources.
  • use monitoring equipment to gather accurate and detailed information (for example, energy and water meters)
  • review collected data to identify trends and areas where resource efficiency and sustainability can be improved
  • communicate environmental metrics to staff and patients.


Consider introducing small changes that can be enhanced over time. Whether the practice premises are owned or leased, the practice could make use of what is already available, such as:

  • requesting utility usage data from owners instead of setting up additional monitoring
  • contributing to existing initiatives in the building (if sharing premises)
  • using existing property waste and recycling services.

As formal reporting of sustainable activities and results is not necessary to meet this criterion, the practice could produce summaries of key environmental actions and outcomes, and include them as a standing agenda item of team meetings.

 
  • Primary Health Networks provide useful quality improvement tools and resources for primary care. These include Practice Incentives Program (PIP) data to identify areas for improvement, how to use data extraction tools, quality improvement toolkits for specific conditions (for example, asthma, cardiovascular disease, COPD, diabetes), and templates for QI activities like a plan-do-study-act (PDSA) cycle. Examples can be found on websites of several PHNs, including Brisbane South PHN, Eastern Melbourne PHN, Hunter New England and Central Coast PHN, Nepean Blue Mountains PHN and South West Sydney PHN.  
  • The Clinical Excellence Commission has quality improvement resources, including QI toolkits focusing on clinical areas where the risk of harm is well recognised (for example, antimicrobial stewardship).
  • The Australian Commission on Safety and Quality in Health Care clinical care standards can be used to support quality improvement in specific conditions, treatments, procedures and clinical pathways, in order to align with best practice.
  • Business.gov.au provides further rationale and a template to develop a sustainability action plan that can be easily adapted to practices for the purpose of meeting these criteria.
  • MedicineInsight is a primary care quality improvement program using data from general practices I Australia to give insights into prescribing patterns and patient care.
  • The Australian Atlas of Healthcare Variation Series (ATLAS) examines a series of health topics, investigates variations and the possible reasons for them, and provides specific achievable actions to reduce unwarranted variation.
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