Evidence has shown that quality improvement activities lead to positive change in practices, particularly when a whole practice team approach is adopted.

The RACGP Standards for general practices (4th edition) (the Standards) describes Quality Improvement (QI) as an activity undertaken within a general practice where the primary purpose is to monitor, evaluate or improve the quality of health care delivered by the practice (RACGP standards for general practices 4th edition).

The Standards recommend practices engage in quality improvement activities that review structures, systems and processes to aid the identification of required changes to increase the quality of healthcare delivery and safety of patients.

Quality improvement is the process where an opportunity to change practices occurs as a result of learning. Professional advice and a growing body of evidence demonstrate quality improvement activities lead to positive change in practices, particularly when involving a whole practice team approach. Activities the College recognises as inherently QI are:

  • Supervised clinical attachment
  • Plan, do, study, act
  • Clinical audit
  • GP research
  • Evidence based medicine journal club
  • Small group learning


Accreditation allows general practice to be measured against a set of minimum standards based upon high quality, safe and effective care for patients. Should general practices choose to become accredited, they are assessed against the RACGP Standards for general practices (4th or 5th edition). Currently, general practices can choose to register for accreditation with one of four providers. The main surveying organisations in NWMPHNs region are Australian General Practice Accreditation Limited (AGPAL) and Quality Practice Accreditation (QPA).

The 5th edition standards (mandated from November 2018) include a Quality Improvement Module based on the practice’s data and information. Ideas for activity could be developed based on:

  • Response to patient or staff feedback;
  • Day to day operations that are not working (e.g. record keeping processes);
  • Auditing clinical databases; and/ or,
  • Safety concerns.

RACGP Quality Improvement and Continuing Professional Development (QI&CPD)

The RACGP QI&CPD Program is recognised by many organisations including Australian Health Practitioner Regulation Agency (AHPRA) and Medicare. GPs are required to be enrolled in a Continuing Professional Development (CPD) program to satisfy the formal requirements of their medical registration (AHPRA), to access preferential rates from the national health insurance scheme (Medicare) and to achieve other career credentials.

The current RACGP QI&CPD 2017-19 Triennium requires GPs to participate in at least one Category 1 QI activity, a PLAN (Planning Learning And Need) activity and CPR. Category 1 activities can include any of the following quality improvement type options:

  • Clinical audit
  • Plan, Do, Study, Act (PDSA) cycles
  • Small group learning
  • Supervised clinical attachment
  • GP research

The establishment of a PLAN enables the GP to identify their professional development needs, how they intend to achieve their goals and evidence that these needs are being met.

More information regarding these activities can be found on the RACGP website.

In response to the rise in chronic disease and the continuing challenge of improving our health system, the Federal Government announced in the 2017-18 Budget a new Quality Improvement (QI) incentive starting from 1 August 2019.

The aim of the new Practice Incentives Program Quality Improvement (PIP QI) payment is to improve detection and management of chronic conditions and to help GPs focus on issues specific to their practice population.

The new QI incentive replaces five of the 11 PIP payments. This change involves general practices providing de-identified data to demonstrate improvements in patient care.

 Read more about PIP QI

If you have any questions about the PIP QI changes, please email quality@nwmphn.org.au

NWMPHN can assist you to prepare for the QI PIP and/or other QI-related activities by providing the following support:

  • Data quality improvement activities
  • Identifying patient populations
  • PENCAT installation, training and upskilling
  • Resources and tools - NWMPHN toolkit coming soon!
  • Practice team health assessment
  • Quality improvement ideas and templates

Please email quality@nwmphn.org.au to arrange a practice visit.

We understand that a whole of practice approach is needed to drive changes that lead to better patient care. Your practice can use a Quality Improvement (QI) process to make small and large changes, from driving better, more sustainable outcomes for staff, to reducing costs, improving patient experience of health care and delivering better outcomes for the overall health of communities.

This document will help you to understand how to complete QI activities in your practice, and includes tools, templates and examples.

Quality improvement activities

Research shows that strong primary health care involvement is associated with greater cancer screening participation rates. In particular, the following primary care activities have led to higher participation rates:

  • Having a GP endorse an invitation to take a screening test
  • Use of recall and reminder systems
  • Participation in quality improvement programs, incorporating audit and feedback on screening

GPs who complete activities in this toolkit may be eligible to accumulate RACGP CPD Accredited Activity points. For more information on the CPD requirements and process (prior to commencing your activities) please contact North Western Melbourne Primary Health Network Workforce (NWMPHN) Education and Training team for more information by email to education@nwmphn.org.au or call (03) 9347 1188.

The resources have been developed as part of the community-led cancer screening program which aims to increase early detection of bowel, cervical and breast cancer by strengthening workforce capacity within primary care settings and targeted community-led interventions.

Cancer Screening Tool Kit

This Cancer Screening Quality Improvement Tool Kit is a free resource which can assist you to apply a structured quality improvement approach to cancer screening within your practice and will assist your practice to meet the requirements for the Practice Incentives Program Quality Improvement (PIP QI) Incentive.

The document is available as a single file or as individual sections.

Education workshop videos

From May 2019 to May 2020, NWMPHN worked with eight practices from the Brimbank and Wyndham regions on an intensive quality improvement project to improve their approach to cancer screening within their organisations. NWMPHN supported the participants to plan and undertake activities to improve their recall and reminder processes and increase promotion of national bowel, cervical and breast screening programs within their practice.

The Innovation in cancer screening educational workshop videos and a transcript are available below:

  1. Community-led cancer screening: A quality improvement perspective
  2. Cervical cancer screening
  3. Improving colorectal cancer screening
  4. Screening for breast cancer
  5. Quality improvement and cancer screening: Final summary

    Video transcript

General practice plays a key role and is well placed to provide end-of-life care for patients. With the growth and ageing of Australia’s population, and an increase of chronic and life-limiting illnesses, the types of patient groups requiring palliative care has widened. Can your practice improve the care it is providing to patients at this stage of their life?

This workbook is part of a collection created by North Western Melbourne Primary Health Network (NWMPHN) to help general practices undertake self-directed quality Improvement. The workbooks have been created by general practice, for general practice, with input from NWMPHN teams and subject matter experts, and through consultation with the community and the broader primary care sector.

This workbook is perfect if you are new to quality improvement (QI) as it provides easy to follow steps to take you through Plan Do Study Act (PDSA) cycles and QI activities. It also contains tips and resources to assist you to apply a structured quality improvement approach to end-of-life care within your practice. The workbook covers several aspects of end-of-life care including advance care planning, palliative care, and voluntary assisted dying.

Included in this booklet are:

  • PDSA templates and examples
  • Useful PEN CAT recipes
  • Data collection ideas
  • How to track changes in your data
  • Helpful resources
  • Education and further training ideas
  • Links to HealthPathways

This workbook can be used by practices and individual professionals as evidence for:

  • The Practice Incentive Program Quality Improvement (PIP QI) Incentive
  • RACGP accreditation standards
  • Continuing professional development points

Follow these steps:

Step 1

Download the workbook and use it for self-guided quality improvement. The document is available as an interactive PDF.

  End-of-Life Care: Quality Improvement Workbook for General Practice

Step 2

Before you begin, reach out to your NWMPHN relationship manager for support on using this book effectively.

Your relationship manager can support you to:

  • Utilise PenCAT4 to extract practice data
  • Understand and interpret your data
  • Determine a goal for your project
  • Plan and undertake QI activities
  • Review the success of your QI activities

If you would like to hear more about what support the PHN can provide you please  Call 03 9347 1188 or email: primarycare@nwmphn.org.au

GPs can be eligible for 40x RACGP Accredited CPD points (formerly Cat 1 points) by undertaking activities in this booklet. Speak to your relationship manager or contact the NWMPHN Workforce, Education and Training team for assistance, and information on CPD requirements and process. Email education@nwmphn.org.au or call (03) 9347 1188. 

This workbook is developed through through the Commonwealth Government’s Greater Choices for At Home Palliative Care measure.

Case studies

New treatment plans that put the patient’s needs and goals first are having a positive impact on care at one general practice in West Melbourne.

The new plans use motivational interviewing and health coaching approaches to create and record health goals that are meaningful and achievable for patients, taking account of barriers and challenges specific to their circumstances.

A quality improvement grant from North Western Melbourne PHN provided the opportunity for Practice Nurse Maria Hussey from Premier Health Partners to redesign the treatment plan templates to make them more patient focused. “All the patients involved have said the care plan has really been able to give them some control and a real sense of what they need to do,” Ms Hussey said.

School holiday clinics for young children and their families are helping connect refugee and asylum seeker communities in Fitzroy with the health services they need.

cohealth on Brunswick St Fitzroy started the school holiday sessions in April 2016, part of an innovation program funded by North Western Melbourne PHN. One in every 10 patients at cohealth Fitzroy identifies as a refugee or asylum seeker, and with appointments for large family groups difficult to accommodate outside of school hours the school holiday program enables non-urgent health screening at a convenient time.

Nurse Jeanette George from cohealth said the holiday sessions “helped staff build relationships with local families and identify children who could benefit from early intervention services and follow up visits.”

Hundreds of VCE students in Caroline Springs had a less stressful time this year thanks to a new youth mental health program offered by local medical centre Active Medical.

Helped by a $3000 grant from North Western Melbourne PHN, Active Medical delivered a mindfulness and meditation session to over 300 students from nearby Lakeview Senior College, as well as an evening discussion with Active Medical clinical staff for both students and their parents.

Practice Manager Raphael Sammut said there was an overwhelmingly positive response to the sessions, both from the students and for the practice itself. “In the following weeks we saw a lot of students come in, and it was clearly linked to the sessions that we did,” Mr Sammut said.

A Hoppers Crossing health centre is leading the way in tracing and protecting people in refugee communities who may be at risk of contracting hepatitis B.

Supported by a grant from North Western Melbourne PHN, IPC Health Nurse Vicki Muscat and her team traced 420 people who were close contacts of 122 local Karen people known to be hepatitis B positive.

Most were already immune but around 12% were unprotected and just under 8% were already chronically infected with hepatitis B.

As well as giving close contacts the opportunity to be vaccinated or begin receiving treatment, Ms Muscat said the contact tracing program has also helped keep the original group of patients engaged with the health centre.

“It can be very hard to get people living with chronic hepatitis B to go to the GP and to get regular reviews,” Ms Muscat said.

“The project has really helped build the connection between the patients and the centre and encourage them to come in regularly for testing and review.”

More information

For further information about Quality Improvement, please email primarycare@nwmphn.org.au or call (03) 9347 1188.