Accreditation tip of the month: Meeting the requirement for quality improvement

  27 August 2020  Dr Jeannie Knapp   

By Dr Jeannie Knapp, GP and Primary Health Care Improvement GP Adviser, North Western Melbourne Primary Health Network.

The Royal Australian College of General Practitioners (RACGP) has developed the Standards for general practices (5th edition) to protect patients from harm by improving the quality and safety of health services.

The RACGP Standards for general practices (5th edition).

The requirement for quality improvement

General practices across Australia have embarked on a new quality improvement journey, with the implementation of the Practice Incentives Program Quality Improvement (PIP QI) Incentive. The PIP QI Incentive is a payment to encourage practices to participate in quality improvement activities, aimed at improving patient outcomes through the delivery of high-quality care.

To participate in the PIP QI Incentive, practices must be accredited, or registered for accreditation against the RACP Standards for general practices (5th edition), share the PIP eligible data set with their local Primary Health Network (PHN) and  commit to implement continuous quality improvement activities in partnership with this PHN.

QI Standard 1

From the Standards (5th edition):

Criterion QI1.1 – Quality improvement activities

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.

Engaging the practice team

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

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 (for example: 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.

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 internally shares information 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.

Support is available

North Western Melbourne Primary Health Network has introduced a General Practice Improvement Plan. This plan is a resource practices can use to identify specific priorities and objectives that you would like to achieve over 12 months and outlines how the PHN will work with you.

The plan allows practices to identify priorities for the practice over the next 12 months, including priorities for quality improvement. This plan can contribute to meeting the QI related accreditation criteria as evidence of the quality improvement that has been undertaken and discussed at the practice.

If you would like support with quality improvement activities within your general practice please contact your NWMPHN relationship manager on 03 9347 1188 or email: