QI in action: improving patient lifestyle and risk factor measures at Moreland West Medical Centre

Moreland Medical Centre team photo
  26 April 2023  NWMPHN   

Implementing small changes to routines can make a big difference, this practice discovered.

Moreland West Medical Centre is situated in Brunswick West and has 10 GPs and 3 practice nurses. It is a doctor-owned, family general practice and offers the full range of services, as well as psychology and podiatry. 

Planning for QI with NWMPHN support

Following a quality improvement (QI) meeting with North Western Melbourne Primary Health Network (NWMPHN), the clinic chose to focus on improving patient lifestyle and risk factors. Specifically, it would look at blood pressure, smoking status and waist measurement. These are linked to measures 2, 3 and 7 in the Practice Incentives Program (PIP).

Baseline measures were downloaded from Pen CAT4 in December 2022:

  • smoking status recorded for patients over 10 years of age – 88.5 per cent
  • blood pressure recorded for patients over 15 years of age who visited the practice in past 12 months – 82.56 per cent
  • patients for whom waist measurement was recorded – 20.11 per cent

The team planned to record specific QI measures indifferent months, during which all clinicians would be advised to opportunistically obtain. They would also implement a lifestyle waiting room survey. QI recording targets were:

  • January – blood pressures
  • February – smoking status
  • March – waist measurements

The results speak for themselves

The same measures were downloaded again from Pen CAT4 in April 2023:

  • smoking status recorded in patients over 10 years of age – 89.44 per cent, an increase of 1.06 per cent
  • blood pressure recorded in patients over 15 years of age who visited practice in the past 12 months – 83.07 per cent, an increase of 0.62 per cent
  • patients for whom waist measurement was recorded – 31.33 per cent, an increase of 55.79 per cent

The general practice team was surprised at how a small intervention made a positive difference in the statistics. Having more risk factors and lifestyle factors recorded means the practice can provide better care for patients. The team also learnt that this QI intervention was highly successful even when patients were unaware of any changes to practice.

Accurate data extraction and analysis was key to the project. NWMPHN’s QI program officer, Catherine Ferreira, supported the team throughout, helping to get the most out of tools including the clinic’s PIP QI data report and QI templates that align with the PIP QI measures.

Continuous improvement

The practice will continue to run a different lifestyle and risk factor blitz each month and monitor the data. It may also trial some new ideas to complement this activity. The hope is that taking these measures will eventually become integrated into everyday practice.


The NWMPHN QI website hub includes:

To support data-driven QI, we offer all accredited general practices the CAT PLUS software (CAT4 and Topbar) and training. This software and support are free. Learn more about our QI program.

For support with quality improvement please contact us on (03) 9347 1188 or email primarycare@nwmphn.org.au