Quality improvement

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Quality improvement in general practice

The Royal Australian College of General Practitioners (RACGP) defines quality improvement (QI) as an ongoing activity undertaken within a general practice with its purpose being to monitor, evaluate or improve the quality of health care services provided to patients.

Brisbane South PHN is committed to working with the primary care sector to deliver best practice, person-centred care through a range of QI activities from DIY toolkits to structure person-centred care programs.

Our Primary Care team works with general practices providing practical advice and resources to help them plan, implement, and review their QI activities. Outcomes of QI are best summarised by The Quadruple Aim.

QI programs

Brisbane South PHN offers a range of QI supports for general practices in our region. Support include self-paced online learning modules and structured programs developed and delivered in conjunction with industry experts, such as AGPAL.

Our QI programs and activities align with the Quadruple Aim, and many support practices to meet the requirements of RACGP Accreditation and the Practice Incentive Program for Quality Improvement (PIP QI).

Person-centred care programs

Across Australia and internationally, general practices are also working to undertake QI activities to become Patient-Centred Medical Homes (PCMH) – a care model endorsed by the RACGP.

Brisbane South PHN’s Person-Centred Care Practice Initiative (PCCPI) supports practices at any stage of their progression towards becoming more Person-Centred through a range of structured QI programs and activities. Our PCCPI offers two programs that engage participating general practices to focus on incorporating three Patient-Centred Medical Home Change Concepts into their daily operations. Completing PCCPI activities can support participation in the programs or be done as standalone QI activities.

Quality Improvement Support

Brisbane South PHN’s General Practice Quality Improvement Coordinators can provide your practice with Quality Improvement coaching and support to:

  • analyse monthly benchmarking and trend reports
  • identify opportunities for QI in your practice
  • use QI resources (i.e. Toolkits, MFI and PDSA, Practice Plans).

DiscoverPHN: Self-Paced Online Learning Portal

DiscoverPHN is Brisbane South PHN’s learning and collaboration portal providing self-paced online education modules, resources and support to primary health professionals in our region. Quality improvement courses and resources available through DiscoverPHN include:


  • Quality improvement using clinical software
  • Improving data quality using Pen CS CAT4 (coming soon)
  • How To Guide: Quality improvement in general practice (coming soon)


  • Practice plan (coming soon)

Tools and resources

Data analysis tools

We provide several tools to help practices to collect, analyse and improve the quality of their data. The Pen CS Suite, including CAT4 and Topbar, are provided by Brisbane South PHN to the practice at no cost and offers a number of benefits including:

  • automatic data extraction to meet PIP for QI requirements
  • monthly data to identify opportunities for QI
  • streamlining internal processes
  • improving patient-centred care.


For support with Pen CS CAT4, or to get more information about the system, contact the Brisbane South PHN support team.

Quality Improvement Tools

*Instruction document included. The first page of this document can be printed as a blank template or completed online then printed.

**This document can be printed as a blank template or partially completed online then printed.

Quality Improvement Toolkits

Brisbane South PHN has developed 34 Quality Improvement Toolkits for general practices, covering a range of topics:

  1. General quality improvement
  2. Specific conditions
  3. Mental health
  4. Prevention
  5. Patient populations
  6. Quality records and business
  7. Disaster & Pandemic Planning & Management.

Modules included in these toolkits are designed to support practices to achieve the PIP QI requirements.

As practice teams complete the activities within the toolkits, they are shown how to analyse practice data to develop a more comprehensive understanding of their patient population and the care pathways being provided in their practice. Reflections from completion of these activities and the related data may support the identification of improvement opportunities that can be actioned using the Model For Improvement.

Activities can be planned and documented in a practice’s online Practice Plan, accessible through DiscoverPHN, ensuring QI activity can be planned, tracked and saved for future accreditation and PIP QI reporting requirements.

QI toolkit activity workbooks

Activity workbooks are available in DiscoverPHN for some of the QI toolkits. The workbooks have been created as a PDF fillable document which will allow you the opportunity to complete the workbooks on your computer. These workbooks are also able to be shared amongst team members to allow a team approach to completion. For more support, email the Brisbane South PHN support team.


Train IT

Brisbane South PHN has a library of webinars and resources from Train IT that guide a practice through QI activities using clinical software. Access to this library is available to our region via DiscoverPHN.

Model for Improvement

The Model For Improvement (MFI) uses the Plan-Do-Study-Act (PDSA) cycle, a tried and tested approach to achieving successful change that offers the following benefits:

  • It is a simple approach to change management that anyone can use
  • It reduces risk by testing small changes before wider implementation
  • It minimises resistance to change by starting with small changes
  • It helps foster team unity by creating shared goals
  • It encourages individual creativity and ideas from team members.

How to use the MFI

When an area for improvement is identified in your practice, use the MFI and PDSA templates to create a Quality Improvement plan. This plan will help identify opportunities for change and develop a change management approach for successful change implementation. 

For a step by step approach and detailed instructions on using the MFI, download and read the Quality Improvement Toolkit: Overview.

Each QI Toolkit also has recommendations for using the MFI and PDSA cycle to achieve the QI activities in the toolkits.

MFI and PDSA Examples

RACGP Health Record Quality Guide 

This guide outlines what constitutes a high-quality health record and provides advice to general practices about how to put suitable data recording systems in place. A suitable data system will produce health records that facilitate effective, safe and personalised patient care, and contain accurate and usable data for other purposes, such as medico-legal matters and QI activities.

Practice Incentive Program for Quality Improvement

The Federal Government’s Practice Incentive Program (PIP) encourages general practices to provide quality care, build and enhance their clinical capacity and improve accessibility and health outcomes for patients through a range of incentives.

The PIP Quality Improvement (PIP QI) incentive is a quarterly payment to practices to undertake and provide evidence of continuous QI by:

  • providing the PIP Eligible Data Set (de-identified data) to their PHN
  • participating in QI activities provided by their PHN that address any of the ten specified improvement measures or directly meet the needs of their practice population.

PIP QI Improvement Measures

The improvement measures for the PIP QI support a regional and national understanding of chronic disease management in areas of high need. They do not assess individual general practice or general practitioner performance. In future, these ten improvement measures may be altered to reflect emerging high need areas at a regional or national level.

The Ten Improvement Measures

  1. Proportion of patients with diabetes with a current HbA1c result
  2. Proportion of patients with a smoking status
  3. Proportion of patients with a weight classification
  4. Proportion of patients aged 65 and over who were immunised against influenza
  5. Proportion of patients with diabetes who were immunised against influenza
  6. Proportion of patients with COPD who were immunised against influenza
  7. Proportion of patients with an alcohol consumption status
  8. Proportion of patients with the necessary risk factors assessed to enable CVD assessment
  9. Proportion of female patients with an up-to-date cervical screening
  10. Proportion of patients with diabetes with a blood pressure result

The Quality Improvement Toolkit: PIP QI Ten Measures guides you through QI activities directly related to the ten improvement measures.

Providing De-identified Data

Brisbane South PHN provides practices with free access to the Pen CS CAT4 software suite to enable secure encryption, de-identification, and transmission of data from the practice to Brisbane South PHN. For information on our Data Sharing Agreement, read our Data Sharing Agreement Fact Sheet.

For more information about the Pen CS CAT4 software suite click here.

Monthly benchmark and trend reports

Each month, we will produce a benchmark and trend report for your practice using your data. This report will help you identify key priority areas and quality improvement opportunities for your practice.

For assistance in accessing or interpreting your reports, please contact the Brisbane South PHN support team.

For information on how to apply for PIP QI, please click here.

Practice Readiness for PIP QI

To get ready for PIP QI you need to register via your Provider Digital Access (PRODA). Step-by-step instructions are available on the Services Australia website.

Practice PIP QI checklist

  • Hold current Practice Accreditation Certificate
  • Arrange data-sharing with Brisbane South PHN
  • Train your team to use Pen CS CAT4 and Topbar tools
  • Register for PIP for QI via PRODA
  • Register for Monthly Benchmark Reports
  • Start planning and actioning QI activities using our QI Toolkits and Resources
  • Maintain a record of QI activities and progress using your online practice plan.

Primary Health Insights

Brisbane South PHN, along with PHN’s across Australia have commenced using Primary Health Insights – a secure storage and analytics platform designed to store the de-identified practice data collected under Brisbane South PHNs Data Sharing Agreement. 

Primary Health Insights allows PHNs to bring together an increase in data analytic capabilities and privacy protection, data security and data governance capabilities. The platform enhances data analytic capabilities to support PHNs in identifying needs and planning services.

For further information, please visit the Primary Health Insights website.