Quality improvement

The Brisbane South PHN quality improvement (QI) support team are here to assist you in delivering the best quality of care for your patients. There are 3 main sections on this page, please refer to the content list below. If you are unable to find what you are looking for, please contact the QI support team.

On this page:

All about QI

What is quality improvement

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.

We are committed to working with the primary care sector to deliver best practice, person-centred care through a range of QI activities that range from QI toolkits to structured person-centred care programs.

Our Primary Care team works with general practices to provide practical advice and resources to help them plan, implement, and review their QI activities. Outcomes of QI are best summarised by the quadruple aim.

Quality improvement in general practice

We offer a range of QI support for general practices in our region. Support includes self-paced, online learning modules and structured programs developed and delivered in conjunction with industry experts.

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).

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 given to practices to undertake and provide evidence of continuous QI by:

  • providing the PIP Eligible Data Set (de-identified data) to their Primary Health Network (PHN)
  • participate in QI activities provided by their PHN that address any of the 10 specified improvement measures or directly meet the needs of their practice population.

PIP QI measures

The 10 improvement measures for the PIP QI have been identified to support understanding of chronic disease management in areas of high need. They facilitate a common data baseline and data analysis to observe improvements within general practice.

There are no prescribed targets associated with any of the improvement measures. Practices may choose to focus their QI activities on the specified measures or alternatively, focus on any other areas informed by their clinical information system data.

The 10 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.

These measures may be altered to reflect emerging high-need areas regionally and nationally. The Quality Improvement Toolkit: PIP QI Ten Measures guides you through how to implement these 10 improvement measures.

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.

Providing de-identified data

  • We provide practices with free access to the Pen CS CAT4 software suite to enable secure encryption, de-identification, and transmission of data from practices back to us. 
  • Read our Pen CS CAT4 software suite Data Sharing Agreement Fact Sheet.

More information on how to apply for PIP QI can be found here.

Primary Health Insights

All PHN’s have started using Primary Health Insights, a secure storage and analytics platform designed to house the de-identified practice data collected under our data sharing agreement. 

Primary Health Insights allows PHNs to increase our data analytic capabilities, privacy protection, data security and data governance competences. Primary Health Insights enhances data analytic capabilities to support PHNs to identify needs and planning services.

More information can be found on the Primary Health Insights website.

QI programs available for your practice

We can provide general practices with QI coaching and support to:

  • analyse monthly benchmarking and trend reports
  • identify opportunities for QI in your practice
  • use QI resources (i.e. toolkits, etc)
  • assist with PIP QI, including the registration, guidelines, and improvement measures.

QI support tiers

Our General Practice Quality Improvement Coordinators offer a variety of access tier levels, to offer catered support for your individual practice’s needs. It is up to decide which access tier level would be most appropriate for your practice team to engage with.

Annual QI support cycle with general practice

Our General Practice Quality Improvement Coordinators will determine opportunity areas for your practice, through the Practice Partnership Planning Discussion (PPPD). Within this meeting, your QI coordinator will discuss:

  • the current key focus for the practice
  • what is working well and what could be better
  • areas of interest
  • top population and health priorities
  • your chosen support level.

QI support flow chart

My Health for Life QI program

The My Health For Life (MH4L) program is a free behaviour change program designed for people at high risk of developing a chronic disease. It is designed to support participants to make small lifestyle changes that can have significant, long-term health benefits.
The program supports the primary health care network through the extension of advice given by health professionals.

The program includes 6 coaching sessions (either phone or group sessions) for participants over a 6-month period. These sessions are facilitated by qualified health professionals and MH4L facilitators, there is also an ongoing maintenance program.

Person-centred care

We work with heath care providers to support their journey towards enhanced person-centred care.

We offer a range of programs and activities that are designed by General Practitioners (GP) and subject matter experts to support practices to build their team, enhance the sustainability of their practice and improve patient experiences and outcomes.

QI tools and resources

Data analysis tools

Brisbane South PHN has committed to adopting Primary Sense – a population health management, clinical decision support and data extraction tool. Primary Sense will be replacing the Pen CS systems CAT4 and Topbar by May 2023.Primary Sense has been developed by GPs, for GPs and:    

  • is easy to use  
  • can be quickly installed  
  • provides real time medication safety alerts, patient care prompts and near real time data extractions      
  • remains free for general practices that share data with Brisbane South PHN  
  • all data extracted from Primary Sense is privacy protected, securely stored and managed in Australia

Quality improvement tools

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. planning and management of pandemics and disasters.

The quality improvement toolkits are in the process of being updated to align with the new clinical support tool. Please continue to use the toolkits, however, to assist you identify eligible patients and other data activities, please use the clinical support tools that you have available. If you require assistance with this, please contact the QI team on support@bsphn.org.au.

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 comprehensive knowledge about 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 MFI.

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 allows you 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 practice support team.

*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.

Model for Improvement

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

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

How to use the MFI

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

Each QI toolkit also has recommendations on how to use the MFI and PDSA cycle to achieve the QI activities in the toolkits.

RACGP QI & CPD points for completing in quality improvement

GPs are required to complete Reviewing Performance or Measuring Outcomes hours as part of the current triennium.  More information is available from RACGP.  The Quality Improvement team are available to assist GPs to meet these criteria. The team can assist with:

  • identifying an area for improvement in the practice (patient related, systems improvement, data cleansing etc.)
  • planning how GPs will work towards their improvement (who will be involved, what will be done, how will any improvements be measured)
  • working through the planned steps
  • reviewing results.

GPs can report the number of hours working on QI by logging into their RACGP account by scanning the QR code on the front of the MFI/PDSA RACGP template.

Pre-approved activities with RACGP

To support GPs to meet their CPD hours, there are some pre-approved checklists available to step you through the process. Please follow the steps and if you require support, please contact us via support@bsphn.org.au.

MFI and PDSA examples

DiscoverPHN: Self-paced online learning portal

DiscoverPHN is Brisbane South PHN’s learning and collaboration portal that provides self-paced online education modules, resources and support to primary health professionals in the Brisbane south region. More specifically, DiscoverPHN has useful modules surrounding topics such as digital health technologies, resources to assist in meeting the RACGP accreditation standards and QI courses and resources.

These 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

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.

Contact QI support team

To request further practice support, please don’t hesitate to contact the quality improvement team at support@bsphn.org.au.  

Our team is dedicated to providing the best possible support for your practice.