July: QI Activity

Step 1: Identify your QI Measures

Start by considering which of the relevant QI measures you will work towards in support of this topic. Measures you could choose from include:

• Proportion of patients with diabetes with a current HbA1c result

• Proportion of patients with diabetes who were immunised against influenza

• Proportion of patients with diabetes with a blood pressure result.

Accreditation Requirements

The RACGP Standards for general practices 5th edition outlines specific criteria related to the capture of patient information, including CVD. These criteria are relevant to the accreditation of general practices, as they form part of the broader focus on preventive health and chronic disease management.

• Comprehensive Patient Records (Criterion C6.1):
  - General practices are required to maintain comprehensive and accurate patient health records. This includes regularly updating key health indicators such as smoking status, BMI, and alcohol consumption (ideally, every 12 months).
  - These indicators are critical for preventive health care, allowing practitioners to identify risk factors and provide appropriate interventions.
• Health Assessments and Chronic Disease Management:
  - The Standards emphasise the importance of preventive health activities, including regular health assessments where smoking status, BMI, and alcohol consumption are recorded and reviewed.
  - These assessments are essential for managing chronic diseases, providing a basis for patient education and care planning
• Patient Health Summaries:
  - Practices are expected to maintain up-to-date patient health summaries that include smoking status, BMI, and alcohol consumption as part of the essential patient information.
  - The presence of these details in patient summaries is crucial for the practice's accreditation, demonstrating a commitment to comprehensive care.
• Quality Improvement and Preventive Health:
  - The Standards also stress continuous quality improvement (CQI) in preventive health measures. Regularly capturing and reviewing smoking status, BMI, and alcohol consumption is part of this ongoing improvement process.
  - Accreditation bodies may review how practices use this data to engage in CQI activities, such as targeted health campaigns or interventions.

Step 2: Undertake your QI activity

We've prepared a simple worksheet that can help you work through activity you will need undertake to meet the Improvement Measure you have selected.

1. Identify your plan, using the Model for Improvement:

• What are you trying to accomplish? e.g. increase the proportion of active eligible patients with Type 1, Type 2, or undefined diabetes who have had an HbA1c measurement recorded in the last 12 months, by the end of the PIP quarter.
• How will we know that change is an improvement? Track the proportion of eligible patients who have NOT had their HbA1c recorded in the last 12 months by comparing the baseline data in August 2025 to the result data collected in October 2025. Use PenCS CAT4 and the QI Team to run reports and track the improvement.
• What changes can you make that will result in improvement? Come up with your own ideas or consider ours below.

2. Some possible ideas you could choose to do:

• Team Engagement: Hold a team meeting to ensure all practice staff are aware of the QI activity and goals.
• CAT4 Searches: PenCS CAT4 to identify eligible diabetes patients who had not had their HbA1c recorded in the last 12 months.
• Patient Outreach: Use HotDoc to send recall reminders to those patients for HbA1c testing.

3. Document your actions

• Use our PDSA Worksheet to document your activity. It also walks you through how to complete a CAT4 search and use PHN Exchange to track trends in GPMP claims.

4. Resources to help you

• Consider creating a specific CAT Prompt Topbar notification to flag this patient cohort during consultations.

Further resources

Resources for GPs and practice nurses

Need PHN support?