February: 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 the necessary risk factors assessed to enable CVD assessment

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 identification of regular (active) patients aged 30 years and over, with specific chronic conditions and no diagnosis of CVD, who are eligible for both a Heart Health Check and a GP Chronic Disease Management Plan and have not claimed a Heart Health Check, GP Chronic Disease Management Plan, or any other health assessment in the previous 12 months.
• How will we know that change is an improvement? Set a specific measure or SMART goal, e.g. increase the proportion of active eligible patients identified for Heart Health Checks and Chronic Disease Management Plans by [insert percentage] % by the end of the PIP quarter.
• 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:

• Conduct a team meeting to ensure all relevant team members are aware of the PIP QI focus for the quarter and highlight the importance of identifying this patient cohort.
• Complete a CAT4 search for patients aged 30 years and over with no diagnosis of CVD and at least one of the specified chronic conditions (diabetes, respiratory conditions, chronic renal failure, musculoskeletal diseases, cancer) who have not claimed a Heart Health Check or GP Chronic Disease Management Plan in the previous 12 months.
• Regularly use Pen CS CAT4 and/or Topbar to track and report the percentage of eligible patients in this cohort. Save and document these reports throughout the PIP quarter (ensure all staff are aware that a PDSA is to be completed and filed each quarter should your practice be audited).
• Use health promotion materials and patient communication (e.g., SMS, phone calls, letters) to inform patients about Heart Health Checks and Chronic Disease Management Plans and encourage them to book appointments.
• Utilise PHN Exchange to track trends in GPMP claims over time.

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?