Curriculum standards
Entrustable Professional Activities
LG4: Quality improvement
Quality improvement
Improve safety, effectiveness, and experience of care for patients and staff
This activity requires the ability to:
- identify and report actual and potential (‘near miss’) errors
- conduct and evaluate system improvement activities
- adhere to best practice guidelines
- audit clinical guidelines and outcomes
- contribute to the development of policies and protocols designed to protect patients and enhance health care
- monitor one’s own practice and develop individual improvement plans
Professional practice framework domain
Medical expertise
Ready to perform without
supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- use evidence, population health outcomes, and current consensus to identify opportunities for improvement in delivering appropriate care
- evaluate environmental and lifestyle health risks, and advocate for healthy lifestyle choices
- use standardised protocols to adhere to best practice and prevent the occurrence of wrong-site, wrong-patient procedures
- regularly monitor personal professional performance
- collaborate with other healthcare professionals to collectively inform and develop local guidelines
- advise on limiting the spread of multi-resistant organisms according to available evidence and clinical practice guidelines
- recognise presentation of reactions to common agents that could be used in bioterrorism, and contact appropriate public health officials for advice and notification
Requires some
supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- contribute to processes on identified opportunities for improvement
- recognise the importance of prevention and early detection in clinical practice
- use local guidelines to assist patient care decision making
- use guideline-based care to meet the needs of patients or populations, and to demonstrate an understanding of circumstances in which patients require management that deviates from guidelines
- manage an incident of notifiable disease containment, including contact tracing and counselling of patients, in collaboration with the hospital infection control team and/or public health officials
Communication
Ready to perform without
supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- support patients to share decision making about their own health care, to the extent they choose
- assist patients’ access to their health information, as well as complaint and feedback systems
- discuss with patients any safety and quality concerns they have relating to their care
- implement the organisation’s open disclosure policy in consultation with relevant supervisors / consultants or appropriate hospital delegate
Requires some
supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- demonstrate awareness of the evidence for consumer engagement and its contribution to quality improvement in health care
- apply knowledge of how health literacy might affect the way patients or populations gain access to, understand, and use health information
- participate in effective health promotion and media communication of public health issues
Quality and safety
Ready to perform without
supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- demonstrate safety skills, including infection control, adverse event reporting, and effective clinical handover
- participate in organisational quality and safety activities, including morbidity and mortality reviews, clinical incident reviews, root cause analyses, and corrective action preventative action plans
- participate in systems for surveillance and monitoring of adverse events and ‘near misses’, including reporting such events
- ensure that identified opportunities for improvement are raised and reported appropriately
- use clinical audits and registries of data on patients’ experiences and outcomes, learnings from incidents, and complaints to improve care
- recognise the need for notification, and contact appropriate public health officers
- apply basic health economic concepts to health promotion, including the rational use of resources and set priorities to improve health equity
- recognise the process of licensure, recommendation, and funding of new vaccines in Australia and Aotearoa New Zealand
Requires some
supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- demonstrate understanding of a systematic approach to improving the quality and safety of health care
- identify notifiable infectious diseases, and know how to access reporting requirements
Teaching and learning
Ready to perform without
supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- translate quality improvement approaches and methods into practice
- participate in professional training in quality and safety to ensure a contemporary approach to safety system strategies
- supervise and manage the performance of junior colleagues in the delivery of high-quality, safe care
- educate hospital staff regarding, and promote, the principles of antimicrobial stewardship and infection control
Requires some
supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- work within organisational quality and safety systems for the delivery of clinical care
- use opportunities to learn about safety and quality theory and systems
Research
Ready to perform without
supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- ensure that any protocol for human research is approved by a human research ethics committee, in accordance with the national statement on ethical conduct in human research
- use statistics appropriately in analysing health data, and make relevant inferences
- remain current with new vaccine development and release
- appraise and apply new knowledge to modify clinical practice
- incorporate new material rapidly into clinical response to, and assessment of, returned travellers and pre-travel advice
Requires some
supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- recognise that patient participation in research is voluntary and based on an appropriate understanding about the purpose, methods, demands, risks, and potential benefits of the research
- identify and appraise resources used to keep up to date on current disease outbreaks and new diseases and syndromes
Cultural safety
Ready to perform without
supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- undertake professional development opportunities that address the impact of cultural bias on health outcomes
Requires some
supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- communicate effectively with patients from culturally and linguistically diverse backgrounds
Ethics and professional behaviour
Ready to perform without
supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- align improvement goals with the priorities of the organisation
- contribute to developing an organisational culture that enables and prioritises patients’ safety and quality care
- comply with local and national infection control guidelines
- recognise the Security Sensitive Biological Agents (SSBA) Regulatory Scheme and associated legislations
- practice with due regard to legislation and processes pertaining to public health measures
- follow current guidelines for assessment and management of returned travellers from transmission regions
Requires some
supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- comply with professional regulatory requirements and codes of conduct
- follow standard immunisation procedures
Judgement and decision making
Ready to perform without
supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- use decision-making support tools, such as guidelines, protocols, pathways, and reminders
- analyse and evaluate current care processes to improve care
Requires some
supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- access information and advice from other health practitioners to identify, evaluate, and improve patients’ care management
Leadership, management, and teamwork
Ready to perform without
supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- formulate and implement quality improvement strategies as a collaborative effort, involving all key health professionals
- support multidisciplinary team activities to lower patients’ risk of harm, and promote interdisciplinary programs of education
- implement local and national antimicrobial prophylaxis guidelines through consultation with relevant disciplines
- cooperate with various health sectors, such as public health and community services
- enlist cooperation from hospital staff to ensure adherence to infection control interventions
Requires some
supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- demonstrate attitudes of respect and cooperation among members of different professional teams
- partner with clinicians and managers to ensure patients receive appropriate care and information on their care
Health policy, systems, and advocacy
Ready to perform without
supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- participate in all aspects of the development, implementation, evaluation, and monitoring of governance processes
- participate regularly in multidisciplinary meetings where quality and safety issues are standing agenda items, and where innovative ideas and projects for improving care are actively encouraged
- measure, analyse, and report a set of infectious diseases process of care and outcome clinical indicators, and a set of generic safety indicators
- take part in the design and implementation of the organisational systems for:
- clinical education and training
- defining the scope of clinical practice
- performance monitoring and management
- safety and quality education and training
- discuss key aspects of state and national policies, including gaps and limitations
- contribute to local infection control practices and public health interventions
Requires some
supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- maintain a dialogue with service managers about issues that affect patient care
- contribute to relevant organisational policies and procedures
- help shape an organisational culture that prioritises safety and quality through openness, honesty, learning, and quality improvement