Entrustable Professional Activities

LG4: Quality improvement

Learning Goal 4

Quality improvement

Identify and address failures in health care delivery

This activity requires the ability to:

  • identify, mitigate, and report actual and potential (‘near miss’) errors
  • conduct 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

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • regularly review patients and outcomes
  • evaluate practice to ensure it aligns with available evidence and guidelines
  • evaluate population, 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 using mandatory informed consent
  • evaluate practice regularly to ensure it aligns with available evidence and guidelines

direction
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

Communication

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • use and support patients’ access to high-quality, easy-to-understand information about health care
  • assist patients in participating in the decision-making process regarding their health care, according to their preferences and availability of care
  • help patients comprehend the organisation’s open disclosure policy
  • discuss with patients any safety and quality concerns they have relating to their care
  • implement the organisation’s open disclosure policy

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • explain how health literacy may affect the way patients or populations gain access to, understand, and use health information

Quality and safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • demonstrate best practice, including infection control, radiation safety, adverse event reporting, and effective clinical handover
  • facilitate organisational quality and safety activities, including peer review, morbidity and mortality meetings and clinical incident reviews, and apply decisions to practice
  • use clinical audits and registries of patients’ experiences and outcomes, and learn from incidents and complaints, to improve patients’ experiences and outcomes and mitigate against potential adverse outcomes

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • demonstrate an understanding of a system approach to improving the quality and safety of health care

Teaching and learning

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • participate in professional training in quality and safety to ensure a contemporary approach to safety system strategies
  • supervise and manage junior colleagues’ performance in the delivery of safe, high-quality care
  • ensure continuing professional development as per RACP or RANZCR training requirements

Research

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • ensure protocols for human research are approved by a human research ethics committee, in accordance with the national statement on ethical conduct in human research

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • recognise patient participation in research is voluntary and based on an appropriate understanding about the purpose, methods, demands, risks, and potential benefits of the research

Cultural safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • actively participate in professional development opportunities that focus on the influence of cultural bias on health outcomes

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • communicate effectively with patients with cultural awareness

Ethics and professional behaviour

confident
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
  • consistently demonstrate integrity and a patient-centred approach in all work activities
  • comply with professional regulatory requirements and codes of conduct

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • recognise the importance of regulatory requirements and codes of conduct

Judgement and decision making

confident
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, including ALARA principles
  • analyse and evaluate current care processes to improve health care

direction
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 care practitioners to identify, evaluate, and improve patients’ care management

Leadership, management, and teamwork

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • support multidisciplinary team activities to lower patient risk of harm and promote multidisciplinary programs of education
  • contribute to developing an organisational culture that enables and prioritises patients’ safety and quality

direction
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 that patients receive appropriate care and information on their care

Health policy, systems, and advocacy

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • support the development, implementation, evaluation, and monitoring of governance processes

direction
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 to shape an organisational culture that prioritises safety and quality through openness, honesty, learning, and quality improvement