Entrustable Professional Activities

LG4: Quality improvement

Learning Goal 4

Quality improvement

Contribute to improving safety, effectiveness and experience of healthcare

This activity requires the ability to:

  • identify and report actual and potential (near miss) errors
  • conduct and evaluate quality improvement activities
  • adhere to best practice guidelines (e.g., approaching ADHD, medication management and follow up in ADHD, CRC guidelines)
  • audit clinical guidelines, clinical processes, and outcomes
  • contribute to the development of policies and protocols designed to protect patients and enhance healthcare
  • 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’ or population health outcomes to identify opportunities for improvement in delivering appropriate care
  • apply relevant theory related to quality improvement processes
  • use standardised protocols to adhere to best practice
  • regularly monitor personal professional performance

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
  • learn the theory related to the process of quality improvement and apply these to a clinically relevant context
  • use appropriate and evidence-based 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:

  • support patients to have access to, and use, easy-to-understand, high-quality information about health care
  • 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
  • demonstrate effective skills in knowledge translation and awareness of knowledge mobilisation as part of implementation science processes

direction
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 healthcare
  • apply knowledge of how health literacy might 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 safety skills, including infection control, adverse event reporting, and effective clinical handover
  • participate in organisational quality and safety activities, such as:
    • antimicrobial stewardship
    • audits
    • clinical incident reviews
    • corrective action and preventative action plans
    • morbidity and mortality reviews
    • review of clinical guidelines and protocols
    • root cause analysis
  • 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 healthcare

direction
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 healthcare

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:

  • 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
  • promote and role model high quality and safe clinical practice

direction
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

confident
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
  • demonstrate familiarity with both quantitative and qualitative research methodologies
  • hypothesise, interpret, critically analyse, and apply up to date evidence from research to clinical practice
  • participate in clinical research that aims to improve patient outcomes, where applicable

direction
Requires some supervision

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

The trainee may:

  • understand 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

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:

  • undertake professional development opportunities that address the impact of cultural bias on health outcomes
  • demonstrate commitment to improving cultural safety in own practice, teams and the health service
  • apply frameworks and policies related to improving healthcare for Māori and Aboriginal and Torres Strait Islander peoples

direction
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

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
  • contribute to developing an organisational “no blame” culture that enables and prioritises patients’ safety and quality
  • speak up for the safety of patients and staff using appropriate systems

direction
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

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
  • critically appraise published literature, including the quality, applicability to the local population and limitations of the evidence

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 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:

  • 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 multidisciplinary programs of education
  • actively involve clinical pharmacists in the medication-use process

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 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:

  • participate in all aspects of the development, implementation, evaluation, and monitoring of governance processes Health policy, systems, and advocacy
  • 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
  • take part in the design and implementation of the organisational systems for:
    • defining the scope of clinical practice
    • performance monitoring and management
    • clinical and safety education and training

direction
Requires some supervision

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

The trainee may:

  • contribute to relevant organisational policies and procedures
  • help shape an organisational culture that prioritises safety and quality through openness, honesty, learning, and quality improvement