Entrustable Professional Activities

LG 4: Quality improvement

Learning Goal 4

Quality improvement

Identify and address failures in health care delivery

This activity requires the ability to:

  • identify and report actual and potential (near miss) errors
  • conduct and evaluate system improvement activities
  • apply best practice guidelines
  • audit clinical outcomes and implement clinical guidelines where applicable
  • 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.
  • participate in morbidity and mortality meetings and review systems to prevent adverse patient outcomes

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
  • evaluate practice to ensure it aligns with available evidence and guidelines
  • recognise the complex care needs of patients living with chronic endocrine conditions and proactively institute care planning to mitigate acute deterioration
  • use population health outcomes to identify opportunities for improvement in delivering appropriate care
  • regularly review patients’ or population health outcomes 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

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
  • regularly monitor personal professional performance

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 share decision making about their own health care, to the extent they choose
  • support patients to have access to, and use, easy-to-understand, high-quality information about health care
  • direct patients on processes for accessing their own health information, as well as complaint and feedback systems
  • discuss with patients any safety and quality concerns they have relating to their care
  • assist patients to understand about hospital open disclosure policy
  • 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:

  • 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

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, including morbidity and mortality reviews, clinical incident reviews, root cause analyses, and corrective and preventative action plans
  • participate in systems for surveillance and monitoring of quality care, 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 health care
  • demonstrate understanding of the principles of organisational quality and safety activities, including root cause analyses and corrective and preventative action plans

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
  • maintain Continuing Professional Development obligations as per regulatory requirements

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:

  • apply the principles underlying ethical research
  • 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 and understand the processes for obtaining this approval within an organisation
  • communicate to patient that they will not be treated differently should they opt not to participate in research
  • ensure research adherence to the local and national codes for the responsible conduct of research1

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
  • explain that routine care will continue if the participant decides not to participate in research

References

1. Trainees can refer to the National Health and Medical Research Council (NHMRC) code and/or Australian clinical trials code.

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:

  • communicate effectively with patients from diverse backgrounds, including through effective collaboration with interpreters
  • undertake professional development opportunities that address the impact 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 from 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 culture that enables and prioritises patients’ safety and quality of care

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
  • 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:

  • formulate and implement quality improvement strategies as a collaborative effort involving all key health professionals
  • support multidisciplinary team activities and promote interdisciplinary programs of education to lower patients' risk of harm
  • actively involve clinical pharmacists in the medication-use process
  • demonstrate attitudes of respect and cooperation among members of different professional teams

direction
Requires some supervision

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

The trainee may:

  • 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
  • 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 specialty-specific 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:
    • defining the scope of clinical practice
    • performance monitoring and management
    • clinical, and safety and quality education and training

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