Entrustable Professional Activities

LG4: Quality improvement

Learning Goal 4

Quality improvement

Identify and address quality systems in health care delivery and workplaces

This activity requires the ability to:

  • develop, implement, assess, evaluate, and clinically govern systems that protect and/or promote occupational and environmental health
  • identify and report actual and potential incidents (near misses), including by integrating human factors strategy with incident-related policy
  • conduct, evaluate, design, and govern system improvement activities
  • adhere to and lead the development of health protection standards and best practice guidelines
  • audit clinical guidelines, workplace health protection programs, and health outcomes, including but not limited to psychosocial health outcomes
  • contribute to the development of policies and protocols designed to protect workers/patients, enhancing health care and supporting good work that protects and promotes workers’ health outcomes
  • 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:

  • use population health outcomes to identify opportunities for improvement in delivering appropriate care and support good work that protects and promotes workers’ health
  • review workers/patients or population health outcomes to identify opportunities for improvement in delivering appropriate care and support good work that protects and promotes workers’ health
  • evaluate environmental and lifestyle health risks, and advocate for healthy lifestyle choices
  • evaluate environmental and workplace risks to inform programs that support good work and protect and promote the continuous, systematic improvement of health outcomes at and for work
  • use standardised protocols to adhere to best practice
  • review health and safety events
  • develop, implement, assess, and evaluate a medical surveillance program
  • regularly monitor personal professional performance
  • identify risks to health arising from one’s own work activities
  • demonstrate an understanding and delivery of health promotion activities
  • identify high-risk transitions, such as between compensation schemes and in / out of work) and key risks for workers/patients during transition, and manage the transition in a demonstrably risk-based, outcomes-driven way
  • recognise changes in workers’/patients’ conditions, and provide values-driven, structured recommendations in a medicolegally appropriate, evidence-based, and authoritative framework on how to manage them

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 workers’/patients’ 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 workers/patients to have access to, and use, easy-to-understand, high-quality information about health care, workplace health risks, and their effective control
  • support workers/patients to share decision making about their health care
  • assist workers/patients to access their health information, as well as complaint and feedback systems
  • discuss with workers/patients any safety and quality concerns they have relating to their care and the management of workplace health risks
  • 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 workers/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 and adverse event reporting
  • participate in organisational quality and safety activities, including:
    • clinical incident reviews
    • corrective action preventive action plans
    • morbidity and mortality reviews
    • root cause analyses
    • workplace injury and illness reviews
  • participate in systems for surveillance and monitoring of adverse events and near misses, such as workplace injuries and illness events and near misses, including reporting such events
  • identify improvement opportunities for improvement, and report appropriately
  • use health and safety audits, data and outcomes, learnings from incidents, and complaints to improve the management of workplace health and safety risks
  • discuss risk management approaches and systems used by corporate organisations

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

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

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:

  • use protocol for human research that is 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:

  • demonstrate that workers’/patients’ participation in research is voluntary and that workers/patients understand 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

direction
Requires some supervision

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

The trainee may:

  • communicate effectively with workers/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 culture that enables and prioritises worker health and safety

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 processes to improve the management of workplace health and safety risks

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 workers’/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 and other stakeholders, such as employers, worker representatives, and health and safety professionals
  • support, facilitate, build, and clinically govern multidisciplinary team activities to reduce workplace health and safety risks, and promote multidisciplinary programs of education
  • actively involve other stakeholders, such as occupational hygienists, in workplace improvement projects

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 workers/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 workplace health and safety are actively encouraged
  • measure, analyse, and report a set of workplace-specific process of risk management and health and safety indicators, participating in the design and implementation of organisational systems for:
    • clinical, and safety and quality education and training
    • defining the scope of workplace health risks
    • performance monitoring and management

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