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 and report actual and potential (near miss) errors
  • perform and evaluate system improvement activities
  • comply to best practice guidelines
  • inspect clinical guidelines and outcomes
  • enhance the development of policies and protocols designed to protect patients and enhance health care
  • monitor 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
  • evaluate environmental and lifestyle health risks, and advocate for healthy lifestyle choices
  • use standardised protocols and best available evidence 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 of cancer
  • 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:

  • 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
  • respectfully discuss with patients any safety and quality concerns they have relating to their care, appropriately acting on these concerns
  • 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
  • advocate for patients

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 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
  • participate in systems for surveillance of adverse events and near misses, including the reporting of such events
  • ensure that identified opportunities for improvement are raised and reported appropriately
  • improve health care through the use of clinical audits and registries of data on patients’ experiences and outcomes, learnings from incidents, and complaints

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:

  • participate in professional training in quality and safety
  • 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:

  • 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
    • conducted in accordance with best Good Clinical Practice principles

direction
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

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:

  • identify and address biases, such as those regarding gender identity, sexual orientation, and cultural and religious diversity, in personal and group decision making to prevent harmful impacts on patient outcomes
  • use the expertise of culture-specific liaisons, such as Māori and Aboriginal and Torres Strait Islander peoples hospital liaison officers, to achieve best outcomes for patients and organisations

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
  • effectively assess, understand, and respect cultural factors that contribute to patient decision making and health care engagement

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:

  • 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 practitioners to identify, evaluate, and improve patients’ 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, collaboratively 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, especially where concerns regarding the quality of health care provision are raised
  • 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
  • measure, analyse, and report a set of palliative care-specific process of care and outcome clinical indicators, and a set of generic safety indicators
  • take part in designing and implementing 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 shape an organisational culture that prioritises safety and quality through openness, honesty, learning, and quality improvement
  • identify local and major international agencies with a role in cancer control, research, and/or treatment
  • recognise legal issues relating to anticancer treatments, the institution and withdrawal of life support systems, and the Voluntary Assisted Dying Legislation across states, countries, and the Commonwealth