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 with best practice guidelines
  • inspect clinical guidelines and outcomes
  • contribute to 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
  • perform audits to identify areas of improvement in health care, and ideally perform re-audits to see the impact of amelioration strategies
  • 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
  • enrol patients on appropriate clinical trials and adhere to them as per Good Clinical 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
  • use local guidelines to assist patient care decision making
  • be aware of appropriate clinical trials

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
  • manage complaints appropriately, according to local policies
  • implement the organisation’s open disclosure policy
  • gain consent from families via an informed consent process for appropriate procedures, clinical trials, and other 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 health care
  • apply knowledge of how health literacy might affect the way patients or populations gain access to, understand, and use health information
  • understand informed consent processes for procedures and clinical trials

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 or preventative action plans
  • 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 health care
  • participate in local, national, and international clinical trials for the best outcome for the patient and ongoing improved practice for all

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 an understanding of the importance of standards of practice and clinical trials

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:

  • 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
  • take informed consent for research

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

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 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:

  • 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’ 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
  • take responsibility for investigating, reporting, resolving, and evaluating risk / hazard incidents

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
  • 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 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