Entrustable Professional Activities

LG4: Quality improvement

Learning Goal 4

Quality improvement

Improve safety, effectiveness, and experience of care for patients and staff

This activity requires the ability to:

  • identify and report actual and potential (‘near miss’) errors
  • conduct and evaluate system improvement activities
  • adhere to best practice guidelines
  • audit clinical guidelines and outcomes
  • contribute to the development of policies and protocols designed to protect patients and enhance health care
  • 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 evidence, population health outcomes, and current consensus 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
  • regularly monitor personal professional performance
  • collaborate with other healthcare professionals to collectively inform and develop local guidelines
  • advise on limiting the spread of multi-resistant organisms according to available evidence and clinical practice guidelines
  • recognise presentation of reactions to common agents that could be used in bioterrorism, and contact appropriate public health officials for advice and notification

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
  • use guideline-based care to meet the needs of patients or populations, and to demonstrate an understanding of circumstances in which patients require management that deviates from guidelines
  • manage an incident of notifiable disease containment, including contact tracing and counselling of patients, in collaboration with the hospital infection control team and/or public health officials

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
  • 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 in consultation with relevant supervisors / consultants or appropriate hospital delegate

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
  • participate in effective health promotion and media communication of public health issues

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 action 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 care
  • recognise the need for notification, and contact appropriate public health officers
  • apply basic health economic concepts to health promotion, including the rational use of resources and set priorities to improve health equity
  • recognise the process of licensure, recommendation, and funding of new vaccines in Australia and Aotearoa New Zealand

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
  • identify notifiable infectious diseases, and know how to access reporting requirements

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
  • educate hospital staff regarding, and promote, the principles of antimicrobial stewardship and infection control

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
  • use statistics appropriately in analysing health data, and make relevant inferences
  • remain current with new vaccine development and release
  • appraise and apply new knowledge to modify clinical practice
  • incorporate new material rapidly into clinical response to, and assessment of, returned travellers and pre-travel advice

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
  • identify and appraise resources used to keep up to date on current disease outbreaks and new diseases and syndromes

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 care
  • comply with local and national infection control guidelines
  • recognise the Security Sensitive Biological Agents (SSBA) Regulatory Scheme and associated legislations
  • practice with due regard to legislation and processes pertaining to public health measures
  • follow current guidelines for assessment and management of returned travellers from transmission regions

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
  • follow standard immunisation procedures

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 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 interdisciplinary programs of education
  • implement local and national antimicrobial prophylaxis guidelines through consultation with relevant disciplines
  • cooperate with various health sectors, such as public health and community services
  • enlist cooperation from hospital staff to ensure adherence to infection control interventions

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 infectious diseases 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:
    • clinical education and training
    • defining the scope of clinical practice
    • performance monitoring and management
    • safety and quality education and training
  • discuss key aspects of state and national policies, including gaps and limitations
  • contribute to local infection control practices and public health interventions

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