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:

  • conduct 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
  • identify, mitigate, and report actual and potential (near miss) errors related to treatment of patients in hospital and community settings
  • 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:

  • identify opportunities for improvement in services by using both clinical outcomes and population health outcomes
  • evaluate environmental and lifestyle health risks, and advocate for healthy lifestyle choices and favourable public policy
  • use standardised protocols 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 in clinical practice
  • 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 high-quality, easy-to-understand 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
  • 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, and root cause analyses
  • 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, learning from incidents and complaints to improve health care outcomes

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:

  • use quality improvement approaches in educational 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 safe, high-quality 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:

  • 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
  • work with Māori and Aboriginal and Torres Strait Islander communities and service providers to improve the cultural safety of services

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:

  • contribute to developing an organisational culture that enables and prioritises patients’ safety and quality
  • align improvement goals with the priorities of the organisation

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
  • recognise the complex care needs of patients with substance use and addiction use disorders

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:

  • advocate for appropriate care for patients with substance use and addiction disorders in other areas of the healthcare system
  • formulate and implement quality improvement strategies as a collaborative effort involving all key health professionals
  • support multidisciplinary team activities to lower patient risk of harm, and promote multidisciplinary programs of education
  • actively involve clinical pharmacists in improving the use of medications

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 clinical process and outcome indicators, and generic safety indicators
  • take part in the design and implementation of the organisational systems for:
    • clinical, and safety and quality education and training
    • defining the scopes of clinical practice
    • performance monitoring and management
  • work with consumer representative groups to ensure systems of care are designed to aid consumer engagement in decision making
  • work with regulatory agencies to optimise legislation, regulations, and administrative processes relevant to the needs of people with substance use and addiction disorders to minimise harms

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