When do you undertake quality improvement
Overview of the “Mandatory Quality Indicator Program Manual 2.0 –Part B” (Program Manual B)

Program Manual B’s is designed to help providers understand how they can support continuous quality improvement for each of the quality indicators. It explains what “quality improvement” is and how to undertake it by,
reintroducing the five quality indicators found in Program Manual A
• describes the adverse impacts of each of the quality indicators on recipients
• details the causes and risk factors for each of the quality indicators
• provides checklists for the prevention and management of the quality indicators

What is “quality improvement”?

“Quality” is described as care that is “effective and safe, and provides a positive experience by being caring, responsive and person-centered.” (Program Manual B, p. 3). An important part of providing “quality” care is quality improvement which is “a systematic, coordinated and ongoing effort to improve the quality of care and services.” (Program Manual B, p. 3).

Overall quality improvement is about identifying what systems are working well, the quality of care and services being provided, and understanding where we could do better and improve outcomes for consumers. Throughout the quality improvement process, three key areas need to be considered with respect to change:

• Being open to change and exploring ways that will improve the way we deliver care and services – what changes that we can make that will result in improvement.
• The goal or the purpose – why is change needed and what we hope to achieve
• The way you will be able to measure or show the change is an improvement – how we
well know that a change is an improvement

How do you make quality improvement possible?

There are six steps to enabling quality improvement:

1. Collecting and submitting data in line with your Quality Indicator Program obligations
2. Reviewing quality indicator data reports through the My Aged Care provider portal
3. Comparing your performance to data available on the Australian Institute of Health and Wellbeing GEN Aged Care Data Website
4. Identifying how your performance compares to the national benchmark, previous performance, and/or other similar services
5. Recording performance and noting that a quality issue exists
6. Taking action to improve quality of care through initiating a quality improvement activity (Program Manual B, p.5)

How do you undertake quality improvement?

The Program Manual proposes a “Plan-Do-Check-Act” tool that can be used across each quality indicator (Program Manual B, p. 6). This method allows you to identify a “quality issue” and then trial a “quality improvement activity” to gauge whether the activity should be implemented more broadly.

A summary of the tool and its four steps is set out in the table below



Involves developing a plan by gathering information about what is causing the quality issue, establishing goals for your quality improvement activity, and making a plan for how the activity will be carried out

STEP 2: D :

This is where you carry out the activity by allocating resources, testing the activity on a small scale, and documenting observations


Involves collecting data and analysing information from the QI program to understand if your current systems and related processes are achieving the desired outcomes.


This step involves deciding whether the current systems and related processes are successful in achieving quality of care and services. Depending on the outcome you will:
• if successful, embed the activity into business-as-usual processes and continue to monitor outcomes
• if the activity was unsuccessful, determine what you may need to do differently next time – this is a quality improvement opportunity
• repeat the process to continue to increase the quality of care and services for consumers

When do you undertake quality improvement?

Quality improvement is an ongoing process. This means that you should regularly repeat the quality improvement process to continually improve the care and services you deliver (Program Manual B, p. 5)

What are some benefits of quality improvement?

By regularly undertaking quality improvement, you will:
• improve the delivery of your care and services
• identify quality issues promptly
• be more responsive to the changing needs of recipients
• improve outcomes for recipients
• improve systems to monitor and track change
• create long-term sustainable improvement across your organisation
• increase collaboration amongst staff
• enhance professional development across the workforce (Program Manual B, p. 4).

What are some benefits of quality improvement

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