8
Self-Assessment
Continuous Improvement
Rate your practice against each indicator. Use this as a working reference - print it, copy it into a spreadsheet, or work through it on screen.
Version 1.0 - First Edition
Maturity Levels
Not in Place
Not done, or unaware of the requirement
Developing
Done inconsistently or informally
Established
Done reliably with evidence
Excelling
Actively reviewed and improved
8.1
Quality Improvement Planning
We have a structured, documented approach to identifying priorities and tracking improvement.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 8.1.1 | The practice has a documented quality improvement plan that is reviewed at least annually | ||||
| 8.1.2 | The improvement plan identifies specific goals, responsible persons, and target timeframes | ||||
| 8.1.3 | The improvement plan is informed by the outcomes of the practice's self-assessment against this framework | ||||
| 8.1.4 | Progress against improvement goals is reviewed at defined intervals (at least quarterly) | ||||
| 8.1.5 | Completed improvement actions are documented and the outcomes recorded | ||||
| 8.1.6 | Where an improvement action did not achieve its intended outcome, this is reviewed and a revised approach is documented | ||||
| 8.1.7 | The improvement plan is accessible to relevant staff and is not held solely by a single individual | ||||
| 8.1.8 | Quality improvement goals are prioritised by patient safety impact, not organisational convenience | ||||
| 8.1.9 | The practice revisits its full self-assessment against this framework at least once every two years |
8.2
Internal Audit
We regularly review our own processes against defined standards and act on what we find.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 8.2.1 | The practice conducts at least two internal audits per year | ||||
| 8.2.2 | Internal audits are planned in advance and cover a mix of clinical and operational topics | ||||
| 8.2.3 | Internal audit findings are documented and shared with relevant staff | ||||
| 8.2.4 | Internal audits result in documented actions where gaps are identified | ||||
| 8.2.5 | Audit topics are selected based on risk, prior incidents, or known areas of variability | ||||
| 8.2.6 | At least one internal audit per year addresses a clinical process or outcome (not solely administrative topics) | ||||
| 8.2.7 | Previous audit findings are reviewed in subsequent cycles to assess whether improvements have been sustained | ||||
| 8.2.8 | The practice has conducted a medication management audit in the past two years (where medications are held or administered) | ||||
| 8.2.9 | The practice has conducted an infection prevention and control audit in the past two years | ||||
| 8.2.10 | The practice has conducted a health records audit in the past two years |
8.3
Data Use and Performance Monitoring
We collect, review, and act on data about our practice's performance.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 8.3.1 | The practice has identified a small set of key performance indicators (KPIs) relevant to its operations | ||||
| 8.3.2 | KPIs are reviewed at defined intervals by the principal practitioner(s) and practice manager | ||||
| 8.3.3 | Waiting time data (time from referral to appointment) is monitored and reviewed | ||||
| 8.3.4 | Did-not-attend (DNA) and cancellation rates are monitored and reviewed | ||||
| 8.3.5 | Patient feedback data (see Domain 4) is reviewed in the context of quality improvement | ||||
| 8.3.6 | Incident and near-miss data is reviewed in aggregate at least annually to identify patterns | ||||
| 8.3.7 | Complaint data is reviewed in aggregate at least annually to identify patterns | ||||
| 8.3.8 | Where available, clinical outcome data is reviewed by the principal practitioner(s) at least annually | ||||
| 8.3.9 | Data review findings are connected to the improvement plan where action is indicated | ||||
| 8.3.10 | The practice does not rely solely on absence of complaints as evidence of quality |
8.4
Learning from Incidents Near Misses and Complaints
We treat things that go wrong as opportunities to improve, not just problems to resolve.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 8.4.1 | A documented process exists for reviewing incidents and near misses for learning, separate from the initial response process | ||||
| 8.4.2 | Significant incidents are subject to a structured review (e.g. case discussion, root cause analysis) within a defined timeframe | ||||
| 8.4.3 | Learning identified from incident reviews is translated into documented changes to policy, process, or training | ||||
| 8.4.4 | Changes made in response to incidents are communicated to relevant staff | ||||
| 8.4.5 | Complaints are reviewed for themes and patterns at least annually (see also Domain 1) | ||||
| 8.4.6 | Learning from complaints is connected to the improvement plan where systemic issues are identified | ||||
| 8.4.7 | The practice monitors external safety alerts, recalls, and clinical advisories relevant to its specialty and acts on them promptly | ||||
| 8.4.8 | Near misses are treated with the same learning intent as incidents that caused harm | ||||
| 8.4.9 | Staff feel safe to report incidents and near misses without fear of blame (see also Domain 6) | ||||
| 8.4.10 | The practice can demonstrate at least one documented improvement that originated from an incident or complaint in the past two years |
8.5
Peer Review and External Benchmarking
We look outside our own practice to test and calibrate the quality of what we do.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 8.5.1 | The principal practitioner(s) participate in at least one form of structured peer review, case discussion, or clinical audit activity annually | ||||
| 8.5.2 | Peer review activity is documented (including the nature of the activity and any learning identified) | ||||
| 8.5.3 | Where the practice's specialty college or professional association offers clinical audit or benchmarking programs, the practice has considered participation | ||||
| 8.5.4 | The practice is aware of relevant national or state-based clinical registries in its specialty and has considered participation where applicable | ||||
| 8.5.5 | Findings from peer review or benchmarking activities are connected to the practice improvement plan where relevant | ||||
| 8.5.6 | Where the practice participates in clinical training (students, registrars, or fellows), feedback from supervisory bodies is reviewed and acted on |
8.6
Regulatory Currency and Awareness
We stay current with our legal obligations, relevant standards, and evolving clinical guidance.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 8.6.1 | A named person in the practice is responsible for monitoring changes to regulation, standards, and guidelines relevant to the practice | ||||
| 8.6.2 | The practice has a defined process for reviewing and acting on updates to relevant legislation (including the Privacy Act, Work Health and Safety Act, and applicable state health legislation) | ||||
| 8.6.3 | The practice monitors updates from AHPRA and relevant specialist college(s) and acts on guidance relevant to its operations | ||||
| 8.6.4 | Clinical policies and procedures are reviewed at defined intervals (at least every two years) and updated to reflect current standards | ||||
| 8.6.5 | The practice has reviewed its obligations under the Australian Privacy Principles in the past two years | ||||
| 8.6.6 | The practice is aware of current mandatory reporting obligations (AHPRA, child protection) and reviews these at staff induction and at least biennially thereafter | ||||
| 8.6.7 | The practice monitors safety alerts and product recalls from the TGA and other relevant bodies | ||||
| 8.6.8 | Relevant changes to regulation or standards are communicated to affected staff promptly | ||||
| 8.6.9 | Policy updates triggered by regulatory change are documented with the reason for the update and the effective date |
8.7
Improvement Culture
Our leadership actively creates the conditions for improvement to happen.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 8.7.1 | The principal practitioner(s) visibly champion quality improvement within the practice | ||||
| 8.7.2 | Quality improvement is a standing agenda item at practice meetings | ||||
| 8.7.3 | Staff at all levels are encouraged to identify improvement opportunities and their suggestions are taken seriously | ||||
| 8.7.4 | Staff who identify problems or raise concerns are thanked, not managed | ||||
| 8.7.5 | The practice celebrates and communicates improvements that have been achieved | ||||
| 8.7.6 | Time and resource are allocated (however modestly) to quality improvement activity - it is not expected to happen in staff members' personal time | ||||
| 8.7.7 | New staff are introduced to the practice's quality framework and improvement approach during induction | ||||
| 8.7.8 | The practice manager has access to professional development relevant to healthcare quality and governance | ||||
| 8.7.9 | The practice does not treat this framework as a compliance exercise - it can articulate at least two specific improvements made as a result of using it |
Not sure what counts as evidence?
The evidence guide provides concrete examples for every indicator in this domain.