Quality Improvement and PIP QI


Quality in general practice

Practices need to engage in activities to improve quality and safety for patients in areas such as practice structures, systems, processes and clinical care.

The RACGP standards for general practice indicate focusing on quality improvement should be based on evidence produced from the practice's own data.

One way this can be gathered is data audit and analysis from the practice’s clinical database, using a clinical audit data extraction tool. Measuring quality focuses on a multi-dimensional approach of the interactions between structure, process and outcomes.

The New PIP QI August 2019

The Quality Improvement PIP Incentive commenced on 1 August 2019.

This PIP is designed to encourage improvements in quality care, enhance capacity, improve access to care and improve health outcomes for patients.

As part of the new PIP QI Incentive, you’ll have to undertake continuous quality improvement activities through the collection and review of your practice data or information.The QI PIP will replace the following incentives:

  • Asthma Incentive
  • Cervical Screening Incentive
  • Diabetes Incentive
  • Quality Prescribing Incentive

The following incentives will stay the same: 

  • eHealth Incentive
  • After Hours Incentive
  • Teaching Payment
  • Indigenous Health Incentive
  • Procedural General Practitioner Payment
  • Rural Loading Incentive
  • General Practitioner Aged Care Access Incentive


pdf Click here (517 KB) for the latest fact sheet regarding what practices need to know - August 2019
Click here
for the latest information regarding the new Quality Improvement PIP.


Getting started with PIP QI

Quality Improvement generally follows these simple steps:

The 10 Quality Improvement Measures (QIM’s)

As part of the new PIP QI, participating practices (insert link to how to enrol) must share the following data with the CESPHN.  This data is known as the Quality Improvement Measures (QIM).

Practices must also commit to Continuous Quality Improvement (CQI)(insert link to fact sheet) based on one of the QIMs or any other QI Activity that is based on data from the practice electronic medical records (EMR)

The 10 QIMs are:

  1. Proportion of patients with diabetes with a current HbA1c result
  2. Proportion of patients with a smoking status
  3. Proportion of patients with a weight classification
  4. Proportion of patients aged 65 and over who were immunised against influenza
  5. Proportion of patients with diabetes who were immunised against influenza
  6. Proportion of patients with COPD who were immunised against influenza
  7. Proportion of patients with an alcohol consumption status
  8. Proportion of patients with the necessary risk factors assessed to enable CVD
  9. Proportion of female patients with an up-to-date cervical screening
  10. Proportion of patients with diabetes with a blood pressure result.


New to QI

Before you commence your clinical data quality improvements, you may want to start with our “Beginners - Level 0” QI Activities (QIA’s).  These activities will help to build the team, cleanse your data and generally make you familiar with quality improvement terminology and process.  You can then progress to our higher level QIA’s, that are designed to build on lower level activities.  The Beginners QIA’s will help you establish a “Person Centred” (insert link to PCMN page) approach to your patients.

To assist your practice in meeting the requirement of maintaining evidence that CQI activities have been undertaken, we have developed a new suite of templates and tools for your practice to get started with. Our QIA’s are based on the 10 QIM’s and are designed to build on the outcomes from the lower level QIA.  We welcome any feedback or suggestions you might have to improve these templates.

Level 1 QIA’s can generally be carried out by non-clinical staff at the front desk and generally focus on demographics or data cleansing especially current contact details.

Level 2 may involve the nurse or a GP leader and require some clinical skill and access to patient files.

Level 3 tend to focus on patient outcomes and will require GP participation, preferably practice wide.

We will continue to develop the Walk Throughs (POLAR) and Recipes (Pen CAT) that will step you through the use of the extraction tools to develop the reports we refer to in the templates.  Both websites have substantial resources available, and we encourage you to refer to them directly.

POLAR users              Confluence Health log in

Pen CAT                     Pen CAT Recipes

Our dedicated Quality Improvement Officers Sara and Thuy Ann are here to help so please get in touch with them. 

Sara Matin              E: s.matin@cesphn.com.au  M: 0448 377 230     

Thuy Ann Vuong     E: t.vuong@cesphn.com.auM: 0439 137 818    


Quality Improvement Activity Templates 

Quality Improvement Measure (QIM) No



Diabetes (1)

Find diabetics without a usual GP


Update the diabetic register

pdf CESPHN QIA Undiagnosed Diabetics QIA level 2 (359 KB)


Recall patients without a HbA1c 


Diabetes (5)

Find diabetic patients who have not been immunised against influenza


Diabetes (10)

Find diabetics without a current blood pressure result

pdf CESPHN QIA Diabetes without blood pressure Level 2 (367 KB)


Find diabetics with three of less missing items to complete their cycle of care

pdf CESPHN QIA Diabetes Cycle of Care QIA level 3 (359 KB)


Smoking (2)

Improve the recording of patient smoking status

pdf CESPHN QIA Smoking recording level 1 (359 KB) folder


Identify pregnant women who are current smokers

pdf CESPHN QIA smoking level 2 (359 KB)


Identify current smokers with COPD and of CVD

pdf CESPHN QIA smoking level 3 (359 KB)


Weight (3)

Improve the recording of patient BMI

pdf CESPHN QIA BMI recording Level 1 (359 KB)


Find obese patients who might be eligible for a Health Assessment

pdf CESPHN QIA BMI level 2 (359 KB) pdf
(359 KB)


Find patients with a BMI over 30 and are type 2 diabetic or a current smoker

pdf CESPHN QIA BMI level 3 (359 KB)


Influenza vaccination (4)

Improve the recording of patients 65+ years and immunised against influenza

pdf CESPHN QIA 65 and immunised against influenza level 2 (359 KB)



Influenza vaccination (6)

Improve the recording of patients with COPD and immunised and immunised against influenza



Alcohol (7)

Improve the recording of patient alcohol consumption



Reduce alcohol consumption in patients with a mental health condition

pdf CESPHN QIA alcohol level 2 (359 KB)


Reduce alcohol consumption in hypertensive patients

pdf CESPHN QIA alcohol level 3 (359 KB)


CVD risk (8)

Improve the recording of patients with necessary risk factors to enable CVD assessment


Cervical Screening (9)

Improve the cervical screening rates in female patients


Other PHN QI Projects


For those practices interested in pursuing QI at a higher level, CESPHN offers many programmes of different complexities to support practices.  Some of these programmes have financial incentives.

They Include:

My Health Record

Shared Health Summary uploads for eHealth PIP

Contact: Digital Health Team (digitalhealth@cesphn.com.au)

Mental Health

Black Dog StepCare Program

Contact: Catherine O’Donnell (c.odonnell@cesphn.com.au)

Population Health & Chronic Disease    

Staying Health Living Well Telehealth Program

Contact: Jason Phillips (j.phillips@cesphn.com.au)                                                           

Please see the Person Centred Medical Neighbourhood page here.



Why are quality records important?

Quality health records are essential to all practices. They facilitate the safe, accurate sharing of health information between health professionals to achieve safe and effective patient care.

The auditing of your practice’s data, processes and systems is important. The audit outcomes can indicate target areas for health record QI, such as:

  • completeness of content in patient health records like allergy status, smoking status and other health summary information
  • consistency in standardising processes for entering data in line with a nationally recognised coding system
  • the ability to access, share and retrieve recorded information in a timely manner

For further information see the links below

Improving health record quality in general practice

Quality records in Australian primary healthcare



Focusing on clinical quality improvement

Practices can focus on activities specifically designed to improve individual care or the health of their entire practice population. For example, a clinical QI activity could focus on improving the care of individuals with diabetes.

Why do I need a data extraction tool?

Data extraction tools are designed to make analysis of your data as simple and as easy as possible. It lets you look for sources of revenue, build and maintain disease registers and even highlight coding errors. These tools are essential for helping your practice profitability and your patient care. CESPHN supports practices that use Pencat and now offers Polar as an alternative data extraction tool.

Who can see my data?

At this stage if you want to participate in the new QIP you must upload your de-identified data base to CESPHN. At no point does any identifiable patient data leave your practice. The data extraction tool deidentifies your data at your practice and sends the encrypted data securely to us. It does not upload any of your financial information. Privacy is our top priority. Depending on which extraction tool you use and how it is set up, your data may be uploaded automatically. Contact your Practice Support Officer for more information.

If you need a copy of the Pen CAT privacy notice for your practice pdf click here (930 KB) or the POLAR privacy notice, pdf click here (130 KB) .

How can we support your practice?
  • Strategies to embed QI in your practice
  • How to analyse your practices own data to identify areas for QI
  • Assist with goal setting and activities
  • Measuring quality improvement in your practice
  • Progress reports and feedback
  • For further information please contact our Quality Improvement Officers on 1300 986 991, press 2 or email pipqi@cesphn.com.au 
Data extraction tools are designed to make analysis of your data as simple and as easy as possible. It lets you look for sources of revenue, build and maintain disease registers and even highlight coding errors. These tools are essential for helping your practice profitability and your patient care. CESPHN is in the process of phasing out our support of Pencat (link) and now offer Polar (link) as our preferred data extraction tool.