Primary Care - Quality Improvement
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Quality Improvement

Everyone who works in healthcare has a part to play in creating a safe and high-quality healthcare system. Quality improvement is the science of process management.

Quality improvement draws on a wide variety of methodologies, approaches and tools. However, many of these share some simple underlying principles, including a focus on:

  • understanding the problem, with a particular emphasis on what the data tell you,
  • understanding the processes and systems within the organisation—particularly the patient pathway—and whether these can be simplified,
  • analysing the demand, capacity and flow of the service,
  • choosing the tools to bring about change, including leadership and clinical engagement, skills development, and staff and patient participation,
  • evaluating and measuring the impact of a change.

Regardless of the approach used, how the change is implemented—including factors such as leadership, clinical involvement and resources—is vital.

ELDAC Palliative Care and Advance Care Planning Organisational Audit

This interactive (fillable) pdf can be completed online, downloaded and printed for your organisation’s records. The audit should be completed by a staff member who has clinical and organisational knowledge of the palliative care and advance care planning processes and care provided in the service. In some instances, consultation with other staff may be required to complete the audit. Once completed bring the audit to the working group to identify areas for quality improvement. The Aged Care Quality and Safety Commission has a template that can be used to plan continuous improvement activities. The quality improvement plan should be reviewed at every working group meeting.

It is recommended that the organisational audit be completed at least yearly and the results used as part of your organisation’s accreditation documents. Provide a date for when the audit was completed and a date for future review.

The ELDAC Organisational Audit has been revised to address the learnings from Phase 1 of ELDAC and to align with the Aged Care Quality Standards. Version 2 is available below.

>>Download the updated Version 2 ELDAC Palliative Care and Advance Care Planning Organisational Audit (848kb pdf)

>>Version 1 ELDAC Palliative Care and Advance Care Planning Organisational Audit (465kb pdf)

ELDAC After Death Audit

This interactive (fillable) audit provides more detail on care provided to individual clients and families. It is recommended that a baseline audit be completed for either the most recent five to ten deaths or for a certain timeframe (e.g. all deaths that occurred over the previous 3-month period).

Following the initial audit using the ELDAC Palliative Care and Advance Care Planning Organisational Audit, it is recommended that the ELDAC After Death Audit is completed for every client who dies, and a formal review of deaths is conducted at a working group every 3 months.

The ELDAC After Death Audit has been updated and the new Version 2 is available below. The audit can be completed online, downloaded and printed for your organisation's records. The content has been streamlined and reflects the feedback received from Phase 1 of ELDAC.

>>Download the updated Version 2 ELDAC After Death Audit (636kb pdf)

>>Version 1 ELDAC After Death Audit (929kb pdf)

Advance Care Planning Continuous Quality Improvement Audit Tool


The Start2Talk website has a more detailed advance care planning audit and supporting resources: 

Australian Safety and Quality Framework for Health Care—Putting the framework into action: Getting started (923kb pdf)

Australian Commission on Safety and Quality in Healthcare (ACSQHC)

The Australian Safety and Quality Framework for Health Care describes a vision for safe and high-quality care for all Australians, and sets out the actions needed to achieve this vision. This ‘Getting started’ document will help you and your team to start putting the Framework into action. It highlights several of the Framework’s 21 areas of action that particularly apply to healthcare providers and describes some examples of activities to help you.

Quality improvement action plan template

Palliative Care Australia—Palliative Care Self Assessment (PaCSA)

A template to support the planning and implementation of a palliative care quality improvement program for a primary care practice or community palliative care collaboration. The Quality improvement action plan template is free to download requires registration, but the developers of the tool ask that you register your details prior to download.

A Palliative and End of Life Care—A Blueprint for Improvement

NSW Health Agency for Clinical Intervention (ACI)

A flexible guide for health services to help them meet the needs of people approaching and reaching the end of life, their families and carers. The Blueprint can be implemented across all settings of care—acute, subacute, aged and community spanning across public, private, not-for-profit and community sectors.

This online resource aims to guide services and Local Health Districts in constructing their own, localised models of care. It emphasises that everyone can have a role to play in supporting or providing care to people approaching and reaching the end of life.

Quality Improvement Audit Package

Palliative Care Outcomes Collaboration (PCOC)

This package supports palliative care services to effectively use the PCOC audit tools to improve compliance of clinical assessment and identify areas for improvement.

Quick Guide to Quality Improvement Audits

Palliative Care Outcomes Collaboration (PCOC)

A concise guide to using and understanding audits.
>>Download Quick Guide to Quality Improvement Audits (203kb docx)

Template for Quality Improvement

Palliative Care Outcomes Collaboration (PCOC)

Assists services with summarising the plan and outcome of quality improvement activities.
>>Download Template for Quality Improvement (48kb docx)

Practice Incentive Program (PIP) Quality Improvement (QI) Incentive

The Practice Incentive Program (PIP) Quality Improvement (QI) Incentive commenced in August 2019. It aims to improve:

  • access to care
  • detection and management of chronic conditions, and
  • quality, safety, performance and accountability.

General practices eligible to participate in the Practice Incentive Program can apply for the Quality Improvement Incentive. In doing this the practice must commit to:

  • participate in continuous quality improvement activities, and
  • share de-identified general practice data against agreed measures.

Collection of de-identified improvement measures included the following PIP Eligible Data Set initial improvement measures:

  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 assessment
  9. Proportion of female patients with an up-to-date cervical screening
  10. Proportion of patients with diabetes with a blood pressure result.

Find further information at PIP QI Incentive guidance.

Page updated 12 May 2022