Quality Improvement Policy and Activity Log Template

What's in this template?

This Quality Improvement Policy and Activity Log gives Australian general practices a complete QI policy plus a ready-to-fill Activity Log, aligned to RACGP Standards 5th edition criterion QI1.1 and the Practice Incentives Program Quality Improvement Incentive (PIP QI). The Activity Log at the back of the document is the practice's primary QI record, the single piece of evidence accreditors and PHN reviewers most often ask to see.

The policy covers 14 sections plus a sign-off block plus the Activity Log table:

1. Purpose: RACGP QI1.1 and PIP QI alignment
2. Scope: clinical, non-clinical, systems, population health
3. Quality improvement framework: PDSA explained with example
4. PIP QI Incentive, the 10 Measures: listed in full
5. Roles and responsibilities: QI Lead, Clinical Lead, manager, clinicians, nurses, reception
6. How QI activities are identified: PIP QI, incidents, complaints, software, suggestions
7. The quarterly QI meeting: attendees, agenda, minutes
8. Activity Log, what each row contains: title, lead, goal, baseline, change, result, decision
9. Audit, accreditation and reporting: accreditation evidence, PIP QI submissions
10. Data quality and ethics: de-identification, HREC considerations
11. Training and culture: induction, refresh, celebrating wins, learning from failure
12. Related documents
13. Approval and review
14. Activity Log: ready-to-fill table

Editable placeholder fields

• {{practice_name}}, {{practice_address}}
• {{clinical_lead}}, {{qi_lead}}, {{practice_manager}}
• {{phn_pip_qi_status}}, whether the practice is PIP QI-registered with its PHN
• Activity Log rows for ongoing use
• Sign-off blocks for Clinical Lead, Practice Manager and QI Lead

Who needs a Quality Improvement Policy and Activity Log?

Every Australian general practice that is RACGP-accredited or seeks accreditation. Practices registered for the PIP QI Incentive also need documented activity to justify the payment. The template is suitable for:

• General practices: solo, group, corporate
• Aboriginal Community Controlled Health Services (ACCHOs)
• Specialist medical practices running QI, adapt the PIP QI section
• Allied health practices running QI, keep the PDSA and Activity Log structure; PIP QI does not apply

RACGP and PIP QI requirements at a glance

Criterion QI1.1, Quality improvement. The RACGP Standards 5th edition requires the practice to engage in continuous quality improvement. Surveyors look for:

• A documented QI policy
• Evidence of completed QI activities (the Activity Log)
• Team involvement in QI
• A QI Lead or equivalent role
• Outcomes documented and reviewed

PIP QI Incentive: practices register with their Primary Health Network (PHN) and submit data on 10 measures quarterly via a data extraction tool. The incentive provides ongoing funding to practices that submit. The 10 measures cover diabetes, smoking, weight, alcohol, COPD, cervical screening, BP, and influenza immunisation in priority cohorts. The current measure set is reviewed periodically by the Department of Health and Aged Care, confirm at health.gov.au before each submission cycle.

The PDSA framework, built in

The policy includes a worked example (diabetes HbA1c testing recall) to show what a full PDSA cycle looks like in a busy general practice.

How to customise this template

1. Download the Word document and replace every {{placeholder}} with your details
2. Confirm PIP QI registration: if registered with a PHN, the 10 measures are pulled by your data extraction tool (Pen CS Topbar, PEN CAT4, Polar, Train IT, POLAR Explorer)
3. Nominate a QI Lead: usually the Practice Nurse or a senior GP; this is the role surveyors will ask to meet
4. Set the quarterly QI meeting: block 60-90 minutes in the diary on a recurring quarterly cadence
5. Start the Activity Log immediately: even a single completed PDSA cycle is far stronger evidence than the policy alone
6. Link QI to other practice systems: incidents, complaints, open disclosure, accreditation findings all feed QI activity selection
7. Connect to PIP QI submissions: review the 10-measure trends quarterly before the data goes to the PHN
8. Celebrate wins: share results at team meetings; learning from a "did not work" activity is as valuable as a "worked" activity

What surveyors look for

At RACGP accreditation, the QI surveyor will ask:

• "Can I see your Activity Log?"
• "Show me a recently completed PDSA cycle, what was the change, what was measured, what was the result?"
• "How does the team know about QI activities?"
• "How do you identify the next QI priority?"

A current Activity Log with 2-3 completed cycles per year for the standard 3-year accreditation period answers these well.

Related templates and tools

The QI Policy is the home for outputs from many other practice systems:

• Recall and Reminder System Policy: recall audit data and improvement
• Follow-up of Tests, Results and Referrals Policy: loop-closure audit feeds QI
• Patient Identification Policy: identification errors feed QI
• Open Disclosure Policy: every formal disclosure triggers learning into QI
• Complaints Handling Policy: patterns from complaints feed QI
• Incident and Hazard Report Form: incidents drive QI activity selection
• Cold Chain Management: vaccine fridge audit feeds QI
• Clinical Risk Management: risk register links to QI
• Practice Information Sheet: improvement-driven changes communicated to patients

Frequently asked questions

Is a documented QI policy and Activity Log mandatory for RACGP accreditation?

Yes. RACGP criterion QI1.1 requires continuous QI with documented activity. The Activity Log is the primary evidence surveyors look for. Without it, the criterion is not met.

How many QI activities do we need per year?

There is no fixed number. The practical answer is at least 2-3 completed activities per year, enough to demonstrate continuous QI across the 3-year accreditation cycle, but not so many that quality suffers. Quality over quantity. A single deep PDSA cycle is more valuable than ten shallow ones.

What is PIP QI and is it mandatory?

PIP QI is the Practice Incentives Program Quality Improvement Incentive. Practices register with their PHN, share data on 10 measures quarterly via a data extraction tool, and receive ongoing incentive payments. It is optional but financially significant, most accredited general practices register. The data extraction is automated; the practice reviews trends and uses them to drive QI activities.

What if we're not PIP QI registered?

The QI Policy still applies. RACGP QI1.1 is mandatory regardless of PIP QI. The PIP QI section of the template explains what the measures are, but if you are not registered, the focus is on locally identified QI priorities, incidents, complaints, recall data, software searches, team suggestions.

What data extraction tool should we use?

Common options in Australian general practice: Pen CS Topbar (and POLAR Explorer), PEN CAT4, Train IT Medical, Polar. Most PHNs provide a tool to registered practices. The choice is usually driven by what the PHN supports.

Do QI activities need ethics approval?

Generally no, for internal QI using de-identified or aggregated data. External publication (case studies, conference presentations) may require notification to a Human Research Ethics Committee or formal HREC approval. The policy covers this in section 10. The PIP QI submissions are aggregated and de-identified at the practice level, no patient identifiers leave the practice.

Who runs QI in the practice?

The QI Lead, usually the Practice Nurse or a senior GP, coordinates. Every team member may propose a QI activity; the QI Lead supports them in turning the idea into a PDSA cycle. The quarterly meeting brings the team together to review and prioritise.

Will accreditors accept this template?

Yes, when populated and active. The policy maps directly to RACGP QI1.1 indicators. The Activity Log is exactly what surveyors look for. Pair the policy with at least one completed PDSA cycle before survey and the criterion is well-evidenced.