Practice Incentives Program Quality Improvement (PIP QI)

The 10 Quality Improvement Measures (QIMs)

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

Practices must also commit to Continuous Quality Improvement (CQI) that is based on data from the practice electronic medical records (EMR).

The 10 QIMs are:

Proportion of patients with diabetes with a current HbA1c result
Proportion of patients with a smoking status
Proportion of patients with a weight classification
Proportion of patients aged 65 and over who were immunised against influenza
Proportion of patients with diabetes who were immunised against influenza
Proportion of patients with COPD who were immunised against influenza
Proportion of patients with an alcohol consumption status
Proportion of patients with the necessary risk factors assessed to enable CVD assessment
Proportion of female patients with an up-to-date cervical screening
Proportion of patients with diabetes with a blood pressure result

Click here to view the PIP QI report walk through.

To participate in PIP QI, practices must:

Be an accredited practice
Have a data extraction tool installed in the practice
Share de-identified data with CESPHN
Sign applicable Data Management Agreements (DMAs) (POLAR DMA) and have the appropriate posters (POLAR Patient Opt-out Poster) visible in the practice
Register via PRODA and HPOS
Complete an annual confirmation statement each year
- Note: Please inform CESPHN & provide your PIP Identifier Number to assist The Department in processing payments
Provide the main contact person for the program including 2 email address to receive the quarterly practice progress report
Submit the PIP Eligible Data set to CESPHN on a quarterly basis (CESPHN will extract submission data on a monthly basis)
Work in partnership with CESPHN on practice relevant Quality Improvement Activities (QIA)
Retain evidence (for 6 years) of the QI activities you have undertaken in the practice

Quality Improvement Activities

To assist your practice in meeting the requirement to maintain evidence that CQI activities have been undertaken, we have developed a new suite of sample templates and tools for your practice to get started with as a guide. Our QIAs are based on the 10 QIMs, are classified as Level 0, 1, 2 or 3 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 0 – We recommend starting with these activities which will help build the team, cleanse your data to prepare you for the higher level activities and familiarise you with quality improvement terminology and processes. These will help you establish a “Person Centred” approach to your patients.

Level 1 – 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 – Tends to focus on patient outcomes and will require GP participation, preferably practice wide.

We will continue to develop the walkthroughs 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: Polar Knowledge Base Walkthroughs

Quality Improvement Activity Templates

We have created Quality Improvement Templates for you to download and use:

Blank Quality Improvement Activity Template (PDF)

Blank Quality Improvement Activity Template (Word)

Level 0 (Getting Started):

Building the quality improvement team

Finding duplicate patients

Cleaning up the active patients registry

Improving the coding of diagnoses

Updating patient demographics

Improving the recording of patient allergy

MD – Configure user options to help maintain data quality

BP – Configure user options to help maintain data quality

Quality Improvement Measure (QIM) No	Name	Level
Diabetes (1)	Find diabetics without a usual GP	1
	Update the diabetic register	2
	Recall patients without a HbA1c Pen CAT recipe POLAR walkthrough	3
Diabetes (5)	Find diabetic patients who have not been immunised against influenza Pen CAT recipe Polar Walkthrough (QIM 5)	3
Diabetes (10)	Find diabetics without a current blood pressure result Pen CAT recipe POLAR walkthrough	2
Diabetes (10)	Find diabetics with three of less missing items to complete their cycle of care	3
Smoking (2)	Improve the recording of patient smoking status Pen CAT recipe POLAR walkthrough	1
	Identify pregnant women who are current smokers	2
	Identify current smokers with COPD and/or CVD	3
Weight (3)	Improve the recording of patient BMI Pen CAT recipe POLAR walkthrough	1
	Find obese patients who might be eligible for a Health Assessment	2
	Find patients with a BMI over 30 and are type 2 diabetic or a current smoker	3
Influenza vaccination (4)	Improve the recording of patients 65+ years and immunised against influenza Pen CAT recipe Polar Walkthrough (QIM 4)	2
Influenza vaccination (6)	Improve the recording of patients with COPD and immunised and immunised against influenza Pen CAT recipe Polar Walkthrough (QIM 6)	2
Alcohol (7)	Improve the recording of patient alcohol consumption Pen CAT recipe POLAR walkthrough	1
	Reduce alcohol consumption in patients with a mental health condition	2
	Reduce alcohol consumption in hypertensive patients	3
CVD risk (8)	Improve the recording of patients with necessary risk factors to enable CVD assessment Pen CAT recipe POLAR walkthrough	3
Cervical Screening (9)	Improve the cervical screening rates in female patients Pen CAT recipe POLAR walkthrough	3