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Quality Improvement and PIP QI

Quality improvement 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.

Quality Improvement generally follows these simple steps:

  • Utilise data extraction tool to conduct clinical audit
  • Record outcomes of clinical audit
  • Document proposed actions following clinical audit, including delegated responsibilities
  • Keep evidence of implementation
  • Document follow up plans

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 (CQI) activities through the collection and review of your practice data or information.

The PIP QI 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

The 10 Quality Improvement Measures (QIMs)

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

Practices must also commit to CQI 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 assessment
  9. Proportion of female patients with an up-to-date cervical screening
  10. 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 (CESPHN supports Pen CAT & POLAR)
  • Share de-identified data with CESPHN (for PEN this includes a scheduler)
  • Sign applicable Data Management Agreements (DMAs) ( Pen CAT/ POLAR) and have the appropriate posters (Pen CAT / POLAR) visible in the practice
  • Register from 1 August via PRODA and HPOS
  • Complete an annual confirmation statement each year
  • Notify CESPHN you have applied for the PIP QI incentive and provide your PIP Identifier Number (PIPIN) – this is so we can assist the department in processing payments
  • Provide the main contact person for the program including 2 email address to receive the quarterly benchmarking 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 (QIAs)
  • Retain evidence (for 6 years) of the QI activities you have undertaken in the practice

Click here 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

Click here for our manual on registering for PRODA and PIP QI

Click here for our PIP QI & Data Sharing FAQ Sheet

Click here for the PIP QI factsheet for consumers


Your patients have the right to request that their information is permanently excluded from the practice’s de-identified data set. Simple step-by-step guides on how to exclude the patient are available:

Pen CS – How to opt out patients

POLAR – How to opt out patients



Not an accredited practice but would like to enrol in PIP QI?

If you would like to participate in the new Quality Improvement (PIP QI) Incentive but are not an accredited practice, our Practice Support and Development team can help you through the accreditation process. The Practice Support team can be contacted on or call 1300 986 991 and press 3.

Practice support can also support your practice with:

  • Staff orientation of general practice staff including GPs, GP Registrars and Practice Nurses
  • Practice Incentive Programs (PIPs), Service Incentive Program (SIPs), MBS items and Chronic Disease Management (CDM) items.
  • Undertaking quality management practices in accordance with best practice and appropriate accreditation standards
  • Advice based upon industry knowledge and legislative changes and emerging trends.

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 (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 users: Pen CAT Recipes


For more information contact


Quality Improvement Activity Templates 

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

CESPHN’s Blank Quality Improvement Activity Template (editable PDF version)

CESPHN’s Blank Quality Improvement Activity Template (Word version)

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


Diabetes (5)  Find diabetic patients who have not been immunised against influenza


Pen CAT recipe

POLAR walkthrough


Diabetes (10)  Find diabetics without a current blood pressure result

Pen CAT recipe

POLAR walkthrough


 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


 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

 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

Influenza vaccination (6)  Improve the recording of patients with COPD and immunised and immunised against influenza

Pen CAT recipe

POLAR walkthrough

Alcohol (7)  Improve the recording of patient alcohol consumption

Pen CAT recipe

 POLAR walkthrough

 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

Cervical Screening (9)  Improve the cervical screening rates in female patients

Pen CAT recipe

POLAR walkthrough


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.
These include:


Identifying patients eligible for voluntary patient registration – PENCAT

Identifying patients eligible for voluntary patient registration – POLAR

Project GROW 

QIA 1 – Improve the coding of diagnoses of intellectual disability – POLAR

QIA 2 – Increase uptake of annual health assessments for patients with intellectual disability – POLAR

Project GROW POLAR walkthrough steps for QIA 1 & 2

My Health Record

QIA – Shared Health Summary uploads for eHealth PIP

Contact: Digital Health Team (


QIA – Use Lumos Report to Improve Coding of “Undiagnosed” Diabetics

QIA – Use Lumos Report to Identify Potential Hospital Admissions QIA – Use Lumos Report to Identify Potential Hospital Admissions

Contact: Digital Health Team (

Mental Health

Black Dog StepCare Program

QIA Level 1 – Mental Health Screening

QIA Level 2 – Mental Health Treatment Plan

QIA Level 3 – Mental Health Treatment Plan Review

Contact: Jen Aboki (

Population Health & Chronic Disease    

Diabetes cycle of care: Diabetes foot assessment – QIA Level 1 

Referring diabetic patients to the High Risk Foot Service (HRFS) – QIA Level 2

Aged Care

Advance Care Planning QI Toolkit

Palliative and end-of-life-care QI Toolkit

Covid-19 QIAs 

Missing Covid-19 polar

Missing Covid-19 Pencat

Lifestyle Modification

Think, Eat And Move (TEAM) Program

QIA – Referring patients to the TEAM Program 2023

Sexual Health

Self-collected specimens for Chlamydia testing in your practice (QIA Level 1)

Improving Hepatitis C (HCV) screening – Checklist Blitz (QIA Level 1)

Contact: Phoebe Chomley and Zoe Richards (

Maternal & Child Health

QIA – Increasing influenza vaccination uptake in pregnant women

QIA – Increasing pertussis vaccination uptake in pregnant women

QIA – Ensuring asthmatic children have completed a current asthma cycle of care or a GP management plan

QIA – Monitoring child growth and wellbeing parameters for patients 0 – 5 years

Contacts: Karen Wheeler ( or Jane Miller (


AIR10A Due/Overdue Immunisation Practice Report

How to request AIR Due/Overdue 10A Report

How to analyse AIR Due/Overdue 10A Report

QIA – Using AIR 10A report to improve immunisation rates

Contact: Immunisation Team (

Please see the Person Centred Medical Neighbourhood page here.


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


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.

Click here to go to the GP Support Program website.


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.


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 click here or the POLAR privacy notice, click here .

  • 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 Practice Support Officers or Digital Health Officers on 1300 986 991 or email