» Quality Improvement Programme (QIP)

Quality Improvement Programme (QIP)

Published: 25/06/2025 | 12 files

On 1 July 2024 Pinnacle moved from a quality assurance programme to a quality improvement (QI) programme in general practice. This will ultimately lead to improved health outcomes for patients.

What is the quality improvement programme?

QI looks at systems and processes through a cycle of improvement, which includes problem identification, planning and testing ideas, data collection and analysis, and measurement of change.

Tools are used to support practices to problem solve and access data. This includes PDSA cycles (plan, do, study, act) which many will be familiar with, and tools such as Power BI to access the data and for simple measurement.

The programme aligns with the RNZCGP CQI module for Cornerstone.

What do I need to do? Year 3 QIP

The only incentivised indicator for 2026/2027 is the 24 month immunisation indicator. Practices are encouraged to continue the work they have done with the clinical indicators but this work is not compulsory.

This means practices will be asked to only complete one indicator:
24-month childhood immunisation remains compulsory for practice.

For the second clinical indicator, practices have two options:

Continue with the same clinical indicator from 2025/26 and build on the work already underway. This gives practices the opportunity to sustain the gains made this year, or further develop and scale up successful change ideas.
If your practice has exhausted the change ideas associated with its existing clinical indicator, and has measured the impact of those changes with an equity focus, you may choose one of the other clinical indicators. Please talk to your development manager if you are considering this option.

Reporting requirements

No reporting requirements are required for 2026/2027. Pinnacle staff will gather information around any change ideas that have had a positive impact through nurse peer group meetings and development manager practice meetings.

Practice change ideas

Reporting identified the following change ideas that were put through PDSA cycles.

Immunisation 24 months

Refresh of pre-call and recall processes

The practice implemented a more proactive approach to immunisation recalls, including:

adding a recall for all delayed vaccines
tasking the manager, nurses and HCAs with calling patients to follow up on overdue immunisations, while reception staff and GPs checked appointment books for additional opportunities
aiming to schedule each child’s next immunisation appointment before they left their six-week immunisation appointment
making earlier referrals to OIS
ensuring the responsible nurse followed up by phone after a DNA
adding an alert to the records of all children whose immunisations had been declined
reviewing and strengthening processes with the iwi provider.

Practice resourcing and other initiatives

The practice also:

allocated one nurse to lead the recall work
conducted regular audits
provided additional after-hours immunisation clinics
implemented a structured maternity programme designed to strengthen early engagement.

CVD and triple therapy

Many practices used Power BI lists to identify patients and then either recalled / sent out invitations to patients who may benefit from changes in treatment / nurse and GP review / focussed on hypertension as the most impact on risk.

Others used the heart foundation training as an opportunity to upskill their staff around latest evidence and then implement learnings through the nursing teams.

Asthma SABA/ICS

Many practices used Power BI lists to prioritise their patients for treatment and then either recall / clinical review / added a next visit alert to those patients / tied the appointment into the POAC proactive respiratory funding.
Other practices:
- upskilled their staff through online training such as the Goodfellow training / inhouse pharmacist training.
- cleaned up the classifications for those patients on the lists ie ensuring they do have a diagnosis of asthma.

MDI vs DPI

Provided prescriber education then clinical pharmacist consultations for those appropriate to change.
Flagged a review during repeat prescription process.

Diabetes SGLT2i/GLP1RA

Upskilling nurses by diabetes clinical specialist / clinical pharmacist.
Used Power BI lists to identify patients and then:
- flagged these patients as part of their DARs appointment.
- clinical pharmacist reviewed and developed a poster to show progress internally.

Diabetes cholesterol lowering

Upskilled nurses by diabetes clinical specialist.
Trained MCA on recalls for DAR.
Appointments scheduled into clinical pharmacist template
Used Power BI lists to:
- prioritise Māori/ Pasifika patients and targeted for clinical review / documented if they were intolerant to statins in their notes.
- add a next visit alert to those patients / add LDL quality management alert to patient files.

Have any pātai?

Development managers are leading the programme in each region. These people are your first line of contact around the QI Programme.