CPD PDSA guide
A Plan, Do, Study, Act (PDSA) implementation guide
A worked PDSA cycle for identifying unmet health needs, optimising MBS billing and meeting CPD requirements as a whole practice team.
GPs can meet a significant share of their 50-hour annual CPD requirement without leaving the practice. When submitted as a practice-based or group activity, hours can be logged across EA, RP and MO categories. Nurses maintain their own CPD records and declare compliance at annual registration renewal via AHPRA. Practice managers count it toward AAPM certification.
A practice that runs structured QI activities absorbs a substantial portion of the 50-hour CPD obligation on behalf of its GPs. The GP gets CPD hours done within practice time, on problems relevant to their clinical work. That benefit disappears if they leave.
Data extraction shows what is happening with patient care, recalls and coding. Most practices find gaps they did not know existed. A documented PDSA is ready-made evidence for RACGP accreditation.
Depending on the topic, PDSAs surface missed MBS items, lapsed recall lists and unregistered incentive payments. This topic addresses items 715, 228, 10987, 10997, 965, 967 plus PIP IHI and CTG PBS Co-payment.
Most GP practices have Aboriginal and Torres Strait Islander patients whose preventive care needs are not fully met. The gap is rarely about intent. It is about systems: identification at reception, recall and reminder processes, health assessment templates and MBS billing workflows that do not flag eligible patients consistently.
MBS item 715 (health assessment, claimable every 9 months). PIP Indigenous Health Incentive: sign-on payment plus Tier 1 and Tier 2 outcome payments per registered patient per 12-month assessment period for chronic disease and mental health management. CTG PBS Co-payment registration supports patient retention. Nurse follow-up via item 10987 (up to 10 per patient per year). Chronic condition management via item 965 (GPCCMP).
Note: The PIP IHI patient registration payment was removed from 1 July 2025. The program now operates on a back-ended outcome payment structure. See the PIP Indigenous Health Incentive section in Background and reference for current payment details.
Approximately 9 hours when submitted as a practice-based or group activity: 3 EA (practice education sessions), 3 RP (data extractions and analysis), 3 MO (the PDSA cycle itself). All participating GPs log via myCPD or their preferred portal. Nurses and practice managers claim separately under their own frameworks.
Note on CPD categorisation: The RACGP currently classifies PDSAs under Measuring Outcomes (MO). However, the broader project involves components that qualify separately as Educational Activities and Reviewing Performance. When submitted as a group or practice-based activity, each component can be logged to its correct category.
| Category | Focus | Hours |
|---|---|---|
| EA | Practice education sessions (cultural safety, health assessment workflow) | 3 |
| RP | Data extractions and clinical audit analysis | 3 |
| MO | PDSA cycle (plan, do, study, act with documented outcomes) | 3 |
| Total | All components when submitted as practice-based or group activity | 9 |
Each section includes a worked example from a real cycle conducted by Chris Mitchell in a mixed rural practice with approximately 33 regularly attending Aboriginal and Torres Strait Islander patients, followed by space for your practice to document your own process.
The educational materials at the end of this document contribute to EA (Educational Activities) hours. When you review and discuss this material with your practice team, those hours count toward the 3 EA hours for this PDSA.
All participating GPs log via myCPD or their preferred portal. Nurses maintain their own CPD records and declare compliance at annual registration renewal via AHPRA. Practice managers count it toward AAPM certification requirements.
This PDSA can be submitted individually or as a group/practice-based activity. When submitted as a group or practice-based activity, CPD hours can be allocated across EA, RP and MO categories as shown above.
Identify Aboriginal and Torres Strait Islander patients of the practice who have unmet health needs the practice could better support through systematic identification, assessment and follow-up.
Map the current state: how many patients identify as Aboriginal or Torres Strait Islander, what proportion have had a recent health assessment (item 715), how many are registered for CTG PBS Co-payment and PIP Indigenous Health Incentive, and where the gaps sit in vaccination schedules and care plans.
We ran the numbers in Cubiko and found 147 patients flagged as Aboriginal or Torres Strait Islander. Cross-referencing against Best Practice direct search returned 33 regularly attending patients. The discrepancy was from inactive and non-attending patients captured in the broader extraction. We decided to focus on the 33 active patients and work through their care systematically.
Run an initial data extraction. Record your numbers below.
| Total patients flagged as Aboriginal or Torres Strait Islander | |
| Regularly attending patients (active in last 12 months) | |
| Patients with a 715 health assessment in last 9 months | |
| Patients registered for CTG PBS Co-payment | |
| Patients registered for PIP Indigenous Health Incentive |
| Executive planning meeting | |
| Clinical discussion meeting | |
| Practice planning and education meeting | |
| First data extraction | |
| Strategy confirmation meeting | |
| Second data extraction | |
| Third data extraction | |
| Follow-up meeting to confirm learnings | |
| RACGP portal upload |
| Measure | Extraction 1 | Extraction 2 | Extraction 3 |
|---|---|---|---|
| Active patients identified as Aboriginal or Torres Strait Islander | |||
| Health assessments completed (item 715) | |||
| CTG PBS registrations | |||
| PIP Indigenous Health Incentive registrations | |||
| GPCCMPs in place (item 965) | |||
| Mental health care plans in place | |||
| Vaccination schedules up to date | |||
| Nurse follow-up appointments (item 10987) |
The initial data showed that Best Practice permitted health assessments for identified patients aged over 50, but the template was not titled as an Aboriginal and Torres Strait Islander health assessment. We identified the ATSI Updated Health Assessment as the preferred document.
From 1 March 2026, MBS items 715 and 228 no longer require age-based clinical activities. The assessment is holistic and tailored to the patient's individual needs regardless of age group. This is a recent change and practices should update their templates and workflows accordingly.
Recalls and reminders were generated for Indigenous Health Incentive (annual) and Aboriginal Health Assessment (annual). Shortcuts were created for common clinical documentation.
Vaccination requirements were more complex than expected. Doctors Control Panel handled this well, but the team needed education on the specific NIP schedule for Aboriginal and Torres Strait Islander people, particularly around pneumococcal vaccines (Prevenar from age 50, different sequencing for high-risk patients) and Shingrix eligibility from age 50 rather than the general population threshold.
Schedule fees are not listed as they are updated annually. Verify current fees against MBS Online before billing.
| Item | Description | Notes |
|---|---|---|
| 715 | Aboriginal and Torres Strait Islander health assessment | Claimable every 9 months. Not time-based. Updated 1 March 2026: age-based clinical activities removed in favour of holistic, individualised care. |
| 228 | Health assessment by prescribed medical practitioner (ATSI) | Alternative to 715 where a PMP conducts the assessment. Same 9-month frequency. Updated 1 March 2026. |
| 10987 | Nurse follow-up after health assessment | Up to 10 per patient per calendar year. Provided by practice nurse or Aboriginal and Torres Strait Islander health practitioner on behalf of the medical practitioner. |
| 10997 | Nurse follow-up for patients with a care plan | Up to 5 per patient per calendar year. Billable in addition to 10987 if a current GPCCMP or equivalent care plan exists. |
| 965 | GP chronic condition management plan (GPCCMP) | Replaced items 721 (GPMP) and 723 (TCA) from 1 July 2025. |
| 967 | Review of GPCCMP | Replaced item 732 from 1 July 2025. Required for PIP IHI Tier 1 outcome payment. |
Patients with an existing GPMP and/or TCA created before 1 July 2025 can continue to access services under that plan until 30 June 2027. Any new plan or review after 1 July 2025 must be a GPCCMP (item 965) or GPCCMP review (item 967). From 1 July 2027, a GPCCMP is required for ongoing allied health access.
CTG PBS Co-payment registration is a one-off via HPOS/PRODA. The receptionist can register on the doctor's behalf once eligibility is confirmed. The patient does not need to re-register if they change practices. PIP Indigenous Health Incentive consent is separate and is lifetime for patients aged 15 and over (from 1 January 2025).
The practice changed its new patient registration form to include a cultural status question, updated recall and reminder templates, set the ATSI Updated Health Assessment as the standard document and created shortcuts for common billing and documentation workflows. Two staff members (one GP) enrolled in the RACGP Cultural Awareness Active Learning Module while waiting for the next PHN cultural safety training session.
| Vaccine | Eligibility | Schedule notes |
|---|---|---|
| Influenza | Age 6 months and older (NIP funded) | Annual |
| Shingrix | Age 50+ (NIP funded). Age 18+ if immunocompromised. | 2 doses, 2-6 months apart (1 month if immunocompromised) |
| Pneumococcal (Prevenar) | Age 50+ (PBS covered) | See sequencing for high-risk patients. 13vPCV at diagnosis of high risk or age 50 if ATSI, then 23vPPV 2-12 months later, then 23vPPV at least 5 years later. |
| Pneumococcal (Pneumovax) | As per schedule | Private script (not PBS covered) |
| Tetanus (ADT/Boostrix) | As per schedule | ADT free / Boostrix private |
| COVID-19 | As per current recommendations | Boosters as required |
Verify all vaccination schedules against the current National Immunisation Program Schedule. Doctors Control Panel provides up-to-date patient-specific recommendations.
Log this PDSA via myCPD or your preferred CPD portal as a group or practice-based activity. Record the time as you go and document discussions in meeting minutes for AHPRA requirements. Consider how the activity addresses your reflections on culturally safe practice, professional and health inequities, and ethical practice.
The activity structure maps to all three AHPRA CPD types when each component is submitted separately under its correct category:
| Activity component | AHPRA CPD type | Estimated hours |
|---|---|---|
| Practice education sessions (cultural safety, health assessment workflow) | Educational activities (EA) | 3 hours |
| Data extractions and clinical audit analysis | Reviewing performance (RP) | 3 hours |
| PDSA cycle (plan, do, study, act with documented outcomes) | Measuring outcomes (MO) | 3 hours |
Nurses log separately via AHPRA/NMBA. Practice managers count toward AAPM certification requirements.
Check where you sit in the triennium before logging hours. If the project spans two triennium periods, start the new submission from the date the new triennium begins. Do not log hours to a period where you have already met your requirements.
| Doctor's name | QI and CPD number |
|---|---|
Medius Global helps GP practice owners strengthen operations, meet compliance requirements and build a practice that attracts and retains GPs. Structured quality improvement is one of the most effective ways to deliver CPD to your team within the practice, reduce individual compliance burden, and demonstrate to prospective GPs that your practice invests in professional development.
Whether you are three years from exit or building for the long term, we can help you implement PDSA cycles, clinical audits and practice-level QI programs that meet CPD, accreditation and PIP QI requirements.
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This section contains the educational and clinical background material that supports the PDSA. It forms part of the Educational Activities (EA) component of the CPD hours for this project. Review and discussion of this material with your practice team contributes to the 3 EA hours.
To register a patient for the PBS (cheaper medications) the receptionist can do it on PRODA acting on the doctor's behalf (the doctor confirms eligibility) and no forms are required. You also need to tick in the patient demographics regarding CTG status.
A patient is eligible if they:
The PIP IHI encourages health services to meet the health care needs of Aboriginal and Torres Strait Islander people with a chronic disease. Health services include general practices, Aboriginal Medical Services and Aboriginal Community Controlled Health Services.
Register patients using PIP Online in HPOS. You can also use form IP017 (patient registration and consent) or IP029 (patient withdrawal of consent).
Practices can register patients aged 15 years and over. The patient must be an Aboriginal and/or Torres Strait Islander person who:
The PIP IHI has two payment types:
Sign-on payment: A one-off payment when the practice registers for PIP IHI. Paid in the next quarterly payment after approval.
Tier 1 outcome payment: Per registered patient per 12-month assessment period. Requires the practice to prepare a GPCCMP (item 965) or GP Mental Health Treatment Plan, plus at least one review (item 967 or equivalent), OR complete two reviews if a plan is already in place.
Tier 2 outcome payment: Per registered patient per 12-month assessment period. Requires a minimum of 5 eligible MBS professional attendance or procedural items delivered to the registered patient within the assessment period. This may include services counted for Tier 1.
Source: Services Australia, PIP IHI Guidelines (updated December 2025). Specific dollar amounts are updated periodically. Verify current payment rates via Services Australia.
From 1 January 2025, all new registrations for patients 15 years and above are lifetime (ongoing). Practices no longer need to re-register these patients annually. Once a young patient reaches 15, they must be re-registered under their own consent (withdraw the current registration and re-register them).
At least 2 staff members (one must be a GP) must complete appropriate cultural awareness training within 12 months of the practice being approved for PIP IHI. Training options include PHN cultural safety training sessions (usually annual) and the RACGP Cultural Awareness Active Learning Module (available online).
Medicare rebates for preventive health assessments are available for all Aboriginal and/or Torres Strait Islander people of any age through MBS item 715. Claimable once every 9 months.
From 1 March 2026, items 715 and 228 no longer require age-based clinical activities. The assessment is holistic and tailored to the patient's individual needs regardless of age group. Revised item descriptors include the clinical activities required to bill the item.
When providing the assessment, you must:
You should offer the patient a written report, including any recommendations. If the patient agrees, you may provide relevant extracts to the patient's carer. You can refer for up to 5 allied health follow-up services per calendar year.
After an Aboriginal and Torres Strait Islander health assessment, you can bill item 10987 for nurse or Aboriginal and Torres Strait Islander health practitioner follow-up, up to 10 per patient per calendar year. If the patient also has a care plan (GPCCMP), item 10997 can be billed in addition, up to 5 per patient per calendar year.
Note: Items 10987 and 10997 cannot be claimed when a practice nurse or ATSI health professional assists with the health assessment itself.
The following shortcuts were created during Chris Mitchell's PDSA cycle. Practices could adapt these to their own clinical software.
Aboriginal and/or Torres Strait Islander
Aboriginal and/or Torres Strait Islander Health Assessment (Item 715, not time-based)
Reason for visit: Health assessment – ATSI
Management section should cover: Advance Health Directive, health priorities, allergies, medications, family history, social history, employment, mood, memory, routine screening tests, diet, activity, smoking history, alcohol use, gambling, vaccinations, acuity, dental reviews, cardiovascular risk assessment, recalls and reminders, eligibility for nurse item 10987, CTG registration confirmation, Indigenous Health Incentive consent.
PHNs commission local services to provide the ITC Program. The program aims to contribute to improving health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions through better access to care coordination, multidisciplinary care and support for self-management, and improve access to culturally appropriate mainstream primary care services (general practice, allied health and specialists).
Contact your local PHN for details of ITC services available in your area.
Under the PIP QI Incentive, PHNs have a central role. They can:
Under the Medical Board of Australia's registration standard, all GPs must complete 50 hours of CPD annually:
PDSA cycles are classified under Measuring Outcomes. However, when a PDSA is run as a practice-based project, the associated education sessions qualify as EA and the data extraction and audit components qualify as RP. Submit each component separately under its correct category via myCPD or your preferred portal as a group or practice-based activity.
Using the GP-led Activity form, one GP can record the activity for multiple GPs on their behalf.