CPD PDSA guide
A Plan, Do, Study, Act (PDSA) template for any clinical or administrative topic
A blank, fillable template for running a Plan-Do-Study-Act quality improvement cycle in your practice. Includes pre-planning guidance, data collection tables, CPD logging guidance and team role assignments.
GPs can meet most or all of their annual 50-hour CPD requirement without leaving the practice. Hours count across EA, RP and MO categories. Nurses claim through AHPRA. Practice managers count it toward AAPM certification.
A shared project with defined roles, regular meetings and visible progress. One of the few structured activities where the whole practice works toward the same goal.
Data extraction shows what is happening with patient care, recalls and coding. Most practices find gaps they did not know existed.
Depending on the topic, PDSAs surface missed MBS items, lapsed recall lists and unregistered incentive payments.
A documented PDSA is ready-made evidence of continuous quality improvement against the RACGP Standards for general practices. Assessors look for a structured cycle with baseline data, measurable aims, team involvement and documented outcomes. The 6th edition Standards (expected 2026) strengthen the continuous QI requirements.
Practices registered for the Practice Incentives Program Quality Improvement (PIP QI) Incentive must participate in continuous quality improvement in partnership with their local Primary Health Network (PHN) and submit the PIP Eligible Data Set quarterly. A completed PDSA, presented to your PHN, qualifies as a PIP QI activity. This applies whether your topic aligns with one of the ten PIP QI Improvement Measures or addresses a different area relevant to your practice population.
A well-structured PDSA typically generates 5 to 9 hours of CPD across three categories: EA from education sessions, RP from data extraction and analysis, and MO from the PDSA cycle itself. Log as a GP-led activity (individual or group) via the RACGP CPD portal. All participating GPs can claim hours. ACRRM members and members of other medical colleges can self-report individually.
The Model for Improvement, used by the RACGP and the Institute for Healthcare Improvement (IHI), has two parts. The thinking part comes first. It generates the goal, measures and change ideas that feed into the PDSA cycle (the doing part). Skipping the thinking part is the most common reason PDSAs stall or produce results that nobody acts on.
1. What are we trying to accomplish? This becomes your goal. A useful goal is SMART: specific, measurable, achievable, relevant and time-based. For example: ‘Increase the proportion of active Aboriginal and Torres Strait Islander patients with a completed health assessment (MBS item 715) from 22% to 40% within six months.’
2. How will we know that a change is an improvement? This defines your measures. You need two types. Process measures track whether you are doing what you planned (e.g. number of patients contacted, number of reminder letters sent). Outcome measures track whether it worked (e.g. percentage of eligible patients with a completed health assessment).
3. What changes can we make that will result in improvement? This generates your change ideas. Draw on practice data (Cubicio, CAT4 or your clinical software’s audit tool), patient feedback, staff observations and published guidelines. Each idea can become a PDSA cycle.
Your PHN can provide training and support if your team has not used data extraction tools before.
Define the problem. Set aims (use your SMART goal from the thinking part). Decide what data you will collect, how and when. Assign team roles. Set meeting dates.
Run the change. Hold meetings. Extract data. Document what happens, including the unexpected.
Analyse the data. Compare process measures and outcome measures against your aims. Record what you learned.
Decide what to keep, what to change and what to test next. Embed the improvements that worked. If the results did not meet your goal, identify what to do differently and start the next cycle.
The cycle works for clinical topics (screening programs, chronic disease management, vaccination schedules) and administrative ones (cybersecurity, results handling, recall systems). It is designed to be small, repeatable and team-based.
| Role | Responsibilities |
|---|---|
| GP lead | Clinical oversight, CPD submission, RACGP portal upload, reflective practice documentation |
| Practice manager | Coordination, scheduling meetings, data extraction support (CAT4), PIP QI administration, PHN liaison |
| Practice nurse | Patient-facing implementation, health assessment support, recall and reminder generation |
| Reception/admin | Patient identification at registration, reminder follow-up, consent form administration |
| Topic | |
| Goal (SMART) | |
| Process measures (how will you track activity?) | |
| Outcome measures (how will you track results?) | |
| Change ideas (what will you test?) |
Describe what you will do and what data you will collect.
Consider: data sources and ease of extraction (CAT4, clinical software reports, manual audit), who runs the initial search, what the baseline numbers look like, whether you need to suspend inactive patients or clean coding first.
What are you trying to achieve? Be specific. Aim for measurable targets: percentage improvement, number of patients identified, number of assessments completed.
Record your dates as you go.
| Activity | Date |
|---|---|
| Executive planning meeting | |
| Clinical planning meeting (buy-in and feedback) | |
| Practice education meeting | |
| First data extraction | |
| Second data extraction | |
| Third data extraction | |
| Follow-up meeting | |
| RACGP portal upload |
Define your measures in the first column. Record results from each extraction.
| Measure | Extraction 1 | Extraction 2 | Extraction 3 |
|---|---|---|---|
Record your analysis and reflections.
Consider: what changed between extractions, what worked, what did not, what surprised you, what needs more investigation. Compare your process measures (did you do what you planned?) with your outcome measures (did it make a difference?).
Record changes to embed in the practice.
Consider: shortcuts and templates to create, recall/reminder changes, workflow changes, coding changes, training needs, policy updates. If the results did not meet your goal, what will you do differently in the next cycle?
List relevant MBS items for your topic. Verify item numbers against MBS Online before use.
| Item | Description | Notes |
|---|---|---|
| Activity type | Hours claimed | Evidence |
|---|---|---|
| Educational Activities (EA) | Education session attendance, materials reviewed | |
| Reviewing Performance (RP) | Data extractions, audit results, benchmarking | |
| Measuring Outcomes (MO) | PDSA documentation, meeting minutes, outcome data | |
| Total |
Submit via the RACGP CPD portal as a GP-led activity (individual or group). Document any discussion and reflections in meeting minutes for AHPRA requirements.
Record time as you go. The RACGP CPD year runs from 1 January to 31 December. If the project spans two calendar years, allocate hours to the year in which the activity was completed. Do not log hours to a year where you have already met your requirements unless you are banking toward the next period.
The Medical Board also requires reflection across three domains. Record your reflections below or in your meeting minutes.
List all doctors involved in the PDSA.
Medius Global produces worked PDSA guides with real practice examples across clinical, preventive and administrative topics. Each guide includes data collection templates, MBS item references and CPD claiming guidance tailored to the specific topic.
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