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Mandatory Quality Indicator Manual 2.0 – Part B: A Summary for Aged Care Providers


The National Aged Care Mandatory Quality Indicator Program started on 1 July 2019. It requires residential aged care providers to collect data and report quarterly on the following quality indicators:

  • pressure injuries
  • physical restraint
  • unplanned weight loss
  • falls and major injury
  • medication management.


To help providers comply with their obligations, the Department of Health has provided a three-part manual on its website.

Part A of the Program Manual includes definitions of each quality indicator and how to collect and submit quality indicator data.

Part C includes information for approved providers to access and use the QI Application in the My Aged Care provider portal as well as submit quality indicator data and access QI Program reports.

In this article we will look at the Part B of the Program Manual which aims to help providers “improve quality of care through continuous quality improvement.” Here are the key points from Part B of the manual.


Overview of the “Mandatory Quality Indicator Program Manual 2.0 – Part B” (Program Manual B)

Program Manual B’s purpose is to help providers understand how they can support continuous quality improvement for each of the quality indicators.

To this end, Program Manual B explains what “quality improvement” is and how to undertake it. It also:


What is “quality improvement”?

“Quality” is described as care that is “effective and safe, and provides a positive experience by being caring, responsive and person centred.” (Program Manual B, p. 3).

An important part of providing “quality” care is quality improvement which is “a systematic, co-ordinated and ongoing effort to improve the quality of care and services.” (Program Manual B, p. 3).

Overall quality improvement is about identifying what systems are working well, the quality of care and services being provided and to understand where we could do better and improve outcomes for consumers. Throughout the quality improvement process three key areas need to be considered in respect to change:

  • Being open to change and exploring ways that will improve that way we deliver care and services – what changes that we can make that will result in improvement.
  • The goal or the purpose - why is change needed and what we hope to achieve
  • The way you will be able to measure or show the change is an improvement – how we well know that a change is an improvement.


How do you make quality improvement possible?

There are six steps to enabling quality improvement:

  1. collecting and submitting data in line with your Quality Indicator Program obligations
  2. reviewing quality indicator data reports through the My Aged Care provider portal
  3. comparing your performance to data available on the Australian Institute of Health and Wellbeing GEN Aged Care Data Website
  4. identifying how your performance compares to the national benchmark, pervious performance and/or other similar services
  5. recording performance and noting that a quality issue exists
  6. taking action to improve quality of care through initiating a quality improvement activity (Program Manual B, p. 5).


How do you actually undertake quality improvement?

The Program Manual proposes a “Plan-Do-Check-Act” tool which can be used across each quality indicator (Program Manual B, p. 6).

This method allows you to identify a “quality issue” and then trial a “quality improvement activity” to gauge whether the activity should be implemented more broadly.

A summary of the tool and its four steps is set out in the table below.



STEP 1: PLAN Involves developing a plan by gathering information about what is causing the quality issue, establishing goals for your quality improvement activity, and making a plan for how the activity will be carried out.
STEP 2: DO This is where you carry out the activity by allocating resources, testing the activity on a small scale and documenting observations.
STEP 3: CHECK Involves collecting data and analysing information from the QI program to understand if your current systems and related processes are achieving the desired outcomes.

This step involves deciding whether the current systems and related processes are successful in achieving quality of care and services. Depending on the outcome you will:

  • if successful, embed the activity into business-as-usual processes and continue to monitor outcomes
  • if the activity was unsuccessful, determine what you may need to do differently next time – this is a quality improvement opportunity
repeat the process to continue to increase the quality of care and services for consumers.

When should you undertake quality improvement?

Quality improvement is an ongoing process. This means that you should regularly repeat the quality improvement process to continually improve the care and services you deliver (Program Manual B, p. 5).


What are some benefits of quality improvement?

By regularly undertaking quality improvement, you will:

  • improve the delivery of your care and services
  • identify quality issues promptly
  • be more responsive to the changing needs of recipients
  • improve outcomes for recipients
  • improve systems to monitor and track change
  • create long-term sustainable improvement across your organisation
  • increase collaboration amongst staff
  • enhance professional development across the workforce (Program Manual B, p. 4).


Is Part B of the Program Manual legislatively binding?

Unlike Part A of the Program Manual, Part B is not legislatively binding.

However, it is still important to consult the Program Manual to help you improve the quality of care and services you provide to consumers as well as drive quality improvement within your organisation.


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