Quality Assurance Projects in Medical Practice – Part 2: Plan, Execute and Learn
In Part 1 of this series, we explored what Quality Assurance (QA) projects are, why they matter, and how they can enhance both patient care and your CPD. Now, in Part 2, we’ll walk through the practical steps of developing a QA project—from idea to action—and making it stick.
Step 1: Develop Your Idea
The best QA projects start with a simple question: “Is this process working the way it should?”
To develop a focused project:
Reflect on recent frustrations, complaints, delays, or safety concerns
Think about areas where outcomes vary, where protocols aren't followed, or where patients seem confused or underserved
Review clinical guidelines or college standards to spot possible gaps
Examples:
Are mental health care plans being reviewed at appropriate intervals?
Do surgical discharge summaries consistently include wound care instructions?
Is follow-up for abnormal blood tests reliably occurring?
Once you’ve identified an issue, clarify your focus:
What specific process or outcome do you want to look at?
What does “good” look like? (use a published guideline or internal protocol as your benchmark)
It is important to discuss your concepts with your team - there is no point going much further if no one else believes there is an issue. Most importantly, discuss with the people responsible for Quality in your organisation (for instance, in many hospitals, there is a Quality Team).
Step 2: Do Some Background Research
Before collecting data, take time to understand:
What the ideal process is (based on guidelines, consensus statements, MBS criteria, etc.)
Whether similar QA or audit work has already been done (ask your practice manager, college, or quality team)
How this issue has been handled elsewhere
You don’t need to write a literature review—but grounding your project in a clear standard gives it meaning and structure.
The ideal place to start is the national standards(opens in a new tab), developed for all healthcare sectors - mental health, primary care and clinical. They have all been created as best practice guidelines and for minimum standards following issues that have been identified. They are also great processes to use for quality improvement.
Step 3: Engage stakeholders
This is a critical step in your project.
Ensure you discuss your plans with all the stakeholders in your project, particularly departmental leads and the Quality Team in your environment, as they are likely to be taking responsibility for the outcomes.
Who will be your champions? These are people who help you to engage the rest of your team.
Now consider who could be affected by your project - senior staff, junior staff, allied health, administration, patients? Consider involving any or all of them in the planning and execution of the project.
Step 4: Plan and Execute the Project
This step turns your idea into action. Keep it simple and realistic.
Scope the project
Review a manageable number of cases (10–20 is often enough)
Decide on the timeframe (e.g. one month of consults, last 10 procedures)
Identify your data source (EMR, logs, paper notes)
Choose what to measure
Use a checklist or form with specific criteria
Keep it binary where possible (Yes/No; Done/Not done) and concrete / objective
Assign roles if working in a group
Who’s collecting data?
Who’s analysing it?
Who will present the findings?
Set a timeline
Keep the timeline tight enough to maintain momentum
Plan a feedback point or presentation date to give the project a clear deadline
Step 5: Analyse and Reflect
Once you’ve gathered your data:
Compare current performance against your chosen standard
Quantify the gap (e.g. “Only 60% of patients on opioids had bowel regimens charted”)
Identify patterns (e.g. worse adherence on weekends? junior staff unaware of guideline?)
Then reflect:
Why is this happening?
Is it a system issue, knowledge gap, workflow design problem, or cultural habit?
What would need to change to fix it?
This reflection is where the deep learning happens—and what makes QA so valuable for CPD.
Step 6: Take Action and Implement Change
This is where many QA projects lose momentum—but it’s also where they can make a real difference.
a. Build an Action Plan
Focus on one or two achievable improvements
Keep it measurable and time-limited
Include both system fixes (e.g. protocol changes) and behavioural goals (e.g. education or reminders)
b. Communicate Effectively
Share your findings clearly and without blame
Use team meetings, emails, huddles, or posters
Show how the issue affects patients and workflow—not just compliance
c. Engage the Team
Ask for feedback on proposed changes
Involve people from different roles (nursing, admin, junior staff)
Recognise that improvement is a team effort
d. Identify Project Champions
Find respected team members to:
Reinforce the message informally
Model good practice
Help with monitoring and follow-up
e. Use Forcing Functions and Nudges
Add EMR prompts, checklists, or pre-filled templates
Place reminders where decisions are made (e.g. drug chart, procedure room)
f. Reward and Celebrate Improvement
Thank contributors
Show “before and after” graphs or feedback
Use positive framing: “We improved compliance by 25%—great work!”
Step 7: Re-Evaluate and Close the Loop
Every QA project should end with follow-up:
Repeat your measurement 3–6 months later
See whether change was implemented—and whether it stuck
If not, revise the strategy (you’ve still learned something valuable)
Even if the problem hasn’t been fully resolved, the act of measuring, sharing, and learning has impact. You’ve created awareness, built momentum, and modelled a reflective approach.
Step 8: Document It for CPD (and Share It!)
Don't forget to document your project in your CPD under Measuring Outcomes / Quality Projects
To document:
Write a 1–2 page summary (Problem → Standard → Data → Findings → Action → Impact)
Log it in your CPD Home
Present it at a teaching session, team meeting, or journal club
All elements of the project can be claimed, from research and education, planning, execution and followup. Keep accurate notes on the breakdown of the time you put into the project, for example in a spreadsheet.
Bonus: your project may inspire others, strengthen your professional profile, or lead to broader system change.
Final Thoughts: Start Small and Start Now
You don’t need a title or a committee to lead improvement. Some of the most effective QA projects are small, informal efforts to fix things that frustrate or concern you. It's also worth noting most QA projects do not need ethics approval as they fall under service improvement.
However, make sure your departmental leads are involved and approve the projects you do.
By doing a QA project, you’re not just ticking a CPD box—you’re:
Sharpening your clinical reasoning
Improving the system for patients and colleagues
Modelling leadership and professionalism
And learning in the way that matters most: by doing
Missed Part 1?
Catch up here