Defining quality improvement
Quality improvement (QI) is an ongoing process of reviewing and refining systems and processes to enhance care quality and outcomes. It uses specific methods and tools to achieve measurable improvements. [1-3]
An important aspect of QI is identifying problems and systematically testing solutions on a small scale before broader implementation. The process follows a repeating cycle, where solutions are planned, tested, and evaluated. Effective solutions are expanded or made permanent, while ineffective ones undergo refinement and re-testing. This continuous cycle drives ongoing enhancements in care practices over time. [1,4-6]
In aged care, QI initiatives are designed with the needs of people receiving care in mind, often incorporating their contribution into the process. [1,7] As part of a broader quality system, these initiatives contribute to assessing provider performance and service standards. [7] Success relies on engagement from residents, clients, carers, staff, volunteers, board members, and advocates, ensuring a collaborative approach to improving care. [7]
Why quality improvement matters in aged care
Quality improvement allows aged care providers to implement changes that improve care and services. [2,7] Engaging staff, older people, and families fosters collaboration and shared responsibility for continuous improvement. [2,7] Strengthening monitoring systems ensures that changes lead to lasting benefits. [2,7] Ultimately, quality improvement supports a culture of learning, feedback, and better care in aged care settings. [2]
The Aged Care Quality Standards embed continuous improvement across governance, service delivery, and workforce management. They require providers to implement quality systems (Standard 2), integrate clinical governance (Standard 5), and use risk, incident, and complaints management to drive ongoing improvements (Standards 2.3, 2.4, 2.5, 2.6). Providers must also engage older people and their supporters in service design and feedback (Standard 2.1), ensuring a culture of safety, inclusion, and person-centred care that is regularly reviewed and enhanced. [8] Additionally, Section 62 of the Aged Care Quality and Safety Commission Rules 2018 requires aged care providers to keep a written plan for improvement and how this assists the provider to meet their obligations to residents, clients and families. [1,7]
What the evidence tells us
Quality improvement is a proven approach for enhancing quality care and staff practices in aged care. [3] A key principle is that all improvement involves change, but not all change leads to improvement. [5] Tracking results over time using reliable data helps aged care providers demonstrate meaningful improvements and identify areas where care has not improved.
Data is essential for monitoring and reviewing to show improving care. Key sources include incident reports, quality indicators, audits, benchmarking, complaints and feedback, and self-assessments. These sources provide valuable information on risks, performance, and areas for improvement, helping to drive compliance, innovation, and better care outcomes. Regular reviews of this data ensure any changes made in response to the issue are effective, sustainable, and aligned with aged care standards, promoting ongoing service improvements. [1] Data used is often quantitative, that is it can be counted, measured, and given a numerical value. Qualitative or descriptive data is also used in QI in aged care to discover what older people, families and nursing staff value, and to evaluate and improve care services based on their experiences. [9]
In Australia, aged care quality indicators are part of the National Aged Care Mandatory Quality Indicator Program and are used to monitor and improve care in residential aged care homes. As of 2023, providers must report on 11 indicators across areas like pressure injuries, falls, medication use, and quality of life. [10] These indicators inform Star Ratings published on the My Aged Care website, supporting transparency and consumer choice. [11]
Quality improvement approaches
There is no one-size-fits-all model for QI. [1] However, approaches generally follow an ongoing, repeated process to ensure improvements are tested, refined, and sustained over time. [1,6]
The PDSA Cycle
The Plan-Do-Check-Act cycle, also known as Plan-Do-Study-Act (PDSA), is widely used in Australian aged care and endorsed by the Aged Care Quality and Safety Commission. [1,4,6,7,12-15] It supports both small- and large-scale QI projects. The cycle continuously helps providers identify areas for improvement, implement interventions, assess outcomes, and refine processes as needed. [1,6]
Steps of the PDSA include:
- Plan: Identify a problem, develop a hypothesis, and plan an intervention
- Do: Implement the intervention on a small scale
- Check: Analyse the data and assess whether the intervention worked as expected
- Act: Based on the results, decide whether to adopt, adjust, or abandon the intervention. [1,7]
This structured approach ensures continuous feedback, helping aged care services refine processes and enhance care outcomes over time. For example, aged care facilities using PDSA might test changes in mealtime routines to improve resident satisfaction, focusing on elements such as food quality, meal timing, adapted eating utensils, or staff interaction. [4,15-17]
Successful QI in aged care: What works
Aged care QI projects have led to improvements in pain management, reduced hospital admissions, and increased discussions with families about care preferences. [6,18] They have also enhanced documentation, standardised care plans, and supported more comprehensive and individualised care planning. [19] Successful QI in aged care appears to be shaped by several factors related to the organisation and to staff. [20]
Organisational factors
Successful QI relies on a well-resourced workplace with sufficient staffing, funding, time, and technology. Strong leadership, staff autonomy, and clear organisational priorities influence the adoption of new practices. [3,19,20] Supportive leadership encourages teamwork, helps staff manage competing priorities, and aligns efforts with organisational goals, ensuring sustainability. [14,18,21,22] It also removes barriers and improves staff engagement and adherence to new practices. [3] With clear goals, training, and support, care home staff can lead improvements, but ongoing management backing and staff engagement and are essential for lasting success. [5,6]
Emerging research suggests that nominated advocates, usually nurses or careworkers, can play a key role in QI initiatives. With adequate resources, they help educate staff, reinforce best practices, and lead change. However, staff turnover and heavy workloads can limit their impact. Addressing these challenges and empowering champions can enhance care quality, job satisfaction, and staff retention. [23]
Effective communication and strong relationships also drive successful QI. [20,24] Collaboration between staff, leadership, and any external providers builds shared understanding and helps address concerns early. [20] Leadership support is essential, with engaged managers guiding staff and reinforcing the benefits of change. [20] Mentoring, incentives and regular feedback strengthen implementation. [3,21]
Success is more likely when:
- Staff have time to participate, meetings encourage equal input, and large challenges are broken into manageable steps [5]
- QI aligns with daily work priorities, making it easier to integrate [5]
- A structured approach ensures clear communication, staff involvement, and leadership support [20]
- Responsibility for new initiatives in assigned, and regular feedback enhances compliance and sustainability. [3,21]
Training to understand QI should be phased, with ongoing resources, mentors, and structured QI teams to support learning and adaptation. [3] Quality improvement teams in aged care often include nurses, careworkers and family members supported by care or quality coordinators. [3, 14] In QI research projects, multidisciplinary teams have included aged care staff with pharmacists, social workers, dietitians, GPs, geriatricians, dementia specialists, and aged care volunteers. [5, 15, 24] Simple, practical projects that build momentum over time are more effective, especially when staff have clear goals and supportive teams. [5]
Reducing the burden of data collection by embedding it into routine practice and presenting it clearly can improve staff engagement. [24] Involving older people, families, and carers through storytelling may bring valuable perspectives to guide meaningful change, but staff need time and organisational support to reflect on these insights. [9,14,19,25]
Individual factors
Staff are more open to change when they understand its value and feel confident implementing it. [19,20] Training, structured tools, and mentoring to assist staff in understanding the change has resulted in improved preparedness. This has been demonstrated to help staff feel more confident in identifying residents nearing the end of life and discussing death with families. [18] Even small, practical changes—such as modifying care routines—can drive improvement, especially when formal data tracking is difficult. [14,25] Resistance often decreases when staff see benefits for older people in their care or improvements in their own work experience. [14] Flexibility is important, as initiatives may need to be adapted over time as continue to use PDSA approach. [24] QI projects are more successful when changes are simple, fit into daily routines, and staff feel a sense of ownership over them. [5]
Challenges and barriers to QI
Quality improvement in aged care is often difficult due to staff shortages, high turnover, heavy workloads and cost concerns. [18,26] Staff may resist change because of increased workload, unclear responsibilities or lack of training. [19,26] Difficulty in tracking quality indicators can also hinder progress. [24] Simplifying data collection, making information accessible, and providing extra support can help staff integrate QI into daily practice. [24] More training and technical support can help staff implement and sustain improvements. [26]
Sustaining improvement
For lasting change in aged care services, staff need to engage in ongoing QI, monitor solutions, and address barriers over time. [4] QI projects initiated in a facility, where staff have experience with improvement strategies, are easier to sustain. [4] Changes are more likely to last when they are practical, adaptable, and aligned with staff workflows and resident needs. [20]
Continuous measurement and the cyclic nature of QI help maintain high standards of care. [26] Factors supporting implementation—such as staff commitment, resources, communication, and organisational fit—also influence sustainability. [16] Establishing QI teams, appointing mentors, and using phased training with ongoing feedback improve compliance and sustainability. [3]
Encouraging a culture of continuous improvement
A strong culture of continuous improvement is as important as structured QI systems. Beyond compliance, it encourages teamwork, better performance, and openness to change. Leadership plays a crucial role in promoting values such as open communication, learning from mistakes blame-free, and innovation. Leaders who model these behaviours help create an environment of curiosity, ongoing learning, and continuous care improvement. [1]
Page updated 26 March 2025