CQI Action Plans of ACCHOs -

Sources of Data

Member ACCHOs of NACCHO are required to submit “CQI Action Plans” to the Commonwealth Department of Health by 31 January 2016.

In August 2015, the Department issued a template which was “developed to align with the core components in the draft National CQI Framework for Aboriginal and Torres Strait Islander Primary Health Care that are relevant at the local service level.” There are 9 of these core components. In an accompanying “Guide to developing the Action Plan”, the Department gave examples of what to put in to their template.

The Department said that its “Guide” was not prescriptive. But the Department did specify 5 elements that all ACCHOs should include as a minimumin their CQI Action Plans, and these elements are what the Department will assess when it considers each ACCHO’s CQI Action Plan:

1)Identifying priority health areas for action within your local context

2)Reviewing patient data and service information to identify baseline data and potential targets

3)Identifying priorities and possible ways to address them

4)Evaluating progress

5)Reporting back to communities.

The NACCHO Secretariat has taken these 5 elements and prepared this Table which identifies the sources of data that Chief Executive Officers and senior managers of ACCHOs can go to for completing these minimum required elements. If you want to ask any questions about the contents of this Table, please contact NACCHO’s Chief Information Officer, Dr Robert Starling, at [.

Data Sources for preparing ACCHO CQI Action Plans, December 2015. © NACCHO.

Existing Data Sources ACCHOs can access for the Five CQI Compulsory Reporting Elements.

# / Elements / Example Existing Data Sources
1 / Identify priority health areas for action within your local context (regional approach) /
  • OSR Reports- Section on Information for Policy Development and Planning (F-1)
  • OSR Reports – Section on Planning and Policy (AP-3)
  • NACCHO Baseline Profiles local and regional plans (
  • ACCHO Sector’s Regional Aboriginal Health Plans (e.g. WA).
  • Medicare Local Needs Assessments (completed)
  • PHN Needs Assessments (in progress)
  • Strategic Plans
  • Business Plans
  • Annual Activity Plans (Standard Funding Agreement

2 / Review patient data and service information to identify baseline data and potential targets /
  • Practice Health Atlases (ACCHO specific)
  • Regional Health Atlases (Aggregations of clinics for regions)
  • Commissioning Atlases (Medicare Locals)
  • QAIHC Indicators– for ACCHOs in Queensland
  • NT KPIs
  • nKPIs
  • QAIHC Benchmark Reports – for ACCHOs in Queensland
  • Clinical Dashboard reports
  • OSR
  • PIRS Recall reports
  • Program Reports (Mothers and Babies)
  • MBS Income reports
  • OSR Reports – Section on Substance Use issues - (S-15)
  • OSR Reports – Section on SEWB issues, (S-16)
  • Reports from PENCAT4 for an ACCHO
  • Reports from PAT-CAT for aggregated reports– eg. for a region
  • OSR Reports – Section on Advocacy, Knowledge and Research (AP-1, AP-2)
  • OSR Reports – Section on Planning and Policy (AP-3).
  • OSR Reports – Section on Continuity of Care (CS-9)
  • Continuity of care with local hospital(s) and specialists e.g. IUIH Connect (
  • Strategic Plans
  • Business Plans
  • Annual Activity Plans (Standard Funding Agreement)

3 / Identify (service) priorities and possible ways to address them. / There are 3 broadpossibilities that this element refers to:
  • enhancements/extension of existing services e.g. use of mobile clinics (hub and spoke model);
  • expansion into completely new services e.g. agedcare, drug and alcohol rehabilitation; and
  • new services in new locations previously with no access to an ACCHO.
  • OSR Reports
  • PENCAT4 and PATCAT reports and Dashboard summaries
  • Medicare LocalNeeds Assessments and analyses
  • PHN Needs Assessments and analyses (in progress)
  • ACCHO Sector’s Regional Aboriginal Health Plans
  • AIHW Report 2015: “Spatial variation in Aboriginal and Torres Strait Islander people’s access to primary health care”
  • NACCHO Baseline Reports available on [
  • QAIHC Access Gap Reports– for Queensland ACCHOs
  • Jurisdictional Aboriginal Health Plans – where these exist, eg in WA
  • Preventable hospitalisations (
  • Strategic Plans
  • Business Plans
  • Annual Activity Plans (Standard Funding Agreement)

4 / Evaluating progress /
  • Dashboard management reports (e.g. QAIHC Practice Report Card)
  • nKPIs
  • QAIHC Indicators– for ACCHOs in Queensland
  • NT KPIs key performance measures as time series– for ACCHOs in NT
  • Practice manager clinical performance meetings informed by PIRS dashboards,
  • PENCAT4 and PATCAT reports and Dashboard summaries
  • MBS reports from each ACCHO’s billing claims to Medicare
  • Strategic Plans
  • Business Plans
  • Annual Activity Plans (Standard Funding Agreement)

5 / Reporting back to communities /
  • Community Report Dashboard (e.g. NhulunduWooribah and MIACCHS in Queensland)
  • Websites of ACCHO, Affiliate, Regional organisations and NACCHO
  • OSR Reports – Sections on Community Engagement, Control and Cultural Safety; Governance (AG-1 to AG-6)
  • OSR Reports – Sections on Cultural Safety (CC-1, CC-2)
  • Strategic Plans
  • Business Plans
  • Annual Activity Plans (Standard Funding Agreement)

Data Sources for preparing ACCHO CQI Action Plans, December 2015. © NACCHO.