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Quality Improvement Initiatives

We regularly run QI programs for practices in the region. Typically 6-9 months in length, the benefit of joining one of these formal QI programs is that you have the opportunity for peer to peer learning with likeminded practices and have the added support and structure associated with a defined approach.

Below is a list of programs that we currently have availabilities for. 

QI Programs available to practices include:

COPD - Register your EOI (Aug 2020 – May 2021)

Did you know that COPD has remained the leading cause of potentially preventable hospitalisations since 2015, with 1,344 potentially preventable hospitalisations in the Nepean Blue Mountains region in 2016-17?

The COPD Collaborative aims to reduce the number of hospital admissions in our region and will focus on improving the quality of life and wellbeing of people living with COPD. Complete the expression of interest form for the next COPD Collaborative Wave 

Winter Strategy - Register your EOI (Feb 2021 – Nov 2021)

Program Objective: To support general practice to improve the management of patients with chronic conditions, by implementing important preventative care measures to minimise their risk of hospitalisation. Patients are encouraged to be equal partners with their care team to manage their chronic conditions better, avoid hospitalisation and stay as well as possible during the winter months.

If you are interested in joining our Winter Strategy Program for 2021 please fill in the expression of interest form at the bottom of the page. 

Cancer Screening Quality Improvement Program Spaces Now Available.

Did you know?

  • People with breast, cervical and bowel cancers detected through national cancer screening programs have better cancer survival outcomes than those diagnosed who had never been screened (Australian Institute of Health and welfare)
  • 6 out of 10 eligible people are not participating in the National Bowel Cancer Screening Program (Cancer Institute NSW)
  • 40% of eligible women are overdue for a screening mammogram (CINSW)

Patients who are reminded by their GP to attend cancer screening are more likely to screen (CINSW). We are seeking practices who have a passion for preventative health to help drive improvement in screening rates in the region. The program will run from 1 November 2020 to 30 June 2021 and will support your practice to make easy, measurable and sustainable improvements to provide best practice care for your patients; and to pro-actively implement preventative activities that enable the early detection of breast and bowel cancers.


  • Participation and outcome payments for the Practice
  • Free training and online resources for Cancer Screening and conducting Quality Improvement Activities
  • Increased awareness of cancer screening services in the region and increased screening rates for your patients
  • Assists to fulfil QI requirements for both Accreditation and PIPQI

Please register your interest by completing the expression of interest form below.

Other QI initiatives available: 


CareMonitor is a shared care management and real time remote monitoring platform with telehealth capability linking healthcare providers with patients. Accessing this tool may support your QI activities related to Chronic Disease Management and improve patient outcomes. 

The value of CareMonitor is that it combines many key aspects in a General Practice's clinical service:

  • Team Based care in real time shared across the care team, patients, allied health providers, hospital and specialists.
  • Pre-built care plan templates based on clinical pathways.
  • Interactive Population Management dashboard and reporting.
  • Secure messaging between care team members and patient via a mobile app.
  • Send reminders and notifications to patients and providers about follow up referrals/reviews.
  • Improve patient activation and engagement including SMART goal targets, questionnaires and education content.
  • Identifies patients at risk and may avoid preventable hospitalisations.
  • Integrates with Best Practice, Medical Director, Genie and Zedmed

For more information

If your practice would like to start using CareMonitor, the PHN is currently providing free access. Please complete our Telehealth expression of interest formThis EOI form should only be completed by the person wishing to register their interest in Care Monitor or to receive further information


In our current Health System, it is difficult to profile how a person interacts with the health system.

As GPs, sometimes you have a limited view of your patients’ journey across the health system and you may feel like you are managing in the dark.

LUMOS is a new partnership initiative between the NBMPHN and NSW Health to assist practices to gain a greater understanding of their patients’ journey across the health system. LUMOS is a program that securely links encoded data from general practices to other health data in NSW, including hospital, emergency department, mortality, ambulatory and cancer. 

By signing up to LUMOS, you are provided with a FREE 6 monthly report which sheds light on your patients journey through the NSW health system and reduces the risk of potentially preventable ED presentations.

To express interest in signing your practice up to LUMOS, please complete the expression of interest form below. 

HealthDirect Videocall 

Healthdirect Video Call service is a simple, easy to use, scalable and sustainable model for enabling more convenient access to care for those who find it difficult to see a clinician in person. The technology that underpins the service is purpose-built for health settings, designed to create fully secure personalised virtual clinics and waiting areas. 

Healthdirect Video Call is available to General Practices and Aboriginal Medical Services in the Nepean Blue Mountains region until 31 March 2021 under a special funding arrangement from the Australian Department of Health. This funding provision enables telehealth as a whole-of-population model of care during the COVID-19 pandemic to protect the health and wellbeing of general practice staff and patients.

Please complete our Telehealth expression of interest form

Winter Strategy, Cancer Screening and LUMOS Expressions of Interest Form 

Nominated Primary Contact 

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