Quality Improvement/Quality Assurance Registration & Authorisation Process

Quality Improvement (QI) is an organised process that evaluates, assesses and seeks to improve an aspect of Monash Health’s health service delivery to our patients and community. It is also referred to as Quality Assurance. QI activities often involve the collection, use and disclosure of health, personal and sensitive information for the purpose of funding, management, planning, monitoring improvement or evaluation of health services. Common QI activities include sentinel event monitoring incident monitoring, root cause analysis, medical record review and clinical audit. QI activities may include activities involving staff, patients and members of the community.

The National Health and Medical Research Council document NHMRC Ethical Considerations in Quality Assurance and Evaluation Activities(March 2014) advises that regardless of whether an activity is called research or QI, those conducting the activity must consider whether the people involved will be exposed to any risk, burden, inconvenience or possible breach of their privacy. Further, attempts to distinguish between whether an activity is research or QI can be unhelpful because one form of activity may evolve into another activity over time. Institutions are advised to develop policies around oversight of QI.

Registration for Quality Assurance Activities at Monash Health.

  1. Complete the Decision Consideration Guideline, to assess whether the activity would meet QI criteria at Monash Health or whether the activity would be deemed to be a research activity requiring ethical review.
  2. Complete the  QA Form
  3. Email the QA Form to research_qa@monashhealth.org

The Decision Consideration Guideline and QA Form will be reviewed by the HREC Manager and an email will be sent to the first named investigator within 3 working days.

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