1. Purpose

This Continuous Quality Improvement (CQI) Plan sets out how Newcastle Cosmetic Doctor (NCD) systematically improves patient safety, clinical effectiveness and experience across cosmetic injectables, dermal fillers, biostimulators, PDRN, thread lifts, laser/energy procedures and prescription/non‑prescription skincare. The plan integrates Australian regulatory standards with global quality science to create a learning system that monitors outcomes, identifies variation, and implements evidence‑based changes through iterative testing and governance review. ^{1 2 3 4}

2. Scope

The CQI Plan applies to all services and all staff — from patient registration at front‑of‑house to medical practitioners, nurses and laser therapists. It includes governance processes, measurement and audit, incident/complaint analysis, patient feedback, staff education, medicines and device safety, infection prevention, privacy, workplace health and safety and advertising compliance. Aligning every function to nationally endorsed standards ensures consistent, safe and transparent care for every patient. ^{1 2 5 6}

3. Governance & Leadership

Clinical governance is led by the Medical Director, supported by a Governance Manager and Laser Safety Officer. The leadership team sets annual quality objectives, approves indicators, reviews dashboards, and sponsors change projects. Quarterly governance meetings examine audit results, incidents, near misses and patient feedback, with corrective actions tracked to closure. External obligations such as Ahpra notifications, TGA adverse event reporting and WHS duties are built into the governance agenda. ^{2 7 8 9}

4. CQI Framework: Model for Improvement & PDSA

NCD adopts the Institute for Healthcare Improvement (IHI) Model for Improvement: define aims, establish measures and select change ideas; then run rapid Plan‑Do‑Study‑Act (PDSA) cycles to test changes at small scale before implementation. This structure supports data‑driven experimentation for topics such as reducing post‑injection bruising, improving consent completeness, strengthening laser plume control and optimising clinic flow without compromising safety. ^{12 1 13 10}

5. Quality Objectives & Indicators

Annual quality objectives translate into measurable indicators across safety, effectiveness, experience and efficiency. Examples include: consent completeness rate; identity‑matching compliance; cold‑chain temperatures within range; filler/thread batch traceability; time to hyaluronidase during simulated VO drills; hand‑hygiene compliance; laser eyewear availability; advertising compliance checks; privacy breach rate; and closed‑loop percentage for patient feedback. ^{1 2 11 12 13 14 15 16}

6. Data Collection, Audit & Reporting

NCD uses structured data capture in the electronic medical record and device logs to populate monthly dashboards. Audits cover documentation quality, infection control, emergency readiness (including BLS/AED drills), medicines/device traceability and WHS. Findings are trended using run charts or statistical process control where appropriate and shared with teams. Serious findings trigger corrective actions with owners and due dates, and their effectiveness is re‑audited. ^{1 5 6 8 17 11}

7. Incident, Complaint & Adverse Event Learning

All incidents, near misses and complaints are logged and reviewed using proportionate methods — from concise after‑action reviews to root cause analysis for serious events. Reportable events are notified to relevant external bodies (Ahpra for practitioner concerns, TGA DAEN for medicines/devices, or WHS for notifiable workplace incidents). Lessons learned inform revisions to protocols, training and patient information. ^{2 3 4 8 18}

8. Patient & Consumer Feedback

NCD treats patient feedback as clinical data. We collect comments from post‑visit surveys, Google Business reviews and direct complaints, categorise them by theme (communication, access, comfort, outcomes) and test improvements through PDSA. This fulfils the NSQHS Partnering with Consumers Standard and the Australian Charter of Healthcare Rights, strengthening transparency and trust. ^{1 15 11}

9. Medicines & Device Safety

Medicines management covers prescribing standards, cold‑chain integrity, storage and expiry monitoring, advertising compliance and pharmacovigilance. Device safety focuses on ARTG verification, batch‑lot traceability for fillers/threads, laser maintenance and eyewear checks. Adverse trends prompt action plans and, where indicated, TGA reporting and manufacturer feedback. ^{4 5 9 10 16}

10. Infection Prevention & Control

The CQI program monitors hand hygiene, aseptic technique, environmental cleaning, sterilisation logs, and surgical plume control in laser suites. Interventions include competency refreshers, checklists and visual prompts. Any suspected outbreak or cluster escalates to incident management protocols and liaison as required by NSW Health policy. ^{5 2 9}

11. Emergency Preparedness & Simulation

NCD conducts scheduled simulations for anaphylaxis, filler‑related vascular occlusion, syncope and code blue. Drills measure time‑to‑adrenaline, time‑to‑hyaluronidase, team roles, and equipment access (oxygen, AED). Post‑simulation debriefs yield changes to layouts, checklists or training. Alignment with Australian Resuscitation Council guidance ensures currency of algorithms and documentation. ^{6 1 2}

12. Privacy, Security & Ethics

Patient privacy is safeguarded through access controls, audit trails, secure backups and breach response procedures. Staff receive training on the Australian Privacy Principles, consent for photography and the boundaries of advertising and testimonials. Any significant privacy incident is investigated and reported consistent with law, with remedial actions tracked. ^{7 16 17}

13. Work Health & Safety (WHS) & Laser Safety

The risk register covers sharps injury, chemical hazards, plume exposure, ergonomic risks and radiation/optical hazards. Controls follow the hierarchy of control and include engineering controls (plume evacuation), administrative measures (signage, training) and PPE (fit‑tested respirators where indicated). Laser safety aligns to ARPANSA advice and AS/NZS 4173 with an appointed Laser Safety Officer. ^{8 9 10}

14. Training, Credentialing & Competency

CQI is underpinned by a structured education plan: induction modules, device‑specific competencies, annual BLS, and micro‑learning based on audit/incident findings. Credentialing verifies Ahpra registration and scope‑of‑practice; laser operators maintain device certificates. Completion rates and competency currency are tracked as quality indicators and reviewed at governance. ^{3 6 10 11}

15. Document Control & Change Management

Policies, procedures, patient information and checklists are version‑controlled with review cycles and explicit ownership. Proposed changes undergo impact assessment and PDSA testing before adoption. Version histories and distribution logs ensure staff are always using the latest approved documents, supporting consistency across the clinic. ^{1 2 14}

16. Review Cadence & Public Transparency

Quality dashboards, audit outcomes and improvement actions are reviewed monthly in service meetings and quarterly at the governance committee. NCD publishes selected governance policies and safety statements on its website to promote transparency and community trust. Progress against annual objectives is summarised in a year‑end quality report approved by the Medical Director. ^{1 2 15}

Sources

1. ACSQHC, National Safety and Quality Health Service (NSQHS) Standards (2nd ed.)., viewed 24 October 2025, https://www.safetyandquality.gov.au/standards ↩
2. NSW Health, Clinical Governance and Patient Safety Framework (PD2017_043)., viewed 24 October 2025, https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_043.pdf ↩
3. Ahpra, Guidelines for Non‑Surgical Cosmetic Procedures (2025)., viewed 24 October 2025, https://www.ahpra.gov.au/News/2025-01-31-Guidelines.aspx ↩
4. TGA, Reporting adverse events (DAEN) & ARTG., viewed 24 October 2025, https://www.tga.gov.au/reporting-issues ↩
5. NHMRC, Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019)., viewed 24 October 2025, https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019 ↩
6. Australian Resuscitation Council, Guidelines (BLS/CPR/ALS)., viewed 24 October 2025, https://resus.org.au/guidelines/ ↩
7. OAIC, Australian Privacy Principles (Privacy Act 1988)., viewed 24 October 2025, https://www.oaic.gov.au/privacy/australian-privacy-principles ↩
8. SafeWork NSW, Work Health and Safety Act & Regulation., viewed 24 October 2025, https://www.safework.nsw.gov.au/law-and-policy/work-health-and-safety-legislation ↩
9. ARPANSA, Lasers/IPL/LED advice for providers., viewed 24 October 2025, https://www.arpansa.gov.au/understanding-radiation/sources-radiation/more-radiation-sources/lasers-and-intense-pulsed-light-1 ↩
10. Standards Australia/NZ, AS/NZS 4173:2018 Safe use of lasers (summary/purchase)., viewed 24 October 2025, https://store.standards.org.au/product/as-nzs-4173-2018 ↩
11. RACGP, Standards & Quality Improvement resources., viewed 24 October 2025, https://www.racgp.org.au/clinical-resources/clinical-guidelines ↩
12. IHI, Institute for Healthcare Improvement: Model for Improvement/PDSA., viewed 24 October 2025, https://www.ihi.org/resources/Pages/HowtoImprove/default.aspx ↩
13. WHO, Quality of care & patient safety (global framework)., viewed 24 October 2025, https://www.who.int/teams/integrated-health-services/quality-of-care ↩
14. ISO 9001:2015, Quality management systems (overview)., viewed 24 October 2025, https://www.iso.org/standard/62085.html ↩
15. ACSQHC, Partnering with Consumers Standard & Australian Charter of Healthcare Rights., viewed 24 October 2025, https://www.safetyandquality.gov.au/our-work/partnering-consumers ↩
16. TGA, Therapeutic Goods Advertising Code Instrument 2021., viewed 24 October 2025, https://www.legislation.gov.au/Series/F2021L00207 ↩
17. Ahpra, Advertising guidelines., viewed 24 October 2025, https://www.ahpra.gov.au/Resources/Advertising-resources/Legislation-guidelines/Advertising-guidelines.aspx ↩
18. OECD, Patient safety & system-learning resources., viewed 24 October 2025, https://www.oecd.org/health/patient-safety.htm ↩