Refugee Health QI Toolkit

The refugee health QI toolkit

A practical companion to the NQPHN Foundational QI Toolkit. It supports general practice teams across northern Queensland to reduce gaps in refugee health access and outcomes, strengthen refugee-responsive care, and deliver culturally safe care for newly arrived and established refugee-background patients.

What this toolkit can help practices do

The activities in this toolkit are designed to support practical improvements that make refugee-responsive care easier to deliver and easier to sustain within routine general practice workflows.

Depending on the activities selected, practices may use the toolkit to:

identify patients from refugee backgrounds more reliably
reduce missed follow-up and improve continuity of care
plan interpreter-supported appointments earlier
support longer or staged consultations for complex needs
reduce duplicated administrative work and avoidable rework
improve coordination between reception, nursing and clinical staff
strengthen recall, communication and follow-up processes
support documentation of quality improvement activity for PIP QI, accreditation or CPD purposes
identify appropriate MBS billing opportunities where eligibility requirements are met

This toolkit should be used alongside the Australian Refugee Health Practice Guide, which provides detailed clinical guidance for the assessment and ongoing care of people from refugee backgrounds, including people seeking asylum.

The Guide includes practical guidance on:

refugee health assessments
screening and immunisation
mental health considerations
common health conditions
referral pathways
culturally responsive care

This toolkit complements the Guide by focusing on practice systems, workflows, follow-up, communication and quality improvement activities that support refugee-responsive care in general practice settings.

How to use this toolkit

The toolkit is split into two streams. The first builds understanding of the QI process and the local refugee health context. The second applies that understanding to guide practical change activities. A list of references and external tools that may support understanding and improvement activities is provided in the appendices.

Stream A

Building understanding and readiness

Introduces the foundations of refugee-responsive care and supports practices to build understanding, readiness, and shared QI approaches across the practice team. Use it to identify priorities, build team engagement, and develop confidence before testing changes in practice.

Stream B

Taking action and driving improvement

Helps practices make practical improvements to refugee-responsive care. Choose a pathway matching current capacity, select one focus area, and pick one or more activities to begin with. Activities are grouped into Quick Start, Core, and Stretch pathways across four refugee health focus areas.

The five-step guide below shows how Stream B fits together. Most practices start with one focus area and a small number of activities, test changes, and build from there.

Practices do not need to complete every activity. Start small, test changes, review what is working, and build progressively over time.

Stream A

Building understanding and readiness

The foundations of refugee-responsive care, the local context, and the QI concepts that underpin the activities in Stream B.

Section 01

Introduction to refugee health quality improvement

Why refugee health?

People from refugee backgrounds often arrive with complex physical, psychological and social health needs. Primary care may need to address migration history, communicable disease screening, catch-up immunisation, chronic disease, women’s and child health, mental health, trauma, oral health, and social determinants of health within standard GP consultation models. Without structured tools and coordinated support, variation in care is likely. Screening outcomes can differ between services, patient follow-up can lapse, mental health needs can go unrecognised, and refugee status may not be captured consistently in practice data.

Why northern Queensland?

Townsville and surrounding areas of northern Queensland are already operating in a pressured health system. General practices, hospitals, community services and settlement organisations are working within constraints that include workforce shortages, funding limitations, high service demand, transport barriers, and existing inequities for priority populations.

Recent refugee arrivals to the region have been concentrated among specific cohorts, including people from the Central African Republic and Sango-speaking communities, where locally tailored services, particularly translation and interpreting support, are very limited.

Why was this toolkit developed?

Quality improvement can address these challenges by providing tools to improve workflows, data systems and staff roles, rather than relying on individual clinicians or practice staff to do more. Engagement work has revealed strong enablers, such as the Multicultural Liaison Officer at Townsville Hospital, QPASTT bicultural workers and existing community trust, that QI initiatives can build upon. By completing the activities presented in this QI toolkit we can work towards closing the equity gap and ensure refugees receive consistent, culturally informed care and create better health outcomes.

This toolkit does not replace clinical guidelines, local referral advice, professional judgement, or the existing high-quality refugee health resources already available to general practice. It does not provide detailed clinical management guidance for individual conditions, prescribe treatment pathways, or cover the management of urgent clinical events, mental health crises, safeguarding concerns, or complex case-specific decisions.

Section 02

Understanding your patient population

Good refugee health QI starts with understanding your refugee patients. That means knowing which patients are from refugee backgrounds, which patients are newly arrived, what their interpreter needs are, and which patients have incomplete assessments, screening, immunisation, referrals or follow-up.

Diversity of refugee communities in northern Queensland

Townsville is home to a significant refugee population, with the largest arrival groups from the Central African Republic and the Democratic Republic of Congo, and smaller numbers from Burundi, Cambodia, Cameroon, Ethiopia, Myanmar, Afghanistan, Iran, Somalia, South Sudan and Sudan. This local profile matters for general practice. Refugee patients may come from different countries, language groups, migration pathways and settlement circumstances. Each group has arrived under different circumstances and each group has differing prevalence of healthcare priorities.

Not every patient from a refugee background needs the same type of support. Once patients are visible in the system, practices may segment the population into groups. This helps the team decide what action is required and avoids assuming all refugee patients have the same health needs or journeys.

Useful patient groupings may include:

Newly arrived patients who need an initial or on-arrival health assessment
Patients with incomplete screening, pathology or immunisation catch-up
Patients with active referrals but no recorded referral outcome
Patients who missed their last appointment and have no future appointment booked
Patients with interpreter needs not recorded or inconsistently recorded
Patients with complex health, mental health or social needs requiring staged care
Established refugee-background patients who need chronic disease, preventive health or mental health follow-up

Why equity, trust and timing matter for refugee-background patients

Clinical records can identify patients from a refugee background, but not always why gaps in care occur. For refugee health, three factors are important.

Equity

Refugee-background patients may be undercounted or underserved when refugee status, country of birth, language need or interpreter requirement is not recorded. Care gaps often reflect workflows that do not fit the patient’s needs, including interpreter scarcity, transport barriers, settlement pressures and lack of familiarity with the health system.

Trust

Patients are more likely to disclose concerns, attend follow-up and accept referrals when they feel respected, understand confidentiality and know why information is being collected. A culturally informed first encounter is therefore part of safe care.

Timing

Missed opportunities compound. If interpreter needs, support contacts or follow-up actions are not recorded early, assessments, referrals, results and recall can lapse. For limited-access languages, early planning is essential because same-day interpreter access may not be reliable.

Positive experiences matter

For people from refugee backgrounds, a culturally informed first encounter can shape whether existing health concerns are disclosed early and influence long-term health outcomes. A welcoming reception, visible interpreter access, respectful explanation of confidentiality, longer appointments where needed, and continuity with a trusted GP or nurse all help create the conditions in which patients unfamiliar with the Australian health system feel safe to speak and become more comfortable accessing the care they need.

The Australian Refugee Health Practice Guide should be used as the key clinical reference for this section. The Guide is designed for doctors, nurses and other primary care providers caring for people from refugee backgrounds, including people seeking asylum. It supports both on-arrival and ongoing care.

The Townsville refugee community and language quick guide is designed to help general practice teams create a respectful first encounter with patients from refugee backgrounds in Townsville and surrounding areas. It should be used alongside the Australian Refugee Health Practice Guide to support language recording, interpreter planning, culturally informed reception processes and links to translated resources.

Sango-speaking patients

Some recent arrivals in Townsville, including people from the Central African Republic, speak Sango. Sango interpreter access is in short supply, and the language is primarily spoken rather than written.

Where relevant, practices should record:

Whether Sango is required for clinical care
Whether another language can be used, and in what format
Whether that other language is suitable for administration only or for clinical discussion
Confidentiality concerns, especially for patients from a small community group
Failed Sango interpreter bookings
Appointments delayed or rescheduled because no interpreter was available

The same approach should be used for any other language where professional interpreter access is limited, delayed or unreliable. The purpose is to make language-access risk visible so the practice can plan appointments, arrange interpreters earlier, involve support services appropriately, and avoid unsafe communication.

Section 03

Having difficult conversations in refugee health

What conversations may be difficult to have

Patients from refugee backgrounds may have experienced conflict, persecution, displacement, detention, deprivation, family separation, torture, sexual violence or prolonged immigration uncertainty. Some may also come from communities or circumstances where mental illness, trauma, chronic and communicable diseases (such as tuberculosis and HIV), reproductive health concerns, disability, child safety or family violence carry shame, fear or stigma. Safe medical history disclosures depend on clear confidentiality, trusted relationships, appropriate language support and a practical pathway for care.

Creating the conditions for disclosure

Health concerns, especially mental health, often surface well after initial settlement. Patients may be concerned that certain medical disclosures could affect their visa status or be shared with government, while the relief of arrival and the immediate work of housing, income, school, family and learning a new system can temporarily push trauma and distress into the background. As early settlement supports reduce and patients are expected to manage their own care, deferred physical and mental health needs may become more visible.

Creating the conditions for disclosure requires time: enough appointment time to raise sensitive issues safely, enough relationship time for trust to develop, and enough planning time to arrange appropriate language support. For limited-access languages such as Sango, early interpreter planning is especially important because a sensitive conversation may not be safe, informative or productive if an appropriate interpreter is unavailable. Disclosure builds across multiple encounters where each consultation strengthens trust and provides the opportunity for the patient to raise concerns when they are ready.

Interpreter realities and language-access risk

Interpreter access is a major safety consideration for patients from a refugee background, with interpreter shortage being one of the most consistent barriers. Most notably, scarcity of Sango interpreters presents a particularly acute challenge in northern Queensland: interpreters often need to be pre-booked, and may not be available if the patient arrives outside the booked appointment time. In small language communities, patients may also have concerns about confidentiality, interpreter familiarity or whether the interpreter can safely support a sensitive conversation.

When an appropriate interpreter is unavailable, practices may need to narrow the conversation to immediate needs and reschedule with language support. Any use of family members or informal supports, while often the only immediately available means of addressing interpreter shortage, should be recorded as a language-access gap so the practice can see where interpreter limitations are affecting safety, continuity and equity.

Explaining confidentiality, consent and why information is being collected

Sensitive questions can feel intrusive or unsafe when patients do not understand why information is being collected and who will see it. Practices should explain confidentiality and consent in plain language, translated where required, before asking. This task becomes significantly harder when interpreters are scarce because the explanation itself requires accurate language support and enough time for questions. For limited-access language groups, practices may need to separate urgent clinical care from sensitive questioning, arrange a better-supported follow-up appointment, and avoid relying on family members or informal supports for consent and confidentiality discussions wherever possible.

Cultural meanings, stigma and different explanations of distress

Patients may express distress through sleep problems, pain, tiredness, appetite changes, irritability, worry, family conflict, grief, spiritual concerns or difficulty managing daily life, rather than using terms such as “mental health”, “trauma”, “depression” or “anxiety”. The meaning attached to these terms will vary between patients, families and communities, and may be shaped by experiences of displacement, religion, gender roles, family expectations, community reputation and previous contact with health or government systems.

Section 04

Testing practical improvements

Quality improvement does not require large-scale redesign or major new programs. In most practices, improvement starts with identifying one small change, testing it in day-to-day workflow, and reviewing whether it made care easier, safer, or more consistent. Small tests of change help practices improve refugee-responsive care without overwhelming staff or disrupting normal operations.

For a detailed understanding of quality improvement fundamentals, see the NQPHN Foundational QI Toolkit.

The Model for Improvement

The Model for Improvement (MFI) asks three simple questions:

What are we trying to improve?
Define a clear and practical goal.
How will we know a change is an improvement?
Identify a small number of measures or observations that indicate whether the change is helping.
What change can we test?
Choose one practical change idea that can be trialled on a small scale.

The activities in this toolkit and presented in Section 08 are designed to help practices answer these questions in practical ways.

Question	Example
What are we trying to improve?	More patients requiring interpreters are identified before appointments
How will we know?	Reception staff can see interpreter needs when booking appointments
What change can we test?	Add preferred language and interpreter requirement to the registration workflow

Using a PDSA cycle

Many practices use small Plan-Do-Study-Act (PDSA) cycles to test changes before introducing them more broadly.

Plan: choose one small change to test and decide how progress will be observed.
Do: test the change with a small number of patients, appointments or staff.
Study: review what worked, what did not, and any unexpected issues.
Act: decide whether to:
- adopt the change
- adapt the change and test again
- abandon the change and try a different approach

Most improvement work involves several small adjustments over time rather than one perfect solution.

Practices do not need to implement every activity in this toolkit at once. Starting with one or two practical changes is often more effective than attempting large-scale redesign immediately. Small improvements that fit into existing workflows are more likely to be sustained over time.

Sharing progress with the team can help maintain momentum. Small improvements are more likely to continue when teams can see results, reflect on what worked, and recognise staff contributions along the way.

Section 05

Practical tools to support improvement

This toolkit includes a set of practical templates, checklists and planning tools that practices can adapt to support refugee health improvement activities. The tools are designed to support practical implementation within routine general practice workflows and can be adapted to suit different practice sizes, systems and staffing models.

The activities in Section 08 identify which tools may be most useful for each improvement activity.

Planning and tracking tools

These tools help practices define improvement goals, identify priorities, plan activities and track progress over time. They are most useful when planning or reviewing an improvement activity.

Tool	Purpose
Appendix 1: AIM Statement Template	Helps practices define a clear improvement goal
Appendix 2: Measures Template	Supports tracking of process and outcome measures
Appendix 3: Driver Diagram Template	Maps contributing factors and possible change ideas
Appendix 4: Problem Statement Template	Helps describe the issue, impact and contributing factors
Appendix 5: Cause and Effect Template (Fishbone)	Supports structured exploration of barriers and causes
Appendix 6: Model for Improvement Guidance	One-page reference guide for using the Model for Improvement
Appendix 7: MFI & PDSA Template	Supports planning, testing and reviewing small improvement activities
Appendix 16: Action Plan Template	Helps practices assign actions, responsibilities and timelines

Workflow and coordination tools

These tools support patient follow-up, appointment planning, interpreter coordination and day-to-day team workflows. They are most useful when improving recall systems, interpreter workflows, appointment planning or continuity of care.

Tool	Purpose
Appendix 8: Refugee Patient Register, Identification and Review Checklist	Supports patient identification, tracking and follow-up
Appendix 9: Monthly Snapshot Template	Supports regular review of refugee health activity and progress
Appendix 10: Team Huddle Template	Helps teams discuss workflow issues, risks and priorities
Appendix 11: SMS and Call/Recall Script Sheet	Supports consistent patient communication and follow-up
Appendix 12: Pre-Booking Workflow Template	Helps practices plan appointments, interpreter use and preparation
Appendix 15: Partnership Planning Template	Supports coordination and communication with external services and community organisations

Cultural responsiveness and communication tools

These tools support culturally responsive care, communication and patient engagement. They are most useful when reviewing patient experience, communication approaches or culturally safe care practices.

Tool	Purpose
Appendix 13: Flexible Access Strategy Planner	Supports planning for transport, appointment flexibility and access barriers
Appendix 14: Cultural Readiness Assessment	Helps practices reflect on culturally responsive systems and environments
Appendix 17: Steps to Having Difficult Conversations	Supports safe and respectful communication around sensitive issues

Clinical support resources

These tools and resources support refugee health assessment, screening and ongoing care. They should be used alongside local referral pathways, clinical guidance and professional judgement.

Tool / resource	Purpose
Appendix 18: Health Screen for Refugee Patient from the Central African Republic	Supports structured health assessment for a key local refugee cohort
Australian Refugee Health Practice Guide	Primary clinical reference for refugee health assessment and ongoing care
Victorian Refugee Health Network, Refugee Health Assessment Template	Structured assessment template for refugee health consultations

Stream B

Taking action and driving improvement

Choose a pathway, select a focus area, and pick one or more activities to test in your practice. Most teams begin with three to five activities in a first improvement cycle.

Section 06

Choose your pathway

Practices across northern Queensland start refugee health QI from very different positions. Some have structured QI processes already in place. Others are new to systematic change or are balancing competing service demands. This toolkit offers three pathways so each team can begin where it is, with the time and capacity it has.

The Quick Start Pathway defines the minimum viable starting point, focusing on a small number of practical activities that establish the core systems for identifying and supporting patients from refugee backgrounds and create a foundation for further improvement. The Core Pathway builds on this foundation, supporting practices to scale improvement through more structured processes, including care delivery, follow-up, and communication. The Stretch Pathway extends this work further, embedding improvement into routine practice and supporting ongoing benefits for patients, staff, and services. The individual activities for each pathway are described in a step-by-step manner in Section 08.

The pathways are cumulative, but they are not a ladder you must climb. They are a practical way of mapping the scale and impact of the QI work to what the team can realistically sustain.

Quick Start Pathway

Approximate effort: around 2–4 hours per month

A practical entry point for practices beginning refugee health quality improvement activities. This pathway focuses on establishing the minimum systems needed to identify refugee patients, support communication needs, and improve continuity of care. It is designed for practices with limited time, limited QI experience, or those wanting to align refugee health activities with existing PIP QI work.

What is involved

Activity 1: Capture refugee status and key indicators at registration
Activity 2: Apply consistent coding to identify refugee patients
Activity 8: Record and respond to patient communication preferences
Activity 11: Assign responsibility for refugee patient follow-up and coordination

Core Pathway

Approximate effort: four to six weeks of focused work

Designed for teams ready to embed refugee health improvement into broader systems of care. This pathway focuses on strengthening follow-up, communication, coordination, and culturally responsive care through structured quality improvement activities. Teams test practical changes, monitor what happens, and refine approaches over time to support more consistent and effective care delivery.

What is involved

Activity 3: Generate and review refugee patient lists
Activity 5: Conduct structured refugee health assessments
Activity 6: Establish recall and follow-up processes after initial assessment
Activity 9: Create a culturally safe and welcoming practice environment
Activity 10: Establish a consistent interpreter workflow

Stretch Pathway

Approximate effort: ongoing effort, embedded in routine operations

Designed for practices seeking to embed refugee health improvement into long-term systems, workflows, and partnerships. This pathway focuses on sustaining improvement over time, strengthening coordination with external services, and adapting care models to better respond to complex or evolving patient needs. It supports practices to move beyond individual activities toward more integrated and routine approaches to refugee-responsive care.

What is involved

Activity 4: Use repeat data measures to track key indicators
Activity 7: Plan longer or staged consultations for complex needs
Activity 12: Strengthen referral pathways and communication with external services

Pick the pathway that matches the team’s current capacity, not its ambition. A Quick Start done effectively outperforms a Stretch that stalls after three weeks. Teams can move up a pathway once the previous one is embedded. Most practices begin with a small number of Quick Start activities and build over time as systems and team confidence in QI activities develop.

Section 07

Identifying a refugee health focus area

Most practices begin with one focus area that reflects a visible workflow issue, patient need, or gap in follow-up or communication. Starting with one practical area is usually more effective than trying to improve multiple systems at once.

Practices may wish to focus on areas where patients are commonly lost to follow-up, interpreter or communication needs are inconsistently managed, refugee patients are difficult to identify in the clinical system, or staff experience recurring workflow challenges. Where possible, use available data and discussion across the practice team to help identify the most practical and achievable starting point.

Focus areas for refugee health

The focus areas below cover the most common and impactful refugee health improvement opportunities in general practice. They are not a checklist. Most practices pick one focus area for their first cycle and move to another once the first is embedded. The QI pathways described in Section 06 contain activities that span multiple, or all, of these focus areas.

Focus 01

Patient identification, data and follow-up

Ensure patients from refugee backgrounds are correctly identified, recorded, and visible in clinical systems.

Capture status at registration
Apply consistent coding
Generate and review patient lists
Track repeat data measures

Focus 02

Refugee health assessment and care delivery

Strengthen how initial assessments and ongoing care are delivered, particularly for patients with complex needs.

Conduct structured health assessments
Establish recall and follow-up
Plan longer or staged consultations

Focus 03

Cultural safety and communication

Improve how the practice communicates with and supports patients, including interpreter use and culturally safe care.

Create a welcoming practice environment
Establish interpreter workflow
Record communication preferences

Focus 04

Continuity, coordination and navigation

Strengthen follow-up, clarify responsibility, and improve connections with external health and settlement services.

Assign a follow-up lead
Strengthen referral pathways

Practices new to refugee health should start with Patient identification, data and follow-up activities, as improvement is difficult without knowing who the patients are. Once patients are visible in the system, move to Refugee health assessment and care delivery or Cultural safety and communication, where early gains in access and safety are often highly impactful. Practices with more established refugee health systems may begin with Continuity, coordination and navigation, particularly where patients are already being seen but are not progressing through care.

It is worth recognising that cultural safety work is sometimes treated as a later-stage or stretch activity, but for many patients it is perhaps the most impactful focus area, particularly where language barriers, trust, or prior experiences of the health system are affecting engagement and outcomes.

Section 08

Refugee health QI activities

This section sets out twelve concrete activities that make up the doing layer of refugee health QI in general practice. Each activity is a self-contained piece of work that a team can take on within a PDSA cycle, and is supported by the tools listed at the end of each block.

The pathways in Section 06 bundle these activities into sensible starting points based on practice capacity. The focus areas in Section 07 group the activities into key domains of refugee health care.

Activities are ordered by the typical sequence in which practices are suggested to undertake them within each focus area, from identification and data processes, through to care delivery, communication and coordination. However, a team does not need to do all twelve, or in the order that they are presented. Most practices work through three to five activities in any given improvement cycle.

If you would like to take a capacity-based approach to refugee health QI, you may decide to conduct the activities in the order that they are presented in their assigned Quick Start, Core or Stretch Pathway in Section 06. Alternatively, if you would like to pursue a defined thematic area for improvement, you may wish to tackle them in the order that they are presented in their assigned focus area as described in Section 07.

Most activities involve both clinical and administrative workflows and are generally most effective when responsibilities are shared across the practice team. Practices may also find it helpful to identify one staff member to help coordinate refugee health improvement work, maintain momentum and support communication across the team over time.

Each activity is assigned to a Quick Start, Core or Stretch pathway, as outlined in Section 06. Practices can choose activities based on their priorities and capacity.

Patient identification, data and follow-up

Activity 01

Capture refugee status and key indicators at registration

Quick Start

Why this matters?

Accurate and consistent identification of patients from refugee backgrounds is the foundation for safe, appropriate care.

Without structured data:

refugee patients remain invisible in practice systems
screening, immunisation and follow-up are applied inconsistently
practices cannot proactively identify or recall patients at risk

Evidence shows that inconsistent or absent recording of refugee indicators limits equity, monitoring, and prevents targeted care. Structured data at presentation to a clinic enables:

appropriate use of interpreters
risk-based screening and assessment
population-level searches and recall systems

Early, routine capture reduces reliance on individual clinicians identifying refugee status during consultations, which is often incomplete or missed.

How to do it

Update new patient registration processes to systematically capture a small set of key indicators.

Some patients from refugee or humanitarian entrant backgrounds may feel uncomfortable sharing personal information such as country of birth, preferred language, interpreter need, or year of arrival, particularly if they are unfamiliar with the Australian health system or uncertain how the information will be used.

Practices should explain why information is being collected, how it supports care, and how confidentiality is maintained. For example: “We ask these questions so we can communicate with you properly, organise interpreters if needed, and make sure we provide the right care and follow-up. Your information is kept confidential within the health service.”

Patients should not feel pressured to disclose information they are uncomfortable sharing. Where possible, explanations should be provided in the patient’s preferred language using a professional interpreter or translated materials.

Step 01

Update registration forms (paper and digital)

Include a small number of structured fields in both paper and electronic forms. These should be clearly labelled and easy for patients or staff to complete:

Ethnicity or cultural background – supports risk-based screening, health assessment planning and may help practices better understand cultural background
Preferred language – identifies how the patient prefers to communicate in healthcare settings
Interpreter required (yes/no) – ensures interpreter needs are flagged early
Interpreter gender preference (if relevant) – supports culturally safe care and medical history disclosure
Year of arrival in Australia – helps clinicians understand settlement stage and risk profile

Keep wording simple and consistent across all forms to reduce confusion and variation.

Step 02

Record data in clinical software

Ensure all information collected at registration is entered into the clinical system in a way that can be reliably used:

enter all fields into coded, structured, and searchable fields (not free text) so they can be used for recalls and data searches
apply consistent practice-wide conventions (e.g. same field names, same coding approach) to avoid duplication or fragmentation
ensure key fields (e.g. interpreter need, preferred language) are clearly visible to clinicians at the point of care

This step is critical – data that is not coded cannot be used for follow-up or improvement activities.

Step 03

Standardise the process

Make this part of routine practice workflow so it happens consistently:

administrative staff collect and enter data at the time of registration as part of standard intake
clinicians confirm or update key details during early consultations or comprehensive health assessments, particularly if information is unclear or incomplete
update fields periodically as circumstances change (e.g. language preference, support needs)

Document the process so all staff follow the same approach.

Implementation note: Keep the dataset minimal and practical. A small number of consistently completed fields is more useful than a large dataset that is incomplete or inconsistently recorded.

How to involve the team

This activity should be shared across the practice.

Reception staff collect and enter key details at registration. Nurses and GPs can confirm or update information during early visits, especially if anything is unclear.

You may choose to nominate a registration or data lead to do a quick check of new records and ensure fields are being completed consistently.

Teams can build this into routine workflows:

confirming details when patients attend
prompting updates at reception
reviewing a small sample of records at team meetings

How to measure progress

Use a small number of simple checks. For Core or Stretch teams, this can link to a simple goal or PDSA cycle (e.g. improving completeness of new records). Focus on consistent, usable data rather than perfection.

Most new patient records include preferred language, interpreter need and country of birth
Interpreter needs are visible before the consultation

A monthly review of 10 new records finds most key refugee status fields completed and correctly entered
Information is recorded in structured fields, not free text

The team can identify patients with a refugee background
The team can identify patients requiring interpreters

Tools that may help with this activity

Activity 02

Apply consistent coding to identify refugee patients

Quick Start

Why this matters?

Consistent coding allows practices to reliably identify patients from refugee backgrounds and use this information for care, follow-up and improvement.

Without a standard approach:

refugee patients remain difficult to identify in the system
recalls, screening and follow-up are inconsistent
data cannot be used for searches or monitoring

Structured coding makes identification visible and usable, enabling proactive care rather than relying on individual clinician awareness.

How to do it

Introduce a simple, consistent approach to coding refugee-related information in your clinical system.

There is currently no single nationally standardised method for recording refugee status within general practice clinical software. Practices may therefore need to develop a consistent local approach using existing structured fields within their clinical system.

In Best Practice and MedicalDirector, refugee-related information is commonly recorded using combinations of country of birth, preferred language, interpreter requirement, ethnicity or cultural background fields (where used locally), patient alerts or reminders, and coded diagnoses or administrative notes. Interpreter need should be clearly visible to reception, nursing, and clinical staff during booking and consultations.

Practices may wish to seek support from NQPHN or their clinical software provider when developing refugee patient identification and coding workflows.

Step 01

Agree on a standard coding approach

Define how the practice will record refugee status or related indicators (e.g. country of birth, year of arrival, interpreter need). Strongly consider adopting a standardised, broadly adopted coding convention for use in general practice.

use existing clinical system fields where possible
avoid multiple or inconsistent labels or tags for the same concept
document the agreed approach for all staff

Using a single, agreed approach improves consistency and makes refugee patient data easier to identify, search and use across the practice. Practices may also wish to reference the Australian Digital Health Agency clinical terminology and coding standards when developing local coding conventions.

Step 02

Apply coding consistently

Ensure all relevant patients are coded in the same way:

apply coding when new patients register
update coding during early consultations if information is revised or identified later
avoid recording key information in free text only

Consistent coding improves data quality and reduces reliance on individual clinician knowledge or memory.

Step 03

Review and clean existing records

Identify and update patients who may already be in the system:

run a simple search (e.g. by country of birth or language)
check a small number of records at a time
apply the consistent coding approach where required

Regular review helps improve the accuracy and usability of patient lists over time.

How to involve the team

This activity is shared across the practice.

Practice managers and nurses can help define the coding approach and ensure it is applied consistently. Reception staff can support by capturing relevant information at registration.

You may nominate a data or coding lead to review records and check consistency, particularly in the early stages.

Teams can:

review a small number of records at a team meeting
agree on a single standardised approach and apply it consistently
link this work to a simple improvement goal (e.g. coding a set number of records each week)

How to measure progress

Use simple checks to confirm coding is consistent and usable.

The practice uses a single, agreed approach to coding refugee-related information
Relevant patients can be identified using a simple search

A monthly review of 10 records finds coding applied consistently
Key information is recorded in structured fields, not free text

The team can generate a basic list of patients from refugee backgrounds
Fewer patients rely on ad hoc identification during consultations

Tools that may help with this activity

Activity 03

Generate and review refugee patient lists

Core

Why this matters?

Once refugee patients are identified and coded, practices need a way to use this information to support care and follow-up.

Without patient lists:

patients with incomplete assessments or unmet needs are harder to identify
follow-up becomes reactive rather than planned
preventive care and screening can be missed

Generating and reviewing lists allows practices to:

identify patients needing follow-up
prioritise care based on need
move from opportunistic care to proactive patient management

How to do it

Use your clinical system to generate simple, targeted lists of patients from refugee backgrounds.

Step 01

Define your intent

Start with a clear, manageable group so the task is practical and achievable. For example:

patients without a completed refugee health assessment
patients requiring interpreter support
patients with incomplete screening or immunisation

Focus on one priority area or datapoint at a time. This makes it easier to act on the list and avoids creating large, unmanageable outputs.

Step 02

Run a search in your clinical system

Use coded fields (e.g. country of birth, preferred language, interpreter need, year of arrival) to generate a list:

base searches on structured data, not free text
use built-in filters, reports or query tools in your clinical software
combine fields where needed (e.g. language + interpreter required)
save commonly used searches so they can be reused

The goal is to produce a clear, usable list, not a perfect dataset. If unfamiliar with running searches start with a simple search or seek support from your practice manager, PHN or software provider.

Step 03

Review the list

Before taking action, check that the list is accurate and relevant:

confirm patients are active and still attending the practice
identify duplicate, inactive or transferred patients
check for obvious gaps (e.g. missing data or incorrect coding)

This ensures time is spent following up the right patients and improves data quality over time.

Step 04

Take action

Use the list to guide practical follow-up based on identified gaps. That may include:

identifying patients who:
have not completed a comprehensive refugee health assessment
require interpreter supported appointments
have incomplete immunisation or screening status
may need review for mental health or other complex needs
allocate follow-up tasks to appropriate team members (e.g. reception for calls, nurse for recalls)
contact patients, send recalls, or flag for discussion at next visit
document actions taken in the clinical system

Start with a small number of patients (e.g. 5–10 at a time) to keep the process manageable and build confidence.

Step 05

Repeat regularly

Re-run and review lists at regular intervals (e.g. monthly or quarterly):

check whether identified gaps are reducing
refine search criteria as data quality improves
build list generation and review into routine practice workflow

Over time, this becomes a standard way of managing care proactively, rather than relying on opportunistic identification.

How to involve the team

This activity works best as a shared task.

Practice managers, nurses or a nominated data lead can run and review lists. GPs and nurses can help prioritise follow-up.

Teams can:

review a list together at a team meeting or huddle
allocate follow-up tasks across staff
focus on a small number of patients each week

For Core or Stretch teams, this can link to a simple goal (e.g. how many patients can be reviewed this week).

How to measure progress

Use a small number of simple, practical checks.

The practice can generate a list of patients from refugee backgrounds that the team recognises and expects to follow up
Most patients on the list are active and known to the practice

A monthly review of 10 patients on the list finds most are active, and suitable for follow-up
Duplicate, inactive or transferred patients are identified and cleaned as part of the review
The same search can be re-run and produces a consistent, usable list

The team is able to identify patients who have not completed a refugee health assessment or require follow-up
More follow-up is planned using lists rather than relying on opportunistic identification
Fewer patients are missed or only identified during unrelated consultations

Tools that may help with this activity

Activity 04

Use repeat data measures to track key indicators

Stretch

Why this matters?

Once patient identification, coding and lists are in place, practices need a way to track whether care is improving over time.

Without repeat data measures:

it is difficult to know if changes are making a difference
improvement efforts rely on perception rather than actual data
gaps in care may persist without being identified

Using simple, repeat measures (such as monthly reports) allows practices to:

track changes over time (e.g. more patients completing health assessments)
identify where follow-up is still needed
maintain focus on refugee health as part of routine care

This supports ongoing improvement rather than one-off activity.

How to do it

Use a small number of repeatable measures to track key indicators at regular intervals.

Step 01

Choose a small number of indicators

Select 1–3 practical measures linked to current activities. For example:

number of patients with a completed refugee health assessment
number of patients with interpreter need recorded
number of patients who have completed catch-up immunisations
number of patients identified for follow-up from a list

Choose measures that:

can be generated from your clinical system
reflect work the team is already doing
are simple to understand and explain

Step 02

Establish a baseline

Run your chosen search once to create a starting point:

record the total number (e.g. 14 patients with completed health assessments)
note the date the search was run
save the search so it can be repeated in the same way

Record this in a simple format, for example:

a spreadsheet with one row per month
columns for each measure being tracked

This baseline allows you to compare results over time.

Step 03

Repeat the same measure regularly

Re-run the same search at a regular interval (e.g. monthly):

use the same search criteria each time
avoid changing definitions or filters
record the new result alongside the previous one (e.g. Month 1: 14, Month 2: 18)

This creates a simple monthly snapshot of progress.

Step 04

Review and interpret the results

Compare current results to previous months:

are numbers increasing, decreasing or staying the same?
for example, are more patients completing health assessments over time?
does the result match what the team is seeing in practice?

Use this to identify:

where improvement is occurring
where follow-up or additional effort is still needed

Keep review brief and focused (e.g. 5 minutes in a team meeting).

Step 05

Adjust and continue

Use results to guide next steps:

focus on areas where numbers are not improving
adjust workflows or follow-up processes if needed
continue measuring to track whether changes have an impact

Over time, this becomes a routine way of monitoring care, not an additional task.

How to involve the team

This activity works best when measurement is simple and visible.

A practice manager, nurse or nominated data lead can run the desired monthly search and record results. GPs and the broader team can help interpret results and decide where to focus.

Teams can:

review results briefly at a team meeting or huddle
link measures to current activities (e.g. follow-up lists, health assessments)
agree on the focus area for the next period

Keep involvement light so the process is sustainable and achievable on an ongoing basis.

How to measure progress

Use simple, observable checks that show measurement is consistent and useful.

The practice produces a monthly output (could be a replicable report) for each selected indicator (e.g. number of completed health assessments)
Results are recorded in a simple format (e.g. spreadsheet with one row per month)

The same search produces consistent results when repeated
A sample of 10 patient records matches what the measure is reporting
The team can explain how the number is generated and what it represents

The team can see changes over time (e.g. completed assessments increasing from 14 to 18 to 22)
Results reflect actual activity (e.g. more patients booked and completed follow-up)
Importantly, measurement is used to guide action (e.g. focusing on patients still missing assessments)

Focus on consistency and usefulness rather than complex reporting. Data measures should be informative of the next area of focus for improvements or for monitoring progress.

Tools that may help with this activity

Refugee health assessment and care delivery

Refugee health care in general practice often requires longer consultations, staged assessment, interpreter use, care coordination, and follow-up. Several Medicare Benefits Schedule (MBS) items may support this work where usual eligibility and claiming requirements are met.

Eligible refugee and humanitarian entrants may receive a once-only MBS health assessment using GP items 701, 703, 705, or 707. These are time-tiered health assessment items. The patient must be Medicare-eligible and must either hold a relevant refugee or humanitarian visa held for less than 12 months at the time of assessment, or have first entered Australia less than 12 months before the assessment.

Refugee health assessments are recommended to be commenced early, preferably within 4 weeks to 1 month of arrival, but this is clinical guidance rather than a separate MBS claiming requirement.

Longer GP consultation items, such as Level C item 36 and Level D item 44 for in-consulting-room GP attendances, may be relevant for complex or staged refugee health care where clinically appropriate and where no more specific MBS item applies.

Practices should check current MBS Online before claiming or embedding billing processes.

Activity 05

Conduct structured refugee health assessments

Core

Why this matters?

Refugee patients often present with complex and unmet health needs that are not identified in routine consultations.

Without a structured approach:

important physical and mental health issues may be missed
care becomes reactive and fragmented
follow-up and coordination are inconsistent

Structured refugee health assessments allow practices to:

identify priority health needs early
provide more coordinated and staged care
reduce reliance on opportunistic or incomplete assessments

This supports safer, more consistent care, particularly in the early settlement period.

How to do it

Use a structured, practice-level approach to plan and deliver refugee health assessments.

Step 01

Identify patients requiring assessment

Use your patient list or registration data to identify patients who:

are newly arrived or recently registered
have not completed a refugee health assessment
or have complex or unmet health needs

Flag these patients in the clinical system and include them in your follow-up or recall process.

Step 02

Plan the assessment

Prepare for the consultation using a consistent practice approach:

follow the practice’s agreed process for booking refugee health assessments
book a longer appointment or plan staged appointments where needed
arrange a professional interpreter in advance
consider clinician gender preferences if relevant
review available information (e.g. referral notes, prior records)

Avoid relying on standard short consultations for initial assessments.

Step 03

Use a structured assessment approach

Conduct the assessment using a consistent framework or template: You may consider using the Australian Refugee Health Practice Guide – Refugee Health Assessment guide or the Victorian Refugee Health Network – Refugee Health Assessment Template.

use a refugee health assessment template where available
cover key domains such as:
physical health and screening
immunisation status
mental health and wellbeing
social and settlement context

Templates help ensure key areas are covered consistently across clinicians.

Step 04

Document and code findings

Record key information in a structured way so it can be used for ongoing care:

document assessment findings clearly in the clinical record
update coded fields (e.g. conditions, risk factors, interpreter need)
record required actions (e.g. tests, referrals, follow-up)
enter tasks or reminders into the system where available

This ensures information is visible and can be followed up by the practice team.

Step 05

Plan and track follow-up care

Ensure the assessment leads to coordinated ongoing care:

identify required follow-up (e.g. tests, referrals, review appointments)
allocate responsibility for each action (e.g. reception to book, nurse to recall, GP to review results)
record tasks in the clinical system so follow-up does not rely on memory
use recall systems to track outstanding actions

Where needed, stage care across multiple visits rather than attempting to complete everything at once.

How to involve the team

This activity requires a clear, shared workflow across the practice and willingness to perform longer and more comprehensive appointments by clinicians.

Reception staff follow the agreed booking process, including longer appointments and interpreter arrangements. Nurses can support preparation, screening, immunisation and follow-up tracking. GPs lead and conduct the assessment with the patient and are responsible for clinical decision-making.

Teams should agree:

how patients are identified and flagged for assessment
how refugee health assessments are booked (especially appointment length and interpreter requirements)
who completes each part of the assessment
who checks that follow-up actions are completed

A nominated clinical or coordination lead can oversee the process and review progress, particularly in the early stages.

How to measure progress

Use simple, observable checks linked to assessment completion and follow-up.

The practice can generate a list of patients who have completed a refugee health assessment
Assessments are booked with appropriate time and interpreter support

A monthly review of 10 patients from the refugee patient list shows most have either completed an assessment or have one booked
Records show structured documentation (e.g. use of templates, coded entries)
Follow-up actions (e.g. tests, referrals) are recorded and assigned

More patients complete a refugee health assessment within a reasonable timeframe after registration
Fewer assessments are attempted in short or unsuitable appointments
Follow-up actions are completed (e.g. test results reviewed, referrals actioned), not left outstanding

Tools that may help with this activity

Activity 06

Establish recall and follow-up processes after initial assessment

Core

Why this matters?

Refugee health assessments often identify multiple follow-up needs that cannot be completed in a single visit.

Without a clear recall and follow-up process:

tests, referrals and review appointments may not be completed
patients can be lost to follow-up, particularly after the initial settlement period
care becomes fragmented and dependent on individual clinicians

Structured recall and follow-up processes allow practices to:

ensure identified needs are acted on
support continuity of care over time
reduce missed or delayed care

This is critical given the known drop-off in system navigation after initial settlement support ends.

How to do it

Set up a simple, consistent process to track and complete follow-up after refugee health assessments.

Step 01

Identify required follow-up at the time of assessment

At the end of the assessment, clearly identify what needs to happen next:

pathology tests, imaging or screening
referrals (e.g. specialists, mental health, allied health)
review appointments
immunisation or treatment follow-up

Record all required actions in the clinical system.

Step 02

Record and assign follow-up tasks

Ensure each action is visible and assigned:

enter tasks or reminders into the clinical system
assign responsibility (e.g. reception to book, nurse to recall, GP to review results)
include due dates where required

Avoid relying on informal notes or memory.

Step 03

Use recall systems to track outstanding actions

Use your clinical system’s recall or reminder functions:

generate a list of patients with outstanding follow-up
track completion of tests, referrals and appointments
follow up patients who have not attended or completed actions

Start with a small number of patients if setting this up for the first time.

Step 04

Actively follow up patients

Use standard practice processes to complete follow-up:

contact patients to book appointments or tests
send reminders (SMS, phone, letters)
arrange interpreter-supported follow-up where needed
re-engage patients who have missed appointments

Document all contact attempts and outcomes.

Step 05

Review and update regularly

Review outstanding follow-up at regular intervals (e.g. weekly or monthly):

check which actions are completed or still pending
update records to reflect current status
remove completed or no longer relevant tasks

Build this into routine workflow to maintain continuity.

How to involve the team

This activity requires a clear, shared workflow.

Reception staff can support patient contact and booking. Practice nurses can manage recalls, track outstanding actions and support follow-up care. GPs review results, manage clinical decisions and confirm next steps.

Teams should agree:

how follow-up tasks are recorded and assigned
who is responsible for checking outstanding actions
how patients are contacted and re-contacted if needed
how often follow-up lists are reviewed

A nominated coordination or recall lead can oversee the process and ensure follow-up is completed.

How to measure progress

Use simple, observable checks linked to follow-up completion.

The practice can generate a list of patients with outstanding follow-up actions
Follow-up tasks are recorded and assigned in the clinical system

A review of 10 patients with identified follow-up needs shows most have tasks recorded and assigned
Outstanding actions (e.g. pathology tests, referrals) are visible and tracked
Duplicate or unclear tasks are identified and corrected

More follow-up actions are completed (e.g. pathology tests done, referrals attended, review appointments booked)
Fewer patients are lost to follow-up after initial assessment
Fewer patients require re-identification of missed care at later visits

Tools that may help with this activity

Activity 07

Plan longer or staged consultations for complex needs

Stretch

Why this matters?

Refugee patients may require longer or staged consultations due to interpreter use, to conduct a refugee health assessment, address complex health needs or the lack of familiarity with the health system, and provided the time needed to build trust and rapport.

Without a planned approach:

consultations can become rushed or incomplete
important issues (e.g. mental health, trauma, chronic conditions, immunisation status) may not be identified
patients may not feel safe to disclose sensitive information

Planned longer or staged consultations allow practices to:

address priority needs over time
create conditions for safe disclosure
reduce pressure on single consultations or bulk-billed appointments

This supports more effective, patient-centred care. Longer Level C and D consultation items may support this work where clinically appropriate.

How to do it

Plan and structure consultations to better meet complex needs.

Step 01

Identify patients who may benefit from longer or staged care

Use clinical judgement and available data to identify patients who:

are new to the practice and are of refugee status (where identifiable)
have multiple or complex health needs
require interpreter-supported consultations
may need time to build trust before discussing sensitive issues
have multiple follow-up actions from an assessment

Flag these patients in the clinical system where possible.

Step 02

Plan the consultation approach

Decide whether care should be delivered as a longer appointment or across multiple visits:

book longer appointments where possible, or,
plan staged consultations to spread care over several visits, and,
prioritise key issues for each visit rather than covering everything at once

Use a consistent approach across the practice where possible. You may wish to consider scheduling longer appointment blocks throughout the week to see refugee patients during those times.

Step 03

Prepare for each consultation

Ensure the consultation is set up appropriately:

arrange a professional interpreter where required
review previous notes, results and outstanding actions
confirm appointment length is appropriate
consider clinician continuity where possible

Preparation supports more effective use of time.

Step 04

Deliver care in stages where appropriate

Structure consultations to focus on manageable components:

address priority health concerns first
introduce sensitive topics gradually (e.g. mental health, trauma) where appropriate
allow time for questions and clarification
plan the next step at the end of each visit

Avoid attempting to complete all care in a single standard-length consultation for complex cases or new patients.

Step 05

Plan and document next steps

At the end of each consultation:

clearly identify what will happen next
book follow-up appointments before the patient leaves where possible
record planned next steps in the clinical system
use recall systems to track ongoing care

This ensures continuity between visits.

How to involve the team

This activity relies on coordinated planning and booking processes.

Reception staff play a key role in booking longer or staged appointments and arranging interpreters. Nurses can support preparation, follow-up and continuity. GPs lead clinical prioritisation and staging of care.

Teams should agree:

when or for which patients longer or staged consultations are used
how these appointments are booked and flagged
how continuity of the same GP is supported where possible
how follow-up is scheduled and tracked

A nominated clinical lead can support consistency across the team.

How to measure progress

Use simple, observable checks linked to consultation planning and continuity.

Longer or staged consultations are being used for patients with refugee backgrounds and complex needs
Interpreter-supported appointments are planned in advance

A review of 10 patients with complex needs shows most are booked into longer or staged consultations where appropriate
Records show clear documentation of staged care (e.g. planned next steps, follow-up appointments)
Follow-up appointments are booked or scheduled, not left open

Fewer consultations attempt to cover multiple complex issues in a single short visit
More patients return for planned follow-up rather than re-presenting with unresolved issues
Care is delivered across a series of planned visits rather than fragmented encounters

Tools that may help with this activity

Cultural safety and communication

Activity 08

Record and respond to patient language and communication preferences

Quick Start

Why this matters?

Clear and respectful communication via agreed channels and formats is essential for safe care.

For patients from refugee backgrounds, language and communication needs may vary and can change over time. Without a consistent approach:

important information may not be understood
patients may feel uncomfortable or unsafe
clinicians may rely on assumptions rather than patient preference

Recording and responding to language and communication preferences allows practices to:

provide care in a way that patients understand
support safe disclosure of sensitive information
reduce reliance on ad hoc or informal communication

This improves both clinical safety and patient experience.

How to do it

Capture and use patient language and communication preferences as part of routine care.

Step 01

Ask about language and communication preferences

Include simple, standard questions such as:

preferred spoken language
need for an interpreter
preferred method of contact (e.g. phone, SMS, letter)
any relevant preferences (e.g. interpreter gender, privacy considerations)

Ask these questions in a respectful and consistent way.

Step 02

Record preferences in the clinical system

Ensure preferences are visible and usable:

enter information into structured, searchable fields (not free text)
ensure key details (e.g. interpreter need, language) are clearly visible
use consistent field names and coding across the practice

This allows preferences to be used during booking and consultations.

Step 03

Use preferences when delivering care

Apply recorded preferences in day-to-day practice:

book interpreter-supported appointments where required
use the patient’s preferred contact method for recalls and follow-up
consider preferences when planning consultations (e.g. privacy, gender considerations)

Avoid relying on assumptions or previous patterns.

Step 04

Confirm and update preferences over time

Check preferences periodically:

confirm details during visits, particularly if circumstances change
update preferences in the clinical system as needed
ensure outdated information is corrected

This keeps information accurate and relevant.

How to involve the team

This activity should be part of routine workflow across the practice.

Reception staff can ask and record preferences at registration and when booking appointments. Nurses and GPs can confirm or update preferences during consultations.

Teams should agree:

what questions are asked and how they are phrased
where and how preferences are recorded
how preferences are used when booking and delivering care

A consistent approach helps avoid variation between staff.

How to measure progress

Use simple, observable checks linked to recording and use of preferences.

Most patient records include preferred language and interpreter need
Communication preferences and contact details are visible at the point of care

A review of 10 patient records shows most have communication preferences recorded and correctly entered
Preferences are recorded in structured fields, not free text
Recorded preferences match what staff use when booking or contacting patients

Interpreter needs are identified and planned in advance, not at the time of consultation
Patients are contacted using their preferred method
Fewer issues arise due to unclear or mismatched communication approaches or language barriers

Tools that may help with this activity

Activity 09

Create a culturally safe and welcoming practice environment

Core

Why this matters?

A culturally safe and welcoming environment supports patients to engage with care and disclose health needs.

For patients from refugee backgrounds, unfamiliar systems, past experiences and language barriers can make healthcare settings feel unsafe or difficult to navigate. Without a considered approach:

patients may delay or avoid care
sensitive issues (e.g. mental health, reproductive health) may not be disclosed
trust may not be established with the practice

Creating a culturally safe environment allows practices to:

support patient trust and engagement
improve communication and understanding
enable safer and more effective care

This activity is foundational for achieving better refugee health outcomes and facilitates or supports the effectiveness of many other activities in this toolkit.

How to do it

Make small, practical changes across the practice to improve cultural safety and accessibility.

Supporting refugee-responsive care requires more than clinical knowledge alone. Practice staff may benefit from training in refugee health, cultural safety, trauma-informed care, cross-cultural communication, interpreter use, and working with patients who may be unfamiliar with the Australian health system.

Training can help practices better understand the impact of trauma, displacement, and resettlement on health and healthcare engagement; barriers to communication and disclosure; culturally responsive communication approaches; appropriate use of interpreters; and how practice systems and workflows may unintentionally create barriers to care.

Relevant training, resources, and professional development opportunities may be available through organisations such as the Queensland Refugee Health Network, QPASTT, local Hospital and Health Services, and other refugee health services.

Step 01

Review the patient experience from arrival to consultation

Walk through the patient journey from the perspective of a new patient:

what happens at reception when a patient arrives?
is it clear how to check in and what will happen next?
are forms, signage and instructions easy to understand?
is privacy maintained when discussing personal information?

Identify 2–3 simple areas where the experience could be improved. This may also be obvious from points of feedback received in the past.

Step 02

Improve communication and accessibility

Make key information easier to understand and act on:

use simple, clear language when explaining appointments, tests and next steps
ensure reception staff explain what will happen during the visit
display clear information about interpreter availability (e.g. signage at reception)
provide translated materials where available for common processes (e.g. consent, appointments)

Focus on reducing confusion at key points (e.g. arrival, booking, follow-up).

Step 03

Support respectful and consistent staff interactions

Ensure all staff interact with patients in a way that supports trust:

avoid assumptions about what patients understand or prefer
allow time for patients to ask questions, especially when using interpreters
explain processes clearly (e.g. referrals, follow-up, costs where relevant)
be mindful of privacy, gender and cultural considerations during consultations
consider undertaking cultural appropriateness and awareness training for staff

Consistency across staff helps build trust over time.

Step 04

Embed interpreter use as part of routine care

Embed interpreter use as standard practice:

offer interpreters as a standard option, not only when requested
plan interpreter use in advance rather than at the time of consultation
consider interpreter gender preferences where relevant
avoid relying on family members except where essential
ensure all staff know how to book and use interpreters
use available cultural or community supports where appropriate

This supports safe communication and disclosure.

Step 05

Review and refine the approach

Make this an ongoing process:

seek informal feedback from patients and staff
discuss cultural safety at team meetings
note any recurring issues (e.g. confusion at reception, missed interpreters)
identify small improvements that can be made
adjust processes as needed

Focus on continuous, practical improvement and awareness rather than large changes.

How to involve the team

This activity involves the whole practice.

Reception staff shape first impressions and communication. Nurses and GPs support safe clinical interactions. Practice managers can coordinate changes to processes, environment and materials.

Teams should agree:

how patients are welcomed and communicated with
how interpreters are offered and arranged
how cultural safety is discussed and reinforced across staff

A consistent approach across all staff is key.

How to measure progress

Use simple, observable checks linked to patient experience and staff practice.

Interpreter availability and communication support are visible within the practice
Staff follow a consistent approach when interacting with patients

A review of 10 patient records shows interpreter use is recorded where required
Patients requiring interpreters are booked appropriately in advance
Staff can describe how to arrange interpreters and support communication

Fewer consultations rely on ad hoc communication methods (e.g. family members interpreting)
Patients are more likely to return for follow-up care
Staff report greater confidence in supporting patients from refugee backgrounds

Tools that may help with this activity

Activity 10

Establish a consistent interpreter workflow

Core

Why this matters?

Professional interpreters are essential for safe, accurate and culturally appropriate care.

Without a consistent interpreter workflow:

interpreter needs may be identified too late or missed entirely
family members may be used instead of professional interpreters
consultations can be delayed, shortened or incomplete
patients may not feel safe discussing sensitive issues

A structured interpreter workflow allows practices to:

identify interpreter needs early
plan appointments appropriately
support safer communication and disclosure
reduce variation between clinicians and staff

This improves both patient experience and clinical safety.

How to do it

Set up a clear, practice-wide process for identifying, booking, and using interpreters.

GPs and eligible private medical practitioners can access TIS National’s Free Interpreting Service when delivering Medicare-rebatable services in private practice to Medicare-eligible patients. This may include consultations commonly associated with refugee health care, such as longer consultations, health assessments, chronic disease management, mental health discussions, and follow-up appointments, where these services are Medicare-rebatable. Practice nurses, reception staff, and other practice support staff can also access the service through the registered practitioner’s client code when supporting patient communication and practice coordination activities.

Use the links below to access TIS services:

TIS National website
TIS Online log in
Immediate phone interpreting: call 131 450
Automated Telephone Interpreting Service (ATIS): call 1800 131 450

Step 01

Identify interpreter needs early

Ask about interpreter needs at registration and confirm them during early visits:

record preferred language and interpreter requirement in structured clinical system fields
ask whether patients have preferences that may affect communication (e.g. interpreter gender)
ensure interpreter needs are visible when booking appointments

Do not rely on assumptions about English proficiency.

Step 02

Establish a standard booking process

Agree on a consistent workflow for arranging interpreters:

define who is responsible for booking interpreters
identify which interpreter services the practice uses
include interpreter booking as part of appointment scheduling workflow
book interpreters in advance for planned consultations where possible

Document the process so all staff follow the same approach.

Step 03

Prepare interpreter-supported consultations

Plan appointments so interpreters can be used effectively:

book longer appointments where appropriate
confirm interpreter details before the consultation
ensure clinicians know an interpreter is booked
avoid using family members or children except where unavoidable or clinically appropriate

Preparation reduces delays and communication breakdowns.

Step 04

Use interpreters consistently during care

Embed interpreter use into routine practice:

use professional interpreters for assessments, consent, results and complex discussions
speak directly to the patient, not the interpreter
allow additional time for clarification and questions
document interpreter use in the clinical record

Consistency helps build trust and improves communication quality.

Step 05

Review and refine the workflow

Review how the process is working in practice:

identify common issues (e.g. missed bookings, unavailable interpreters, short appointment times)
discuss workflow challenges at team meetings
update processes as needed
ensure new staff understand the workflow

Focus on making interpreter use routine and reliable across the practice.

How to involve the team

This activity requires coordination across administrative and clinical staff.

Reception staff often identify interpreter needs and arrange bookings. Nurses and GPs confirm communication needs and use interpreters during care. Practice managers can support workflow design and troubleshooting.

Teams should agree:

how interpreter needs are identified and recorded
who books interpreters and when this occurs
how interpreter-supported appointments are flagged in the system
when longer appointments should be used

A consistent workflow reduces missed interpreter needs and last-minute arrangements.

How to measure progress

Use simple, observable checks linked to interpreter planning and use.

Interpreter needs are visible when appointments are booked
Interpreter-supported appointments are arranged using a consistent process

A review of 10 patients requiring interpreters shows most had interpreters booked in advance where appropriate
Interpreter use is documented in the clinical record
Staff can explain the agreed interpreter booking workflow

Fewer consultations rely on ad hoc interpreter arrangements or family members
Fewer appointments are delayed or disrupted due to interpreter issues
Interpreter-supported consultations are planned as part of routine care rather than arranged reactively

Tools that may help with this activity

Continuity, coordination and navigation

Activity 11

Assign responsibility for refugee patient follow-up and coordination

Quick Start

Why this matters?

Refugee patients often require follow-up across multiple appointments, tests, referrals and services.

Without clear responsibility for coordination:

follow-up tasks can be missed or duplicated
patients may be lost between services or appointments
care becomes fragmented and dependent on individual clinicians

This is particularly important for refugee patients, who may face additional barriers navigating the health system independently.

Assigning responsibility for follow-up and coordination allows practices to:

improve continuity of care
reduce missed follow-up
ensure important actions are tracked and completed

Even a simple coordination process can significantly improve consistency.

How to do it

Establish a simple, shared process for coordinating refugee patient follow-up.

Step 01

Define what needs coordination

Identify the types of activities that commonly require follow-up. For example:

refugee health assessments
pathology tests and results
specialist or allied health referrals
immunisation and screening follow-up
interpreter-supported appointments

Focus first on the areas where follow-up is most commonly missed or delayed.

Step 02

Assign clear responsibilities

Agree on who in particular is responsible for different follow-up tasks:

reception staff may manage booking and patient contact
nurses may track recalls, referrals or outstanding results
GPs may review results and determine next clinical steps

You may also choose to nominate a single follow-up or coordination lead to oversee the process.

The aim is for staff to know:

what they are responsible for
when follow-up should occur
how tasks are recorded and tracked

Step 03

Record and track follow-up tasks

Use the clinical system to make follow-up visible:

enter tasks, reminders or recalls into the system
assign tasks to the appropriate staff member where possible
document contact attempts and completed actions
use consistent processes across the practice

Avoid relying on verbal handover or memory alone.

Step 04

Review outstanding follow-up regularly

Build follow-up review into routine workflow:

review outstanding tasks at regular intervals (e.g. weekly or monthly)
identify patients who have not attended or completed follow-up
reassign or escalate tasks where needed
close completed tasks so that lists remain accurate

Start small and focus on consistency.

How to involve the team

This activity works best when coordination is shared and clearly understood.

Reception staff, nurses and GPs all contribute to follow-up and continuity of care. Practice managers can support workflow design and ensure systems are being used consistently.

Teams should agree:

what types of follow-up are tracked
if a nominated follow-up or coordination lead role is required and who it should be
who is responsible for different tasks (if not the follow-up or coordination lead)
how follow-up is recorded in the system
how outstanding tasks are reviewed and escalated

Remember, a simple, clearly understood process is more effective than a complex system that is used inconsistently.

How to measure progress

Use simple, observable checks linked to follow-up completion and task visibility.

Follow-up tasks are recorded and assigned in the clinical system
Staff can explain who is responsible for different follow-up activities

A review of 10 refugee patient records shows most have clearly documented follow-up actions where required
Outstanding tasks are visible and regularly reviewed
Completed actions are closed or updated in the system

Fewer follow-up actions rely on informal reminders or verbal handover
Fewer patients are lost to follow-up after referrals, tests or assessments
Follow-up responsibilities are shared consistently across the team rather than relying on one clinician

Tools that may help with this activity

Activity 12

Strengthen referral pathways and communication with external services

Stretch

Why this matters?

Refugee patients often require care across multiple services, including hospitals, allied health, mental health, settlement and community services.

Without clear referral pathways and communication processes:

referrals may be delayed, incomplete or difficult to navigate
patients may not understand what the referral is for or what happens next
services may operate in isolation with limited communication between providers

This can contribute to fragmented care and patients being “lost in the middle” between services.

Strengthening referral pathways allows practices to:

improve continuity and coordination of care
support patients to navigate the system more effectively
reduce duplication, missed care and communication gaps

How to do it

Develop clear and consistent referral and communication processes with external services.

Step 01

Identify commonly used referral pathways

Map the services, particularly in the local area, that are most commonly used by refugee patients. For example:

pathology and imaging providers
hospitals and outpatient clinics
mental health services
allied health providers
settlement or community support organisations

Focus first on pathways that are used frequently, located nearby or where breakdowns commonly occur.

Step 02

Build a simple referral directory or pathway guide

Create a practical referral directory for staff:

record key referral service contacts (name and titles of key personnel, email and phone numbers) and processes
note which services use interpreters or have refugee health experience
include referral requirements (e.g. forms, eligibility, waitlists)
store the information somewhere accessible to staff

Keep the directory simple and easy to update.

Step 03

Improve patient communication during referrals

Use consistent processes when making referrals:

explain the referral clearly to the patient
arrange interpreter support where needed
provide clear appointment details and next steps
include relevant background information in referral letters where appropriate

Do not assume patients understand how referrals or appointments work.

Step 04

Track and follow up referrals

Ensure referrals are not just sent, but followed through:

record referrals in the clinical system
track whether appointments were booked or attended
follow up missed appointments or incomplete referrals
review incoming letters, results or discharge summaries promptly

This supports continuity between services.

Step 05

Strengthen relationships with external services

Build communication and familiarity with commonly used services:

identify key contacts where possible and build or maintain professional relationships
clarify referral expectations and communication processes at both ends of the referral
share information about interpreter or support needs where appropriate
discuss recurring issues or barriers as they arise

Small improvements in communication can significantly improve coordination over time.

How to involve the team

This activity requires coordination between clinical and administrative staff.

Reception staff may support booking, patient communication and referral tracking. Nurses can assist with coordination, follow-up and communication with services. GPs lead referral decisions and clinical communication.

Teams should agree:

which referrals are tracked and how
who follows up outstanding referrals or appointments
how communication to/from external services is reviewed and actioned
where referral information and contacts are stored

A nominated coordination lead can help maintain consistency across pathways.

How to measure progress

Use simple, observable checks linked to referral completion and communication.

The practice has a documented list of commonly used referral pathways and contacts
Referrals are recorded and tracked in the clinical system

A review of 10 refugee patient records shows most referrals are documented and followed up where required
Referral information includes interpreter or communication needs where relevant
Incoming letters or discharge summaries are reviewed and actioned consistently

Fewer referrals require re-sending or clarification due to missing information
Fewer patients are lost between referral and follow-up
Staff report greater confidence navigating common refugee health referral pathways including familiarity with the key contacts at major referral partner services

Tools that may help with this activity

Model for Improvement Guidance

One-page reference, adapted from the PHN National Improvement Network Collaborative (NINCo) template by Prestantia Health

Download →

Appendix 07

MFI & PDSA Template

Combined Thinking Part and Doing Part worksheet

Download →

Refugee health operational tools

While the Australian Government Department of Health and Aged Care has contributed to the funding of this material, the information contained in it does not necessarily reflect the views of the Australian Government and is not advice that is provided, or information that is endorsed, by the Australian Government. Due to constant developments in research and health guidelines, the information in this document will need to be updated regularly.

Version 1.0 · Printed copies of this document are uncontrolled.

Refugee Health QI Toolkit

Table of Contents

The refugee health QI toolkit

What this toolkit can help practices do

How to use this toolkit

Building understanding and readiness

Introduction to refugee health quality improvement

Why refugee health?

Why northern Queensland?

Why was this toolkit developed?

Understanding your patient population

Diversity of refugee communities in northern Queensland

Why equity, trust and timing matter for refugee-background patients

Positive experiences matter

Sango-speaking patients

Having difficult conversations in refugee health

What conversations may be difficult to have

Creating the conditions for disclosure

Interpreter realities and language-access risk

Explaining confidentiality, consent and why information is being collected

Cultural meanings, stigma and different explanations of distress

Testing practical improvements

The Model for Improvement

Using a PDSA cycle

Practical tools to support improvement

Planning and tracking tools

Workflow and coordination tools

Cultural responsiveness and communication tools

Clinical support resources

Taking action and driving improvement

Choose your pathway

Quick Start Pathway

Core Pathway

Stretch Pathway

Identifying a refugee health focus area

Focus areas for refugee health

Patient identification, data and follow-up

Refugee health assessment and care delivery

Cultural safety and communication

Continuity, coordination and navigation

Refugee health QI activities

Patient identification, data and follow-up

Capture refugee status and key indicators at registration

Why this matters?

How to do it

Update registration forms (paper and digital)

Record data in clinical software

Standardise the process

How to involve the team

How to measure progress

Tools that may help with this activity

Apply consistent coding to identify refugee patients

Why this matters?

How to do it

Agree on a standard coding approach

Apply coding consistently

Review and clean existing records

How to involve the team

How to measure progress

Tools that may help with this activity

Generate and review refugee patient lists

Why this matters?

How to do it

Define your intent

Run a search in your clinical system

Review the list

Take action

Repeat regularly

How to involve the team

How to measure progress

Tools that may help with this activity

Use repeat data measures to track key indicators

Why this matters?

How to do it

Choose a small number of indicators

Establish a baseline

Repeat the same measure regularly

Review and interpret the results

Adjust and continue

How to involve the team