Green Book

Putting prevention into practice

Iterative cycles

Key points

The PRACTICE framework:

  • Is useful when implementing preventive activities – it incorporates elements of several other theories and frameworks
  • Helps identify and overcome barriers to implementation (eg engagement, collaboration and systems)
  • Helps remind us that change is incremental and that we should plan for and recognise ‘small’ successes along the way.

The Green Book brings together two main themes: prevention and implementation.

Both of these sit within QI and are inherently associated with behaviour change.

The iterative cycles component of the PRACTICE framework relates to the fact that putting prevention into practice is an iterative process; that is, measurement of the desired target is repeated to see whether improvement occurs.

Change is an incremental process. The only way of knowing whether an intervention has made a difference is to measure the situation before and after the intervention.

Is there a cyclical planning process that measures progress and ensures necessary adaptation?

Measurement and evaluation are essential to determining that the implementation processes have been carried out, barriers to implementation identified, and implementation strategies have been effective. This process creates a learning cycle, ideally leading to more effective strategies being developed and/or to discarding ineffective strategies. Improvement takes time and a commitment to reflect on progress.103 An iterative approach will help both the GP and practice address the following questions.

Does the practice use a ‘plan, do, study, act’ (PDSA) process to review progress and develop strategies for improvement?

Assessment and feedback can be used to adjust an intervention or determine priority areas.

  • Does the implementation process need to be changed?
  • Is there a logical, evidence-based argument that an alternative implementation approach is preferable to the current one?
  • Is there evidence that the GPs and the practice are not using a preferred alternative? Can you measure your progress in implementing changes? What is the problem with the current approach? What strategies are used to identify progress?

Measurement usually requires identification of a particular cohort of patients in a target group. Practice registers, patient surveys and data-mining tools can assist in identifying eligible patients to be included in the target group.

Is there an opportunity for reflection?

Deciding on a change to the delivery of preventive care requires both measurement of progress and a discussion of the findings. All those involved need to be informed of the progress in order to facilitate making further changes.104


It is important to have a means of tracking your progress and ensuring your plans are on schedule. A reminder system that is visible to your practice team will prove helpful. Consider having an interactive chart that has a timeline displayed in the staff room.

– Dr Cory Lei, Green Book Editorial Committee

Figure 7. Gantt chart in practice

Figure 7

Gantt chart in practice

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