Green Book

Putting prevention into practice - Chapter 4.6

Targeted to people and priorities

Guidelines for the implementation of prevention in the general practice setting
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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.

Targeting involves identifying the priority prevention areas and obtaining consensus from all participants, including on the level of need for the prevention activities. It can also mean identifying the specific groups that you wish to address. For example, if you wish to improve immunisation coverage rates, it would be more efficient to focus on those who are not immunised than on the entire practice cohort, unless the level of coverage is very low or is very variable. In the latter case, targeting the entire cohort would be the better option.

The identification of prevention areas to tackle first is influenced by a range of factors such as burden of illness, frequency, ability of the GP to alter the outcome, feasibility, professional values and preferences.

It is helpful to obtain some form of objective information (from your local community as well as from your practice) about the extent or nature of the problem.

Targeted groups can include those eligible for specific prevention activities, those at higher risk and those who express greater interest in making changes. Targeting at-risk and priority populations is especially important. Prevention reduces health inequalities in disadvantaged groups and patients with chronic disease and/or ‘at risk’ behaviours. While an opportunistic approach to prevention targets individuals attending the practice, it rarely encompasses all patients eligible for a prevention activity.

Consider your community and whether or not your practice is adequately serving high-risk groups. For example, if your local community has a high proportion of Aboriginal or Torres Strait Islander patients, assess whether their health needs are being met by your practice.

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Secondary prevention of coronary artery disease: Case study

We instituted a project at the Fairfield GP Unit to improve our care of patients who are known to have coronary artery disease (ie secondary prevention).

We focused on increasing the percentage of patients with established coronary artery disease who had a GP management plan completed in the previous 12 months. We chose this secondary outcome because we believed that if a plan had been completed, a number of issues such as smoking, hypertension, exercise and lipid control would have been addressed.

We undertake a monthly data extraction from our electronic medical records and produce a run chart of the percentage of patients with a GP management plan completed in the last 12 months. This data is then presented to the whole team at our regular monthly practice meeting.

We learned that we needed to improve our coding of patients with coronary artery disease so that we can identify who is or is not receiving good care. We suspect we still haven’t identified all our patients, given the known prevalence of coronary artery disease.

We found that recalling patients improved our figures. By making GP management plan completion rates part of the monthly meetings, we tried to make sure we keep working on this issue.

We would recommend to others to focus on a particular area for improvement and delegate a small team to work on it. An enthusiastic medical student helped us with the project. We used formal quality improvement processes such as the Langley and Nolan ‘Model for Improvement’ and rapid improvement (PDSA) cycles.

– Dr Andrew Knight, Fairfield GP Unit, NSW

Identifying a target goal provides something to aim for and a benchmark against which to measure progress.

Identifying and addressing barriers to implementation

It is also useful to identify the actual and potential barriers and difficulties that may be encountered when trying to improve performance.43–48 For example, consider the health literacy of the target population, as this may be a significant barrier to patients engaging with and taking up preventive activities and adhering to preventive advice.

One simple strategy is to ask all the practice team about the potential (and actual) challenges that they will likely face if implementation is to proceed. Also ask the team about possible ways of addressing these barriers and challenges.

Knowing how well the practice is performing, together with an understanding of barriers, will assist in the development of appropriate strategies to overcome the difficulties.

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When implementing prevention activities for our Aboriginal and Torres Strait Islander patient group, we identified that the biggest barrier was keeping appointments. The practice team agreed to change our approach to targeting patients opportunistically in the waiting room. This meant ensuring nursing staff have capacity to do this without disturbing the flow of appointments. We achieved this by empowering the nurses to:

  • review the appointment book and the waiting room, both in the morning and during the day, to identify potential patients to invite in for ‘added value care’
  • invite the patients to spend some time updating their records while they are waiting for their doctor. They are often able to get preventive care activities started or finished while patients are waiting. They are also able to have patients come back to finish their prevention activities after seeing the doctor (if not completed during the appointment)
  • have adequate ‘unscheduled’ patient time slots to enable this flexible approach to care.

– Assoc Prof Charlotte Hespe, Green Book Editorial Committee

Common challenges to effective implementation relate to a practice’s capability in terms of whether practice members have:

  • adequate knowledge
  • positive attitudes/beliefs about prevention
  • sufficient skills
  • enough time, resources and personnel
  • adequate organisational infrastructure.

Making changes at one level (eg the individual practitioner) without considering the implications or paying attention to other levels (eg organisational or system issues) is less likely to be associated with successful implementation.1,3,8,11,12,14,49–101

Implementation needs to be targeted to each of the following levels:

  • individual (eg education, skills development, feedback, academic detailing, guidelines)
  • group (eg team development, clinical audit, guidelines)
  • organisation (eg organisation culture and development, continuous improvement)
  • larger system (eg accreditation, payments systems/incentives, national bodies).

Interventions selected need to tailor the process to the context of both the practice and the patients.

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Improving influenza vaccination in patients 65 years and older

Rather than sending out reminder letters to patients when the flu vaccine becomes available, it is better to flag the case notes of this group as more than 90% will come to the practice in the months prior to the flu season. Many are used to having the flu vaccine, and this can be offered when they attend for other reasons. By May, the number in the target group who have not been vaccinated will be relatively small and likely comprise various groups, including infrequent attenders and those less (or not) interested in getting the flu vaccine. A tailored phone call or SMS from the PN coupled with a strong GP recommendation will further increase coverage rates and save the practice cost and time sending numerous letters.

Offer pneumococcal vaccine or the zoster vaccine when giving the flu vaccine to save the patient an extra visit.

– Assoc Prof John Litt, Green Book Editorial Committee

In summary, effective targeting is more likely if you have addressed these questions:102

  • Whose health are you seeking to improve (target population/s)?
  • What behaviour are you seeking to change (behavioural target)?
  • What contextual factors need to be taken into account? (What are the barriers to, and opportunities for, change? What are the strengths/potential of the people you are working with?)
  • How will you know if you have succeeded in changing behaviour? (What are your intended outcomes and outcome measures?)
  • Which social factors may directly affect the patient’s behaviour, and can they be tackled?
  • What assumptions have been made about the theoretical links between the intervention and outcome?
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