Green Book

Understanding the basics - Chapter 1.2

About implementation

Guidelines for the implementation of prevention in the general practice setting
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  1. Figures and tables
  2. Green book resources
  3. Provided under licence

Key points

  • Prevention is relevant to patients across all life stages and applies to the whole natural history of disease.
  • Implementing preventive activities involves recognising the challenges of implementation and using evidence-based strategies to overcome them.
  • Successful implementation of preventive care requires coordination and collaboration within the practice team and with external organisations (eg PHNs).
  • Focusing on prevention is part of a QI approach

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

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

Implementation in the healthcare context is the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings.9 Note the use of ‘strategies’, plural. There is no single (and simple) way of putting evidence-based preventive activities into practice.10

Implementation science helps us identify and understand the determinants, processes and outcomes of implementation.11,12 There are many individual and organisational factors that influence implementation (Figure 4).

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Evidence-based medicine should be complemented by evidence-based implementation.

–    Richard Grol

While research has yet to provide many absolute recommendations for implementation strategies proven to be effective in all settings, we do know that improving implementation is highly dependent on changing the behaviour of health professionals, managers and others working within and with the healthcare system.14,15 This typically involves changing organisational behaviour rather than (or as well as) individual behaviour.

Figure 4. Barriers and enablers of implementation

Figure 4

Barriers and enablers of implementation

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The most cited enablers of preventive care are:
•    availability of a PN16,17
•    collaboration with other disciplines.1

Refer to the Australian Primary Health Care Nurses Association (APNA) for information about the role of PNs in preventive care.
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The introduction of financial support for childhood vaccinations provided motivation for individual and organisational change. By rewarding GPs per child vaccination and the practice for meeting population targets, significant increases in completed childhood immunisation schedules were achieved.

– Prof Danielle Mazza, Green Book Editorial Committee

Refer to 'Clinical indicator 8: Childhood immunisation rates'
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Getting the best outcome means that we need to pay attention to all steps in the process. Consider a relay race – winning is more likely if every sector is maximised. In such races, the strongest competitor is frequently allocated the final leg to catch up.

In healthcare, there is often much less attention paid to the final leg (implementation). By focusing as much attention on the final leg as on the earlier stages (or strategies), we can dramatically improve outcomes (ie high coverage can improve outcomes even when the intervention efficacy may be modest).

– Assoc Prof John Litt, Green Book Editorial Committee

Interventions may be delivered at different levels: during face-to-face patient consultation, at a practice patient population level, or targeting the community where a practice is located (Figure 5).

Figure 5. Levels where interventions may be delivered

Figure 5

Levels where interventions may be delivered

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Reproduced from Sorensen K, Van den Broucke S, Fullam J, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 2012;12:80.

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Cervical cancer screening is primarily undertaken in general practice in Australia. Yet it is supported by a large number of community-based organisations like the Cancer Councils and other healthcare services such as community health centres. These organisations promote cervical cancer screening in the broader community, raising awareness and increasing health literacy.

In addition, GPs receive financial support through the Service Incentive Payment (SIP) program to undertake cervical cancer screening in those women who have not had a Pap test in four or more years. This support encourages screening and is an illustration of targeting screening at different levels (ie community, practice and patient).

– Prof Danielle Mazza, Green Book Editorial Committee
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