Green Book

Understanding the basics - Chapter 1.3

Bringing prevention and implementation together

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.

Implementing preventive activities in your practice is an aspect of a broader QI approach. Implementing a QI approach to prevention usually involves several elements:

  • broadening of focus from just thinking of care of the individual to actively reflecting on the larger population18,19
  • planning for change20
  • promoting a culture of QI in the practice team21–23
  • a collaborative team approach to prevention24-30
  • a realistic framework for implementation31
  • being outcomes-focused23,32
  • acknowledging the context and complexity of general practice33–42
  • choosing implementation strategies that are evidence-based, efficient and ‘do-able’ in general practice.43,44
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Preventive care is part of a broader QI approach.

Quadruple Aim

Implementing preventive care aligns with the Quadruple Aim framework for delivery of high-quality care, which has the goals of:45–47

  • improving the individual experience of care
  • improving the health of populations
  • reducing the per capita cost of healthcare
  • improving the experience of providing care.

Achieving these goals and successful implementation of prevention both require an engaged and resourced team, as well as effective and collaborative organisations.47

Patient-centred medical home

Although preventive care tends to have a population focus, it still aligns with the patient-centred medical home (Medical Home) model, which has five elements:48,49

  • comprehensive care
  • patient-centred care
  • coordinated care
  • accessible services
  • focus on quality and safety.

A successful Medical Home will provide high-quality preventive care to its patient population (refer to the RACGP’s Standards for patient-centred medical homes, Standard 4: Comprehensive preventive, acute and chronic disease care).

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To help practices implement a Medical Home approach, the North Coast PHN has created a website with resources such as videos and print materials, including the Patient centred medical home: A quality improvement handbook for general practice.
  1. Geense WW, van de Glind IM, Visscher TL, van Achterberg T. Barriers, facilitators and attitudes influencing health promotion activities in general practice: An explorative pilot study. BMC Fam Pract 2013;14:20.
  2. American College of Preventive Medicine. Preventive medicine. Washington, DC: ACPM, [date unknown] [Accessed 2 March 2018].
  3. Gelly J, Le Bel J, Aubin-Auger I, et al. Profile of French general practitioners providing opportunistic primary preventive care – An observational cross-sectional multicentre study. Fam Pract 2014;31(4):445–52.
  4. Drewes YM, Koenen JM, de Ruijter W, et al. GPs’ perspectives on preventive care for older people: A focus group study. Br J Gen Pract 2012;62(604):e765–72.
  5. The Association of Faculties of Medicine of Canada. Chapter 4: Basic concepts in prevention, surveillance, and health promotion. In: AFMC. AFMC primer on population health: A virtual textbook on public health concepts for clinicians. Canada: AFMC, updated 2017 [Accessed 2 March 2018].
  6. Pandve HT. Quaternary prevention: Need of the hour. J Family Med Prim Care 2014;3(4):309–10.
  7. Wagner H. Quaternary prevention and the challenges to develop a good practice comment on 'Quaternary prevention, an answer of family doctors to overmedicalization'. Int J Health Policy Manag 2015;4(8):557–58.
  8. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9th edn. East Melbourne, Vic: RACGP, 2016.
  9. Glasgow RE, Vinson C, Chambers D, Khoury MJ, Kaplan RM, Hunter C. National Institutes of Health approaches to dissemination and implementation science: Current and future directions. Am J Public Health 2012;102(7):1274–81.
  10. National Collaborating Centre for Methods and Tools. Implementing best practice guidelines: The RNAO toolkit. Hamilton, ON: McMaster University, updated 2017 [Accessed 2 March 2018].
  11. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci 2012;7:37.
  12. Eccles MP, Hrisos S, Francis JJ, et al. Instrument development, data collection, and characteristics of practices, staff, and measures in the Improving Quality of Care in Diabetes (iQuaD) Study. Implement Sci 2011;6:61.
  13. Grol R. Personal paper. Beliefs and evidence in changing clinical practice. BMJ 1997;315(7105):418–21. 14. Michie S. Implementation science: Understanding behaviour change and maintenance. BMC Health Serv Res 2014;14(Suppl 2):9.
  14. Fogarty International Center. Implementation science information and resources. Bethesda, MD: FIC National Institutes of Health, updated 2018 [Accessed 2 March 2018].
  15. Zwar NA, Richmond RL, Halcomb EJ, et al. Quit in general practice: A cluster randomized trial of enhanced in-practice support for smoking cessation. Fam Pract 2015;32(2):173–80.
  16. Halcomb EJ, Furler JS, Hermiz OS, et al. Process evaluation of a practice nurse-led smoking cessation trial in Australian general practice: Views of general practitioners and practice nurses. Fam Pract 2015;32(4):468–73.
  17. de Lusignan S, Hague N, van Vlymen J, Kumarapeli P.Routinely-collected general practice data are complex, but with systematic processing can be used for quality improvement and research. Inform Prim Care 2006;14(1):59–66.
  18. Stoto MA. Population health measurement: Applying performance measurement concepts in population health settings. EGEMS (Wash DC) 2015;2(4):1132.
  19. Cervero RM, Gaines JK. The impact of CME on physician performance and patient health outcomes: An updated synthesis of systematic reviews. J Contin Educ Health Prof 2015;35(2):131–38.
  20. Verbakel NJ, de Bont AA, Verheij TJ, Wagner C, Zwart DL. Improving patient safety culture in general practice: An interview study. Br J Gen Pract 2015;65(641):e822–28.
  21. Gillam S, Siriwardena AN. Leadership and management for quality. Qual Prim Care 2013;21(4):253–59.
  22. Dawda P, Jenkins R, Varnam R. Quality improvement in general practice: An inquiry into the quality of general practice in England. London, UK: The King’s Fund, 2010.
  23. Walters SJ, Stern C, Robertson-Malt S. The measurement of collaboration within healthcare settings: A systematic review of measurement properties of instruments. JBI Database System Rev Implement Rep 2016;14(4):138–97.
  24. Gibson O, Lisy K, Davy C, et al. Enablers and barriers to the implementation of primary health care interventions for Indigenous people with chronic diseases: A systematic review. Implement Sci 2015;10:71.
  25. Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: A systematic review. Prev Chronic Dis 2013;10:E26.
  26. Olsson LE, Jakobsson Ung E, Swedberg K, Ekman I. Efficacy of person-centred care as an intervention in controlled trials – A systematic review. J Clin Nurs 2013;22(3–4):456–65.
  27. Hayes SL, Mann MK, Morgan FM, Kelly MJ, Weightman AL. Collaboration between local health and local government agencies for health improvement. Cochrane Database Syst Rev 2012;10:CD007825.
  28. Cunningham FC, Ranmuthugala G, Plumb J, Georgiou A, Westbrook JI, Braithwaite J. Health professional networks as a vector for improving healthcare quality and safety: A systematic review. BMJ Qual Saf 2012;21(3):239–49.
  29. Chung VC, Ma PH, Hong LC, Griffiths SM. Organizational determinants of interprofessional collaboration in integrative health care: Systematic review of qualitative studies. PLoS One 2012;7(11):e50022.
  30. Glasgow RE, Kessler RS, Ory MG, Roby D, Gorin SS,Krist A. Conducting rapid, relevant research: Lessons learned from the My Own Health Report project. Am J Prev Med 2014;47(2):212–19.
  31. Agency for Healthcare Research and Quality. National strategy for quality improvement in health care. Rockville,MD: AHRQ, updated 2016 [Accessed 2 March 2018].
  32. Janamian T, Upham SJ, Crossland L, Jackson CL.Quality tools and resources to support organisational improvement integral to high-quality primary care: A systematic review of published and grey literature. Med J Aust 2016;204(7 Suppl):S22–28.
  33. Salisbury C, Procter S, Stewart K, et al. The content of general practice consultations: Cross-sectional study based on video recordings. Br J Gen Pract 2013;63(616):e751–59.
  34. Booth BJ, Zwar N, Harris MF. Healthcare improvement as planned system change or complex responsive processes? A longitudinal case study in general practice. BMC Fam Pract 2013;14:51.
  35. Lau R, Stevenson F, Ong BN, et al. Achieving change in primary care – Causes of the evidence to practice gap: Systematic reviews of reviews. Implement Sci 2016;11:40.
  36. Leeman J, Calancie L, Hartman MA, et al. What strategies are used to build practitioners’ capacity to implement community-based interventions and are they effective?: A systematic review. Implement Sci 2015;10:80.
  37. Lau R, Stevenson F, Ong BN, et al. Achieving change in primary care – Effectiveness of strategies for improving implementation of complex interventions: Systematic review of reviews. BMJ Open 2015;5(12):e009993.
  38. Irwin R, Stokes T, Marshall T. Practice-level quality improvement interventions in primary care: A review of systematic reviews. Prim Health Care Res Dev 2015;16(6):556–77.
  39. O’Mara-Eves A, Brunton G, McDaid D, et al. Community engagement to reduce inequalities in health: A systematic review, meta-analysis and economic analysis. Public Health Research. Southampton, UK: NIHR Journals Library, 2013.
  40. Long JC, Cunningham FC, Braithwaite J. Bridges, brokers and boundary spanners in collaborative networks: A systematic review. BMC Health Serv Res 2013;13:158.
  41. Attieh R, Gagnon MP, Estabrooks CA, et al. Organizational readiness for knowledge translation in chronic care: A review of theoretical components. Implement Sci 2013;8:138.
  42. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci 2009;4:50.
  43. Watkins C, Harvey I, Langley C, Gray S, Faulkner A. General practitioners’ use of guidelines in the consultation and their attitudes to them. Br J Gen Pract 1999;49(438):11–5.
  44. Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff (Millwood) 2008;27(3):759–69.
  45. Bodenheimer T, Sinsky C. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med 2014;12(6):573–76.
  46. Sikka R, Morath JM, Leape L. The quadruple aim: Care, health, cost and meaning in work. BMJ Qual Saf 2015;24(10):608–10.
  47. The Royal Australian College of General Practitioners. Standards for patient-centred medical homes: Patientcentred, comprehensive, coordinated, accessible and quality care. East Melbourne, Vic: RACGP, 2016.
  48. Lembke T, Ewald D, Rahbar S. Patient centred medical home: A quality improvement handbook for general practice [V1.0]. NSW: Australian Government; North Coast Primary Health Network, [date unknown].
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