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Green Book

Whole-of-practice prevention - Chapter 2.4

Team collaboration

Key points

  • Prevention requires consideration of practice populations (without taking away from individual care) – high-quality data is important in obtaining useful information.
  • Every member of the practice team plays a role in preventive care.
  • Your preventive care team will also include people outside your practice (eg PHN QI support officers, allied healthcare providers, disease and consumer peak bodies).

While few would disagree that prevention is an important part of high-quality, comprehensive healthcare, much of the healthcare system (including general practice) is focused on reactive care.

​Although we can intuitively see how prevention can reduce the need for reactive treatment, it can be difficult to change focus when the demand for treatment is so much ‘louder’, more urgent and resource hungry compared to preventive care.

When bringing together a team, consider the nature and extent of collaboration necessary. Factors important in the development of collaboration include:12–17

  • sharing of vision, goal-setting, planning, and protecting QI time
  • clarification of roles, responsibilities and tasks
  • sufficient support and resources
  • regular and open communication
  • adequate time to develop relationships, working arrangements and trust
  • adequate commitment to the process
  • recognition and acceptance of separate and combined areas of activity
  • familiarity and acknowledgment of expertise
  • local advocates and champions
  • decision-making, problem-solving and goal-setting
  • opportunities for cooperation and coordination.


While all of the points above are important, I find the following are the most important:

  • Understand and respect the roles and capabilities of all members of the team (including non-clinical).
  • Identify common goals and understanding – what makes sense to everyone.
  • Foster open communication where it is okay for everyone to have a say.
  • Reflect on how the team is actually working – seeking comment from all the team members (did everyone feel able to contribute, be heard).

Protected time is important, but it doesn’t have to be extensive. Some of the best teamwork can come from 10–15-minute informal meetings at the beginning or end of clinical sessions.

– Prof Mark Harris, Green Book Editorial Committee

All members of the team should work together to maximise the ability of patients to lead their own healthcare.11


Working together to provide comprehensive care: Case study


A north-west Queensland practice team and broad range of allied health providers and specialists are brokered through a subsidised scheme on a monthly roster. They have a total patient load of 5400, with 2900 active patients.

The group provided high-quality comprehensive primary healthcare with a key focus on Aboriginal and Torres Strait Islander patients that present with chronic comorbidities.


Patient information systems were incomplete and did not accurately reflect the active client load. Follow-up items of care were undertaken in an ad hoc manner without due diligence to providing comprehensive primary healthcare against cycles of care.


To ensure patients have access to the cycles of care against particular comorbidities, such as type 2 diabetes or CVD.

To maximise capacity in both the administrative and clinical team to incorporate principles of improvement, namely ensuring data quality and adequacy of patient record information.


The first step was to ensure that the data contained in the patient records was appropriately recorded (clean), and that demographic information was current and completed. Administrative and clinical staff were trained in the use of a data cleansing tool, and were tasked with ensuring data was clean and complete. This activity identified missing demographic information and prompted all clinical staff to complete clinical information for each patient being seen for the day.

Once the clinic had access to high-quality data, systematic recall processes were put in place. At weekly meetings, there was a focus on the follow-up care items suggested for chronic comorbidities. Ongoing reviews of increases in episodes of care were also discussed, and priorities were set for the following week.


  • Completed demographic information now ensures record accuracy.
  • Increased identification of patients with chronic obstructive pulmonary disease (COPD), risk of CVD and type 2 diabetes.
  • Smoking status is recorded on 78% of patient records for patients aged ≥18 years.
  • Follow-up care has increased by 45% for type 2 diabetes cycles of care.
  • Review of recall systems review has resulted in an increase of 200% in recalls.
  • Communication and role autonomy across the administrative and clinical team has been strengthened.
  • The Continuous Quality Improvement program has been added to the weekly staff agenda.
  • Local hyperosmotic hyperglycaemic syndrome (HHS) reports indicate that hospital/emergency presentations have reduced.
  • The Aboriginal community-controlled health service has positioned itself as an employer of choice.


The Aboriginal community-controlled health service has access to patient information systems that reflect their current client load and the team is committed to ongoing Continuous Quality Improvement.

The team are involving all staff from when the patient walks through the doors to when they leave, maximising care and ensuring role autonomy with staff. All position descriptions have been reviewed to include QI. Performance appraisals set and measure achievements against measurable indicators. The Aboriginal community-controlled health service has included the use of the data tools in induction and orientation processes. The service has established and embedded principles to ensure ongoing improvement of the data systems that support patient care.

– Ms Lauren Trask, Accreditation Specialist, Queensland Aboriginal and Islander Health Council

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