Common challenges and solutions

Find solutions to commonly faced challenges when working through the toolkit.

There may be resistance within the practice to commit time to team meetings, data cleaning and reminder activities, all key to quality improvement activities.  


  • Ensure practice decision makers understand the benefits of quality improvement for the practice, and the activities that will be undertaken. The ‘quick reference guide’ is a helpful electronic as well as printable summary prior to committing to participation.
  • Commit to small, continuous steps. Trying to undertake too much change too fast is overwhelming. It is better to take your time and keep the team on board with change.
  • Communicate, communicate, communicate. Plan how you will engage regularly with your practice leadership and the broader team, both prior to starting and ongoing. Share information and get the team’s input into planned activities, benefits, challenges and progress.
  • Celebrate progress, changes and practice champions.


  • Establish whether your practice has time to go through patient records to clean up coding mistakes (i.e. errors in how you have set cancer screening recalls) and input of results from inbox into results.
  • If your practice team decides they do want to retrospectively clean up your patient records:
    1. Confirm your system for coding results.
    2. Identify who will undertake the clean-up.
    3. Specify when they will undertake it and agree as a team to give the nominated team members protected time to complete the task.
    4. Access NCSR to update patient files for cervical and bowel screening.
  • If your practice team decides it does not have time to clean up retrospective mistakes, commit to implementing a recall and reminder policy that ensures consistent coding of results moving forward. This will clean data up over time.

Belief among team members that cancer screening reminders are not a priority due to the reminders being sent by cancer screening registries.


  • Share and discuss your practice’s obligations under RACGP accreditation requirements (5th Edition) (PDF).
  • Share and discuss with the team the evidence that reminders from primary care providers increases participation in cancer screening.

Patients who are reminded by their GP to attend cancer screening are more likely to screen.   

Formative research conducted by the Cancer Institute NSW also supports this. 60% of patients surveyed reported they were more likely to screen when reminded by their GP than when reminded by a registry only.1  

The Royal Australian College of General Practitioners (RACGP) has a resource, Putting Prevention Into Practice ('The Green Book'), which provides guidance on how to overcome the factors that can limit the effective delivery of preventative care.2 


  • As a team, prioritise what actions you want to undertake first.
  • Take one small step at a time.
  •  Use readiness checklists to define where the team would like to focus.


Take a team approach:

  • Consider establishing a ‘micro team’ who lead quality improvement in cancer screening and prevention. Lifestyle risk factors (SNAP) are linked to Chronic disease management and AOD activities. 
  • Have others from the broader team support components of the work. For example, your practice manager and nurse may be your ‘hub’, but reception staff take ownership of reminders for patients eligible for screening, as well as ensuring suitable promotional materials are available.
  • Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting (Green Book), is a helpful resource in support of a team based approach.


Ensure clinical staff are informed about the following:

  • The impact on aggregation of patient data/creation if recalls and reminders are coded/labelled inconsistently.
  • The impact on patient safety and progress monitoring if patient lists/data aggregation is not possible.
  • Clinician input is important when creating your standardised list for recall and reminders codes/labels. Provide clinicians with easy to access cheat sheets so that they can easily select correct codes/labels.

Difficulty engaging with populations at risk of under-screening (e.g. patients with a disability, Aboriginal and Torres Strait Islander patients, LGBQTI patients).


There is a lot of information and resources designed specifically for groups at heightened risk of under-screening, as well as organisations and community groups with whom practices can partner. The patient-centred care section provides links, ideas and resources for engaging with under-screened populations.

Lack of identified points for cancer screening activities in practice models of care and reliance on opportunistic cancer screening education, reminders and screening.


Consider developing a cancer screening policy that integrates screening into the templates for existing practice services (eg. 45 to 49-year-old health assessments, 715 health assessment, ante-natal and post-natal checks and GPMPs.)

  • 6 out of 10 Australians have low health literacy.
  • People with low health literacy find it difficult to understand and act on health information.


  1. Ensure reminder letters/SMS meet health literacy standards. 
  2. Understand simple health literacy strategies that your practice can use to improve a patient’s ability to actively engage in their own care. 
  3. Utilise Teach-Back strategies in discussion with patients to reduce the chance of misunderstanding important health information. View the Teach-Back video to learn more.

Limited knowledge within practice teams about the three population-based screening programs; their evidence-base and how they function.

Review of Cancer Institute NSW-funded cancer screening pilot projects found that there was often not a strong understanding about Australia’s three population cancer screening programs (for breastbowel and cervical cancer) within practice teams.


The information at the beginning of each module will support your team’s understanding of:

  • the burden of disease from cancer, and the benefits of screening and 
  • the basics of how the three population based screening programs work
  • the difference between population based and diagnostic cancer screening


  • Provide your team with information about online learning opportunities.
  • Conduct in-service training - see education links in each module.

1. Cancer Institute NSW. Project overview for the NSW Pap Test Register Electronic Reminder Service for GPs. Sydney: Cancer Institute NSW, 2016

2. Royal Australian College of General Practitioners: Guidelines for the implementation of prevention in the general practice setting: The Green Book Introduction. Available at