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Table 2 Practice organisation and level of guideline compliance

From: Practice organisational characteristics can impact on compliance with the BTS/SIGN asthma guideline: Qualitative comparative case study in primary care

Small practice with high compliance • Organisation of asthma management GPs were aware of how the other GPs worked, with all partners working in a similar way and using the pharmacist in a similar way.
  • Delegation: No delegation of work to other professions. All GPs were dealing with both acute and chronic management of asthma.
 Hierarchy: No hierarchy in relation to asthma management as no GP lead on asthma, with other professional such as pharmacist being highly appraised and considered as part of the team. GPs often made decision together.
 Trust and confidence in all partners ability to manage patients
 Communication and team members' access to each other: informal, but coffee time provided a set time for communication. GPs tried to involve other professionals in educational meeting they held.
Small practice with low compliance Organisation of asthma management: no consistent approach for the roles and responsibilities of the GPs and the nurse in relation to asthma management. No practice asthma protocols. Lack of awareness of how other team members or systems in the practice worked.
 Delegation: partial and inconsistent delegation of responsibilities between GPs and nurse.
 Hierarchy: There were clear hierarchical relationship between GPs and the nurse
 Trust and confidence: GP cautious about nurse management of patients.
 Communication and team members' access to each other informal, unstructured and with no set times
Medium practice with high compliance Organisation of asthma management: local asthma protocols, asthma team which included the practice nurse, lead asthma GP and administrative support which met regularly and ensured a systematic approach for patients' annual reviews, while ensuring flexibility of appointment for patients. Consistent approach for both the diagnosis and management of asthma as those functions were carried out by PN. Practice members of all levels worked closely with one another.
 Delegation: The responsibility for asthma diagnosis and management was exclusively delegated to the PN. Nurse changed medication and agreed action plan with the patient.
 Hierarchy: no hierarchy between GPs and nurse in relation to asthma management
 Trust and confidence: GPs were happy to delegate responsibilities and trusted the nurse to manage patients. Nurse was confident in her ability to influence the GPs and change the way they work
 Communication and team members' access to each other communication within the practice was reported to be good and take both informal and formal forms with regular meetings of asthma team and weekly meetings of the GPs which nurse can attend.
Medium practice with low compliance Organisation of work: no practice asthma protocols. No consistent approach for the diagnosis of asthma or stepwise management of asthma among the GPs. The practice did not actively check patients' compliance with medications but offered flexible appointment system. Lack of administrative support to nurse. Lack of awareness of how others in the practice worked.
 Delegation: GPs responsible for the diagnosis of asthma and treatment of acute attacks and the PN annually reviewed patients.
 Hierarchy: hierarchical relationship between GPs and nurse. GPs made the decisions
 Trust and confidence: nurse lacking confidence to challenge GPs if not agreeing with their decisions.
 Communication and team members' access to each other: no formal meetings, but a lot of informal communication and practice nurse was comfortable with current informal discussions with lead GP for asthma. Practice meetings did not include the nurse and nurse felt that there was no time for multidisciplinary meetings.
Large practice with low compliance Organisation: of work: lead asthma GP for in-house chronic disease management structure with agreed asthma protocols, regular asthma team meetings. Systems for reviewing unstable patients and flexible appointments. Inconsistent approach to diagnosis and review of compliance by GPs and lack of awareness of how nurses worked.
 Delegation: GPs diagnosed and treated acute attacks and nurses reviewed patients and looked at compliance and education.
 Hierarchy: a degree of hierarchical relationship between GPs and nurses in the practice.
 Trust and confidence: nurses felt trusted by the GPs but had difficult influencing the GPs ways of working.
 Communication and team members' access to each other nurses felt they could discuss any problem with the lead GP and there were set asthma team meeting and practice based chronic disease management meetings on a regular basis. There was a rigid arrangement for communication with GPs: daily set (formal times) in the practice where GPs were available to discuss any issues with other health professionals.