Table 2 Barriers and facilitating solutions

Organizational behaviour (i.e., how team works together, is organized, hierarchy, conflicts, etc.)

In regards to dealing with conflict: “Have an open discussion, have everybody voice their concern. If I wasn’t able to do it in the group then it would be 'Send me your challenges’ and then I said hereare some of the challenges that as a team we’re facing”

In regards to facilitating changes in large teams: “For that kind of change, you would need the clinical lead… You see, individual people might sign up, but the head of that team might not. And you really need buy in at the highest level to do anything”

Practice accessibility (i.e., challenges scheduling meetings, not enough time to make significant change)

“The main thing to really be effective is to not put it on their plate, you know, 'call me when you need something’. It’s more like 'is it okay for me to connect with you in two weeks?’”

“Email worked really well too. Cause some things I did not really need to have a discussion”

“And having the flexibility, so with one physician, I knew that Friday afternoon he was finished clinic at 12, so I would always make sure that I had that open…”

“The other strategy in relation to the time piece is to really find out what the practices is working on already and how I can add to it”

“And the administrative staff, I think it’s essential to get them on board, just even from the initial recruitment because then your work within the practice itself is so much easier”

Practice engagement (i.e., lack of interest, no buy-in, maintaining engagement throughout, lack of trust)

“So if I already had a physician that was engaging… I know that I would ask them to put the word out, knowing that if it was peer-to-peer, it would always have more weight”

“The more frequent contact I had with practices, it seemed the better they did. If there was a length of time where I didn’t see them…some of the changes would take a bit of time or wouldn’t happen” (OF1, Line 42)

“If someone was very sort of data oriented and you didn’t come with this, then you would get a lot of resistance… if your approach to that practice doesn’t align with their practice culture, I think it would be harder to make progress”

“The way that I tried to address these is review the program with them, state the goal of the program, how they could benefit from the goals and the work that would have to go into it… that did work for some of them”

“It’s the analogy of a terrier. And I think that’s what you are, you just have to be - or like a sheepdog - you just have to keep going back and going back and going back”

I think I didn’t put forth that kind of, “This is what you need to do” kind of thing, it was more “I’m here to help. I’m not here form the Ministry, I’m not a Pharma rep, I’m here to be able to provide support for some of the changes that you think you would like to change” and so by always framing it that way, I didn’t really get a lot of resistance”

Resistance to change

“Instead of me pushing through and saying 'no, I think it’s really important that you do that’ – it’s not about me, it’s about having the practice work on what they need”

Competing priorities (i.e., urgent priority arises that shifts practices focus, practices losing momentum)

In regards to the competing demands of the H1N1 outbreak - “So although it wasn’t within our cardiovascular component, we actually provided practices with that information” (regarding H1N1) “It’s in that building a relationship that yes, we recognize and realize that something else has taken over and that we can’t really do anything about it but we can still be helpful”

“I think to a large extent, you have to wait… very often, you can’t move forward until these other issues have resolved in some fashion, and you have to respect that”

“I used summaries, especially between the first year, the intensive, and the sustainability. This is what you planned, and this is where you are. What of these five things you said you’re going to do have actually been done? And then present that back to the team. Going back to the data, to keep going back to the data to see where people started and have they achieved what they said they were going to achieve?”