Impacts of Operational Failures on Primary Care Physicians’ Work: A Critical Interpretive Synthesis of the Literature

Carol Sinnott; Alexandros Georgiadis; John Park; Mary Dixon-Woods

doi:10.1370/afm.2485

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Table 1

Inclusion and Exclusion Criteria

Inclusion Criteria

Exclusion Criteria

Set in primary care, general practice, or similar settings
Focused on the work of primary care physicians or their equivalent internationally
Presented empirical data or primary research
Described the impact or effect of the potential operational failures (related terms include disruptions, distractions, breaks-in-task, interruptions, situational constraints etc) on the primary care physician

Set in secondary or tertiary care or hospitals
Focused on secondary care or subspecialty physicians, or other health care professionals in primary care who are not physicians
Focused on the entire organizational system of primary care at a regional, state, or national level
Based in out-of-hours services, community hospitals, or specialty clinic care in the community
Lacking empirical data (ie, theoretical discussions, editorials etc)
Not published in English
Examined practice responses to new policy initiatives without examining if/how these initiatives were problematic for primary care physicians
Focused on adverse events, errors, quality and safety, quality improvement, or task-distribution without problematization of issues from the perspective of primary care physicians
Focused on the implementation of novel innovations/interventions as part of a program of research
Focused only on productivity without identifying or describing specific problems that interfere with efficiency

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Table 2

Categories of Operational Failures in Hospital Nursing Proposed by Tucker et al^2,3

Categories of Operational Failure Experienced by Hospital Nurses²	Measure of Impact of Operational Failures on Hospital Nurses³
Medication Supply items (including food) Medical orders Equipment Insufficient staffing Other	Number of additional tasks Direct time consumed Indirect time consumed Interruptions Direct delay Indirect delay Risk Number of people contacted to resolve problem Losses including wasted materials and loss of confidence in organization

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Table 3

Impact of Operational Failures on Primary Care Physicians’ Work and Examples Associated With These Impacts

Impact of Operational Failure on Primary Care Physicians	Examples
1. Additional steps required to complete task	• Double documentation; duplicating, and repeating notes if no link between notification system and patient’s record • Work shifting to primary care physicians that was previously done by others (eg, filling in forms, scheduling patients, updating patient contact information) • “Looping” of tasks between clinical and nonclinical teams due to uncertainty over roles within practice • Separating prescription items into those that can be prescribed electronically and those needing “wet-signatures”
2. Required workarounds	• Contacting other professionals, insurance, or billing systems for missing information or patients themselves for answers if information in record is thought to be inaccurate or is difficult to find • Using paper-based tracking systems of ordered tests, prescriptions issued, abnormal test results, etc because electronic health record does not facilitate this tracking • Copying and pasting text from patient’s previous notes if system does not auto-populate new templates • Printing out notes owing to difficulties in switching between computer screens • Disabling or ignoring electronic health record functions • Hand-writing prescriptions or test requests if information technology networks go down or if want to add additional details that are not permitted within electronic systems
3. Consumed time	• Manually inputting information if poor interoperability between systems • Opening information systems that freeze or lock physician out • Removing repetitive or unnecessary alerts • Searching for missing test results or repeating tests
4. Disruptions	• Interruptions to consultation from staff, other patients, phone calls • Interference to workflow by computer decision support alerts taking physician into other tasks • Having to leave room to get necessary equipment, find paper for the printer, or use a different printer • Not having access to required examination rooms
5. Delayed decision making	• Lack of information feedback from and difficulty reaching other health care clinicians • Missing or delayed test results • Trying to determine who should undertake pending tests • Not being able to locate necessary information in the notes
6. Interfered with physician-patient relationship	• Poorly designed electronic health records shifts physicians’ focus away from the patient • Addressing clerical or administrative questions with patients during consultations shifts focus away from their presenting complaint, and consumes time
7. Cognitive burden	• Information overload due to multiple streams of incoming patient information, with most relevant information obscured by repetitive or unnecessary information • Decision support systems creating unhelpful signal-noise ratio with clinically irrelevant alerts and alert fatigue
8. Dissatisfaction	• Frustration associated with delayed or missing critical information from other clinicians, laboratories, etc • Stress arising from disruptions during the consultation, inefficient practice organization, and hectic schedules • Dissatisfaction associated with large volumes of non-clinical tasks • Time pressure and work pace leading to stress and burn-out

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The Article in Brief

Impacts of Operational Failures on Primary Care Physicians' Work: A Critical Interpretive Synthesis of the Literature

Carol Sinnott , and colleagues

Background Operational failures in health care are system-level errors in the supply of information, equipment, and materials to health care personnel. By degrading individual and organizational performance, operational failures complicate the delivery of high-quality care, with multiple adverse consequences for patient safety and experience, efficiency, and worker satisfaction. In this systematic review, the authors synthesize the existing research literature on operational failures in primary care.

What This Study Found The included studies show a gap between what physicians perceived they should be doing and what they were doing, which was strongly linked to operational failures--including those relating to technology, information, and coordination--over which physicians often had limited control. Operational failures actively configured physiciansï¿½ work by requiring significant compensatory labor to deliver the goals of care. This labor was typically unaccounted for in scheduling or reward systems and had adverse consequences for physician and patient experience.

Implications

Primary care physicians' efforts to compensate for suboptimal work systems are often concealed, risking an incomplete picture of the work they do and problems they routinely face. Future research must identify which operational failures are highest impact and tractable to improvement.
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