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

The purpose of this study was to define what an operational failure is and determine how prevalent it is in a primary care setting. The authors had to define these operational failures in order to create criteria to use to evaluate the research papers. Operational failures were defined as system level errors involving the supply of necessary materials, equipment, or information to employees. These errors can interfere with healthcare workers' job performance and therefore complicate the delivery of high-quality healthcare. Operational failures can make or break a primary care center due to the time spent making corrections to the failures, such as equipment issues, scheduling, and other mundane activities. Potential complications include a reduction in patient safety, job efficiency, and healthcare worker satisfaction. Many studies have focused on cataloging the shortcomings of primary care. The authors of this study aim to characterize how physicians are affected by operational failures.

Previous literature related to operational failures is primarily focused on hospital settings. There is little information about operational failures and how they impact healthcare providers in primary care settings in the current published literature and this study addresses the gap. The authors also define some moments in crisis when there is a breakdown in system processes because of operational failures. The study used a critical interpretive synthesis technique, which includes a review of literature. When analyzing articles to include in the study, the researchers posed a broad question, which formed the context for their inclusion and exclusion criteria. Next, they reviewed literature with their guided questions and created qualitative findings. Some inclusion and exclusion criteria included whether aims and objectives were clearly stated, research design was specified, and clear accounts of the process was provided by researchers, as well as qualitative data analysis and if it was done appropriately – only 95 studies satisfied this criterion. The researchers formulated their question by mainly focusing on primary care settings and excluded tertiary care or hospital settings. They also focused on what the primary care physicians thought they had to do versus what they actually needed to do – which contributed to emotional and physical tolls that physicians endure leading to poor outcomes and physician burn out. In order to search literature, one reviewer looked into seven databases and looked for citations that fit with the definition of operational failure. After this initial review, two reviewers looked at 30% of the cases that the first reviewer was not sure on. The reviewers reviewed the abstracts for all of the citations retrieved. The second two authors read the 372 full text articles to assess for eligibility. They reviewed articles further for outlying information to only 95 studies included out of 10,962 studies from the initial review. Qualitative and numeric values were obtained regarding the operational failures. After analysis and review, the 95 remaining studies were put into the matrix. Envivo 11, a common qualitative analysis software, was used to look for themes and create conceptual themes.

The key findings are classified within categories of operational failures in hospital nursing, including medication, supply items, medical orders, equipment, insufficient staffing, and more. The measurement of the impact of these failures included interruptions, directly and indirectly consumed time, additional tasks, risks, and wasted materials. Issues identified by the physicians include compensatory labor (additional work to accomplish patient care that was not originally planned or intended) and how that became an essential part of primary care duties and often involved mundane tasks (information chasing, resolving technology issues, etc.). Also, poorly designed technologies- slow running speed, time consuming searches, duplicate data entry, information discontinuity which hindered ability for physicians to make clinical decisions due to missing steps, information overload, and information scatter. The most frequently reported operational failures related to information technology include electronic health records, computer decision support systems, e-prescribing, and e-referral systems. Failures in practice included inefficient information channeling through the practice or inefficient supplies and materials. Impacts of the operational failures include time consumption, disruption of task completion, delayed clinical decisions, and the interference of the doctor-patient relationship. All of these issues affected physician duties and lead to fragmented care.

The concept of work as ‘imagined work’ versus ‘work as done’ or ‘work as configured’ goes into the concept of expectations in physicians’ lines of work that go beyond the job description. We discussed the concept of primary care providers wanting to focus on patient care, but having their time taken up by phone calls, paperwork, and working with other departments to find patient information. We also investigated the possibility of operational failures in medical school and opportunities for burn out, such as rotation miscommunication between the school and provider, and tasks that are not included in the job description varying greatly in each setting. We concluded that learning to compensate for operational failures early in a career might be a good thing as students, so we can be equipped to handle these issues with our own teams in the future. PCPs are seen as a bridge, bringing together all aspects of patient care including letters, ambiguous discharge instructions, and information overload. A possible solution would be to construct a universal way to access information quickly, so information isn’t buried in the EMR. Operational failures have the potential to increase the workload of primary care physicians to ensure patient care. Additional research can be done to analyze the most impactful operational failure. Systems can also review their operational failures and scrutinize the effects these failures have on primary care physicians' work and patient outcomes.

We need to limit operational failures - primary care physicians are being affected now more than ever. A possible answer could be a universal healthcare system. Although this is not a perfect system, but it is a one-stop shop for understanding information about one patient. Also, there is a structural perspective of having the multidisciplinary team-based care approach to help primary care, which can help solve some of these knowledge gaps while limiting the burden of undefined tasks from being unrecognized work in a physician’s productivity. We discussed that adding more physicians in a broken system will not solve the crisis. The answer may be to focus on getting the system to run smoothly in the primary care work environment and focusing on improving primary care. We can also conduct detailed research to find specific operational failures with the greatest impact and need for restructuring. Since this study is a UK study, their system runs differently due to the NHS healthcare system. The US has more specialist physicians, hospitalists, and primary care physicians that all operate very differently and separately, which contributes to fragmented care. The best way to start is to focus on the operational failures within your system and try to combat the ones of highest priority. Currently, as the healthcare system is strained with the COVID-19 outbreak, it is crucial to recognize systems that are flawed for our healthcare providers, and ultimately for patient care. Now, especially, it is apparent that when the current system is tested these erroneous systems can lead to fatal consequences.

References

Carol Sinnott, MB, BAO, BCb, MMedSci, PHD, MICGP, MRCPI, Alexandros Georgiadis MSc, PgDip, PhD, John Park, MB, CbB, & Mary Dixon-Woods, DPhil (2020). Impacts of Operational Failures on Primary Care Physician’s Work: A Critical Interpretive Synthesis of the Literature. Annals of Family Medicine, Vol. 18, No. 2.