BACKGROUND: System problems, known as operational failures, can greatly affect the work of GPs, with negative consequences for patient and professional experience, efficiency, and effectiveness. Many operational failures are tractable to improvement, but which ones should be prioritised is less clear.
OBJECTIVE: To build consensus among GPs and patients on the operational failures that should be prioritised to improve NHS general practice.
METHODS: Two modified Delphi exercises were conducted online among NHS GPs and patients in several regions across England.
METHODS: Between February and October 2021, two modified Delphi exercises were conducted online: one with NHS GPs, and a subsequent exercise with patients. Over two rounds, GPs rated the importance of a list of operational failures (n = 45) that had been compiled using existing evidence. The resulting shortlist was presented to patients for rating over two rounds. Data were analysed using median scores and interquartile ranges. Consensus was defined as 80% of responses falling within one value below and above the median.
RESULTS: Sixty-two GPs responded to the first Delphi exercise, and 53.2% (n = 33) were retained through to round two. This exercise yielded consensus on 14 failures as a priority for improvement, which were presented to patients. Thirty-seven patients responded to the first patient Delphi exercise, and 89.2% (n = 33) were retained through to round two. Patients identified 13 failures as priorities. The highest scoring failures included inaccuracies in patients\' medical notes, missing test results, and difficulties referring patients to other providers because of problems with referral forms.
CONCLUSIONS: This study identified the highest-priority operational failures in general practice according to GPs and patients, and indicates where improvement efforts relating to operational failures in general practice should be focused.

UNASSIGNED: Direct access to hospital radiology facilities by general practitioner (GP) cooperatives is known to decrease the number of emergency department referrals, but the effects on length of stay (LOS; time from patient arrival at GP cooperative till departure to home) and patient experiences are unclear.
UNASSIGNED: To provide insight into the LOS and experiences of trauma patients with an indication for radiology at GP cooperatives with and without access to radiology.
UNASSIGNED: A multi-methods observational study in April 2014-October 2015 at six GP cooperatives in The Netherlands, covering three organisational models for access to radiology: no direct access, limited access and unlimited access. Patient experiences were measured with a questionnaire. Patient records were analysed for background characteristics, radiology outcomes, referral and LOS.
UNASSIGNED: In total 657 patients were included, 232 no direct access model, 307 limited access model and 118 unlimited access model. The mean LOS was 99 minutes, with a significant difference between GP cooperatives without access to radiology (121 minutes), with limited access (86 minutes), and with unlimited access (90 minutes). The differences were larger for patients without radiological abnormalities. On a ten-point scale, patients rated GP cooperatives with unlimited access to radiology higher (8.62) than those without access (8.36) or with limited access (8.39).
UNASSIGNED: Access to radiology by GP cooperatives seems to reduce the length of stay and is slightly more appreciated by patients. GP cooperatives with unlimited access seem to provide the most efficient and best-valued care, contributing to more patient-centred care.

Operational failures, defined as inadequacies or errors in the information, supplies, or equipment needed for patient care, are known to be highly consequential in hospital environments. Despite their likely relevance for GPs\' experiences of work, they remain under-explored in primary care.
To identify operational failures in the primary care work environment and to examine how they influence GPs\' work.
Qualitative interview study in the East of England.
Semi-structured interviews were conducted with GPs (n = 21). Data analysis was based on the constant comparison method.
GPs reported a large burden of operational failures, many of them related to information transfer with external healthcare providers, practice technology, and organisation of work within practices. Faced with operational failures, GPs undertook \'compensatory labour\' to fulfil their duties of coordinating and safeguarding patients\' care. Dealing with operational failures imposed significant additional strain in the context of already stretched daily schedules, but this work remained largely invisible. In part, this was because GPs acted to fix problems in the here-and-now rather than referring them to source, and they characteristically did not report operational failures at system level. They also identified challenges in making process improvements at practice level, including medicolegal uncertainties about delegation.
Operational failures in primary care matter for GPs and their experience of work. Compensatory labour is burdensome with an unintended consequence of rendering these failures largely invisible. Recognition of the significance of operational failures should stimulate efforts to make the primary care work environment more attractive.

In spite of the considerable number of studies on co-worker incivility, knowledge on this topic needs to be further enhanced. In particular, no studies have focused on the reciprocal nature of the relationship of incivility with other important aspects of working life, i.e. employee well-being and the quality of the working process. The aim of the present study was to examine the cross-lagged associations among co-worker incivility, work-related exhaustion, and organisational efficiency in a sample of healthcare workers. Based on the conservation of resource theory, we hypothesised that those three variables affect each other reciprocally over the time. Data from a two-wave study design (with a one-year time lag) were utilised, and cross-lagged structural equation models were performed. Results confirmed that incivility and efficiency affected each other reciprocally over time. On the other hand, whereas incivility positively predicted exhaustion and exhaustion at inversely predicted organisational efficiency, the opposite paths were found to be not significant. The study suggests that efficiency is crucial for understanding incivility because it operates both as its cause and as its outcome. Interventions aimed at promoting civility and respect in the workplace may help prevent co-worker incivility, work-related exhaustion, and enhance organisational efficiency.

OBJECTIVE: To examine the relationship of co-worker incivility with organisational efficiency, workload and intention to leave in nursing samples from two different countries, the USA and Italy.
BACKGROUND: Organisational efficiency has received little attention as a possible correlate of co-worker incivility in the nursing management literature. Studies on co-worker incivility have primarily been carried out in North America and no cross-national studies are available.
METHODS: Data were collected by a self-report questionnaire involving nurses from the USA (n = 341) and Italy (n = 313).
RESULTS: Organisational efficiency was negatively associated with workload, co-worker incivility and intention to leave in both samples. The path from co-worker incivility to intention to leave was also positive and significant in both samples. Workload was positively associated with co-worker incivility and intention to leave in the US sample, but not in the Italian sample.
CONCLUSIONS: The present study suggests that organisational efficiency is central to understanding both co-worker incivility and intention to leave among nurses.
CONCLUSIONS: Nurse administrators should adopt interventions aimed at fostering organisational efficiency in an effort to reduce nurse co-worker incivility.

OBJECTIVE: The high resolution clinic (HRC) is an outpatient care process by which treatment and diagnosis are established, recorded, and completed in a single day. The aim of this study was to assess the extent to which patients with medical conditions may benefit from a single consultation system.
METHODS: A descriptive study of 795 first visit events, randomly selected as high-resolution consultations in cardiology, gastroenterology, internal medicine, and chest diseases. A discussion is presented on the percentage of patients who benefited from HRC and the complementary tests performed.
RESULTS: A total of 559 (70%, 95% CI: 67-73%) of all first visits became HRCs, and 483 (61%, 95% CI: 57%-64%) required a diagnostic test that was reviewed on the same day. There were differences between medical consultations (86% in cardiology versus 44% in gastroenterology consultations, P<.001). Performing a test on the same day significantly increased the percentage of HRCs (49 versus 22%, P<.001). Ischaemic heart disease, dyspepsia, headache, and asthma were the conditions most commonly leading to HRC. The most common tests were cranial tomography, blood analysis, and ultrasound.
CONCLUSIONS: Medical consultations may largely benefit from an HRC system, only requiring some organisational changes and no additional costs.

BACKGROUND: Emergency departments (ED) continue to evolve models of care and streaming as interventions to tackle the effects of access block and overcrowding. Tertiary ED may be able to design patient-flow based on predicted dispositions in the department. Segregating discharge-stream patients may help develop patient-flows within the department, which is less affected by availability of beds in a hospital. We aim to determine if triage nurses and ED doctors can predict disposition outcomes early in the patient journey and thus lead to successful streaming of patients in the ED.
METHODS: During this study, triage nurses and ED doctors anonymously predicted disposition outcomes for patients presenting to triage after their brief assessments. Patient disposition at the 24-h post ED presentation was considered as the actual outcome and compared against predicted outcomes.
RESULTS: Triage nurses were able to predict actual discharges of 445 patients out of 490 patients with a positive predictive value (PPV) of 90.8% (95% CI 87.8-93.2%). ED registrars were able to predict actual discharges of 85 patients out of 93 patients with PPV of 91.4% (95% CI 83.3-95.9%). ED consultants were able to predict actual discharges of 111 patients out of 118 patients with PPV 94.1% (95% CI 87.7-97.4%). PPVs for admission among ED consultants, ED registrars and Triage nurses were 59.7%, 54.4% and 48.5% respectively.
CONCLUSIONS: Triage nurses, ED consultants and ED registrars are able to predict a patient\'s discharge disposition at triage with high levels of confidence. Triage nurses, ED consultants, and ED registrars can predict patients who are likely to be admitted with equal ability. This data may be used to develop specific admission and discharge streams based on early decision-making in EDs by triage nurses, ED registrars or ED consultants.