Box 2.

Categories of operational failure based on synthesis of qualitative (ethnographic fieldnotes and interviews) and quantitative (time-motion) data

Category	Definition	Examples	Quotes
Interruptions	Unexpected suspension of a GPs’ work task because an individual or device is seeking an immediate response from the GP	Interruptions to consultation by electronic messages, task alerts, and computer pop-ups; staff entering GPs consultation room with prescriptions for signing, requests to review a patient, or queries about practice management issues; phone calls into consultations from reception or external healthcare professionals; and teaching-related or personal interruptions	‘The GP got a message from one of the nurses in the practice, who wanted to give a flu jab to somebody, but they couldn’t give this flu jab until the doctor had done a patient-specific direction form. So, the doctor quickly accessed the patient details, signed the form and sent it back to the nurse.’ (GP_H5_observation) ‘The instant messages are a real distraction from what you’re doing. People seem to think instant message means instant reply and actually well, no I’m busy at the moment … I think they’re possibly the most distracting because they’re there but they’re not there. The patient doesn’t really know about them. Like a phone call or somebody walking in, the patient at least knows there’s an interruption. But the instant messages, the patient doesn’t realise why you’re suddenly distracted.’ (GP_S3_interview)
Problems in the availability of supplies and function of equipment	Disruption or error in the availability of supplies or function of equipment, supplies needed by a GP to complete a work task	Consultation room not stocked with needed supplies such as urine containers or lubricant; equipment such as baby weighing scales or thermometers going missing; computer freezing or crashing; and problems with function of and information within the electronic health record	‘He updated the electronic health record for the lady who had got the low blood pressure. He typed in quite a lot, then clicked on save but actually found that he couldn’t save it and a thing came up that said you are attempting to save a safeguarding issue and it was like what’s that I’ve never seen that before? And it wouldn’t let him save so he couldn’t progress any further.’ (GP_S4_observation) ‘The doctor asked if she could do a urine sample and went to get one of the specimen pots but there wasn’t any there. So, he had to go outside to one of the other rooms, and got some more pots. He explained that they used to have ancillary staff make sure that all the shelves were stocked up with everything that they needed, such as urine bottles, ear tips, tongue depressors etc, but they don’t have that anymore, and he said that’s quite infuriating. Maybe he should have checked at the beginning of the session, but he’d been really busy, he’d been to a visit, he’d had two emergency patients pushed in really quickly, so he hadn’t had time. So he said that’s one of the things that frustrates him.’ (GP_F4_observation)
Operational failures related to GPs’ coordination role	Disruptions to GPs’ work arising from problems in coordinating the care of patients	Issues with incorrect, delayed, insufficient, or missing information from external healthcare teams; problems referring patients into different healthcare services; and issues caused by external teams not following up on or requesting indicated tests, not arranging follow-up, or not providing information to the patient	‘She said normally we’ll get a follow-up letter from the hospital, but that doesn’t seem to have happened, so, she would look into it, she would write to the hospital.’ (GP_C2_observation) ‘She said we’ve not got your discharge letter yet, so we can’t really see what they are going to do at the moment, but hopefully in four weeks’ time when she saw him again, they would be able to talk about it.’ (GP_F8_observation) ‘The people at the hospital have asked the GP to order an MRI [magnetic resonance image], and the GP says he finds that really crazy, that there’s something about the hospital system which isn’t working when it sends patients back to them unnecessarily to try and get them to do things which actually they can’t do.’ (GP_P6_observation)
Operational failures arising from problems in practice processes	Processes in the practice that are not fit for purpose, poorly documented, or out of date, resulting in duplication of work, inefficiency, or waste	Discrepancies in information provided to patients by different staff; problems in organisation of blood tests because of a lack of internal standard operating procedures; problems in the allocation of work within the practice; insufficient time allocated to specific tasks leading to multitasking and stress; and inefficiencies and discontinuity in allocation of information within practice	‘He explained that the list of appointments is not necessarily truly reflective of the patients they talk to or see during the day.’ (GP_B3_observation) ‘The patient wanted the GP to set up the system so that she could make appointments for her kids. The GP sent her downstairs to the receptionist and he thought that was it. Then during the next appointment, the reception called and interrupted the consultation and said “we can’t do this, you have to do it yourself”. He said no, I can’t, and they said, yes, you need to. He tried to do it but called again the reception, to say, well, I can’t do it for this and that reasons.’ (GP_B4_observation) ‘There’s been problems in the past where the GP had tasked admin team about a blood test for a patient but the wrong test had been requested. So she said that in order to get the right test requested, she’d rather do it.’ (GP_F3_observation)