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Table 2 Vulnerabilities Experienced by Each Clinic

From: Implementation science for ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk patients

Vulnerability from Specialty Clinician Perspective # of Clinics Experiencing Clinic (X = experienced)
Classified by Framework Domaina B P GI E U
Work System: Task
 Have to track some patients in own mind or side system 5 X X X X X
 Creating list of patients requiring monitoring takes time 5 X X X X X
 Looking up each patient’s information takes time 4   X X X X
 Maintaining list of patients requiring monitoring takes time 4   X X X X
 Outside of visit-based care, don’t always know when patients need follow-up monitoring 4 X X   X X
 Manually monitoring patients is time intensive 4   X X X X
 Don’t always know which patients need to be called back for monitoring 3   X   X X
 Have to spend too much time scheduling 2   X   X  
 Manually monitoring patients is error-prone 2     X X
Work System: Technology and Tools
 Analyzing data in ad hoc manner is time intensive 4   X X X X
 Inefficient system to create personal, siloed reminders for follow-up 4   X X X X
 List of patients we use outdates quickly 3    X X X
 Can’t divert alerts to other providers 3   X X X  
 Analyzing data in ad hoc manner is error-prone 3   X   X X
 Don’t always know when patient data is missing 2   X   X  
 Can’t find missing data from outside clinic 1     X  
 Don’t always want alert when patient status changes 1      X
 Don’t have adequate real-time data 1     X  
 Can’t edit patient’s care pathway as needed based on frontline data 1   X    
 Can’t find missing data within clinic 1     X  
Work System: Organization
 Systems don’t talk to each other 4   X X X X
 Don’t have a system that puts patients into subgroups for more efficient monitoring 4   X X X X
 Can’t share patient list with entire care team 3   X   X X
 Don’t always have the time to perform the assigned role 2   X   X  
 Hard to stratify patients into subgroups for monitoring due to many individual patient differences 2   X   X  
 Care plan is poorly documented 2   X   X  
 Don’t know what types of scheduling challenges occur most often 1     X  
Work System: People
 Overlapping efforts 4 X   X X X
 Don’t always know when the loop closes 3    X X X
 Everyone inputs data differently 2   X   X  
 Knowing who is managing at each stage is unclear 2     X X
 Mapping patient to care plan requires clinical judgment 2   X   X  
Work System: Environment
 Coordinating scheduling efforts across care teams is difficult 3   X   X X
 Little or no performance data about monitoring so don’t know where to focus any improvement efforts 3 X X   X  
 Stretched for resources to reach out to all patients in need of follow-up 3   X X X  
 Unaware of clinic’s performance in patient monitoring 2 X    X  
Process: System-Patient Interaction
 Don’t know when patient misses appointment 4   X X X X
 Don’t always know when patient doesn’t have PCP 4 X X   X X
 Don’t always know patient’s vulnerabilities relevant to monitoring (e.g. patient’s work schedule, can’t get to clinic, substance abuse) 3   X   X X
 Difficulty communicating patient needs with entire care team 2   X   X  
 Don’t know when patient changes status 2   X   X  
Process: System-Provider Interaction
 Inconsistent process for informing PCP 3   X   X X
 Can’t use patient data for operational improvement 2   X   X  
 Involving PCP when not necessary 1 X     
Process: Patient-Provider Interaction
 PCP doesn’t have overview of all patient info/care pathway 3   X   X X
  1. aAdapted from the National Academy of Medicine Improving Diagnosis Framework, 2015 and Sarkar et al’s System-related Factors, 2014 to classify each reported vulnerability into Work System versus Process, as well as subdomains of these two framework categories [1, 60]
  2. Legend: Clinics designated as B = Breast, P = Pulmonary, G = GI, E = Ear Nose and Throat, U = Urology