The overall goal of this project is to understand and improve the safety of the testing processes within Access Community Health Network's (ACCESS) 43 primary care health centers. ACCESS is the nation's largest community health center serving over 200,000 individuals in the Chicago area. The specific aims are: 1) to perform a comprehensive risk assessment of ACCESS health centers' testing processes including laboratory testing, imaging studies and special tests; 2) to do a focused risk assessment of ACCESS health centers' management of four critical abnormal test results; abnormal pap smears, abnormal mammograms, INR out of range for patients taking coumadin for atrial fibrillation, and elevated PSA levels; 3) to increase ACCESS physicians and staff awareness of office patient safety issues through errors reporting and completion of an office patient safety culture survey; and 4) based on an analysis of the findings, to produce [unreadable] [unreadable] a plan for improving the safety of ACCESS health centers' testing processes and to present this plan to [unreadable] [unreadable] ACCESS physicians, staff and leadership for implementation. We will use five complementary data-gathering methods designed to detect weak links in the testing process: 1) an office systems engineering analysis performed by an experienced management engineer that will include direct observation of staff work, key informant interviews, a structured survey of office testing processes completed in an interview with the office managers, and process flow mapping; 2) an audit of the process and outcomes of the health centers' testing using chart audits and a patient phone survey; 3) an audit of the management of critical abnormal test results including abnormal pap smears, abnormal mammograms, abnormal prostate specific antigen tests, and out of therapeutic range INR values in patients taking coumadin for atrial fibrillation; 4) event reporting by providers and staff; and 5) a safety culture survey to be completed by all providers and office staff. We will do a limited assessment of the testing processes in 33 ACCESS health centers and a detailed assessment in 10 representative health centers. Data will be verified with staff and physician focus groups using the principles of Sensemaking, and appropriate reports will be presented to staff, physicians, office managers and administration. This work is important because a large proportion of errors observed in primary care practices relate to testing, and other organizations are likely to benefit from our findings as well. [unreadable] [unreadable] [unreadable]