SUMMARY:Anesthesia professionals must navigate the colliding tectonic plates of patient safety and OR efficiency. But we are not unique in facing this industrial challenge. Indeed, Erik Hollnagel describes the engineering efficiency–thoroughness trade-off (ETTO) principle13 that acknowledges the inviolate swap between efficiency on one hand and thoroughness on the other – analogous to medical professionals debating OR efficiency vs. patient safety. In any industry, if forces become misaligned, an accident with defects or harm becomes more likely. Thus, we must continue our vigilance as we endeavor to avoid normalizing deviations, to maintain the balance of efficiency and thoroughness, and to avoid the potential erosion of our educational heritage and responsibility. The thorny and, so far, unyielding threat of production pressure has been a focus of the APSF for over 20 years and likely will continue well into the future.
Stimulated by increasing concerns expressed by anesthesia professionals and also the 1994 landmark systematic discussion of production pressure in anesthesia practice,1 the APSF in 1998 first addressed this concept in the 27th videotape in the educational series produced and nationally distributed by the APSF during its early years. Recognition of the importance of and interest in this topic then led to the comprehensive Spring, 2001, APSF Newsletter—Special Issue: Production Pressure —Does the Pressure to Do More, Faster, with Less, Endanger Patients? Potential Risks to Patient Safety Examined by APSF Panel. Topics included multiple thoughtful discussions of patient safety and production pressure: a patient’s perspective, academic practice, private practice, pre-op assessment, scheduling and staff, ICU, ICU nursing, industry, and administration. Despite these efforts, the problem has only intensified in the last two decades due to conflicting priorities and the involved complexities.
Today’s operating room (OR) culture applauds speed and multitasking as it simultaneously demands cost-cutting. Indeed, the classic mantra of NASA and business culture—“better, faster, cheaper”—has become the adopted stepchild of many OR managers and administrators. Given the universal downward pressures on hospital budgets across the world and the recognition that the operating theater remains a high-cost, high-salary, intensive consumer of resources, leaders believe they have few options but to prioritize increased efficiency (activity per unit time) within the OR. One consequence of these efforts applied to OR personnel is the ongoing evolution of production pressure—now a constant companion of most clinicians.1 Indeed, ten years ago, during the 25th anniversary commemoration of the Anesthesia Patient Safety Foundation (APSF), John Eichhorn, MD,2 reminded anesthesia professionals of two basic tenets: that basic preventable human errors will still occur, and that production pressure in anesthesia practice threatens past safety gains. His words portend the future… then and now.
Production pressure may be defined as overt or subliminal pressure, metrics, and incentives experienced by anesthesia professionals to place production as their foremost priority: “do more with less.” Clearly, virtually all anesthesia professionals experience the current OR cultural-economic climate in which more clinical services of higher quality are expected concurrent with fewer consumption of resources (both people and finances) to provide it. The consequences of such pressures are multidimensional, but we will highlight the impact of production pressure on three key areas of patient safety:
- The normalization of deviance
- Provider stress and burnout
- Impact on education and training.
Normalization of Deviance3
“BETTER, FASTER, CHEAPER”
Why did NASA continue to fly the Challenger Shuttle while O-ring erosion problems were documented numerous times before that cold January launch in 1986? And why did NASA continue to fly the Columbia shuttle knowing foam insulation was regularly striking vulnerable areas of the vehicle years before Columbia’s fatal accident? One explanation is that these mishaps had been “normalized” over many occurrences and many years until managers and engineers began to believe that these flaws were expected and therefore acceptable.3 Diane Vaughan described this behavior as the “Normalization of Deviance.”4 This incremental process is a gradual erosion of normal procedures that would never be tolerated if proposed in one single, abrupt leap. Instead, small incremental deviations are observed and tolerated. Lacking an accident, they become “normalized”.4
Indeed, when the Shuttle was originally designed, no allowance was made for the possibility that the Challenger would launch in sub-freezing temperatures, knowing rocket booster O-rings would contract, weaken, and leak under these out-of-tolerance temperatures. When these events were first experienced, obvious safety implications were recognized. However, faulty analyses concluded that the vehicle could tolerate these abnormal events. Managers and engineers decided to either implement a temporary fix or simply accept the risk. This approach established a precedent for accepting safety violations as technical deviations that can be tolerated and managed. As the problems recurred and the Shuttle kept flying, the fallacy that the errors were acceptable was reinforced.
Most critically, the normalization of deviance process breaks the culture of safety and applies equally to clinical anesthesia practice.3,5 Production pressure is frequently cited as a major driver to work even when fatigued, to create work-arounds for safety systems, to stretch the boundaries of hospital or departmental guidelines, and to expedite patient care to the point of “cutting corners” in the interests of staying on schedule.6
In the aggregate and over time, these practices generate a slippery slope of tolerating more and more “minor” errors and accepting more and more risk, always in the interest of efficiency and on-time schedules. This toxic thinking may progress to a mindset that demands evidence that these shortcuts would clearly harm a patient, instead of demanding proof that such deviations are safe and the patient is not at increased risk.
In reality, most medical organizations fail to recognize when they are drifting towards normalizing dangerous deviations. But brief reflection by most front-line clinicians will identify multiple such “normalizations” within their medical center practices and procedures— undoubtedly driven by ever-increasing expectations to stay on schedule, reduce turnover times, and eliminate delayed starts or even worse, case cancellations, all while consuming fewer resources and decreasing costs. Strategies to mitigate these aberrant practices begin with building a culture of open communication to identify and extinguish deviations before they become normalized. Failure mode and effects analysis (FMEA) is one proven, proactive method to evaluate policies and procedures that may be in need of change before patient harm occurs.7
“It was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair.”
Medical professionals exist in challenging times with change a constant companion to our daily practice (e.g., COVID-19!). Moreover, anesthesiology is experiencing a period of mergers, consolidation of practices, and a trend towards employee contracts that dramatically affect personal autonomy. Bundled payments, declining reimbursements, clumsy and quirky electronic health records (EHRs), and a host of regulatory demands (e.g., submission of clinical statistics) often consume daily life. Within this milieu, we are experiencing rising demand for anesthesia services while simultaneously facing a national shortage of specialized nurses and physicians. Furthermore, our practices are inundated with internal and external pressures to meet or exceed national benchmarks in hospital quality indicators and patient satisfaction/loyalty ratings to effectively compete with local competitors.8 Thus, it is no surprise that over the last decade, health care has also seen a significant rise in provider burnout, and anesthesia professionals are a vivid example of this growing epidemic.9
What is burnout and what contributes to it? Burnout is related to but different than depression. Burnout is a pattern of symptoms, with providers reporting physical and emotional exhaustion, cynicism arising out of depersonalization, and decreased work effort or even absenteeism.7,8 This leads to significant personal and professional consequences. For example, studies have shown burned-out physicians are more likely to have broken relationships, increased incidence of alcohol and drug abuse, and a higher risk of depression and even suicide.10
Numerous studies have identified a handful of dimensions that contribute to burnout, such as excess workload, work-life imbalance, and a loss of professional respect, autonomy, and community (Table 1). Anesthesia professionals report higher than average rates of burnout compared to some other specialties. In fact, 50% of anesthesiologists reported feeling burned out in 2017, a marked increase from 2011, and a rate twice as high as the general working adult population.10
Table 1: Elements that can contribute to burnout of anesthesia professionals
|• Production pressure
|• Exaggerated and continually escalating job demands
|• Erosion of autonomy
|• Lack of recognition and respect at work
|• Loss of professional respect from patients
|• Breakdown of work-life balance
|• Conflict between professional/personal values and organizational values
|• Bureaucratic overload and dysfunctional electronic records
|• Government regulations
|• Employment insecurity
Over the past few years, our workplaces have seen a significant increase in number of cases, hours, and work effort per provider. The Medical Group Management Association (MGMA) data support this as a consistent trend throughout our specialty. Anesthesia professionals are working longer hours, spread over more locations, spending more time in front of electronic health records, and have less control over their schedules. Adding to this challenge is the fact that work/life balance is a top priority for millennials, which is also the fastest growing segment of our anesthesia workforce. Professionals with burnout are less productive, have a higher likelihood of turnover, and are more likely to reduce their work effort in the coming years. Not surprisingly, all this can have a significant negative impact on patient safety. Providers experiencing burnout may deliver lower quality care with associated lower patient satisfaction scores and are more likely to make medical errors.7,8 Therefore, health care professionals’ distress is a quality indicator that is worth measuring in medical centers.10
Impact on Education
“Education is not the filling of a pail, but the lighting of a fire.”
–W. B. Yeats
Conventional wisdom holds that economic (i.e., production) pressure on teaching faculty in the operating room adversely impacts anesthesia resident education and bedside case-oriented teaching. Currently, only a modicum of data exists to directly support this proposition. A German national survey on anesthesia education confirms that 96% of respondents identified “daily workload,” “time pressure,” and “lack of time” as primary obstacles to teaching.11 A more recent cross-sectional survey at four U.S. academic centers found over one-third of the faculty identified “insufficient time,” “covering multiple rooms,” and “an emphasis on efficiency” as key factors that preclude optimal anesthesia resident teaching.12 Regardless, it is reassuring that the majority of faculty return routinely to the operating room during the maintenance phase of anesthesia specifically to teach, and exhibit a high degree of engagement with their role as an anesthesia educator.
Anesthesia professionals must navigate the colliding tectonic plates of patient safety and OR efficiency. But we are not unique in facing this industrial challenge. Indeed, Erik Hollnagel describes the engineering efficiency–thoroughness trade-off (ETTO) principle13 that acknowledges the inviolate swap between efficiency on one hand and thoroughness on the other—analogous to medical professionals debating OR efficiency vs. patient safety. In any industry, if forces become misaligned, an accident with defects or harm becomes more likely. Thus, we must continue our vigilance as we endeavor to avoid normalizing deviations, to maintain the balance of efficiency and thoroughness, and to avoid the potential erosion of our educational heritage and responsibility. The thorny and, so far, unyielding threat of production pressure has been a focus of the APSF for over 20 years and likely will continue well into the future.
- Gaba DM, Howard SK, Jump B. Production pressure in the work environment. California anesthesiologists’ attitudes and experiences. Anesthesiology. 1994;81:488–500.
- Eichhorn JH. The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety, 25th anniversary provokes reflection, anticipation. Anesth Analg. 2012;114:791–800.
- Prielipp RC, Magro M, Morell RC, Brull SJ. The normalization of deviance: do we (un)knowingly accept doing the wrong thing? Anesth Analg. 2010;110:1499–1502.
- Vaughan D. The Challenger launch decision. risky technology, culture, and deviance at NASA. University of Chicago Press, Chicago, IL, 1996.
- Wears RL, Sutcliffe KM. Still not safe. Oxford University Press. NY, NY: 2020.
- Cohen JB, Patel SY. Getting to zero patient harm: from improving our existing tools to embracing a new paradigm. Anesth Analg. 2020;130:547–49.
- Martin LD, Grigg EB, Verma S, et al. Outcomes of a failure mode and effects analysis for medication errors in pediatric anesthesia. Paediatr Anaesth. 2017;27:571–580.
- Gurman GM, Klein M, Weksler N. Professional stress in anesthesiology: a review. J Clin Monit Comput. 2012;26:329–335.
- Kleinpell R, Moss M, Good VS, et al. The critical nature of addressing burnout prevention: results from the critical care societies collaborative’s national summit and survey on prevention and management of burnout in the ICU. Crit Care Med. 2020;48:249–53.
- Kuhn CM, Flanagan EM. Self-care as a professional imperative: physician burnout, depression, and suicide. Can J Anesth. 2017;64:158–168.
- Goldmann K, Steinfeldt T, Wulf H. Anaesthesia education at German University hospitals: the teachers’ perspective – results of a nationwide survey. Anasthesiol Intensivmed Notfallmed Schmerzther. 2006;41:204–209.
- Haydar B, Baker K, Schwartz AJ, et al. Academic anesthesiologists perceive significant internal barriers to intraoperative teaching in a cross-sectional survey. J Educ Perioper Med. 2019;21:E628.
- 13. Hollnagel E, Wears RL, Braithwaite J. From safety-I to safety-II: a white paper. the resilient health care net: published simultaneously by the University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia. 2005