To the Editor:
Scemama and Hull present a “Case Scenario” followed by a fascinating discussion of leadership principles.1 However, several of the scenario’s observations can be explained based on operational (physical) and behavioral (psychological) principles rather than organization (leadership).
(1) “The anesthesiology department of a large academic medical center has recently implemented a series of operating room (OR) and anesthesia efficiency measures designed to improve on-time starts, reduce turnover times, and manage patient preoperative times.” (2) “These measures will be used to set targets and to measure the performance of providers … She is very focused on being as efficient as possible when running her cases …” (3) “Some of the residents she oversees … do not seem to take the newly implemented efficiency initiatives seriously.”
1) Improved on-time starts and reduced turnover times can increase OR and anesthesia group efficiency, but neither is a measure of (allocative or technical) efficiency.2,3 Suppose every Monday a service has mean ± SD of 7.2 ± 0.5 h of cases. The staffing (allocated time) should be 8 h. If reducing turnovers were to reduce the mean from 7.2 to 6.8 h, there would be no change in staffed hours, overutilized time, or efficiency.3 If the workload were 8.4 ± 0.5 h, 8-h staffing would be more efficient than 10 h.3 An equal reduction in turnovers would reduce the mean from 8.4 to 8.0 h, reduce overutilized time, and increase efficiency.2,3
2) Comparing on-time starts and turnovers among anesthesiologists is not evidence based.4–6 Furthermore, unless organizations provide cues (recommendations), decisions made by anesthesiologists supervising (medically directing, etc.) multiple ORs to improve on-time starts and reduce turnover times can worsen efficiency.7 The reason is that anesthesiologists apply rules-of-thumb (“heuristics”) rational for decisions involving single ORs, but suboptimal when applied to multiple ORs.8 Individuals’ and organizations’ perceptions that on-time starts are important for efficiency are due to both lack of scientific knowledge and psychological bias (e.g., known that most cases take less time than scheduled yet [incorrectly] think starting a few minutes late results in the list of cases finishing a few minutes late).9–11
3) Perhaps “some of the residents” not taking the “efficiency initiatives seriously” received systems-based practice training (i.e., knew better).12 I appreciate this is unlikely and that the authors’ goal for the case scenario may have been one of presentation to motivate their excellent review. Yet, it seems to me ideal for leadership to rely on the evidence-based management science, especially when developed in part by and for anesthesiologists.