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Anesthesiology:
doi: 10.1097/ALN.0b013e318286078d
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Case Scenario Consistent with Lack of Knowledge and Psychological Bias

Dexter, Franklin M.D., Ph.D.

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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.
Franklin Dexter, M.D., Ph.D.
, University of Iowa, Iowa City, Iowa. franklin-dexter@uiowa.edu
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References

1. Scemama PH, Hull JW. Developing leaders in anesthesiology: A practical framework. ANESTHESIOLOGY. 2012;117:651–6

2. Dexter F, Epstein RD, Traub RD, Xiao Y. Making management decisions on the day of surgery based on operating room efficiency and patient waiting times. ANESTHESIOLOGY. 2004;101:1444–53

3. Pandit JJ, Dexter F. Lack of sensitivity of staffing for 8 hour sessions to standard deviation in daily actual hours of operating room time used for surgeons with long queues. Anesth Analg. 2009;108:1910–5

4. Dexter F, Epstein RH, Marcon E, Ledolter J. Estimating the incidence of prolonged turnover times and delays by time of day. ANESTHESIOLOGY. 2005;102:1242–8

5. Dexter F, Epstein RH. Typical savings from each minute reduction in tardy first case of the day starts. Anesth Analg. 2009;108:1262–7

6. Ledolter J, Dexter F, Wachtel RE. Control chart monitoring of the numbers of cases waiting when anesthesiologists do not bring in members of call team. Anesth Analg. 2010;111:196–203

7. Dexter F, Willemsen-Dunlap A, Lee JD. Operating room managerial decision-making on the day of surgery with and without computer recommendations and status displays. Anesth Analg. 2007;105:419–29

8. Dexter F, Lee JD, Dow AJ, Lubarsky DA. A psychological basis for anesthesiologists’ operating room managerial decision-making on the day of surgery. Anesth Analg. 2007;105:430–4

9. Dexter F, Xiao Y, Dow AJ, Strader MM, Ho D, Wachtel RE. Coordination of appointments for anesthesia care outside of operating rooms using an enterprise-wide scheduling system. Anesth Analg. 2007;105:1701–10

10. Dexter EU, Dexter F, Masursky D, Garver MP, Nussmeier NA. Both bias and lack of knowledge influence organizational focus on first case of the day starts. Anesth Analg. 2009;108:1257–61

11. Pandit JJ, Abbott T, Pandit M, Kapila A, Abraham R. Is 'starting on time' useful (or useless) as a surrogate measure for 'surgical theatre efficiency'? Anaesthesia. 2012;67:823–32

12. Wachtel RE, Dexter F. Curriculum providing cognitive knowledge and problem-solving skills for anesthesia systems-based practice. J Grad Med Educ. 2010;2:624–32

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