Surgeons' interviews offer eye-opening implications for health-care system

The Schulich School of Business at York University produces stellar research on the functioning of the Canadian health-care system. New research led by Schulich Professors David Johnston and Adam Diamant, in collaboration with University of Toronto Professor Fayez Quereshy, recently broke new ground by looking at scheduling in one of the highest risk areas of patient care: surgery.

Posing the key question – Why do surgeons schedule their own surgeries? – the researchers considered the centralization of this task for standardization of practice and efficient use of hospital resources. They conducted a qualitative study on the scheduling behaviour of surgeons at a large Canadian teaching hospital and concluded that two factors determine surgeon decision-making about scheduling surgery: the timeliness of treatment for their patients; and the surgeon’s idiosyncratic personal and professional priorities. Some surgeons saw limited merit in metrics to facilitate operational improvements.

“Our research should stimulate a broad discussion as to whether trust in a decentralized scheduling system, where surgeons book their surgeries, is optimal for the overall performance of the health-care system,” the researchers conclude.

This research was funded by the Schulich School of Business Research Fellowship and published in the Journal of Operations Management (2019).

Research fills important void

In most Canadian hospitals, decisions around surgery are in the hands of surgeons, which allows them the flexibility to prioritize based on patients’ clinical needs. However, operations management literature favours the standardization or centralization of scheduling to maximize resource use.

But which approach is better for resource use and, of course, meeting the patients’ clinical needs? Talking with surgeons presented an excellent opportunity to gain insights. Prior to this research, little was known as to how surgeons customize their schedules and why they value such control. To fill this research void, Johnston and his collaborators launched a study on the scheduling behaviour of surgeons at a large Canadian teaching and research hospital.

Literature review followed by 11 interviews

The research team started with a literature review and a survey of existing relevant publications, the findings of which illustrated the benefits of standardization:

• the pooling of inventory;
• significant cost reduction;
• better medication management;
• improvements in emergency services; and
• more efficient use of hospitals’ operating room time.

Next, over six months in 2016, Johnston’s team conducted 11 interviews – eight with practising surgeons working at a large Canadian hospital, and three with administrative staff.

What did they ask the surgeons?

The researchers queried the surgeons in three key areas:

1. Factors affecting their ability to execute a planned schedule, including the need to respond to unforeseen disruptions, such as emergency surgeries.
2. The surgeons’ relationships with other medical professionals. Previous research found that a surgeon’s ability to manage the team (nurses, anesthesiologists, residents and Fellows) can affect the team’s ability to complete surgeries on schedule.
3. How the surgeons’ education, professional relationships and opportunities for performance feedback influenced the values that informed their decision-making.

Key findings offer astonishing insights

Not surprisingly, all surgeons expressed strong opinions about centralization. Some realized how poorly the system was working. One said: “How do you get the most value out of an operating room? Well, definitely not leaving it up to every surgeon to figure out how to manage what comes through the fax machine. That’s ludicrous. It’s like we’re 40 or 50 years behind.... Look at industry. No one would run a business like we run our operating room.”

Some surgeons said remuneration was an issue and there were no incentives for surgeons to co-ordinate and economize collectively, since they operate on a fee-per-service basis. (Surgeons are independent contractors granted “privileges” in publicly owned hospitals.) Some said their unwillingness to accept centralized scheduling was a reaction to the hospitals’ managerial deficiencies.

The team gained valuable insights:

• Surgeons vary in how they assign patients to surgical slots, and their reasons for retaining autonomy over scheduling also varies. Johnston elaborates: “The tension between confidence in their own ability and a lack of confidence in their colleagues to provide timely treatment in accordance with their personal preferences partially explains the reluctance of surgeons to surrender control.”
• Surgeons hold idiosyncratic beliefs about their professional obligations. Some put a high value on non-surgical activities, such as teaching and research. This affects how many patients on which the surgeons will operate.
• Surgeons don’t always see the merit in metrics to inform them about scheduling improvements. One said: “Wait times probably have no impact. I can tell you almost certainly [that they] have no impact on [patient] survival. Whether or not you wait 21 days or 31 days for your cancer operation, it's not going to ... impact your survival.”

Implications for surgeons, hospital administrators and the health-care system

This work has implications for achieving surgeon support for initiatives to standardize and centralize routines for patient scheduling. It could lead to important conversations among surgeons about the requisite level of control needed in scheduling to satisfy their concerns for patient safety, well-being and work-life balance.

Johnston states, “I hope these findings will trigger discussion of operational improvement in hospitals and the overall performance of the health-care system.” He is convinced that appropriate metrics on the performance of surgery, accompanied by strong organizational support for sharing best practices, could facilitate the path to efficiencies for hospital administrators with no trade-offs for the quality of care.

To read the article, visit the website. To learn more, visit Johnston’s faculty profile page or Diamant’s faculty profile page.

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By Megan Mueller, senior manager, research communications, Office of the Vice-President Research & Innovation, York University, muellerm@yorku.ca