This informative article is provided by ProAssurance Download Article Introduction Expectations to do more with less, in less time, contribute to medical errors and poor patient outcomes, 1,2 which in turn increases medical liability exposure risk. Issues including poor workload planning, inadequate staffing, incentive systems, personal financial goals, and a culture that does not value safety over production can create unrealistic productivity expectations. 3 Pressure to meet expectations can result in behaviors that impact patient safety, including 4 : Deviation from procedures and practice guidelines that are designed to promote quality and safety Failure to report adverse outcomes or near misses Task completion without adequate time and attention to maintaining quality and safety Increased risk-taking behaviors Communication failure between members of the healthcare team Unrealistic productivity expectations can also contribute to burnout. 5,6 Excessive workload is associated with increased worker stress and an increase in errors and accidents. The evidence supporting an association between job demands and clinician burnout is probably the strongest for any independent variable. 7 More strategies for reducing production pressure stress can be found on the Relieve Production Pressure Stress to Reduce Physician Burnout page in the NORCAL Group, now a part of ProAssurance, Professional Wellness website. A significant portion of responsibility for maintaining appropriate production expectations falls on the shoulders of healthcare administrators, managers, and physician leaders, who must be willing to promote and maintain safe productivity expectations based on the individual characteristics of their workforces, facilities, and practices. An equally important aspect of safely managing pressure on the healthcare workforce is engendering an environment in which clinicians and staff perceive they can report potentially unsafe practices and patient care events without fear of reprisal, and with the knowledge that their reports will result in consideration and change, when necessary. Policies and procedures that explicitly support a culture of safety (its members’ overall values, attitudes, and behaviors that inform safety management practices) can mitigate the adverse outcomes associated with production pressure. 8 Normalization of Deviance Over time, compliance with patient safety policies and protocols can erode. 9 Normalization of deviance (a gradual erosion of acceptable safety practices and standards that becomes “normalized” because no accidents have occurred) can occur in response to unrealistic production expectations. Normalization of deviance can start with one individual and spread throughout an entire practice. For example, a physician may decide not to follow a protocol because it gets in the way of efficiency, seems overly burdensome, or runs counter to perceived patient expectations. Colleagues may observe the physician and mistakenly assume the deviation is acceptable based on their own similar rationalizations. Gradually, everyone engages in the deviant behavior. 10 Common examples of normalization of deviance include disabling alarms on equipment and alerts in the electronic health record, conducting the surgical time-out after the first incision, or leaving the operating room prior to the final sponge count. Shortcuts and workarounds like these can keep things moving according to schedules. Because outcomes are successful and nothing catastrophic has happened despite the deviation from safety policies and procedures, the increasing risk is overlooked. 11 The process of weighing production against the safety of patients will rarely be straightforward. Policies and procedures should be in place that provide the impetus for making a choice against going forward with an elective scheduled procedure that is too high risk. It is important to recognize and guard against normalization of deviance and find ways to comfortably resolve conflict with other surgical team members and administrators who may exert pressure to go forward with procedures that should be canceled. Case Study Pressure to meet production expectations may be internal or external. Internal pressures arise from self-imposed expectations, for example, being agreeable, efficient, competent, and striving for perfection. Examples of external pressures include surgical team member and/or management demands to preserve the daily surgery schedule. The following case study is based on an actual closed claim. It illustrates how both internal and external pressure can influence an anesthesiologist’s decision to allow a surgery to go forward, when it should have been cancelled for patient safety. A stronger culture of safety (the individual’s and entity’s overall values, attitudes, and behaviors that inform safety management practices) might have resulted in this surgery being rescheduled to a more appropriate time. Allegation: If the procedure had been rescheduled, the patient would have had a better outcome. Facts The patient, a morbidly obese, 40-year-old male with diabetes, hypertension, and obstructive sleep apnea, was scheduled for a procedure under general anesthesia at a surgical center on a weekday but, because of scheduling problems, the case was moved to a Saturday. On Saturdays, the center scheduled only one anesthesiologist and no anesthesiology technicians. The operating room would be staffed with a surgeon, anesthesiologist, scrub nurse, and circulating nurse. On this Saturday, the scheduled anesthesiologist was experienced, but recently hired. Due to various complications encountered during a difficult intubation, the anesthesiologist and the surgeon decided to cancel the surgery and wake up the patient. The patient resumed breathing on his own and was extubated; however, he quickly became very agitated. Because of the patient’s size, the surgical team was unable to restrain him adequately, which caused the oxygen and monitors to become disconnected. After struggling for a few minutes, the patient slowly became less agitated, and the team was able to reconnect the oxygen and monitors. They then discovered he had no pulse. Chest compressions were started, and a laryngeal mask airway was placed. The patient returned to sinus rhythm with a normal blood pressure and saturations, but he had suffered an anoxic brain injury. The family filed a medical liability lawsuit against all the providers involved in the patient’s care. Discussion During discussions with the defense team, the anesthesiologist admitted that he recognized prior to surgery that the intubation could be challenging given the patient’s comorbidities, but he did not want his colleagues to think he had “dodged the case.” He was aware that this patient had already been rescheduled and knew that it would be an inconvenience to the patient and other members of the team if the procedure had to be rescheduled again. He also did not want to be responsible for any loss of income. These issues contributed to his decision to continue with the surgery. In retrospect, the anesthesiologist acknowledged that because of the absence of additional anesthesiologists or anesthesia technicians, and the fact that the surgery was not urgent, he should have insisted on a postponement. He noted that many of the problems he encountered with the patient could have been alleviated with the assistance of another anesthesiologist or an anesthesiology technician, who would have been available if the surgery had been postponed to a weekday slot. Although the anesthesiologist’s desire to go through with the procedure is understandable, and there was certainly a chance that nothing would go wrong, proceeding with the surgery turned out to be the wrong choice and resulted in a devastating outcome. Risk Management Recommendations The desire to meet production expectations can skew risk/benefit analyses and result in unacceptable patient injury risk exposure. Clinicians Consider the following recommendations: Do not give in to pressures to keep a patient on the surgery schedule. Support surgical team members who comply with patient safety protocols and do not allow one member of the surgical team to alter or avoid them. The entire team is responsible for ensuring patient safety. Report inability to comply with patient safety protocols in the face of unrealistic production expectations to administration and/or leadership. Self-correct in situations where you deviate from policies, guidelines, and standards that are designed to promote quality and safety. Operations Administrators and physician leaders can take various steps to encourage safe decision-making in a pressure-filled environment, including: 12,13 Evaluate the workplace for systems and factors that result in pressure on clinicians and staff related to workload, efficiency, and productivity expectations. Ensure that scheduling and facility planning optimize staff resources. Many times, there are more factors affecting patient safety than simply the number of people scheduled. Consider the different levels of skill, knowledge, and experience of members of the healthcare team. Review cases in your facility that involved adverse events, near misses, and hospital admissions. Evaluate how normalization of deviance has affected patient safety processes and remove the barriers to appropriately completing them. Create an environment in which a culture of safety can flourish, in part by setting the expectation that members of the healthcare team will speak up if there is a concern for patient safety. Empower team members to halt a procedure or speak up and challenge colleagues who are engaging in unsafe behavior. Use teamwork training such as TeamSTEPPS®, to develop skills involving advocacy and assertion, and mutual support. Conclusion The process of weighing production against the safety of patients will rarely be straightforward. A healthcare entity, or in some cases an individual physician, may sacrifice patient safety for financial objectives, which are often characterized as conflicting goals. 14 Efficiency and productivity should not be emphasized to a degree that members of the healthcare team are forced to work around or curtail patient safety protocols (e.g., surgical time-outs) or necessary clinical tasks (e.g., reviewing the patient record before an examination). In many circumstances, individuals may feel powerless in an environment that demands that patient care be accomplished better, faster, and cheaper. But each member of the healthcare team, including physician leadership and administrators, must work together to create a culture of safety, in which sacrificing patient wellbeing as a means to increase productivity and/or efficiency is rejected. Everyone who works with patients should be made aware of the risks associated with production pressure and should continuously factor these risks into their practice and feel empowered to refuse to engage in providing healthcare that they are reasonably convinced is unsafe. Download Article End Notes 1 Kirsner K, Biddle C. Production Pressure And A Culture Of Deviance In The Insular Operating Room And The Consequences Of Their “Normalization”: Have We Reached A Hooper Moment? Internet Journal of Law, Healthcare and Ethics. 2012; 8(1). http://ispub.com/IJLHE/8/1/14279. Accessed October 6, 2021. 2 Everson, MG, Wilbanks BA, Boust RR. Exploring Production Pressure and Normalization of Deviance and Their Relationship to Poor Patient Outcomes. AANA J. 2020; 88(5): 365-371. https://www.aana.com/docs/default-source/aana-journal-web-documents-1/20-oct-geisz-everson.pdf?sfvrsn=b7624ba1_4. Accessed October 6, 2021. 3 Carayon P. Production Pressures. Agency for Healthcare Research and Quality website. https://psnet.ahrq.gov/web-mm/production-pressures. Published May 1, 2007. Accessed October 6, 2021. 4 Everson, MG, Wilbanks BA, Boust RR. Exploring Production Pressure and Normalization of Deviance and Their Relationship to Poor Patient Outcomes. AANA J. 2020; 88(5): 365-371. https://www.aana.com/docs/default-source/aana-journal-web-documents-1/20-oct-geisz-everson.pdf?sfvrsn=b7624ba1_4. Accessed October 6, 2021. 5 Kuhn CM, Flanagan EM. Self-care as a professional imperative: physician burnout, depression, and suicide. Can J Anesth. 2017; 64: 158–168. https://link.springer.com/article/10.1007/s12630-016-0781-0. Accessed October 6, 2021. 6 National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Factors Contributing to Clinician Burnout and Professional Well-Being. In Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington (DC): National Academies Press (US); 2019. https://www.ncbi.nlm.nih.gov/books/NBK552615/. Accessed October 6, 2021. 7 National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Factors Contributing to Clinician Burnout and Professional Well-Being. In Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington (DC): National Academies Press (US); 2019. https://www.ncbi.nlm.nih.gov/books/NBK552615/. Accessed October 6, 2021. 8 Everson, MG, Wilbanks BA, Boust RR. Exploring Production Pressure and Normalization of Deviance and Their Relationship to Poor Patient Outcomes. AANA J. 2020; 88(5): 365-371. https://www.aana.com/docs/default-source/aana-journal-web-documents-1/20-oct-geisz-everson.pdf?sfvrsn=b7624ba1_4. Accessed October 6, 2021. 9 Harvey HB, Sotardi ST. Normalization of Deviance and Practical Drift. JACR. 2017; 14(12): 1572-1573. 10 Harvey HB, Sotardi ST. Normalization of Deviance and Practical Drift. JACR. 2017; 14(12): 1572-1573. 11 Prielipp RC, Magro M, Morell RC, Brull SJ. The Normalization of Deviance: Do We (Un)Knowingly Accept Doing the Wrong Thing? Anesthesia & Analgesia. 2010;110(5):1499-1502. https://journals.lww.com/anesthesia-analgesia/Fulltext/2010/05000/The_Normalization_of_Deviance__Do_We__Un_Knowingly.43.aspx. Accessed October 6, 2021. 12 Brovender A. Use and Effect of Quantitative Clinical Feedback for Learning and Quality Improvement in Anesthesiology. https://tspace.library.utoronto.ca/bitstream/1807/70199/3/Brovender_Andrea_201511_MSc_thesis.pdf. University of Toronto website. Published 2015. Accessed October 6, 2021. 13 Carayon P. Production Pressures. Agency for Healthcare Research and Quality website. https://psnet.ahrq.gov/web-mm/production-pressures. Published May 1, 2007. Accessed October 6, 2021. 14 Kirsner K, Biddle C. Production Pressure And A Culture Of Deviance In The Insular Operating Room And The Consequences Of Their “Normalization”: Have We Reached A Hooper Moment? Internet Journal of Law, Healthcare and Ethics. 2012; 8(1). http://ispub.com/IJLHE/8/1/14279. Accessed Octo ber 6, 2021.