Rethinking Operating Room Management: Why Clinical Directors Should Embrace Complexity

摘要

THE CURRENT PARADIGM: THE FAILURE OF REDUCTIONISM Managers are not confronted with problems that are independent of each other, but with dynamic situations that consist of complex systems of changing problems that interact with each other. I call such situations messes…managers do not solve problems, they manage messes. —Ackoff1 Health care delivery and its role in the broader economic system is increasingly complex.2 Complexity theory may serve as an ideal platform for operating room (OR) management. OR governance structures have been modeled after administrative leadership structures, in which management decisions are centered on planning, budgeting, organizing, staffing, and problem-solving. These initiatives are all directed at creating predictable, stable processes. In truth, a perioperative system represents an ecosystem of surgeons, nurses, anesthesia health care providers, and patients, interconnected to influence the delivery of surgical care.3 For many health care organizations, perioperative services consume a relatively large share of resources and generate significant revenue streams. Traditionally, OR management decisions are subdivided into 3 categories: strategic, tactical, and operational (Figure 1).3 Strategic decisions focus on establishing a niche or equilibrium in the environment and offer a long-term perspective. Strategic analyses usually aim to identify contextual “boundaries” established by institutional constraints, the local and regional environment, and the organizational mission. Conversely, tactical decisions focus on the utilization of current resources in the near future. Strategic decisions may include building a new service line or expanding an ambulatory surgery center so hospital administrators can expand market share or create operational efficiencies.4 Tactical decisions, in contrast, focus on block allocations, the perioperative nurse skill set needed for the surgical workload, and necessary anesthesia services.Figure 1.: Traditional framework for operating room management decisions showing how strategic and tactical decisions inform operations over time in a unidirectional fashion.Each year, as we attempt to manage the health care system with a series of rules and regulations, the health care system in the United States continues to create tremendous inefficiencies, leading to little progress toward reducing the cost of care. Reeves et al5 recently argued that taming complexity requires the following efforts: creating a modular structure; using simple, common operating principles; embedding a bias for change; relaxing control; optimizing globally; and fixing, repairing, and pruning. Presumably, by adopting the above framework, perioperative managers should be able to manage the perioperative services with better-informed strategic, tactical, and operational processes. Today, much of the current literature is based on the assumption that ORs resemble manufacturing plants. Here, lean manufacturing and Six Sigma approaches are used to reduce variability in clinical processes and minimize inefficiencies to create value.6 With this analytic or reductionist approach, the complex parts are reduced to smaller components. However, we believe that this decomposition usually leads to a loss of information, especially when it comes to downstream consequences, both financial and operational.7 In many respects, these efforts resemble the short-sighted “lean” management style of the past, of a culture that lasts because it works at the present time, even though there is evidence, as we will show, of its inferiority and unsustainability. Previously, Mahajan et al8 noted that perioperative systems behave like complex adaptive systems.9 For example, there are numerous expectations regarding block management, case scheduling, management of add-ons and emergent cases, and individual patient variability. This inherent variability occurs not only at a single institution but also across institutions. Further,