Cases & Commentaries
A 65-year-old man with bipolar disorder was
scheduled for maintenance electroconvulsive therapy (ECT), a
procedure he had received dozens of times before. These procedures
are usually administered in the morning by an anesthesiologist.
Later in the morning, that anesthesiologist staffs the preoperative
anesthesia clinic. A second anesthesiologist in the group spends
the day in the operating room (OR) supervising three nurse
On the day of the scheduled ECT, the clinic
anesthesiologist called in sick. The service, which had no policy
to cover unexpected absences and rarely cancelled a case, scrambled
to try to cover the ECT procedure, finally asking the OR
anesthesiologist to attend on the case. He protested, noting that
he was already responsible for overseeing the anesthesia for three
surgeries in the OR. But finally, to avoid delays in the ECT
administration, he reluctantly agreed to come to the day surgery
unit to perform the quick (usually less than 10 minutes)
After the ECT was performed, the patient did not
wake up promptly as expected. The anesthesiologist checked his
medication cart and realized that he had inadvertently administered
the intermediate-acting muscle relaxant rocuronium, instead of the
short-acting agent succinylcholine. He later attributed this error
to being rushed and stressed, leading him to pull the wrong vial
from the refrigerator. He had never made this mistake before.
The patient was given more sedation to prevent
awareness and bag-and-mask ventilation to support his respirations.
After about 30 minutes, his neuromuscular blockade was
pharmacologically reversed with neostigmine. The patient was
informed of the error, and there were no long-term adverse
This case—in which an OR anesthesiologist
is pressured to step in at the last minute to replace a colleague
and administer ECT—vividly illustrates the issue of
production pressure. Production pressures are the "overt or covert
pressures and incentives on personnel to place production, not
safety, as their primary priority."(1)
After the clinic anesthesiologist called in sick, clinic personnel
desperately sought a short-term solution to accomplish the
scheduled ECT. Adding to the pressure, it is likely that there was
no contingency planning for this situation. Instead, we have a
patient who has already arrived at the clinic and is waiting to
receive his scheduled ECT, creating pressure on the clinic staff to
get the procedure done that day, and subsequently on the OR
anesthesiologist to attend on the case. The OR anesthesiologist
already had a high workload—supervising the work of three
nurse anesthetists for three surgeries in the OR. Faced with the
pressure to avoid delaying the ECT administration—some of
which was likely self-generated, sympathizing with the needs of
this elderly patient with bipolar disorder who has received the ECT
procedure many times before—he finally agreed to perform the
procedure. Although proving causality is difficult, it seems
logical to attribute the medication error of the OR
anesthesiologist, one he had never before committed, at least in
part to the stressful circumstances and the ball juggling he
undoubtedly had to perform.
Production Pressures in Health
Research has shown that various categories of
health care workers experience different types of pressure, such as
time pressure (i.e., having to perform tasks in a short
period of time) and production pressure (i.e., having to
"produce" at the expense of safety).(1) Gaba and colleagues (1)
reported that 49% of the surveyed anesthesiologists have "observed
an anesthetist pressured to conduct anesthesia in a fashion [one]
considered unsafe given the level of urgency of the situation."
These different types of work pressure can be sources of stress,
and even burnout (2,3),
and may threaten patient safety by increasing the likelihood of
errors and workarounds.(4) Given the shortage in many medical specialties and
nursing, it is important to understand how to design the work
system to minimize pressures and stress on the health care
providers, as well as to improve the quality and safety of
Those in upper management who are responsible for designing the
work systems need to understand the negative impact of production
pressures on both the health care providers and the patients.
Various organizational and systemic factors can
contribute to production pressures, such as poorly designed
workload policies, inadequate staffing, poor incentive systems,
hierarchical systems, competition for cases, long work hours, and
low safety culture. A system analysis of production pressures
examines all of the work system factors that can be responsible for
creating both objective and subjective pressures. In approaching
this type of analysis, the work system can be conceptualized as
having five elements—person, tasks, tools/technologies,
physical environment, and the organization (6,7)—that should each be systematically considered.
For instance, high workload or having a lot to do, a characteristic
of the "tasks," can be a source of production pressure. The case
shows this clearly: the anesthesiologist is faced with the tasks
related to his regular workload of supervising three nurse
anesthetists, but also those of a sick colleague.
In addition to the amount of work, the case
illustrates another critical factor in production
pressure—the management of workload. This factor is comprised
of two elements: (i) predicting and planning workload and (ii)
establishing policies and procedures for handling changes in
workload. Safe organizations put effort into analyzing the work
system and attempting to predict and plan for workload. Such
information can be used to quantitatively model workload, therefore
leading to more reliable, effective management of resources,
including human resources (e.g., staffing) and other resources
(e.g., OR allocation), and possibly reducing production
instance, Mullinax and Lawley (9)
present a methodology for assigning patients to nurses in neonatal
intensive care (NICU) based on (i) quantification of nursing
workload for each NICU patient and (ii) a decision analysis model
(integer linear programming) that assigns patients to nurses while
balancing nurse workloads. A test of the methodology with 10 case
studies in an academic medical center shows that this novel
approach to managing workload led to a better balance of nurse
workload. McManus and colleagues (10,11)
provide another example of the application of industrial and
systems engineering tools to workload management in the context of
surgical caseload and availability of beds in an intensive care
unit. This research demonstrates that the variability of scheduled
admissions was greater than the variability of emergencies.
Very often, changes in workload occur in health
care in an unpredictable manner. Therefore, it is also important to
establish policies and procedures for handling those sudden,
unpredictable changes in workload. Such policies and procedures
need to rely on the front-line staff as much as possible and
provide autonomy to the local actors in their response to the
sudden change in workload. The local actors need to be provided
with the resources, responsibility, and autonomy to be able to
respond to the workload changes, and therefore minimize the impact
of production pressures. The Toyota Production System is famous for
providing front-line workers with this type of local control, but
the case of the NUMMI (New United Motor Manufacturing, Inc.) plant
that implemented the Toyota Production System illustrates how local
control can sometimes be an "illusion of control" if not
accompanied by "real" resources and empowerment. As this one
influential case study described, workers on the assembly line were
told that they could stop the line when they were experiencing some
problem. This control over workload can be a very positive job
characteristic. However, the investigators found that when a worker
did stop the line, there were so many negative consequences (e.g.,
being identified as the "weak link," feeling that workers down the
line are let down) that actually exerting that control is not an
Without a robust management commitment and a culture that clearly
prizes safety over production, it is very easy for the promise of
local control or autonomy to deteriorate into an illusion of
control. In addition, there has to be some high-level management
and monitoring of the process in order for the entire system and
process to function safely, effectively, and efficiently while
ensuring appropriate and sufficient local autonomy.
What Can Be Done?
A possible solution to reduce production
pressures is through staffing policies and procedures. If there is
sufficient staff to perform all of the tasks, it is likely that
production pressures will be minimized. It is important to
understand that staffing policies and procedures need to go beyond
the number of people and examine the entire work system to
understand the factors that contribute to workload.(13) Adequate staffing levels depend not only on the
number of people but also their skills, knowledge, and experience,
as well as many characteristics of the work system or clinical
microsystem, such as effective scheduling and facility planning
that will allow better use of staff resources. Therefore, health
care organizations need to evaluate their work systems and the
factors that contribute and/or add to workload and production
pressures. This case illustrates an everyday phenomenon in
workplaces throughout the world: Without a culture in which safety
trumps production, adequate staffing, clear policies and
procedures, adequate working conditions, and front-line empowerment
and resources, proclamations about the importance of safety are
belied by actual events. It is hard to blame the staff for wanting
to get the ECT done that day, or the anesthesiologist for
reluctantly agreeing to staff the case. But the result is a
medication error that could have caused major harm.
A better system would be one in which:
- A prospective analysis assesses the
daily workload of the anesthesiologists in both the OR and the
outpatient center, ensuring that staffing is adequate for both
usual and unusually busy days. Such an analysis would also consider
how often anesthesiologists (or other staff) have unplanned
absences and the impact of these absences on workflow and workload.
This analysis would need to be performed on a continuous basis and
take into account organizational changes.
- Staff would be brought together to
discuss how to handle these unusually busy days—whether
caused by an unusual volume/complexity of patients or unplanned
- Management would help staff identify
additional resources that could be made available on such
days—for example, could an anesthesiologist be pulled from a
critical care unit or an affiliated hospital to help out?
- Everyone would agree that, when staff
members felt that a certain level of production was unsafe, they
would be uniformly supported if they chose to "stop the presses."
This is precisely what the High Reliability Organization approach
(14,15), along with other organizations with impressive
records of safety and quality, now emphasizes, and it needs to
become a standard part of the culture of health care.
- At a broader policy level, accreditors
should consider standards related to methods for managing workload.
In aviation, for example, the Federal Aviation Administration (FAA)
strictly regulates the frequency of take-offs and landings. This
would be far trickier to do in health care. However, health care
organizations should be strongly encouraged to design and implement
systematic methods for managing workload and making decisions
regarding the number of cases per day in an OR or staffing ratios
in order to appropriately balance the inevitable tensions between
production pressures and patient safety.
- Production pressures are caused by
various factors embedded in the structure of health care work
systems and organizations. They can affect health care providers in
the form of stress and burnout, and the safety of care provided to
- Consider identifying work system factors
that contribute to production pressures, and implement
interventions targeted at those system factors.
- Health care organizations should analyze
their work systems and workflows, helping them to appreciate the
frequency and circumstances—unplanned increases in patient
volume or complexity, unplanned staff absences—that lead to
increased production pressures.
- Develop methods, policies, and
procedures for managing workload. Although some of these will be
"top down," the front-line providers also need to be empowered to
call up resources, solve problems, and if necessary "stop the
presses" when production pressures threaten to compromise
Pascale Carayon, PhD
Procter & Gamble Bascom Professor in Total Quality, Department
of Industrial and Systems Engineering
Director of the Center for Quality and Productivity Improvement
University of Wisconsin-Madison
1. Gaba DM, Howard SK, Jump B. Production
pressure in the work environment. California anesthesiologists'
attitudes and experiences. Anesthesiology. 1994;81:488-500.
[go to PubMed]
2. Carayon P, Zijlstra F. Relationship between
job control, work pressure and strain: studies in the USA and in
The Netherlands. Work Stress. 1999;13:32-48.
3. Maslach C, Schaufeli WB, Leiter MP. Job
burnout. Annu Rev Psychol. 2001;52:397-422. [go to PubMed]
4. Reason J. Managing the Risks of Organizational
Accidents. Burlington, VT: Ashgate; 1997.
5. Carayon P, Hundt AS, Karsh B-T, et al. Work
system design for patient safety: the SEIPS model. Qual Saf Health
Care. 2006;15(suppl 1):i50-i58. [go to PubMed]
6. Carayon P, Smith MJ. Work organization and
ergonomics. Appl Ergon. 2000;31:649-662. [go to PubMed]
7. Smith MJ, Carayon-Sainfort P. A balance theory
of job design for stress reduction. Int J Ind Ergon.
8. Reid PP, Compton WD, Grossman JH, Fanjiang G,
eds. Building a Better Delivery System: A New Engineering/Health
Care Partnership. Washington, DC: National Academies Press;
9. Mullinax C, Lawley M. Assigning patients to
nurses in neonatal intensive care. J Oper Res Soc.
10. McManus ML, Long MC, Cooper A, et al.
Variability in surgical caseload and access to intensive care
services. Anesthesiology. 2003;98:1491-1496. [go to PubMed]
11. McManus ML, Long MC, Cooper A, Litvak E.
Queuing theory accurately models the need for critical care
resources. Anesthesiology. 2004;100:1271-1276. [go to PubMed]
12. Parker M, Slaughter J. Management by stress.
Technol Rev. 1988;91(7):36-44.
13. Carayon P, Gurses A. A human factors
engineering conceptual framework of nursing workload and patient
safety in intensive care units. Intensive Critical Care Nurs.
2005;21:284-301. [go to PubMed]
14. Weick KE, Sutcliffe KM. Managing the
Unexpected: Assuring High Performance in an Age of Complexity. San
Francisco, CA: Jossey-Bass; 2001.
15. Roberts KH, Bea RG. When systems fail. Organ
Dyn. Winter 2001;29:179-191.