Why do surgeons schedule their own surgeries?

• Author: Adam Diamant,Fayez Quereshy,David Johnston
• Date: 01 April 2019
• Published date: 01 April 2019
• DOI: http://doi.org/10.1002/joom.1012

ORIGINAL ARTICLE

Why do surgeons schedule their own surgeries?

David Johnston

1

| Adam Diamant

1

| Fayez Quereshy

2

1

Operations Management and Information

Systems, Schulich School of Business, York

University, Toronto, Ontario, Canada

2

Department of Surgery, University of

Toronto, Toronto, Ontario, Canada

Correspondence

David Johnston, Operations Management

and Information Systems, Schulich School

of Business, York University, 4700 Keele

Street, Toronto, ON M3J 1P3, Canada.

Email: djohnston@schulich.yorku.ca

Handling Editor: Anita Tucker

Abstract

Surgery is a knowledge intensive, high-risk professional service. Most hospitals

give surgeons considerable autonomy in deciding which patients to operate on and

when. In theory, this allows surgeons the operational flexibility to prioritize surger-

ies based on intimate knowledge of their patient's clinical needs. At odds with this

strategy is the operations management literature, which favors the standardization

and centralization of scheduling focused on achieving the efficient use of all

resources, such as operating room capacity. Unfortunately, a little is known as to

how surgeons customize their schedules and why they value such control. To this

end, we conduct an exploratory qualitative study of the scheduling behavior of sur-

geons at a large Canadian teaching hospital. We identify significant differences

between surgeons as to their priorities when scheduling. Two constructs are forma-

tive in surgeon decision-making: the timeliness of treatment for their patients and

idiosyncratic personal priorities. Our work has implications for achieving surgeon

support for initiatives to standardize and centralize routines for patient scheduling.

Accordingly, we formulate propositions that address the conditions under which

such efforts will achieve the desired balance between flexibility and efficiency.

KEYWORDS

centralization, healthcare, qualitative research, scheduling, standardization

1|INTRODUCTION

Why does doctors value scheduling the order in which indi-

vidual patients will be treated? Ibanez, Clark, Huckman, and

Staats (2017), for example, found that doctors use their dis-

cretion to regularly deviate from the prescribed rule of first-

in-first-out when interpreting radiology results. Although

this did not impact the quality of their diagnosis, it did lead

to a 13% increase in processing times. In an operating envi-

ronment that increasingly promotes the standardization of

practice and central coordination of medical professionals,

such delegation of authority seems out of step.

Popular operational practices, such as lean, advocate

that managers of organizations should standardize on the

best practice for a task and then put in place systems to

ensure conformance to them (Spear & Bowen, 1999; Shah

and Ward, 2003; Staats, Brunner, & Upton, 2011; Netland,

Schloetzer, & Ferdows, 2015).

Successful applications of lean principles such as in the

Toyota Production System standardize tasks but do not

stifle a requisite level of flexibility and innovation. Adler,

Goldoftas, and Levine (1999) describes “meta-routines”to

manage the occasional nonroutine activities aimed at learn-

ing to improve and solve problems, which are separate from

routines that are the repeated, standardized best practices

implemented on the factory floor to achieve stable day to

day production outcomes. This works well for producing

high volume, high quality replications of the same car model

with limited customization over time. In the healthcare

setting, the pressure to process at volume to high quality

standards is similar but individual patients require custom-

ized medical care and can vary considerably in their saliency

Received: 11 January 2018 Accepted: 3 December 2018

DOI: 10.1002/joom.1012

262 © 2019 Association for Supply Chain Management, Inc. wileyonlinelibrary.com/journal/joom J Oper Manag. 2019;65:262–281.

for treatment. It is reasonable to expect that scheduling rou-

tines in this environment to be more flexible.

The performance of any complex routine, such as patient

scheduling or the performance of surgery, is prone to inter-

pretation and improvisation over time (Feldman & Pentland,

2003). Routines in organizations are repetitive and recogniz-

able patterns of interdependent action carried out by multiple

actors. Advocates for change in medical systems have in-

creasingly promoted routines that centralize the coordination

of standardized practice across medical professionals

to achieve operational improvement (e.g., Timmermans &

Berg, 2010). This is bound to create conflict and does

(e.g., Martin, 2017). The desire of hospital administrators to

increase aggregate capacity and resource utilization through

standardization and centralization is put in direct conflict

with the priorities of surgeons to maintain flexibility and

defend deeply held personal and professional values, all

while appropriately addressing a patient's ever shifting medi-

cal needs.

By scheduling a patient for surgery, a surgeon sets in

motion a professional service supply chain that aims to

achieve positive patient outcomes. Tucker, Nembhard, and

Edmondson (2007) and Harvey (2016) describe surgeons as

one of the essential professional service providers within the

complex hospital environment. Surgeons, along with doc-

tors, nurses, and administrators, exert agency upon a net-

work of services that allow the hospital to respond to the

diverse and changing needs of an increasing volume of

patients. Unfortunately, as Gupta (2007) noted there is a

dearth of operations management models that address the

scheduling of surgical patients and the centralized coordina-

tion of the end-to-end service supply chain within hospitals.

Further to the contribution of our research, none explore the

rationale behind an individual surgeon's decision-making

behavior while scheduling.

In this research, we examine in detail the rationale of

eight surgeons in one large Canadian hospital as to why they

schedule. We also interviewed three administrative staff who

support them about the behavior of these surgeons while

scheduling. As can be expected from exploratory qualitative

research, unanticipated insights emerged from the within-

and cross-interview analysis. We found significant variation

in the rationale across surgeons about why they value the

autonomy to schedule patients. Some followed closely a

regime standardized on a centralized first-come-first-served

(FCFS) system, while the majority scheduled patients based

on both personal and professional priorities. The operational

knowledge that informed their decisions came from personal

experience versus input from a systematic examination of

best practices. As a result, surgeons harbored strong and var-

ied opinions as to the level of flexibility required to manage

their patients effectively. Consequently, based on these

observations, we formulate propositions about the conditions

under which standardized and centralized scheduling might

be more or less effective.

2|LITERATURE REVIEW

Surgeons use their judgment to select, sequence, and assign

patients to available operating room (OR) capacity (Santibanez

et al., 2007). That is, they have the latitude to select who is

assigned to a surgical day and what order they are operated

on. The OM literature has found that incorporating relevant

information (e.g., disease manifestations and patient informa-

tion) can help practitioners make better scheduling decisions,

which in turn, can improve some aspect of system perfor-

mance (Freeman, Savva, & Scholtes, 2016; Saghafian, Hopp,

Van Oyen, Desmond, & Kronick, 2014; Sun, Argon, & Ziya,

2017). However, a little is known about how individuals pro-

cess this information leading to a decision (Ibanez et al.,

2017). Indeed, behavioral OMresearchonhealthcarehas

examined what happens when individuals make decisions that

deviate from known optimal scheduling policies. These devia-

tions can be suboptimal and introduce harmful biases that

affect performance (e.g., Bendoly, Donohue, & Schultz, 2006;

Gino & Pisano, 2011). Further, in the analysis of assignment

and sequencing systems, researchers have yet to address the

influence of individuals' (e.g., surgeons') personal characteris-

tics on decision-making (Cardoen, Demeulemeester, Beliën, &

Samudra, 2013).

The notion of standardizing work has become the domi-

nant paradigm in OM for reducing unpredictable variability in

production systems (e.g., Terwiesch & Cachon, 2012). It is

one of the central tenets of lean six-sigma (Dahlgaard & Mi

Dahlgaard-Park, 2006). Similarly, there is long-standing evi-

dence that the centralization of resource management opera-

tions yields substantial benefits, such as in the pooling of

inventory (e.g., Benjaafar, Cooper, & Kim, 2005; Berman,

Krass, & Mahdi Tajbakhsh, 2011). Several studies demon-

strate that significant cost reductions can be achieved when an

organizations' scheduling activities are centralized (Batun,

Denton, Huschka, & Schaefer, 2011; Roshanaei, Luong,

Aleman, & Urbach, 2017). The application of these tech-

niques to hospital operations has led to improvements in

emergency services (Dickson, Singh, Cheung, Wyatt, &

Nugent, 2009), better medication management (Nayar, Ojha,

Fetrick, & Nguyen, 2016), and more efficient use of a hospi-

tals' OR time (Singh, Remya, Shijo, Nair, & Nair, 2014). It is

now a mainstay in efforts to control healthcare-related expen-

ditures, improve service quality, and providebetter health out-

comes to patients (de Koning et al., 2006).

A central assumption in OM scheduling research is that

having a consistent set of rules applied to the processing of

customers is desirable and this is facilitated by having a

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