Production pressure in the work environment: California anesthesiologists' attitudes and experiences
Background: Pressure to put efficiency, output, or continued production ahead of safety has caused catastrophic accidents in various industries. The authors assessed the attitudes and experiences of anesthesiologists concerning production pressure. Methods: A random, repeated-mailing survey was conducted among 647 members of the American Society of Anesthesiologists residing in California. Questions were asked about attitudes toward production pressure and other patient safety issues, frequency of occurrence of various operating room events, encounters with situations involving unsafe actions, and ratings of sources of production pressure. Results: Forty-seven percent of those sampled returned surveys. The demographics of the respondent population were largely similar to those of the population of anesthesiologists in California. There was no systematic difference between the respondents to the first versus the second mailing, reducing (but not eliminating) the possibility of self-selection bias. Nearly half (49%) of respondents had witnessed production pressure result in what they believed to be unsafe actions by an anesthesiologist. Such events included elective surgery in patients without adequate evaluation or with significant contraindications to surgery. Anesthesiologists felt pressures within themselves to work agreeably with surgeons, avoid delaying cases, and avoid litigation. They also reported overt pressure by surgeons to proceed with cases instead of canceling them, and to hasten anesthetic procedures. Some aspects of production pressure were perceived differently by those reimbursed by fee-for-service versus those paid by salary. Conclusions: Production pressure from internal and external sources is a reality for many anesthesiologists and is perceived in some cases to have resulted in unsafe actions being performed.