Team design as innovation in perioperative care: the case of HPB anesthesiology

For decades, the optimization of surgical outcomes in HPB surgery has been linked to higher case volumes. Complex HPB surgery has been organized in high-volume centres and requirements for minimum number of procedures have been set for surgeons.6–17 But one critical member of the perioperative team has been largely overlooked: the anesthesiologist. Our research has reported that care by anesthesiologists with higher HPB volume is associated with reduced major morbidity, even after adjusting for surgeon and hospital volume.18–20 So why not create specialized HPB anesthesiology teams?

Some worry that concentrating anesthesiologists in HPB work will erode their exposure to other surgical areas, potentially limiting skills for emergencies or elective cases in other specialties. We examined the relationship between HPB case volume and non-HPB surgical volume in a study published in the BJS. 21

The results? Higher HPB volume was not associated with a meaningful drop in other cases. In absolute terms, high-volume HPB anesthesiologists often did more non-HPB work – potentially because they worked more days. When adjusting for total days worked, there was a 0.5% reduction in the rate of non-HPB surgery per additional HPB case, a statistically significant but likely clinically trivial difference. In other words, you could have higher HPB anesthesiology volume without sacrificing exposure to other types of surgery.

The efficiency and quality of care can often be improved more by delivering the current standard of care consistently than by developing new, and often costly, treatments or devices.22 Team organization is a cornerstone of reliable and high-quality care delivery. Our research has shown that not only does an anesthesiologist’s clinical volume matter, but so do the familiarity between anesthesiologists and surgeons and the diversity of the anesthesiology-surgery team.23,24 Consistent teams and more diverse teams can deliver better outcomes. These are structural factors, embedded in how the OR team is organized, that influence patient outcomes.

Re-organizing anesthesiology care to increase provider volume is a structural change. It’s a low- or no-cost intervention that can be implemented within existing resources. It would seem far cheaper than the billions spent on purchasing cutting-edge devices. But unlike high-profile technology launches, team reorganization is not “flashy” and rarely makes headlines or marketing and donor campaigns. Workflow and culture changes can also be daunting, possibly more so than adopting new technology. They can be perceived as threatening or disruptive.

Likely because it challenges a deeply ingrained model that has evolved from a mix of system, hospital, and physician-level factors. At the system level, growing service demands and a shrinking per-capita anesthesiologist workforce have made flexible scheduling a necessity. At the hospital level, assignments are often designed to balance diverse expertise across many clinical areas, respond to call schedules demands, and manage operating room efficiency. At the individual level, preferences may be influenced by case familiarity, length of the work-day, or physician remuneration models. Addressing these challenges requires confronting long-standing norms, aligning incentives, and working collaboratively across multiple stakeholder groups to redesign call structures, room assignments, and career pathways, with the goal of ensuring anesthesiologists in specialized centres maintain a minimum volume of HPB cases.

We’re not advocating for blunt-force HPB anesthesiology specialization without safeguards. We must anticipate and understand potential unintended consequences for the health system, its physicians, and the patients it serves. That’s why our ongoing work now focuses on examining potential unintended consequences. We’re conducting environmental scans, exploring different organizational models, and engaging clinicians to understand their perspectives.

Ultimately, the operating room isn’t just a collection of skilled individuals – it’s a system. And systems can be designed to optimize performance.