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Dismantling the "scarcity mindset" in surgical block time management

The way OR time has been allocated and managed for decades has led to a “scarcity mindset” and all the natural resulting behaviors. Block Time is treated as a zero sum game and here is what happens in almost every OR in this country:

  • If Dr. Smith, or his department is lucky enough to be allocated 2 blocks a week, that’s 104 blocks a year that OR leadership in that facility cannot allocate to anyone else.
  • Not surprisingly, once a block owner is allocated “their time”, it is a precious commodity they do not want to willingly part with. Or release it in advance even if they don’t have cases booked on a particular block day. In fact, they treat it with the love and care of a NY taxi medallion that they’d prefer to hand down to their future generations before even thinking of giving it back to the OR to give to others.
  • This behavior in turn leads to more scarcity which then leads to further “hoarding” and the vicious cycle is perpetrated forever.
  • And so OR block committees which determine how to allocate the finite number of total allocatable blocks end up becoming these really special (often political and influence based), bodies that determine the fate of departments and surgeons.

This “scarcity” mindset is very much akin to many other real world situations.  Think about the behavior of citizens in a town where a storm is forecast and expected to last for a few days. People living in the town don’t know if the grocery stores will be open or what the hours are going to be. So what do they all do? Rush to the store as soon as they can and “hoard” multiple gallons of milk and whatever other commodities they need whether they will be able to use it or not while the storm is raging. Think about the shortage of hand sanitizer in the early panic with COVID-19. These are examples of very natural social dynamics – perceived scarcity leads to unnecessary hoarding which leads to more scarcity. 

In economic terms, all these are real world extensions of the 2-player Prisoner’s Dilemma problem from game theory, where most prisoners “compete” while a prisoner well versed in game theory concepts would know that the “cooperative strategy” creates the best joint outcome for both players together. The problem is that most prisoners don’t know this and end up in the wrong “box”.

How do you solve this problem in the real world? During COVID, one way stores did it after they realized what was happening was by rationing how much hand sanitizer you could buy. In the hurricane scenario, imagine this thought experiment – what if local stores announced that they would “deliver milk to your home even during the storm” and so urge that “please don’t buy more milk than they need”. If most people living in the town believed them, better still if the store showed that milk was always available on their online portal, that would relieve a lot of the anxiety and most people would not want to buy extra gallons of milk and waste them – knowing that would be a lose-lose situation for all.

How could this “cooperation mindset based on abundance” work in the OR? By creating a win-win scenario where block owners are given tools and shown explicitly how it is in their enlightened self interest to cooperate and create abundant open time rather than always just compete for time. Here are the underlying supply and demand dynamics for any given block owner:

  • Demand: Every block owner knows that their own and their patient’s lives don’t work according to a block schedule. Almost everyone regardless of whether they have block or not will need time outside of block at some point
  • Supply: Every block owner also knows that they will not be able to use every single block they have been granted well. Vacations, conferences, seasonal variations, clinic conflicts, practice changes will all lead to variations in how well each block will be used in the future. And oftentimes they can predict way in advance when they won’t use their block days. Which lead to the situation “there is always time in the OR and there is never time in the OR”
  • Co-operate and Win: So what if ORs could get block owners to understand that “when you realize you have too much supply of time, give it up as soon as you realize you do” and in turn “we will guarantee that in all instances where you need time outside of block you will get it”. Why? Because your colleagues also get the same logic and are willing to cooperate.

If there was one positive that emerged from the first wave of COVID-19 it was that OR teams, surgeons, anesthesiologists, administrators, all had to work as a team and cooperate. The backlog created by ORs being shut down for many weeks resulted in everyone having to find ways to fit patients in for maximizing overall benefit to everyone’s patients, not just for one department or one surgeon. Demand / Supply shocks like these are excellent opportunities for us to reassess the tribal rules and committee based practices that have been perpetrated by the “scarcity mindset”.

Dozens of health systems in the country have been able to make this change happen successfully. Hundreds are still stuck in their old ways. But everyone has to move to this new mindset if they are to survive especially as the need for surgery grows but the capital to build more ORs is limited.

Let’s create the mindset of “abundance”. If I cooperate, and others do too, there will always be that gallon of milk and that tub of hand sanitizer when I need it. And that usable slot of OR time when my patient and I need it.

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