Normalization of Deviance and its Impact on Anesthesia and Healthcare: Q&A With Anesthesiologist Dr. Thomas Schares of Somnia Anesthesia Services

Thomas Schares, MD, MBA, an anesthesiologist with Somnia Anesthesia who serves as chief of anesthesiology for Desert Regional Medical Center in Palm Springs, Calif., discusses the phenomenon known as "normalization of deviance" and how it is impacting healthcare and the quality of care provided by anesthesiologists.

 

Q: Can you describe the phenomenon known as normalization of deviance?

 

Dr. Thomas Schares: The term was popularized after the Space Shuttle Challenger disaster, when a deficiency in the "O-rings" (round rings used in the fuel rockets as a gasket for sealing a connection) was discovered. Due to production pressures, timelines, political pressures … [NASA employees] started to compromise and allow launches at temperatures lower than the O-rings were certified to be used, which was 58 degrees.

 

On the day the Challenger exploded, it was 28 degrees outside when the shuttle launched. Twenty-eight degrees was well below the 58 degree-certified temperature for the O-rings. However, since nothing bad had happened by compromising this standard with previous launches, this became the new norm. When you deviate from that new norm, and nothing happens then you constantly reset the norm — the normalization of deviance.

 

With the space shuttle, they had been documenting that there were progressively higher near failure rates at the lower temperatures, but they chose to ignore that data and push on. It can eventually lead to events like with the Challenger accident, and you find that the root of the problem started a long time ago [because of deviations].

 

Q: How does it apply to healthcare and anesthesia?

 

TS: One of the most common examples is in the pre-anesthetic evaluation. The pre-anesthetic evaluation can be very extensive. It is often performed right before the start of the case where there is the most pressure to minimize time spent. The pre-anesthetic evaluation is a very common area where [the process] is abbreviated, abbreviated to the point in some cases of not even occurring. All of this is completely contrary to all of the established policies and procedures.

 

There are many other areas but this a type where you are most visible. [Physicians or the facility] want to get the case going and you're sitting down, reviewing a history and physical with the patient. They question why this didn't happen earlier and why it's necessary to now hold the case up. I've seen providers or even institutions start succumbing to the pressure … and where there have been so many layers of safety, checks and balances, but in the name of enhanced efficiency or because people tried to cut some corners … nothing happens and then that [new method] becomes the norm.

 

Q: Why is this a challenge for healthcare?

 

TS: One of the biggest challenges is that progress is often achieved through normalization. Consider NPO guidelines. They used to be very rigid. I think a lot of people would often just liberalize those rules without any real evidence. However, people were studying and gathering data on NPO, and through true quality-based processes, they ultimately did make changes to some of the NPO guidelines to make them more liberal. That I think is appropriate whereas someone, for example, waiving laboratory guidelines and requirements for reasons of expediency and without having any kind of evidence, can progressively compromise safety to a point where untoward events can occur.

 

With a very small sample size, nothing may happen. But waive once and then it becomes easier to waive twice, three times and then after awhile they stop considering it and that process becomes dangerous because it may or may not be the right [approach]. It would be more appropriate to say, "I wonder if we really need to do this lab test" and then study it.

 

Q: How else does normalization of deviance challenge anesthesiologists?


TS: I think oftentimes in anesthesia we are at a disadvantage because of how highly commoditized the specialty has become; [a physician or facility], if they want to, can usually find someone else to say I don't have a problem [with deviating] and then the surgeons say that is who I want to use.


Q: What can organizations do to fix or avoid unjustified deviations?

 

TS: One of the things I have seen as we have gone into new places with an existing culture and practices … is there is often a significant deviation across all of the aspects of clinical care. One of the real challenges then is to move that culture back. The challenge is often that some of these changes have been viewed as progress because often they have resulted in what looked like increase efficiency or decreased cost. As we come in as a new team, we don't see them as acceptable.

 

One of the tools I've been able to use to help get people to take a step back and think about where they are at is explaining about this phenomenon and making sure these changes were deliberate and evidence-based as opposed to passive, subtle erosion.

 

I would urge [organizations] to think about this concept and distinguish what aspects of it really do lead to real progress. The characteristics of progress are that you are continuously evaluating the changes you are making with evidence-based guidelines and that you have a quality program in place to assess the outcomes from the changes you are making.

 

The danger signs are sort of ad hoc, where someone makes some changes and the only criteria that it is a good change is one where nothing bad happens. Sometimes the warning signs are subtle, and without a vigorous quality process underneath, it is very likely you will get a bad surprise down the road.

 

Q: How will this phenomenon impact the future of quality care?

 

TS: I think this will become one of the primary roles for quality processes. It will be seen as a critical tool to continuously evaluate the practice and make appropriate changes. If the evidence shows it's not the right thing to do, it provides a real strong argument to our colleagues to say, "We're sorry this takes a little longer but this is what it needs to be." You have to be continuously evaluating what you are doing to not let it occur passively.

 

I see this as the biggest danger and the biggest challenge in terms of managing the whole healthcare culture balanced against all of the appropriate needs for efficiency and production pressure.

 

Learn more about Somnia Anesthesia.

 

Read more from Somnia Anesthesia:

 

- 5 Thoughts From Industry Experts on the Future of Anesthesia

 

- Defining the Relationship Between Anesthesia and ACOs: Q&A With Jonathan Friedman, COO of Somnia Anesthesia Services

 

- Somnia Anesthesia Recognizes California and Washington State Anesthesiology Clinicians for Quality Care

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