By Lidia Moura, MD, Ph.D., MPH, and Susanna Gallani, Ph.D.
Healthcare systems are built on the foundational principle of “Do no harm.” Yet, in practice, this promise is repeatedly broken when hospitals prioritize volume over patient outcomes.
The consequences of this volume-driven approach were painfully clear during a recent elective surgery at a Latin American hospital that operates primarily under fee-for-service compensations. What should have been a straightforward procedure turned into a nightmare, revealing a cascade of systemic failures that endanger patients and highlight the urgent need for global healthcare reform.
The case involves a 67-year-old woman admitted for an elective hysterectomy, scheduled to take place early the next morning. She arrived on time at 8 p.m., expecting a smooth process, but was met with delays.
For over two hours, she waited without any explanation in a crowded admissions area. By the time she was finally admitted, it was midnight, robbing her of critical sleep before the surgery. Observers noted a disengagement from hospital staff, with one nurse joking about a malfunctioning thermometer—an offhand comment that appeared to reflect a larger issue of a lack of seriousness toward patient care.
These early signs of dysfunction foreshadowed the more dangerous issues that lay ahead. The next morning, it was revealed that critical materials for the surgery had not been delivered to the hospital. Despite the absence of these essential supplies, the surgeon decided to proceed with the surgery, asserting that he could “make do” and modify the procedure if necessary.
This kind of improvisation is deeply troubling and dangerous.
From a medical standpoint, surgery must never proceed without all necessary tools and materials present, particularly in procedures where patient safety is at risk. The surgeon’s justification—citing that the patient’s daughter had traveled overseas to accompany her mother, and a rescheduling would cause significant disruption to her return trip plans—was inadequate.
Yes, supply chain issues occur—as they are now in medical devices—and in such cases, it is entirely reasonable to reschedule or delay rather than take unnecessary risks.
In the case of surgery on a frail woman with a history of cardiac issues and other risk factors for poor outcomes, this is a matter of both common sense and medical prudence.
Prioritizing Surgical Volume
Nevertheless, the hospital team’s willingness to gamble with the patient’s health demonstrates a broader issue within healthcare systems, where operational surgical volume is often prioritized over patient outcomes. When hospital administrators are rewarded monetarily based on the number of surgeries performed rather than the quality of care delivered, patient safety inevitably becomes secondary.
The New England Journal of Medicine 2023 study, “The Safety of Inpatient Health Care,” highlights the perverse incentives created by the fee-for-service model. Hospital administrators and staff are often driven to perform more surgeries, even when patient outcomes may be compromised.
According to the study, adverse events are identified in nearly one in four admissions, with approximately one-fourth of these events deemed preventable. This issue is partly due to hospitals being paid based on surgical volume, which can lead to cutting corners to maximize throughput. This dynamic creates situations like the patient’s, where improvisation takes the place of proper planning.
The consequences of this failure in planning were cruel. The patient was wheeled into surgery without the necessary tools, and for over an hour and a half, as she was under sedation, the surgical team waited as the surgeon’s assistant made desperate calls to a supplier, hoping the missing materials would arrive before a crisis occurred.
When the supplies finally arrived—delivered by a motorcycle courier navigating the congested streets of a crowded capital city—they were far from the optimal conditions required for the delivery of surgical materials. This unacceptable method of delivery, coupled with the extended delay, increases the risk of infection, prolonged anesthesia, and the likelihood of multiple postoperative complications.
These events reveal a critical vulnerability in healthcare systems, particularly in some fee-for-service hospitals where supply chains are volume-driven.
Despite the World Health Organization (WHO) releasing guidelines for safe surgery more than a decade ago, which clearly state that “hospitals and public health systems will establish routine surveillance of surgical capacity, volume, and results,” supply chain issues remain a major contributor to adverse events in surgeries worldwide.
The procedure was eventually completed, but not without significant risk. The prolonged exposure to anesthesia and the delay in closing the surgical site created unnecessary hazards. Perhaps the most distressing aspect of the experience was the lack of accountability.
No one filed a safety report until a patient’s family member requested one, and hospital administration was not involved until nearly the end of the procedure. The chief of staff apparently was too busy serving as the anesthesiologist in another operating room.
The surgeon and staff continued the procedure as though these systemic failures were simply part of the process, reflecting a troubling acceptance of substandard care.
Value-Based Care Necessary
Unfortunately, this recklessness is not an isolated incident. It reflects a broader crisis in healthcare systems where financial incentives encourage hospitals to prioritize quantity over quality or outcomes. Instead, hospitals must be rewarded based on the outcomes they achieve, not the volume of procedures they perform. Value-based care offers a necessary alternative to the current fee-for-service model.
To achieve this, advanced technologies like artificial intelligence (AI) can play a crucial role in preventing such crises. AI tools can predict supply chain needs, flag safety risks in real time, and assist healthcare providers in making better decisions. Hospital administrators can and must ensure that critical supplies are available when needed and that patient safety is never compromised.
This case is not merely an account of a surgery gone wrong. It is a call for global healthcare reform to ensure that no patient is ever put at unnecessary risk due to systemic failures. The woman’s elective surgery highlighted a critical flaw in how hospitals are incentivized. When volume is prioritized over outcomes, patients ultimately pay the price.
To prevent future harm, healthcare systems must shift toward value-based care models, improve supply chain management, and enforce accountability at every level.
