Operating room management

The management of a surgical suite must take into account all cooperating team members. The operating environment consists of interaction between surgeons, anesthesiologists, nurses, technicians, patients and visionary, committed hospital leadership.

Overhead costs include, but are not limited to, the space, technology and devices, pharmaceuticals and staffing. Hospital administrators have consequently focused their attention towards maximizing OR profitability, and thereby hospital profitability, through contribution margins. This focus, in addition to the boom in demand for elective surgery, has led to a rapid growth of OR facilities. Historically, nurses have been chiefly responsible for the daily functioning of the surgical suite. Increasingly, facilities are hiring a physician medical director for the OR, as represented by a surgeon, anesthesiologist, or both. In some instances, all three branches of surgery, anesthesia, and nursing will be represented in the daily OR management infrastructure. By working collegially, these three fields can mobilize all resources necessary to maximize OR productivity. Because medical needs and regulatory requirements are constantly changing, the concept of appointing a medical director in the OR, an operating room manager, has gained acceptance.[2]

Clinicians typically focus on operational decisions on the day of surgery (short term) such as moving cases from one OR to another, assigning and relieving staff, prioritizing urgent cases, and scheduling add-on case. On the other hand, upper management typically focuses on strategic decision making (long term) such as whether to open a new cancer center, or whether to align the hospital with a regional health care system.

The decisions made by OR management should have a clear and definitive purpose in order to maintain consistency. In order of priority, governing principles of OR managers are to: (1) ensure patient safety and the highest quality of care; (2) provide surgeons with appropriate access to the OR; (3) maximize the efficiency of operating room utilization, staff, and materials to reduce costs; (4) decrease patient delays; and (5) enhance satisfaction among patients, staff, and physicians.[3] If OR management is properly performed ahead of time, all that doctors and nurses have to think about on the day of surgery is the patient. If management is poor, then the medical and nursing staff may waste efforts and resources to rush cases or juggle schedules, thus compromising attention to patient safety.

OR utilization is a measure of the use of an operating room that is properly staffed with people needed to successfully deliver a surgical procedure to a patient.

Block Utilization is a measure of the use of operating room time by a surgeon or group of surgeons to whom time has been allocated.

Raw utilization is the total hours of elective cases performed within OR time divided by the hours of allocated block time.

Raw Utilization = total hours of cases performed ÷ total hours of OR time allocated

Adjusted utilization uses the total hours of elective cases performed within OR block time, including "credit" for the turnover times necessary to set up and clean up ORs.[4]

Adjusted Utilization = [total hours of cases + "credit time"] ÷ total hours of OR time allocated

Factors affecting utilization rates include: the accuracy of estimated case times, cancellation rate, number of add-ons available to fill gaps, longest cases go first, the time of day as utilization typically is highest in the morning and lowest in the evening, outpatient centers have lower utilization, and other constraints (i.e., surgeon can only use room 12, or start at 11 am).

Improvements in operating room efficiency can have a major impact on hospital staff and finances as well as operating room management.

Operating room (OR) efficiency is a measure of how well time and resources are used for their intended purposes. One way to analyze efficiency is to chart under-utilized and over-utilized time spent on a given day in the operating room. If the cases in an operating room finish earlier than scheduled, time is under-utilized. Likewise, if the cases in an operating room run "late" or past its allotted operating room time then this produces over-utilized time.[5][6]

The terms operating room utilization and operating room productivity are also often used when discussing operating room management of a surgical suite.

Operating room productivity is the quantity and quality of output (typically surgical cases) from the surgical suite in contrast to the amount of input required (such as physicians and nurses and equipment for example). Many institutions believe that productivity (output/input) can be accomplished without sacrificing convenience (rapid access to open OR time such that a surgeon can book a case without having to wait) but these two aspects are not separable.

Typically, the greater the operating room utilization, the less the convenience (able to book cases when desired) as defined by surgeons and patients. This is because as utilization goes up there is less available open staffed OR time available on short notice. In other words, the greater the access and convenience, the lower is operating room utilization (because of the need for extra capacity), at least as perceived by hospitals and anesthesiologists. This high level of customer service of being able to book cases on short notice is one reason ambulatory surgery centers typically have lower OR utilization than big city hospitals. The outpatient surgery center usually has reduced overhead when compared to a big city hospital, and therefore can financially get away with lower OR use.

Management of the operating room suite must acknowledge that people are the primary resource. Although management science theory may tend to hold constant the preferences and bias of the individuals working in and utilizing the surgery suite, management of the surgical suite with regards to case scheduling is strongly influenced by personal, political, and economic relationships within an institution.

To best align management goals with institutional objectives the OR director needs to identify the primary customer of the surgical suite. An OR can be completely balanced or it can be biased to one or more its constituents. The main people to consider are surgeons, anesthesiologists, nurses, the hospital (upper management), and of course the patient.

A first step is to determine whose preferences or workload dominates the surgical suite. If surgeons are in large demand with small supply, then that may outweigh other interests. For example, a private facility may have surgeons who can pull their patients to another hospital if made to wait. As another example, in a private surgeon-owned surgery center, management may be directed as maintaining a particular partner's workload and the incentives are to schedule his/her cases with priority.

The same supply/demand balance applies to anesthesia. The situation may exist where a specific surgery group will only work with its contracted anesthesia group. In this case, a manager may have to wait until the contracted anesthesiologist is ready for the case, even if this means idle OR time. This can be avoided in institutions where one group has exclusive rights and controls anesthesia privilege over all the ORs. This arrangement is seen commonly because it eliminates factions and streamlines anesthesia placement for cases, either elective or emergency.

Hospital (Upper Management) run ORs are identified by those facilities where the hospital executives acting as agents for government authorities determine staffing and workload. Examples include hospitals in public health care systems like in European countries or the VA United States Department of Veteran Affairs in the USA.

In other surgical suites, in contrast, management decisions have patients as the first priority. Facilities performing elective cosmetic procedures for cash reimbursement are an example. Due to the patient being able to choose where they have plastic surgery, patients expect special circumstances such as first-rate customer service. Additionally, if a patient is one hour late for surgery the patient will most likely still be able to undergo surgery. This concept is in contrast to a large academic hospital, for example, where a patient who misses their check-in window for elective surgery is often removed from the surgery schedule to make room for re-shuffled elective and emergency cases.

Once the manager has identified the critical few customers and the necessary many customers, then the next step is to determine their preferences and incentives. Surgeons will favor early block surgery times, rapid turnover, low cancellation rates, and on time starts. The hospital (upper management) will want the most surgical output with the least associated cost. Patients will likely favor reduced waiting times for surgery start. Finally, nurse managers and anesthesiologists will be inclined to high operating room utilization, minimal overtime, the flexibility to move cases around, and reserve capacity in the ORs.

Much like economic Game Theory, agents in the OR will position their interests in a nature as to maximize their returns. It is up to the OR manager to weigh the contributions of each agent and provide enough OR time and resources to maximize the output of the surgical suite in its entirety.

This discussion addresses capitalistic healthcare markets. A discussion of socialized medicine would include several other factors which influence the supply and demand for surgical care. Analysis of operating room management within socialized medicine is becoming increasingly frequent in the medical literature, but is beyond the scope of this article.

A manager must select benchmarks in order to analyze changes from baseline operations. Upgrades to existing operating infrastructures should be demonstrated as efficiency gained compared to baseline practices. Management criteria must therefore include preoperative, intraoperative, and immediate postoperative system analysis.

Waiting time and operating room scheduling are the two key preoperative determinates.

Waiting time prior to operation The time from surgical scheduling to check-in for the procedure is defined, for these purposes, as “preoperative wait time.”

Use of a surgical suite depends greatly on, and increases as, the average length of time patients wait for surgery increases. As waiting time increases, more surgical dates (blocks) can be evaluated for a good match between a case's duration and the open times in the blocks. In some communities, competition among surgeons and hospitals may not allow the average length of time that patients have to wait for surgery to be as long as 2 weeks. An OR suite then cannot expect block time utilization from elective cases to exceed 90%, assuming that enough block time is allocated for a surgeon to complete all of the elective cases in the block time.

For these purposes, wait time can be equated to the price of an object. The price for an object increases if demand increases and/or supply reduces for that object. Hence, “preoperative wait time” will increase as demand for surgery increases and/or surgical supply (operating room availability) reduces or fails to grow proportionally to surgical demand.[3]

By accurately gauging a patient population and an operative facility's capacity, an effective manager can minimize the wait for elective and imminent procedures while covering all emergency cases and without overextending the operative team.

Case scheduling or correctly selecting the day on which to do each elective case so as to best fill the allocated hours is most important, much more so than, for example, correcting errors in predicting how long elective or add-on cases would last, reducing variability in turnover or delays between cases, or day-to-day variation in hours of add-on cases.[10]

Poor scheduling is often the cause of lost OR time. To more efficiently operate a surgical setting, managers may consider centralizing all scheduling to the operating room suite itself. Ideally, holding patient and surgeon preferences constant, an operating facility can identify cases and appropriately place them into predetermined time slots, or blocks.

To examine scheduling challenges, consider three possible surgical scenarios: elective (e.g. cosmetic procedures, stable situations not increasing in severity), imminent (e.g. inflamed gall bladder removal, potential for worsening harm if situations not surgically corrected,) and emergency surgeries (e.g. burst appendix, situations in which death or disability is possible or likely). The majority of operative time is a combination of elective and imminent surgeries. Albeit a smaller percentage, emergency surgical cases must always be handled promptly in order to ensure patient safety. Emergency surgeries are often unforeseeable and present a scheduling challenge as a result. Therefore, from a management perspective, one must use the elective and imminent surgical cases as a guideline for pre-determining operative schedules, while allowing flexibility for the emergency situations that indubitably arise.

The historical approach for scheduling operating room time is via analysis of previous surgical information. For example, to estimate how much time a cholecystectomy will require, the management determines how long previous cholecystectomy operations took the participating surgeon. Limiting this approach is the number of prior recorded cases and the surgeon's familiarity with the procedure. Previously recorded information serves to set a precedent for turnover rates. By allowing surgeons to operate efficiently based on their previous timetables, a manager allows all parties involved to work more efficiently.

Nothing is more important than to first allocate the right amount of OR time to each service on each day of the week so that rarely do services fill their allocated OR time and have another case to schedule. This allocation is based on historical use by surgeon and then using computer to minimize ratio of underutilized time and over-utilized time (which is more expensive).

A prevailing school of thought is for managers to allocate operating room time based on the principles of safety, access and operating room efficiency, in respective order of importance.[4] Part of a manager's job is to clearly communicate these factors to all parties involved in care delivery.

There are times when a departmental manager must realize a departure from this practice and intervene to save profitability margins. For instance, an anesthesia practice group may negotiate extra funds from their employer (university, hospital, multi-specialty medical groups) to compensate for underutilized operating room time. In this instance, an anesthesia manager may use predetermined formulas to estimate excess labor costs they incur that are not offset by proper operating room utilization.[11] A manager, whether departmental of administrative, that uses proactive applications can eliminate inefficiencies within their operating systems.

Managers need to evaluate: 1) operating room leadership; 2) departmental leadership within the operating room; 3) interpersonal conflicts amongst the operating team; 4) physical layout and location of the operating room in relation to other integral departments; 5) operating room communication systems; and 6) patient turnover.[12]

Only then can options such as providing rewards and incentives for improved operating room efficiency, assessing logistical and system design, delegating responsibility, and implementing teamwork initiatives be instituted to produce more favorable outcomes for both the provider and the patient.

Generally, an institution or private surgery center will have an agreed upon leader, generally dubbed the “Operating Room Manager.” The reporting structure is typically to a VP of surgical services. A manager may have the business and academic ability to operate a facility, but without the cooperation of staff and practitioners, most reform efforts will be futile.[4]

An OR manager must be in compliance with several internal and external governing bodies. Depending on the institution, a given manager may have to work closely with committees ranging from patient safety and medical staff safety boards to an auxiliary OR committee. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS) puts forth an external, universal regulatory standard for hospitals and ORs. An OR manager must maintain compliance with this spectrum of policies in order to maintain both patient safety as well as hospital accreditation.[3] One of many notable policies put forth by JHACO [Joint Commission] is the universal protocol, implemented to ensure patient safety. This protocol requires that three sequential events must be completed prior to surgical incision in order to reduce iatrogenic errors and postoperative complications. The three checkpoints are (1) preoperative verification of procedure and background information, (2) marking of the operative site with a marker and surgeon's initials, and (3) an official timeout for an audible confirmation of patient identity and the procedure to be completed. These regulations have proven to reduce avoidable complications of intraoperative mistakes and resultant postoperative morbidities and mortalities.

This topic compartmentalizes each member of a surgical suite team to his/her department (e.g. surgery, anesthesiology, environmental services, housekeeping, etc.). The principle behind departmental leadership is the delegation of responsibility. An operating room manager must rely upon departments to uphold their respective regulations in addition to acting in the best interest of the overall institution. This interest directly relates to operating room utilization and operating room productivity. Therefore, a surgical chief must be an active member of scheduling block time for surgery in order to avoid persistent over or underutilization of resources.

The majority of accidents in technical professions have human error as causal elements. More critically, these errors tend to involve interpersonal issues: communications, leadership, conflict, flawed decision making, etc.[13] A questionnaire circulated to operating room staff and professionals identified communication problems as an overwhelming barrier to operating room performance.[14] This problem is a constant theme within healthcare and can disrupt an operating room and detract from operating room efficiency. It is imperative that a manager optimize personal issues and act quickly to correct them.

An effective manager must analyze the layout of each operating room individually and as a whole. The mass of new technologies and equipment, such as Endoscopic surgical procedures, in today's operating room is increasing. Crowding may adversely affect the abilities of the surgical team.[15] Managers must act to appropriately modify pre-existing operating room space or by identifying key design issues during the conception and building of new facilities. Larger cases where more materials and instruments are used should be appropriately scheduled into rooms that can accommodate them.

Likewise, the surgical suite ideally is placed in close proximity to support functions such as radiology, pathology, and intensive care.[4] Creating unnecessary distance between these entities compromises both operating room efficiency and patient safety.

Surgical Suite Communication Systems and Patient Turnover

Current technologies provide managers with tools to reduce patient turnover rate. Standard practices include passive status displays (whiteboards or screens in the surgical suites) and active displays (text pager notifications). These communication tools streamline interdisciplinary planning for real time decision-making. A recent study suggests going further and implementing a system of command displays (text suggestions of how to act)[6] or even patient tracking systems such as with RFID tags. This communication is essential to know when to expect patients to arrive to the holding area prior to entering the OR, or to the recovery room after surgery.

Reduction in turnover time (patient exists operating room until next patient enters operating room) requires all individuals in the surgical suite to work together. The day-to-day management of operating room efficiency is integral to the maximization of both qualitative (improved professional satisfaction) and quantitative (completion of more cases and reduced staffing costs) returns.[16]

Surgical Care Improvement Project (SCIP)

SCIP is a national partnership of organizations [www.medqic.org/scip] that are dedicated to reducing postoperative complications.

The project focuses on four broad areas in which the incidence and cost of complications are high: (1) Surgical site infections, (2) Perioperative myocardial infarctions (heart attacks), (3) Venous thromboembolism, and (4) Postoperative pneumonia.

An operating room manager must consider the preoperative, intraoperative and postoperative factors which reflect in patient safety and hospital efficiency. Ideally, a manager is approachable, intelligent, and an effective leader who communicates well with hospital staff. The above techniques and principles highlight many of the ways in which a manager can successfully direct a surgical suite to maximize its benefit to the patients, staff and hospital.

1. One possible solution to intrapersonal conflict within the operating theatre is medical simulation training. Large institutions are adapting simulator practices to teach everything from communication skills to proper clinical management of crises situations. By identifying interpersonal barriers in a closed environment, a manager can work with all parties involved to address and resolve these problems. Such interventions will reduce intraoperative error as a result of personal conflicts and serve to increase efficiency.

2. Ultimately, a manager may improve hospital functioning by providing rewards and incentives for improved efficiency, assessing logistical and system design, delegating responsibility, and implementing teamwork initiatives. These topics are beyond the scope of this article.

3. Those seeking to learn more about operating room management may find Dr. Franklin Dexter's website of help:

4. Interested persons may also explore topics in administrative structure and supply chain management.