1. Hurry Up and Wait: OR Efficiency
Paul Diana, MD, MPH
OR Medical Director
West Penn Hospital
Clinical Associate Professor
Temple University

2. Disclosure
No Conflicts of interest

3. Sources
Sources
Kindscher J.D. (2015). Operating Room Management. In Miller, R. (Ed), Miller’s Anesthesia, Eighth Edition (pp56- 72). Philadelphia, PA: Elsevier/Sanders.
Duhigg C. (2014). The power of habit. New York, NY: Random House.
Economics of Reducing Turnover Times. (2017). Retrieved July 25, 2017, from

4. Objectives
Understand when and how improvements in FCOT and TAT affect financial performance of OR
Name three ways to improve function on the daily schedule
Give one strategy for dealing with add-on cases the day of surgery

5. OR Efficiency What is OR Efficiency? Number of cases
Utilization of rooms
Profit
Productivity
Flow

6. OR Efficiency Medical Director OR
Day to day management/oversight, block time/utilization, safety, compliance, liaison, planning, staffing, coordination, policy and procedures, metrics

7. OR Efficiency
Advice from CMO: Abhor an empty room

8. OR Efficiency
OR efficiency
Day to day—tactical
Long term---strategic

9. OR Efficiency Basic concepts:
Under utilized OR— a room utilized less than the time it is staffed for (eg a room staffed 7-3 that finishes at 1 pm)
Over utilized OR– a room that is running longer than staffed (eg a room staffed 7-3 that is running at 4pm)
On day of surgery, an hour of under utilized time is much less expensive than an hour of over utilized time in pure monetary terms; long or chronic overutilization can also lead to dissatisfaction and turnover in OR and anesthesia staff
Long term trends should lead to changes in staffing patterns

10. OR Efficiency FCOT—first case on time, start time
Surgeon’s perception—incision time; standard definition—wheels in
Causes of delays
Surgeon controlled 60% (but we can still help them)
Patient controlled 20%
Anesthesia controlled 6%
Nursing/hospital controlled 14%
Miller pg 62

11. OR Efficiency Reason for surgeon controlled delays Data reliability
History and physical missing
Consent
Lab results
Schedule change
Availability
Data reliability
Scheduling foresight, anesthesiologist availability

12. OR Efficiency Strategies to minimize FCOT delays
Clear policies and enforcement for surgeon availability
Chart and patient preparation prior to day of surgery
Standardized preoperative orders and tests
Personnel in preoperative area to address issues
Effect of maximizing FCOT
Monetary—if convert from over to under utilized room
Non monetary—surgeon satisfaction, team expectation and performance—keystone habit; small wins

13. OR Efficiency Turn around time—TAT Defined as wheels out to wheels in
Measures ability of teams to prepare patient, clean room, gather equipment; in our institution largely OR nurses and techs and pre op nurses function; doesn’t capture time to anesthetize (anesthesia ready time) and position patient or time to awaken patient (procedure done to wheels out time).
Surgeons often focus on their own “feet out to feet in” time, or closure to incision

14. OR Efficiency
TAT—preparing a room is a complicated task requiring coordination of various teams
Clearing trash from previous case, cleaning room, pre cleaning and dropping off used instruments
Gathering equipment and supplies for next case
Dropping off specimens from previous case
Hand off and stabilization of previous patient in PACU
Preparation of anesthesia work space for next case
Pre operative area ensures next patient is ready
Safe handoff and review of patient from pre op to OR team

15. OR Efficiency TAT vary according to service TAT strategies
CABG 52 minutes
Total knee 46 minutes
Laparoscopic cholecystectomy 30 minutes
Cataract 21 minutes
TAT strategies
Turn around team—room cleaning, equipment and supplies
Effective communication between services
Timely anesthesia pre op
Process analysis
Planning for transport, lines, extended prep, ancillary help (laser tech, ortho equipment representatives, X ray, neuro monitoring)
Don’t let teams get stuck
pg 63

16. OR Efficiency TAT—does it make a difference
Depends on time savings and room utilization
If there are three turn overs in a room, and the TAT is reduced from 40 to 30 minutes, 30 minutes are saved
If that savings moves room out of over utilized category, then there’s a definite savings
Unlikely 30 minutes will allow for extra case to be performed
Can increase team and surgeon satisfaction
Keystone habit—can build teamwork, focus team on efficiency, engender other positive outcomes
Unrealistic expectations not useful
Duhigg pg 101

17. OR Efficiency OR utilization
Ideal utilization of OR: different perspectives
Surgeon, anesthesiologist, CRNA, circulator/scrub tech, hospital administrator
Raw utilization is percentage of time a patient is in an OR room, divided by total time available
Adjusted utilization includes turn over time in raw utilization data

18. OR Efficiency
As utilization increases, resources are more fully used and revenue increases
As utilization increases, more time will be spent in over utilized rooms
As utilization increases it is harder for surgeon’s to get OR time, and patients may end up waiting longer for surgery

19. OR Efficiency
Raw utilization is the amount of time patients are in a room divided by the amount of time the room is staffed.
Adjusted utilization adds TAT to raw utilization.
70-85% are common goals
Ideal utilization is not a sufficient goal: imagine three 90 minute cholecystectomies vs two three hour ones; or imagine turn over times increasing raw utilization by 50% or more
As reimbursement for cases shifts to bundled payments for episodes of care these distinctions will become more and more important

20. OR Efficiency
Hospitals already track data on collection for OR minute by surgeon. Most surgeons generate revenue with their cases, but margins vary widely and will vary more with different payment mechanisms. As margins fall, OR space will likely be awarded at least partly on these margins.

21. OR Efficiency

22. OR Efficiency Factors to increase utilization Full day blocks
Same surgeon in same room
Verify schedule accuracy—issues with average time
Streamline preoperative processes and testing
Use specialty teams of nurses and anesthesia personnel
Organize supply and equipment needs for room setup
Focus attention on room starts and TATs to create a culture of timeliness and efficiency
Open room(s)
Communication throughout perioperative areas

23. OR Efficiency Daily schedule management Moving cases Add on cases
Cancelled cases
Using OR and anesthesia work force efficiently

24. OR Efficiency OR nursing director’s goal’s may include
Stay in budget
Minimize displeasure of staff
Can be at odds with efforts to increase productivity
Fully use underutilized time
Surgeon and patient satisfaction
Profit margin
Ultimately a useful conflict
Anesth Analg Dec;107(6): Operating room nursing directors' influence on anesthesia group operating room productivity. Masursky D1, Dexter F, Nussmeier NA.

25. OR Efficiency

26. OR Efficiency Check schedule day before surgery Policy for add-ons
Steps for managing daily schedule
Check schedule day before surgery
Policy for add-ons
Use open rooms effectively
Review morning of surgery
Deploy personnel from cancelled cases
Strive for FCOT
Set expectations for TAT
Realistic staffing patterns
Organize turnover process with attention to peak turnover times
Case tracking system so all preoperative area can track progress
Miller pg 66

27. OR Efficiency Assess high cancellation rates (>6-10%)
Cancellations and add-ons
Assess high cancellation rates (>6-10%)
Emergent/urgent add-ons bump add-on surgeon or service
Common reasons:
Use open times or early rooms
Resource based
Strive for open room daily
Medical issues
Add-on policies:
Scheduled cases first if possible

28. OR Efficiency My experience: Changing behavior is hard
Few real “teams” in OR
Hospital administration benefits from decentralized control
Regulations are relentless
Success isn’t always what you expected

29. OR Efficiency
Key points
As utilization increases pressure for efficiency and block time will increase
Maximize underutilized time, minimize over utilized time
Have plans for daily management, especially how to deal with add-ons and cancellations
Increasing FCOT and decreasing TAT directly help bottom line if they achieve above; but they also have many secondary gains

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