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January 16, 2018


To improve efficiency in the OR, reduce your hours of over-utilized OR time, increase first-case on-time starts, use an OR manager with a solid grounding in the scientific principles of OR efficiency to drive improvement with electronic notifications, and search the scientific literature to find examples of what works.  We summarize these and other recommendations from a presentation by Franklin Dexter, MD, PhD, of the University of Iowa at ANESTHESIOLOGY® 2017.

One way for anesthesia groups to strengthen their relationships with the facilities they serve is by demonstrating their department’s ability to achieve lasting gains in operating room efficiency.  Though anesthesia services aren’t typically thought of as among a hospital’s most visible service lines, they’re directly linked to one that is—surgery.  And because surgery produces a substantial portion of hospital revenues, increases in productivity generated by the anesthesia service can have far-reaching impact.

According to anesthesiologist and OR management consultant Franklin Dexter, MD, PhD, of the University of Iowa, the most effective way for anesthesia departments to increase OR efficiency is by applying evidence-based principles to achieve reductions in the hours of over-utilized and under-utilized OR time.  It’s commonly assumed that the way to improve OR efficiency is to improve the number of on-time starts, but while this certainly helps, the number of on-time starts is not actually a measure of OR efficiency, explained Dr. Dexter, who spoke at ANESTHESIOLOGY® 2017.  “If you want to improve OR efficiency you need to measure OR efficiency, which is based on maximizing the efficiency of the use of OR time.  Good OR management decision-making before the day of surgery and on the day of surgery is exquisitely sensitive to high quality statistical calculations of the hours into which cases are scheduled.”

Among Dr. Dexter’s recommendations:

Take the time to do the math.  The inefficiency in the use of OR time is determined by the weighted combination of over-utilized OR time and under-utilized OR time, Dr. Dexter noted.  For this reason, the OR time into which cases are scheduled should not be set by committee; rather, it should be calculated based on three simultaneous equations for evaluating under-utilized time, over-utilized time and the allocated OR time for which under- and over-utilized OR time are determined.  “If a committee says we schedule cases till 5:00, the hours beyond 5:00 are not necessarily over-utilized OR time,” he said.  In addition, Dr. Dexter defines allocated OR time as the hours in which cases are scheduled, not the hours in which staff are scheduled.

Dr. Dexter explained how to use the mathematical formulas (available here) derived by Strum, Vargas and May.  One of these is:  inefficiency of use of OR time = (cost per hour of under-utilized OR time) x (hours of under-utilized OR time) + (cost per hour of over-utilized OR time) x (hours of over-utilized OR time).  The formulas can be used to support more solid management decisions regarding how OR time should be scheduled before and on the day of surgery. 

Increase first-case on-time starts.  Dr. Dexter reviewed research by Sophie D. Lapierre and her colleagues showing that when the hospital staff responsible for transferring patients to the holding area arrived in a timely fashion, the anesthesiologists and surgeons were more likely to be on time as well.  Although multiple studies bear out the common assumption that surgeon tardiness is the most frequent cause of late first-case starts, attempting to address the problem by focusing directly on changing the surgeons’ behavior usually doesn’t work.

Instead, “consider longitudinal changes over time—progressive changes over months in reducing tardiness of first-case starts,” he said.  This approach means starting with the porters and other staff who are charged with moving patients to the holding area, then focusing on the OR nurses, then the anesthesia providers, and finally, the surgeons.  Surgeons are the main cause of delay for first cases, but departments should not target them initially, because starting surgical cases is a chain, a series of steps to be performed. 

Use the data that are already available.  Organizations put too much emphasis on the importance of their own data and are often frustrated when that data fails to yield the desired results.  Start with a literature search.  “The time it takes to do a literature search is not extra time.  In order to know whether the analysis you have done with your data is reliable, you have to do a literature search anyway,” he said.  Many problems with OR efficiency have already been addressed by other institutions, so there is no need to reinvent the wheel.  The results found elsewhere can be applied in your facility.

Drive improvement “autocratically” through an OR manager who understands efficiency science.  Organizational research summarized by Dr. Dexter reveals that when it comes to improving efficiency, individuals perform more effectively than groups.  This is partly because groups tend to have cognitive biases that are often highly resistant to change.

A survey of surgeons, anesthesiologists and OR nurses by Dr. Dexter and his colleagues showed that most of the respondents lacked scientific knowledge regarding OR efficiency and the hours of over-utilized OR time.  “If you don’t have knowledge, you focus on what you think is important, and it’s inaccurate,” he said.  However, even among those who had some scientific knowledge about the principles of OR efficiency, such as the important finding that most surgical cases actually take less time than scheduled, “not a single person applied that knowledge,” because “cognitive bias is immutable to education,” Dr. Dexter said.

The value of education is to realize the importance of applying evidence-based statistical concepts to achieve sustainable improvements.  Some groups, for example, are fixated on the notion of on-time starts as a measure of OR efficiency, believing, erroneously, that if the first case of the day starts 10 minutes late, then all subsequent cases in the OR will start late as well.  This assumption is false, because the data show that most cases actually take less time than scheduled.

“Cognitive bias is what you don’t want to have driving your organization.  These biases can be amplified by small groups,” explained Dr. Dexter.  One effective way to achieve efficiency goals is with a manager who understands the science and identifies ways to drive efficiency in a relatively autocratic manner.  Another is for the people involved to be educated; but, Dr. Dexter explained, education is a course, not a lecture like the one that he was giving.

Provide electronic notifications with evidence-based recommendations.  One key thing that the OR manager can do is to send electronic notifications to OR staff throughout the course of the day offering evidence-based recommendations regarding which ORs are expected to have over-utilized OR time, Dr. Dexter said.  He summarized others’ studies showing that each patient’s information can be reviewed repeatedly and an escalating notification system can be used to contact team members to remind them to attend to pending tasks.  Rather than expect members of the OR team to look at a display board, notify them of the next task.  For example, Michael Brown and his colleagues at Mayo Clinic had patient care assistants notified 45 minutes before the start time to go to the ICU to begin preparing the patient for transport to the OR.  Research shows that these notifications significantly reduced delays in first-case starts.

Target the ORs with expected over-utilized OR time starting the afternoon of the working day before surgery.  This is particularly important when anesthesiologists are supervising more than one OR.  Dr. Dexter used an example for when it is twice as expensive to finish late than to finish early.  The mathematical consequence is that two thirds of the ORs should have under-utilized time and one third should have over-utilized time.  If an anesthesiologist will be supervising three rooms, the room with the expected over-utilized OR time should be started first.  Be aware of the fact that you are going to have differences in start times for the three rooms.  So, target the rooms with over-utilized OR time, and notify the surgeons about it, Dr. Dexter advised.  “The value of letting people know that they’re going to be in the room that’s starting later creates an incentive to target that OR,” he said.  Preferentially focusing on the ORs with over-utilized time will help reduce the hours of over-utilization and reduce the hours anesthetists, nurses and anesthesiologists work late.

Extensive resources on OR efficiency, including PowerPoint presentations, papers published by Dr. Dexter and others, and educational courses can be found at Dr. Dexter’s website here.

With best wishes,

Tony Mira
President and CEO