Published on 07/02/2015 by admin
Filed under Anesthesiology
Last modified 22/04/2025
This article have been viewed 2019 times
James D. Kindscher, MD
The operating room (OR) is a complex and dynamic part of a health care system. Although many centers expect the OR to produce strong profit margins, it is also well recognized that this unit is very expensive to run. The OR relies on coordinated activities among medical specialties, nursing, and support staff to function at an optimal level. The subject of OR management is broad and can be found in more detail in the literature. This chapter will describe aspects of OR management that are important to the anesthesiologist.
Most hospitals have an OR committee that is active in directing the function of this unit. This committee usually consists of leaders in the different sections of surgery, anesthesiology, and hospital management. The scope and authority of the OR committee depend upon local facility and medical practice governance structures. Often this committee will review performance standards, develop policies, offer budgetary guidance, and allocate OR time to surgeons or divisions.
The OR committee is not designed to meet the day-to-day needs of the OR, nor is it able to personally intervene when a challenge occurs in this unit. Therefore, many hospitals have created the position of medical director of the OR. This person is charged with leading improvements in the OR and ensuring compliance with the directives of the OR committee and hospital leadership. The medical director must balance the needs of physicians, nurses, hospital, and patients to maximize OR performance. Anesthesiologists frequently serve in the role of medical director because they are present in the OR on a daily basis, understand the different aspects of OR throughput, and can balance the needs of the different groups working in this area. The medical director position may require significant time and energy from the physician and should be supported by both the physician’s group and the hospital. The expectations for this position must be clearly defined. Responsibilities may include policy development, conflict resolution, regulatory compliance, participation on committees related to OR function, and daily supervision of the unit.
Surgeons, anesthesiologists, nurses, and hospital leadership all have different views on what OR efficiency means. Surgeons want convenient and readily available OR access, anesthesiologists want smooth-running schedules, nurses desire predictable shifts, and hospitals seek maximal profit margins for this costly unit. The medical director can help bridge these different interests to help the OR achieve its best function. Some of the key areas of focus for OR efficiency are scheduling, first-case starts, turnovers, and daily schedule management. Agreement on the definitions of these terms is essential.
Scheduling may be the single most important step in making an OR function well. Accuracy of the data is paramount; the procedure description and case length should realistically match what is to be performed. Errors in scheduling will inevitably lead to delays, lack of proper equipment, and dissatisfaction among the OR team. OR time may be granted to surgeons at regular intervals, called blocks. Surgeons are given a set time to schedule cases in an OR, based on their previous usage of OR time. This block time may be held for this surgeon up to several days prior to the anticipated date of surgery. If the block is not filled, then it may be released so that another surgeon can post a case in the unused time. Most ORs have a combination of block time and open (unblocked) time. The percentage of block versus open time is dependent on the surgery makeup in each hospital.
First-case on-time starts set the emotional tone for an OR. Usually an OR that has a high percentage of on-time starts will also be efficient in other areas of OR throughput. Delays in starting the first case may be related to the surgeon, anesthesiologist, nurse, patient, or hospital support. An objective analysis of delays may help to direct resources in the best way to improve on-time starts.
Perhaps the biggest area of focus by OR committees is turnover time. An immense amount of activity is required by the OR team to prepare an OR from one case to the next. Despite this fact, many members of the OR committee believe turnover times can be reduced to unreasonably short intervals. The OR may set goals for turnover time based on case complexity and personnel. Reasonable turnover times of 15 to 30 minutes are often achievable with commitment of the entire OR team.
Daily schedule management is an essential part of a well-run OR. Because there are frequent changes in the surgery list of cases, with add-ons and cancellations, it is important that the OR be adaptable to applying resources where they can best be utilized. Delays or complications in a surgical procedure may necessitate moving patients into different rooms. Communication between the OR medical director and OR nursing leadership is a key step in making this process work smoothly. It is also important to plan ahead and to anticipate potential roadblocks to the progress of the surgical schedule.
A common method of measuring the function of an OR is calculating the amount of time that this resource is used in actually performing surgical cases. There are different ways to define OR utilization. Perhaps the most commonly used calculation of OR utilization is the amount of time devoted to a case (room set-up time plus OR time for the case plus OR cleanup time) divided by the amount of time the OR is staffed and available. OR utilization goals are dependent on the types of operations performed in a hospital, the need for open time to manage emergencies, and the percentage of trauma or transplant cases that require short schedule-to-incision intervals. A utilization of 80% or more is most often necessary to balance the costs of staffing this unit.
One misunderstood aspect of OR utilization is the concept that utilization equates to OR productivity. Utilization is only a measure of consumption of a resource; it does not account for how well that resource is managed. As an example, if one surgeon spends twice as long to do a common procedure as a different surgeon, then the first surgeon may have greater utilization than the faster surgeon. Likewise, surgeons who perform long, complex procedures often have greater utilization than do surgeons who are efficient in performing short cases. When an analysis is made of the cost effectiveness of an OR, a better picture of value may be obtained. Subtracting the cost per minute of a case from the revenue per minute of the case allows a better measure of OR value for a procedure or surgeon. This information is important to a hospital in determining allocation of resources or expansion of services.
Because the majority of hospital revenue is derived from a bundled payment (diagnosis-related group, or DRG) structure, it is essential that costs for delivery of a service are well controlled. The OR represents one of the most expensive units in a hospital. Most surgeons perform cases that can be profitable to a hospital (contribute a positive margin); however, the range of profitability between surgeons is broad and important to understand before expanding service lines. Infrastructure support, such as capital equipment and intensive care unit availability, are also considerations during surgical services planning
Anesthesia management is also an important area of hospital cost management. When anesthesia personnel are not performing procedures, they are not generating revenue. When the hospital requires availability of an anesthesia service but has lower utilization of that service, then gaps in that support must be accounted for. Examples of areas in which these gaps occur include low utilization of elective OR times and specialty-call coverage (e.g., cardiac, obstetric, pediatric, transplant, and trauma). Because of these issues, hospitals will often contract with the anesthesia group to provide this service coverage in exchange for a fixed level of support.
Anesthesia pharmaceutical costs average 6% of the total costs for a surgical patient’s hospitalization. Although cost differences between various agents used by anesthesiologists may seem like a potential area for cost reduction, many of these drug costs are fixed, and switching to a less expensive agent is unlikely to reduce overall expense. Regularly reviewing anesthesia drug costs and seeking best pricing in acquisition are the best strategies to employ when addressing this aspect of OR costs.
OR management is an important and necessary discipline; anesthesiologists are frequently leaders in improving OR performance. An integrated understanding of surgical, nursing, hospital, and patient needs uniquely qualifies anesthesiologists to serve in OR leadership roles.
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