turnover or delays between cases, or day-to-day variation in hours of add-on cases. 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. 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. a manager, whether departmental of administrative, that uses proactive applications can eliminate inefficiencies within their operating systems. intraoperative management issues 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. 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. surgical suite leadership 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. 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. one of many notable policies put forth by jhaco 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. departmental leadership within the surgical suite 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. interpersonal conflicts amongst the surgical suite team 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. a questionnaire circulated to operating room staff and professionals identified communication problems as an overwhelming barrier to operating room performance. 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. physical layout and location of the surgical suite in relation to other integral departments (i.e. radiology, pathology, etc.) 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. 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. 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) 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. postoperative operating room management surgical care improvement project (scip) scip is a national partnership of organizations 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. notes 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.