operating room management operating room management operating room management is the science of how to run an operating room suite. operational operating room management focuses on maximizing operational efficiency at the facility, i.e. to maximize the number of surgical cases that can be done on a given day while minimizing the required resources and related costs. for example, what is the number of required anaesthetists or the scrub nurses that are needed next week to accommodate the expected workload or how can we minimize the cost of drugs used in the operating room? strategic operating room management deals with long-term decision-making. for example, is it profitable to add two additional rooms to the existing facility? typically, operating room management in profit-oriented health-care systems (e.g. united states) emphasizes strategic thinking whereas in countries with publicly funded health care (e.g. the uk), the focus is on operational decisions. an operating theatre (gynecological hospital of medical university of silesiabytom) the act of coordinating and running all parts of a surgical suite to accomplish a defined set of goals. a most crucial field, operating room management is increasingly studied as how to best: 1) ensure patient safety and optimal patient outcome, 2) provide surgeons with appropriate access to the or so that patients can have operations in a timely manner, 3) maximize the efficiency of operating room utilization, staff, and materials, 4) decrease patient delays, 5) enhance satisfaction among patients, staff, and surgeons. this management science as applied to the surgical suite is gaining more attention because of increasing market pressures on hospitals from competitors (e.g., other surgical suites including office based surgery) and from payers seeking lower prices. the surgical suite is often considered a profitable hospital unit. as such, surgical suites also comprise an important fraction of hospital budget spending. holding patient safety constant, the opportunity to increase financial gain through modifying the use of already existing resources is a prime target for managerial analysis. incremental improvements in operating room utilization and operating room efficiency can have major impacts on hospital staff and finances. some hospital administrators perceive efficiency in the operating room as throughput, completing the most surgical cases within budget. later in this article we will provide examples of tools a manager may use to analyze efficiency. surgical suite personnel 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. the necessity of management 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. 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. principles of operating room management 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. 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. operating room utilization 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. adjusted utilization = ÷ 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 efficiency 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. the terms operating room utilization and operating room productivity are also often used when discussing operating room management of a surgical suite. performance dashboard for a surgical suite an operating room manager must select criteria, key performance indicators, or a dashboard of measurements, to assess overall functioning of a surgical suite. an example of an analytic tool used to rate surgical suites is reflected below. this scoring system was created in order to quantify the efficiency levels of surgical suites. its economical efficacy has yet to be validated by formal studies. in addition, it was developed in the us and contains scoring elements that are applicable for an american surgical suite. it is therefore unlikely to be useful for operating room managers outside the us. or efficiency measurements measurements poor performance medium performance high performance excess staffing costs >10% 5–10% <5% start-time tardiness (mean tardiness for elective cases/day) >60 min 45–60 min <45 min case cancellation rate >10% 5–10% <5% post anesthesia care unit (pacu) admission delays (% workdays with at least one delay in pacu admission) >20% 10–20% <10% contribution margin (mean) per operating room hour <$1,000/hr $1–2,000/hr >$2,000/hr turnover time (for all cases mean time from previous patient out of the or to next patient in the or including setup and cleanup) >40 min 25–40 min <25 min prediction bias (bias in case duration estimates per 8 hours of operating room time) >15 min 5–15 min <5 min prolonged turnovers (% turnovers lasting more than 60 minutes) >25% 10–25% <10% the above objective criteria can be computed from data commonly available in hospital administrative data systems. excess staffing costs nothing is more important than to first allocate the right amount of or time to each service on each day of the week for their case scheduling. this is not the same as the block time! to illustrate this imagine that two cases each lasting two hours are scheduled into or #1 with or nurses and an anesthesiologist scheduled to work an eight-hour day. the matching of workload to staffing has been so poor that little can be done the day of surgery to increase the efficiency of use of the staff. neither awakening patients more quickly nor reducing the turnover time, for example, will compensate for the poor initial choice of staffing for or #1 and/or how the cases were scheduled into or #1. optimal allocation of or time should be based on historical use by a particular service (i.e., unit of or allocation such as surgeon, group, department, or specialty) and then using computer software to minimize the amount of underutilized time and the more expensive overutilized time. under-utilized hours reflect how early the room finishes. in the example above, if staff were scheduled to work from 7:00 am to 3:00 pm and instead the room finished at 11 am, then there would be 4 hours of underutilized time. the excess staffing cost would be 50% (4 hours/8 hours). on the other hand, if 9 hours of cases are performed in an or with staff scheduled to work 8 hours then the excess staffing cost is 25%. over-utilized hours are the hours that ors run longer than the regularly scheduled or hours, or 1 hr in this example. 1hr/8hr=12.5% which is then multiplied by the additional cost of staying late, which often is assumed to be a factor of two (related to monetary overtime cost paid to staff, as well as recruitment and retention costs related to unhappy staff because they have to stay late unpredictably). or suites can reasonably aim to achieve a staffing cost that is within 10% of optimal (i.e., workload is perfectly matched to staffing). if the key is to allocate appropriate time to each service based on historical or use, how do you deal with rooms consistently running late on the day of surgery? the answer: make the allocated time, into which cases are being scheduled, longer. for example, if a surgeon does 12 hours worth of cases every day he is in the or, do not plan 8 hours of staffing (7am-3pm) and have everyone frustrated by having to stay late (overtime). rather, schedule his cases into 12 hours of allocated time (7am-7pm). that way, anesthesia and nursing staff know they will be there 12 hours when they arrive to work and overtime costs (financial and morale) will be reduced. the common response to this approach is, “no one wants to be there till 7 pm.” the answer to that is, “you are there now till 7 pm so why not make scheduled or time 12 hr long and have a more predictable work day duration.” thus, optimizing staffing costs is finding balance between overtime and finishing early. there may be concern about a nurse manager's ability to flex the staff enough to avoid excess staffing costs. it can be difficult from a human resources standpoint to match scheduled cases with staffing perfectly, such that staff still get the hours and shifts they need. for example, if dr smith needs a 12-hour block, the manager needs to find staff who want to work a 12-hour shift (or part-timers in some combination). staffing is not only an or efficiency issue, but a staff satisfaction issue. it can be a challenge at a time when recruiting and retaining nurses are growing concerns. start-time tardiness start-time tardiness is the mean tardiness of start times for elective cases per or per day. reducing the time patients have to wait for their surgery once they arrive to the hospital (especially if the preceding case runs late) is another important goal for the or manager. if a case is supposed to start at 10:00 am (patient enters or), but the case starts at 10:30 am instead, then there are 30 minutes of tardiness. in computing this metric, no credit is given if the 10:00 am case starts early (for example at 9:45 am). the tardiness of start of scheduled