➢ In the operating room setting, optimal efficiency is achieved by the ability to deliver the highest-quality care with the minimal use of time, money, and space.
➢ The recent implementation of quality-improvement methodologies aims to improve patient care and cost-effectiveness in the health-care setting by enabling a system to identify and target valuable metrics of operating room inefficiencies.
➢ The operating room schedule must be developed using a well-planned approach with strategies to buffer unexpected variables, such as moving a patient to another available operating room in cases of delay, while taking into consideration the preferences of the surgeon and staff.
➢ The preoperative medical clearance is essential for managing the risk factors associated with negative outcomes and also can help in predicting and avoiding potential medical factors that might lead to operating room delays and inefficiencies.
➢ All improvement techniques should be managed and implemented by hospital administration personnel and surgeons to ensure optimal operating room efficiency, patient satisfaction, and improved outcomes.
Health-care expenditure in the United States was $1.2 trillion in 2012 and is projected to increase to $2.5 trillion per year by 20231,2. With the current trends of unsustainable growth and increasing cost, health-care facilities are faced with a crucial need to optimize productivity and decrease expenditure while continuing to provide patient-centered care3.
The operating room is often considered the financial epicenter for many hospitals, accounting for about 35% to 40% of costs and 60% to 70% of revenue. With the cost of operating room time ranging between $22/min and $133/min (average, $62/min), substantial cost-saving measures are essential4-6. Surgical cost reduction is especially relevant in orthopaedic surgery as total joint arthroplasty procedures in the older population are among the highest of all health-care expenses7. The number of total knee arthroplasty procedures is projected to increase by as much as 673%, up to 3.48 million procedures per year, by 20308,9. Likewise, the prevalence of total hip arthroplasty is project to double by 20267. While Medicare reimbursements for this older population have increased to help offset the growth in health-care expenses, the cost of providing quality care with newer technologies, particularly joint prosthetics, is rising considerably faster7,10,11. In order for hospitals and orthopaedic departments to successfully maintain financial stability, they must establish a more cost-efficient operating room.
Operating room inefficiency is directly linked to increased costs for the patient and the hospital, decreased satisfaction in operating room staff and patients, and, most importantly, increased patient morbidity, with reported rates as high as 42.4%11-17. Within the health-care setting, quality involves patient safety, improved outcomes, and patient and staff satisfaction (Fig. 1). Patient satisfaction has been viewed as a potential quality measure for physician performance, yet a clear link to patient outcome, whether positive or negative, has been difficult to ascertain13,18. With the future of medicine moving toward a pay-for-performance metric system, this concept may be of increasing importance, further emphasizing the need for preservation of high-quality care alongside efficiency in the operating room19. By improving the preoperative process, it may be possible to increase operative efficiency, decrease patient complication rates, decrease cost, and improve quality of care9,20-28.
In this article, we consider “efficiency” as more than just the operating room procedure time—we examine the entire operative process, with a subsidiary focus on both the quality of patient care and the monetary expenditure impact on the health-care economy. Optimal efficiency can be achieved by a reduction in minutes and dollars spent in the operating room with a simultaneous improvement in the quality of care delivered11,20. An understanding of all three of these components is vital in producing optimal efficiency within the surgical process.
Saleh et al. previously highlighted the implications of operating room efficiency and presented possible interventions8. We present a two-part updated literature review with a similar framework that assesses the new advances in operating room efficiency improvement, with a special focus on orthopaedic surgery. In Part 1 (the present report), we confront general management practices, address new strategies in the preoperative portion of the surgical process, and, finally, present an overview with our recommendations. Variations in both preoperative and managerial approaches have the potential to dramatically improve operating room efficiency, but these entities often receive little consideration by the surgeon.
General Managerial Strategies for Improving Operating Room Efficiency (Table I)
The recent implementation of quality-improvement (QI) methodologies, originally designed and proven successful in the manufacturing industry, aims to improve patient care and cost-effectiveness in the health-care setting29-31. Nicolay et al., in a systematic meta-analysis, reviewed several quality-improvement methodologies (including plan-do-check-act and plan-do-study-act cycles, statistical process control, statistical quality control, continuous quality improvement, total quality management, Six Sigma, Lean, and Lean Six Sigma) and their ability to positively affect a health-care process in terms of multiple variables21. In the studies examined, all of these methodologies were shown to provide benefit to nearly every process in which they were applied. For instance, Does et al. applied Six Sigma ideals, which focus on reducing error and process variability, to their surgical process and found that poor planning and scheduling processes were key factors in delayed operating room start times32. Identifying these flaws allowed for the development of “Standard Operating Procedures” or SOPs, which led to a >25% reduction in operating room start-time delays32. Hence, a quality-improvement strategy was used as a springboard to stimulate change toward a more efficient system in their hospital32.
Nicolay et al. also reported that the utilization of quality-improvement methodologies has the potential to indirectly reduce operating room costs as well as improve surgical care by increasing the quality of the procedures and/or protocols used21. Generally, all of these quality-improvement strategies enable a system to identify valuable metrics of operating room inefficiencies and to use that information to stimulate the change most valuable to each health-care center. Specifically, these management strategies can affect repetitive standardized processes such as infection control, antibiotic administration, and pain management, to name a few, leading to a reduction in delays and length of hospital stay21.
In order for any of the quality-improvement methodologies to be successful, two aspects must be taken into account: (1) the baseline process function prior to quality-improvement implementation and (2) the sustainability of the process after intervention29. Identifying the root cause of operating room inefficiency can be just as valuable as the improvement itself. Through data collection, statistical process control (SPC) is a quality-improvement strategy that allows the identification of inefficient processes21. Following identification, factors affecting operating room efficiency can be targeted and minimized, leading to sustainable improvement. Sedlack noted that the use of statistical process control revealed that surgeons had an average waiting time of fifty-one minutes between procedures, with one surgeon spending 29.5 hours per month waiting for the next procedure to start33. In the study by Seim et al., statistical process control showed that that multiple small improvements in an operative process can have equal or greater potential to considerably increase operating room efficiency as compared with large drastic changes34.
Failures in team communication, patient safety, and equipment might cause a detrimental disruption of the surgical process. The Metric for Evaluating Task Execution in the Operating Room (METEOR) system, developed by Russ et al., evaluates predetermined key tasks within the operating room and assesses the efficiency and accuracy of their completion35. Russ et al. created a list of eighty commonly observed operating room-associated tasks and subdivided them by their relationship to the patient, equipment, or communication35. Identification and assessment of the accuracy and timeliness of completing these tasks can provide information necessary to make noticeable improvements in patient care and operating room efficiency35.
Lean and Six Sigma processing recently have gained popularity as management techniques in the health-care field21,29-31. Lean methodology continually reduces waste and improves workflow, leading to a higher product or service value. Six Sigma reduces the variations within a process and decreases error rates within a minimum of six standard deviations from the individual process average29-31. Lean Six Sigma (LSS) is the simultaneous application of both principles toward a single process21,29-31. Lean Six Sigma was utilized in multiple studies for the construction of a value map detailing patient management from the time of surgical consultation through the postoperative recovery period21,29,36. These Lean Six Sigma data-recording techniques proved to be valuable and cost-effective systems that may be utilized widely to evaluate operating room efficiency and patient care. The data system also serves as a comprehensive tool for physicians and administrators to assess and improve surgical processes29,36.
Lean Six Sigma can potentially affect other less-obvious aspects related to the operating room team, such as interdisciplinary relationships and resident education. Collar et al. found, through the use of validated surveys and the Likert scale, that the implementation of Lean processing had a significant positive impact on teamwork and morale (2.93 compared with 3.61; p = 0.011) without affecting the resident education process31.
The Surgical Safety Checklist was originally adapted from the field of aviation, where such a checklist proved to be a useful template for safety improvement37. Medicine, much like aviation, is a complex field with frequent time-crucial events and potential for devastating human error22,37. Checklists can be utilized to target specific causes of reduced operating room efficiency such as first-case delays. The World Health Organization (WHO) Surgical Safety Checklist was developed to confirm patient safety before each of the three distinct operative phases: “sign in” (prior to anesthesia induction), “time out” (prior to incision), and “sign out” (from completion of the procedure until staff departure from the operating room)22. One study demonstrated that implementing a WHO-adapted surgical safety checklist reduced disposable equipment costs (a finding attributed to better teamwork) but failed to significantly improve operative time, first-case delays, and case cancellations23. On the other hand, Panni et al. noted a significant reduction of 49.2% (p < 0.001) in first-case delays when a checklist was implemented along with the participation of an operating room facilitator who was responsible for enforcing adherence38.
Surgical checklists can potentially address various sources of operating room inefficiency and suboptimal patient safety, and specific checklist content can thus be personalized to specific institution needs22,23,38,39. Russ et al. noted a checklist-associated improvement in the self-perception of operating room team communication, a decrease in near misses (nonroutine events) and other adverse events related to poor communication, and stimulation of open dialogue among staff members, leading to an enhanced team attitude22. Einav et al., at another institution, observed a 16% decrease in near misses and found that longer orthopaedic procedures were influenced more than shorter procedures were40. Furthermore, Semel et al. found that a relative reduction of 10% in the rate of major complications and a cost savings of over $100,000 per year could be obtained with utilization of the WHO Surgical Safety Checklist41.
On the other hand, there is concern that surgical checklists may negatively affect the operating room environment by disrupting positive communication, emphasizing professional partition, and creating interprofessional tension22. Fourcade et al. suggested that current checklists are often too lengthy and time-consuming, given an already heavy workload, leading to the potential for additional delays and/or conflicts42. It has been postulated that checklists may be an inappropriate allocation of time without perceived benefit22,42. While the implementation of surgical checklists can aid in the reduction of avoidable morbidity and mortality, especially in near-miss scenarios39, their impact on surgical team cooperation remains inconclusive22.
Preoperative Strategies for Improving Operating Room Efficiency (Table II)
Patient Safety and Complication Prevention
To ensure the highest quality of care for patients undergoing surgery and to optimize cost-effectiveness, common devastating complications like surgical site and periprosthetic joint infections should be anticipated and prevented whenever possible43,44. The incidence of infections associated with total knee arthroplasty has been reported to be 0.7% to 2.4%45. This complication often requires hospital readmission and extended medical treatment, possible multiple surgical interventions, and rehabilitation45. Periprosthetic joint infections are associated with a fivefold increase in cost per patient and represented an estimated $566 million annual burden in the United States in 2002, which is projected to increase to $1.6 billion by 202045.
Staphylococcus aureus is the most commonly identified organism in cases of periprosthetic joint infection46-49. The prevalence of methicillin-resistant S. aureus (MRSA) colonization has been reported to be as high as 30%46,47. For known carriers, prophylactic decolonization has the added benefit of eliminating the need for contact isolation during transport of these patients to and from the operating room, further streamlining perioperative patient care46,50. The cost of testing and treating colonized patients ranges from $100 to $30050. The current literature indicates that preoperative decolonization is associated with a significant (p < 0.03) reduction in postoperative surgical site infections in patients colonized with MRSA and therefore supports its utilization46,48. Given the substantial cost burden of periprosthetic joint infection, with a potential fivefold increase in cost, standardized preoperative MRSA screening and treatment are likely to provide benefits on both patient-outcome and economic scales45,46,48-50.
Operating Room Scheduling and Time Allocation
Traditionally, a first-fit approach is utilized to organize the weekly operating room schedule, with scheduled procedures organized on a first-come basis, without necessarily taking full advantage of the potential resources and space24. On the other hand, organizing the procedures into operating room blocks based on historical procedure durations for each surgeon could ensure adequate time and space allotment for each case and could free up extra operating room space3,25.
The elimination of inconsistencies in day-to-day operating room schedules can be achieved with the use of “variability methodology” in operating room scheduling51. By evenly distributing weekly procedures, a more reliable agenda can be optimized to decrease wasted time and space51. Dexter et al. provided mathematical formulas that can be utilized by surgical teams to calculate their own projected financial savings that can be achieved through reducing staffing costs via reductions in turnover times25. These calculations provide the theoretically optimal amount of operating room time, which can be utilized to implement a personalized variability management plan. This strategy may substantially improve operating room throughput and financial performance while minimizing resource underuse51. This program relies on a cultural change that asks health-care practices to manage scheduling on the basis of what is best for the hospital as opposed to what is best for the surgeon51. This requires surgeons to completely manage their schedules around the operating room availability; thus, this change may be met with some resistance. Because of reduced surgeon satisfaction, scheduling using variability methodology has been found to augment tension between surgeons and hospital administration personnel51. For this reason, it is suggested that a detailed assessment of the hospital’s culture, its surgeons, and the willingness of the surgeons to accept change should be undertaken prior to implementation51. Attarian et al. found that operating room turnover efficiency could be further improved by creating an “A team” specifically for high-efficiency operating rooms3. “A teams” (consisting of a nurse-circulator, a scrub technician, a room attendant, and an additional person for turnover) were assigned to individual surgeons. In addition, specified anesthesiology teams were assigned to the project as a whole to improve the likelihood of success. This strategy, along with the utilization of parallel processing, aided in reducing turnover time from more than sixty to less than thirty-five minutes3.
Belmont et al., in a multivariate analysis, found that increased patient age (more than eighty years) was the strongest predictive factor for operating room complications, followed by a lengthy procedure (>135 minutes), a high American Society of Anesthesiologists (ASA) score (≥3), and, finally, class-III obesity (body mass index [BMI], >40 kg/m2)16,52. With regard to body weight, as much as a 22% increase in surgical time has been observed in patients with class-III obesity compared with patients with a normal BMI53. Complication rates and intraoperative times have been noted to be higher for patients with a higher BMI, resulting in higher operating room costs (staffing costs, additional equipment needs, etc.)53-55. Hence, an efficiency benefit may be obtained by actively applying this aspect alongside other important patient-related factors (age, comorbidities, etc.) when developing the operative schedule53,55 In fact, one article suggested that scheduling the more complicated procedures toward the end of the day may reduce the next-case delay that is likely to result following such procedures55. Another option is to intersperse difficult procedures in high-risk patients with more simple procedures in order to potentially make up time, resulting in an overall smaller operating room time delay56. Perfectly planning the operating room schedule to obtain the most efficient use of staff and space is ideal. Finding a balance between flexible and stringent scheduling that can actively manage unpredictable emerging variables must be the final aim. Thus, developing a well-planned schedule with strategies to buffer delays, such as moving a procedure to another available operating room when the prior procedure in the scheduled room is not completed on time, will allow for the potential to substantially reduce start-time tardiness26. However, imposing the operating room schedule on surgeons, without taking into consideration their preferences and other commitments, may create multiple conflicts and lead to decreased surgeon satisfaction, which may ultimately negate other potential improvements in efficiency26.
Reducing Preoperative Delays and Improving Operating Room Case-Start Times
Prior to a procedure, a patient must undergo medical clearance. A thorough evaluation of the patient’s medical status is essential for assessing the risk of an adverse event occurring during surgery as well as for guiding preoperative intervention to better ensure positive outcomes57,58. The physician should identify major contraindications to surgery while enabling the optimization of intravascular volume status, the medical anticipation of intraoperative complications, the management of pain control, and the management of drugs when applicable57,58. Moreover, predicting and taking into consideration medical factors that might cause delay in surgery start time can lead to improved operating room efficiency. For example, ensuring that the patient’s blood has been typed and cross-matched one day prior to surgery would theoretically decrease potential postponement of the procedure caused by the unavailability of appropriate blood products. The overall goal is to deliver high-quality medical care and to increase the likelihood of a safe, successful, on-time intervention, thereby decreasing patient morbidity and surgical delay.
Furthermore, patients with renal, gastrointestinal, hepatic, pulmonary, and cardiovascular abnormalities are at higher risk of morbidity and mortality following orthopaedic surgery59-76. As an example of renal complications, acute kidney injury is relatively prevalent among hospitalized patients, particularly following surgical intervention, yielding 30% to 40% of all acute kidney injury cases77. Using the Risk, Injury, Failure, Loss, and End-stage kidney disease (RIFLE) or the Acute Kidney Injury Network (AKIN) criteria, which are both based on urine output and serum creatinine levels, surgeons can preoperatively identify patients who are at greater risk of acute kidney injury and adjust their management to ensure optimal surgical outcome78,79. Patients with inflammatory diseases, for example, are predisposed to thromboembolic complications and should undergo proper coagulation workup to ensure improvements in outcomes and overall operating room efficiency65,67. Similar to preoperatively detecting risk factors for acute kidney injury, using the Child-Turcotte-Pugh criteria can aid in assessing risk in patients with liver abnormalities as these criteria take into account serum albumin and bilirubin levels, prothrombin time, and the severity of ascites and encephalopathy78,80,81. Understanding each patient’s preoperative hepatic risks and the accompanying medical conditions, such as platelet dysfunction and increased bleeding tendency, warrants appropriate management and medical optimization82. Hence, the preoperative assessment of this patient population can minimize operating room delays and cancellations. Cardiovascular ailments, such as myocardial infarction, congestive heart failure, coronary artery disease, stroke, and hypertension also must be addressed during a patient’s preoperative workup74-76,83. Such an assessment enables the development of the ideal plan for patients with cardiovascular disease. For example, waiting at least four to six weeks after a myocardial infarction prior to elective surgery (per the American Heart Association and American College of Cardiology guidelines) results in a drastic decrease in the risk of postoperative infarct76. Implementing a protocol for medical clearance of high-risk patients might ultimately lead to improvement in operating room efficiency by eliminating avoidable delays and cancellations. Furthermore, while extensive testing may be beneficial for high-risk patients, some practitioners have suggested that the overuse of preoperative testing has questionable benefit for low-risk patients undergoing elective, minor orthopaedic surgery28. In fact, the overuse of preoperative testing may result in unnecessary delay without a decrease in the postoperative complication rate, especially in emergency situations28,56. Performing a thorough history and physical examination will help the surgeon to decide whether a benefit can be gained from extensive preoperative testing.
Common reasons for delayed start times include unavailability of the surgeon and/or the anesthesiologist84,85. By implementing a daily morning “huddle” of the entire operating room staff, posting the results of daily team start times, and providing rewards to the staff when they reach 100% on-time case starts, the Hospital for Sick Children in Toronto improved the overall rate of on-time case starts from 6% to 60%84. Implementation of daily operating room team briefings to highlight potential problems, improve team culture, and allow organizational changes may improve operating room efficiency and patient care27. This strategy requires reviewing feedback from the previous day’s list as well as addressing each patient from the current day’s list. A survey given to staff members following the implementation of a briefing system demonstrated that >90% of respondents felt that the system highlighted potential problems, improved communication, and made them feel like part of a team27.
Preoperative delays involving process or equipment are common, occurring in 51.4% of elective neurosurgical cases in one study86. First-case delays, especially due to patients arriving late to the operating room for various reasons, were most common. Does et al. were able to reduce start-time delay with the development and implementation of the following requirements: (1) the patient must be present at the operating room no later than 7:35 or 8:00 a.m. (depending on the facility), (2) the patient must receive preoperative medication before arriving at the operating room, and (3) the referring department and the anesthesiologist must be informed one day prior to the scheduled procedure32. Additionally, Attarian et al. found that preoperative delay secondary to late patient arrival could be reduced by contacting the patient one day before surgery and reminding the patient of the correct location and arrival time (which was two hours before the operating room start time)3. This practice, along with the introduction of an efficient check-in process and on-time preparation in the preoperative holding area, in part, led to an on-time start rating of >90% (compared with <60% previously)3.
Equipment failures are also common causes of delay, representing 57.9% and 55.2% of procedural delays in cranial and spinal procedures, respectively86. Poor imaging scheduling with delays in receiving early-morning image results was another cause of considerable delay. Suggested strategies to minimize perioperative delays include screening and repairing equipment regularly, prioritizing early case imaging and communicating these needs to the radiology department, and increasing the number of patient transporters86. On the other hand, the implementation of a preoperative lounge for same-day admission of surgical patients did not significantly improve delays in operating room start times87.
Soliman et al. established a new staff position, the surgical registrar, whose role was to provide active involvement in and facilitation of the daily operating room patient list88. They reported achieving a 48% overall reduction in case changeover time following this intervention. This team-focused structure was successful in anticipating delays, enhancing staff communication and morale, improving operating room efficiency, reducing surgical costs, and optimizing the quality of patient care88.
While high-quality patient care remains the primary focus in health care, recent economic strains have pushed operating room teams and hospital administrators to emphasize the fiscal implications of current surgical practice1-6. Achieving a balance between financial implications and patient care through operating room efficiency improvement becomes more crucial. In the present report, we summarized the most current literature to provide a better understanding of the surgical process, defined the barriers to an efficient operating room, and reviewed updated strategies for improvement as they pertain to general and preoperative processes.
The majority of applicable methods for efficiency improvement worthy of exploration focused on managerial issues as well as on innovation in prophylactic measures.
Quality-improvement strategies such as Lean Six Sigma, as well as others, can help to identify surgical process weaknesses and can assist in developing improvement methods. Checklists have a substantial impact on improving team communication and patient safety within the operating room setting. In addition, an optimally structured scheduling system could provide optimal use of resources while allowing for unexpected changes that reduce delays. These improvement techniques are generally managed by the hospital administration. Surgeons, however, can better ensure the optimization of these methods and ultimately improve patient satisfaction and outcomes by being well informed and having a substantial input by assuming administrative roles and authority to implement and support change89.
Application of these ideals can have a profound effect on operating room efficiency within a medical institution. Optimization of time spent in the surgical process can only be obtained by exploring all of the steps involved. As the current discussion focused on general and preoperative process improvement, further review of the intraoperative and postoperative phases will be discussed in Part 2 of this article (http://reviews.jbjs.org/content/3/10/e4)90, which is also published in the current issue of JBJS Reviews.
Source of Funding: No external funds were received in support of this study.
Investigation performed at the Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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