The American Journal of Surgery (2015) 209, 447-450

Midwest Surgical Association

Improving operating room efficiency via an

interprofessional approach
Jeffrey S. Bender, M.D.a,*, Teodora O. Nicolescu, M.D., M.B.A.b,
Susan B. Hollingsworth, R.N., M.B.A.c, Krystal Murer, M.H.A.c,
Kristina R. Wallace, R.N., M.B.A.c, William J. Ertl, M.D.d

a
Department of Surgery, bDepartment of Anesthesiology, University of Oklahoma College of Medicine,
Oklahoma City, OK, USA; cOU Medical Center, Oklahoma City, OK, USA; dDepartment of Orthopedic
Surgery, University of Oklahoma College of Medicine, Oklahoma City, OK, USA

KEYWORDS: Abstract
Operating room; BACKGROUND: Third-party payer reimbursements will likely continue to decrease. Therefore, it is
Efficiency; imperative for operating rooms (ORs), often a hospitals largest revenue source, to improve efficiency.
Six Sigma; We report the outcome after 3 years of a lean, Six Sigma program to improve OR utilization.
Utilization; METHODS: In January 2011, our hospital system instituted a facility-wide approach to address the
Performance; problem of OR efficiency. Interprofessional teams were formed to examine all aspects of OR use. An
Interprofessional OR Governance Committee consisting of Department Chairs, nursing and senior administration over-
saw the project.
RESULTS: Outpatients readiness on time for surgery increased from 59% to 95%, while first case
on-time starts improved from 32% to 73%. Block utilization went from 68% to 74% and actual room
utilization improved from 56% to 68%. The number of cases increased by 9%. Overtime went from 7%
of total to 4%, so personnel costs decreased 14% despite 26% more employees. There was a reduction
in annual voluntary OR staff turnover from 28% to 11%. Revenues increased more than 10% annually.
CONCLUSION: A concerted effort to optimize OR performance resulted in marked improvements in
access, overall case efficiency, staff satisfaction, and financial performance.
2015 Elsevier Inc. All rights reserved.

Operating room (OR) inefficiencies are a major surgeon
dissatisfier. Indeed, they are frustrating for all concerned. In
addition, these inefficiencies affect hospital and physician
revenue. As third-party reimbursements are unlikely to
This manuscript has been seen and approved by all authors and the ma-
terial has not been published previously.
Presented at the 57th Annual Meeting of the Midwest Surgical
Association, Mackinac Island, Michigan.
* Corresponding author. Tel.: 11-405-271-8375; fax: 11-405-271-
3919.
E-mail address: jeffrey-bender@ouhsc.edu
Manuscript received July 28, 2014; revised manuscript December 11,
2014
increase (and, more probably, will lessen), it is important to
improve OR efficiency.1
OU Medical Center, a 317-bed facility, is Oklahomas
only American College of Surgeons verified Level I
Trauma Center, only National Cancer Institutedesignated
Cancer Center, and a tertiary referral hospital for the state.
Thus, demand for OR access is constant and often time
sensitive.
This access issue was especially felt by services,
primarily Orthopedics and Trauma that did a high percent-
age of urgent and emergency cases. As access to block time
was limited, such cases were often being done at the end of
the day or on weekends.

0002-9610/$ - see front matter 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2014.12.007
448
Senior leaders recognized that our ORs were not being
effectively utilized and instituted a process to improve this.
A combination of lean and Six Sigma methodology, both of
which have been extensively discussed elsewhere, was
used.25
The initial goals of this reorganization were simple:
get all the cases done in a timely manner; improve access
for unscheduled cases; increase case volume, especially for
referral cases; and improve physician and staff satisfaction.
Methods
A full day retreat involving all surgical-related chairs,
senior administration, nursing, and other interested stake-
holders was held in January, 2011. The immediate result of
this retreat was the formation of an OR Governance
Committee (Table 1) to oversee the improvement process.
One of this committees first acts was to appoint an OR
Medical Director (a general surgeon), an Anesthesiology
Medical Director, and an Assistant Surgical Director (an or-
thopedic surgeon).
In addition, 4 Six Sigma teams were formed to look at
all aspects of possible inefficiencies. These teams (sched-
uling, daily flow, preoperative services, and instruments and
supplies) were headed by a physician and a nurse.
Residents, anesthetists, attendings, and other staff (scrub
techs and head of sterile processing) were included as
appropriate. An anesthesiology OR performance committee
was also created.
An executive committee consisting of the nursing and
physician directors was also created to integrate and
coordinate the team activities and to work on long-term
goals and planning. Initially, the Governance Committee
met weekly to hear reports from the teams and to analyze
data. As progress was made, this decreased to semi-
monthly. Currently, the teams meet once or twice a month
and report to the executive committee plus the Chief
Operating Officer (the administrator in charge of the
ORs). OR Governance Committee meets monthly to give
final approval to projects and provide strategic planning.
A 6-month nurse OR residency program was started.
Eight groups have finished the program with 27 new nurses
Table 1 OR governance committee
Chief Executive Officer, OU Medical Center
Chief Operating Officer, OU Medical Center
Chief Medical Officer, OU Medical Center
Chair, Department of Surgery
Chair, Department of Anesthesiology
Chair, Department of Neurosurgery
President, OU Physicians
OR Medical Director
OR Nursing Director, ex officio
OR Anesthesiology Medical Director, ex officio
OR Assistant Surgical Director, ex officio
OR 5 operating room; OU 5 Oklahoma University Medical Center.
The American Journal of Surgery, Vol 209, No 3, March 2015
hired. The ninth group starts in July 2014. Twelve new
scrub techs were also hired to improve staffing.
An ambulatory surgery center (ASC) containing 5 ORs
was opened on campus in October 2010. Two additional
ORs were added to the inpatient (IP) facility in January
2013, increasing the total number to 22. An additional robot
was added in mid-2013, bringing the total number to 2.
This report covers the first 3 years of our improvement
project (ie, through December 2013).
Results
Results are summarized in Table 2. Of note, even though
an ASC was opened, total numbers of cases in the main
ORs increased in 2013 by 9% over the 2010 baseline.
This was primarily in the number of IP cases, which
increased 14%. Also of note, even though the total number
of IP cases increased and the percentage of IP cases went
from 55% in 2010% to 60% in 2013, the number of OR mi-
nutes only went up by 5%. (Outpatient cases include pa-
tients who were admitted the same day after an elective
operation. Due to a quirk in our data management system,
such patients were initially impossible to separate electron-
ically from true outpatients.) Patients done at the ASC who
required admission are not included in these numbers. The
increase in IPs likely resulted from having more OR capac-
ity to add additional surgeons as there was no change in
referral patterns or payor mix.
Turnover times have not been affected by this process,
remaining constant at 43 to 44 minutes. However, time
from patient in room to procedure starting has decreased
from 40 to 34 minutes. Time from procedure ending to out
of room has decreased from 10 to 8 minutes, an average
savings of 8 minutes per case.
Block utilization increased from 68% to 74% and actual
room utilization improved from 56% to 68%. This was due
to a variety of factors. First, block utilization was examined
by service and underutilized blocks were redistributed to
busier services. Second, block expiration times were
enforced (usually 48 hours prior) with the service getting
credit for full utilization if the block was released before
that time. Exceptions were made for Orthopedics, General
Surgery, and Neurosurgery when data analysis showed that
approximately 40%, 20%, and 15% of their cases were
unscheduled. Thus, a corresponding percentage of their
blocks were staffed but left open until the day of surgery.
This allowed access to rooms during the day and led to a
decrease in the number of rooms running after 1700. This
went from an average of 9 rooms per day to 5 rooms per
day. The average running after 1900 went from 4 to 2.
Finally, a weekend scheduler was hired. Prior to this, any
case seen by a surgeon after 1,200 on Friday or who was
admitted over the weekend could not be scheduled until
Monday morning. This has led a decrease in the number of
unscheduled cases on Mondays and Tuesdays from approx-
imately 25 per week to 10.
J.S. Bender et al. Improving operating room efficiency
Table 2 Summary of results
2010
Total OU Medical Center cases 11,891
Inpatient cases 6,499
Outpatient cases 5,392
ASC* cases 1,312
Total cases 12,035
Minutes 1,897,956
FCOTS 32%
Outpatient readiness 59%
Full-time employees 91
Travelers 14
Overtime 7%
Voluntary staff turnover 28%
ASC 5 Ambulatory Surgery Center; FCOTS 5 first case on-time starts; OU 5 Oklahoma University Medical Center.
*First column is for 2011.
First case on-time starts.
Hospital revenues from the ORs increased by 14% from
2011 to 2012 and by 19% from 2012 to 2013. An even
larger increase is projected for 2014. Similar increases
occurred in surgeons billing. Personnel costs decreased by
14% because of fewer travelers and less overtime. Turnover
in personnel was equally divided between nurses and scrub
techs.
Comments
A hospitals primary goal in running ORs should be safe
and effective care. This does not, however, preclude cost-
effectiveness. Many methods have been described to improve
the OR process69; we elected to use lean and Six Sigma tech-
niques as our original approach. Additionally, all members of
the team providing care were solicited for input. We believe
that this interprofessional approach was crucial to get buy
in from all the stakeholders involved.
One of the first things we concentrated on was first case
on-time starts. Although some have questioned the value of
this,10 we thought it was an important way to start for 2 rea-
sons. First, our ORs poor performance in this statistic was
widely perceived by staff as an indicator of overall ineffi-
ciency. Second, it was something that could be easily fixed
and measured. This allowed us to start the process with an
early success (much of the improvement in on-time starts
came in the first 6 months of the process). This early
improvement was also despite changing the definition of
on-time from within 15 minutes of scheduled start to
even 1 minute late counting as late. As any OR quality
improvement project likely takes months to years to show
measurable success, we felt that an early achievement
was important to keep people from becoming dispirited.
Overall OR minutes have increased by 5%, while cases
have increased by 9%. This relatively smaller percentage
increase in minutes is because of the average patient
spending 8 fewer minutes in a room for his or her operation.
449
2013 Change
12,302 19%
7,396 114%
4,904 210%
1,566 119%
13,868 115%
1,998,699 15%
73% 1128%
96% 163%
115 126%
2 286%
4% 243%
11% 261%
We have not, as yet, achieved a similar improvement in
turnover times. As standard methods have so far not been
successful, we plan on taking a fresh look at the process.
This will be done by the institution of failure mode
analysis.11 Such an approach is common in the aerospace
industry but has not, so far as we know, been used as yet in
the OR. Hopefully, this will be the subject of a future
report.
The value of added staff cannot be overemphasized.
Although the total number of staff (full time plus travelers)
increased from 105 to 117, travelers, or temporary staff,
decreased from 14 to 2. This additional staffing led to a
decrease of 14% in personnel costs. Decreased overtime led
to improved staff satisfaction and a significant reduction in
voluntary turnover.
Another aspect learned, in addition to doing the easy
things first, was that change can only be achieved by
consensus and will come slowly. We also found that while
no one individual can improve the system, any determined
one can slow it down.
Although our efforts have resulted in some satisfactory
improvements, we are not stating that all problems have
been solved. Nor should they be; continuous improvement
is mandatory for complex systems such as an OR. Future
projects will include the following: focus on turnover time;
finding out why 96% of patients are ready 30 minutes
before first case on-time, but only 73% of the cases actually
start on time; and exploring the use of variability method-
ology to re-engineer the ORs.12 This last project will be an
attempt, so far as we are able, to smooth the schedule so
that there are relatively the same number of elective cases
and minutes scheduled every day. These currently fluctuate
by as much as 50%, which makes planning difficult. A new
Six Sigma team has been formed to look at perioperative
obstacles that prevent IPs from being ready on time.
In summary, an interprofessional approach to optimizing OR
performance led to marked improvements in access, volume,
efficiency, staff satisfaction, and financial performance.
450
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Discussion
Dr James Tyburski (Detroit, MI). You went from 91 to
115 total employees, which was 24 up, but you did hire, I
think if I read the manuscript right, 39 people. So the other
15, did you get rid of bad actors? Did you get rid of people
that were non-productive? Did you get high salary people
that were right at the end of their career to retire? Is that
part of what was going on there? Was there any change
in the payer mix or referral patterns for the patients just
in that 3-year period of time? And then because of this
quirk you have in your system that if somebody stays over-
night, and if they are even there sort of as an outpatient but
they maybe did a lap chole late in the day or something,
anybody from the ambulatory surgery center, which opened
in the middle of this, and I think that is a confounding var-
iable here, if they stay overnight, do they go into the inpa-
tients? And if thats not it, then where did all the new
inpatients come from? Did you have more, complex pa-
tients coming in staying or just where do they come
from? And then last, I guess, your best advice overall to
somebody who wants to start this, I think you gave that
in the slide, but can you elaborate a, little bit on that?
Dr Bender: Total number of employees went up. I wish
we could say that we fired bad people, but that is almost
impossible in Oklahoma. Most of these were voluntary
turnovers. It was not getting rid of high, salaried people,
because, if anything, we are in the lower payer among
The American Journal of Surgery, Vol 209, No 3, March 2015
the hospitals in the area, another constant thorn in my
side. The referral patterns changed because we had more
access. We were turning down cases because we didnt
have OR rooms for them. And thats why we got more com-
plex cases. In addition, the cancer center opened about four
years ago, and our, for example, pancreatic surgery busi-
ness has quadrupled in four years. Weve gone from 25 a
year to a 100 a year. And there has been similar increases
in colorectal and other GI malignancies. The trauma service
has gotten busier, and we have more access for them. The
payer mix, unfortunately, hasnt changed. It is still 20%
uninsured and 25 to 30% medical assistance.
My best advice is to be persistent, and, most importantly,
its going to change, but changing culture takes a long time.
And thats what we had to do was change the culture. Im
not sure we still completely, changed our culture.
Dr Ashwani Rajput (Albuquerque, NM). How do you
go about changing the culture and how did you get buy-
in from the staff to actually achieve these goals?
Dr Bender: Well, I discussed this a little bit in the manu-
script. First, theres a lot of debate in the literature. This first
case on time starts really make a difference in the overall ef-
ficiency. But that was why the perceived, as an example, of
how inefficient the hospital was in, running an operating
room. So we elected to concentrate on that as the first thing
we could change. It was relatively easy. We hired a couple of
more transporters. We made it easy to get the electronic pa-
perworks submitted, and an early success built confidence in
the system. And, everything is an easy success so far. We ha-
vent yet made any of the tough decisions. Like there are still
some surgeons who will not schedule accurately, because
they dont trust the system. What do they do if, theyve
scheduled five cases, and we know its going to take them
18 hours to do this, do we still let them do their elective cases
when there are urgent and emergent cases to be done? We
havent yet addressed that, problem. One of the things we
are going to do is probably divide our operating room into
two. There will be 16 to 17 elective case rooms and five or
six urgent/emergent rooms every day.
From the floor: What do you do with surgeons who are
late? How do you take care of that for your first time start?
Dr Bender: Right now what we do is, every month they
get an e-mail saying you were late for X number of cases,
please help us understand why. What are the barriers. I
know when these letters go out, because I get a ton of e-mails,
phone calls and texts, all of which say its never my fault.
But I can tell you I used to send out 40 a month. I now send out
10. So even though it was not their fault, people stopped
showing up late, because they didnt likeand there is no pu-
nitive. I dont even keep records of who gets these.
What we are going to do next is look at one years worth
of data and find out, which surgeons consistently start 35%
of the time or less on time and look at the factors. One of
the worst on time starts is one of our trauma surgeons, but
every one of his patients is in the ICU. So theyre almost
always late getting into the room, so its clearly not his
fault. We still have some system issues to address.
2015 Elsevier