Getting the Schedule Done

Vinod Malhotra

T HE OPERATING room (OR) schedule is the template by which the OR functions on a daily

basis. An efficient and easily administered sched- ule is a prerequisite to getting the schedule com- pleted in a timely manner.

CREATING A REALISTIC ELECTIVE SCHEDULE

The elective schedule must be based on factual information. This information relates to the histor- ical use of the OR by individual surgeons and the services and permits appropriate staffing, as well as availability of equipment and space.

Open Versus Block Booking

Open booking allows cases to be added to the elective schedule whenever the surgeon's office calls. Such calls may be received 1 week before, 1 day before, or the day of surgery. Although open booking appears to give the notion of being flexi- bility and user friendly, it is a set-up to be ineffi- cient on the day of surgery. Such elective sched- uling is unpredictable, and hence it is impossible to appropriately staff the ORs. It is difficult to predict on a daily basis how many ORs will be needed and for how long they will be occupied. If the cases vary greatly between and among specialties, then it will be difficult to obtain and set up instruments and equipment on short notice. This type of sched- ule can run effectively only if ORs are continu- ously overstaffed or on-call staff is available on short notice.

On the other hand, block scheduling allows pre- dictability in the schedule. The concept is not to block the surgeons out but to allow them to plan their cases with predictable availability of the OR.

From the Department of Anesthesiology, New York Presby- terian Hospital-Weill Medical College of Cornell University, New York, NY.

Address correspondence to Vinod Malhotra, MD, New York Presbyterian Hospital-Weill Medical College of Cornell Uni- versity, Department of Anesthesiology, 525 E 68th St, M324, New York, NY, USA 10021.

Copyright �9 1999 by W.B. Saunders Company 0277-0326/99/1804-000551 O. 00/0

For example, let us assume that the plastic sur- gery service operates 20 h/wk, primarily on Mon- days and Thursdays, and the ear, nose, and throat service operates the same number of hours but primarily on Tuesdays and Thursdays and occa- sionally on Fridays. The OR block for a room would appear as shown in Table 1.

Block scheduling makes it easier for both these services and the surgeons to predict the availability of OR time well in advance. It lets staff prepare the OR with instruments and appropriate surgical per- sonnel accordingly. Block time may be allocated by service or by surgeon depending on use. Most ORs will employ a combination of both open and block scheduling. Whatever the mix, it is impera- tive that the entire OR time must not be blocked or there will be no flexibility for add-ons, emergen- cies, and unexpectedly long surgeries. Current ex- perience has shown that block time should be allocated as shown in Table 2.

Block Release Time

Block release time is the time before the day of surgery when a block is released to other surgeons should there be no or inadequate booking in the time block. Recommendations vary and will differ based on the patient population and the referral base. However, it is recommended that blocks be released 48 to 72 hours before the day of surgery. This allows other surgeons to book surgeries and notify patients in advance. It also provides the scheduling manager enough time to rearrange and finalize the schedule. Before releasing block time, a call should be made to the respective service or the surgeon to ensure that there has been no mis- take and there are in fact no cases booked in their block. This advance check will avoid a lot of unpleasantness on the day in question.

Real-Time-Based Schedule

To execute a schedule effectively, it must be real-time based on the day of surgery. This gener- ates accurate expectations among the staff and the surgeons regarding start and end times for the surgeries. A realistic schedule must list the start

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GEl- r ING THE SCHEDULE D O N E

Table 1. Sample OR Block Schedule

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Block Monday Tuesday Wednesday Thursday Friday

7:30 AM to 11:30 AM Plastics ENT Plastics ENT ENT 11:30 AM to 3:30 PM Plastics ENT Plastics ENT Plastics

Abbreviations: OR, operating room; ENT, ear, nose, and throat.

time, the expected duration of surgery, and the end time of every case. This will allow predictable staffing for each OR. Many of the software pro- grams currently in use for OR scheduling automat- ically give an average operating time for each surgeon for each surgery based on their 10 most recent cases. This is a valuable tool for predicting the length of the OR day.

Accurate Listing of Procedures on the OR Schedule

A common cause of OR delays is an inaccurate listing of the procedure. For example, a left colec- tomy may be listed as right colectomy, resulting in the wrong estimation of surgery time and an inap- propriate instrument list. Another example is book- ing of a colectomy but the planned cystoscopy and stent placement is not listed. Obviously, the instru- ments for cystoscopy will not be in the OR, thus causing delays. If the urologist who is to perform the cystoscopy is booked in another room, then both the ORs will be delayed. Special equipment requirements, such as x-ray machines, computed tomography scanners, microscope, etc, must be requested in advance and listed on the schedule. The elective OR schedule should be precise and clear so there are no surprises on the day of sur- gery.

Scheduling Manager

A scheduling manager who is familiar with the ORs as well as the nursing and surgical is essential to creating a realistic schedule. An OR nurse with administrative ability and computer facility would

Table 2. Sample Allocation of Block Time

Type of OR Block Time (%)

Inpatient 80 Ambulatory 90 Surgicenter 95

Abbreviation: OR, operating room.

be well qualified for this job. This individual must have excellent communication skills and would work as a liaison between surgeons' offices and OR personnel.

Scheduling Software

Many commercial OR scheduling software pro- grams are available. Many institutions use "home- grown" modules. Whatever the software, it must meet certain criteria as listed in Table 3.

GETTING THE SCHEDULE DONE: PLANNING THE DAY BEFORE SURGERY

Prepa ration

Assuming that a realistic schedule is generated and released on time the day before surgery, prep- oration for the next day begins. The schedule should be reviewed by the OR director, the clinical director of anesthesiology, and the OR head nurse. Errors can be rectified and potential problems iden- tified at this time. For example, one can identify rooms that will run late as well as the need for OR staff after 3:00 PM or 5:00 PM. One also can identify potential gaps where add-on cases might be ac- commodated. The OR list can be used to order

Table 3. Recommended Requirements of Scheduling Software

Easy to use (user friendly) Fast and accurate data entry and access Allows multiple procedure listing Allows block scheduling Can be linked to multiple sites Has a visual grid of OR time allocation Uses and processes historical data, eg, case time Can be used for data base management, eg, room

utilization, TAT, case volume Can be customized for institutional needs Allows networking, eg, billing, inventory, equipment

supplies Has strong user training and assistance programs

Abbreviations: OR, operating room; TAT, turnaround time.

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EMERGENCY (acute bleeding, trauma)

First available OR

Add-On Case Policy

URGENT (acute appendicitis, ectopic pregnancy, intestinal obstruction)

"Bump" the same surgeon's elective scheduled case. If none,

"Bump" a scheduled case on the same service (eg, GYN case for an ectopic pregnancy). If none,

"Bump" a scheduled case from a nonallocated block service. If none,

"Bump" a scheduled case from an allocated block service.

ELECTIVE CASE (laparoscopy)

Put at end of the schedule or in an available OR

Fig 1. Add-on case algorithm. OR, operating room; GYN, gynecological.

supplies and instrument trays the night before sur- gery. The more that troubleshooting and advance preparation for the next day's schedule is accom- plished the night before, the easier it is to run the schedule on the day of surgery.

Paperwork

The paperwork (patient documentation includ- ing history and physical examination, laboratory, tests, consents, etc.) must be complete the day before surgery. Incomplete paperwork is the most common cause of morning delays in the OR at most institutions. We have effectively eliminated paperwork-related morning delays by adopting a policy that any case with incomplete documenta- tion by 11:00 AM the day before surgery will not be booked as the first case in any OR. However, rigid policies created to gain physician compliance must not result in unnecessary inconvenience to the pa- tient. Paperwork requirements should be reduced and documents consolidated such that a patient's information (eg, allergies, medications) is not du- plicated in several documents, as is commonly the case.

GETTING THE SCHEDULE DONE: THE DAY

OF SURGERY

Remember one dictum: protect the elective schedule. A carefully structured OR list can be easily delayed by add-ons, emergencies, and can- cellations. A clear policy should exist regarding these situations. Some institutions set aside one or two rooms for add-ons and emergencies. This strat- egy works if add-ons and emergencies will predict- ably allow utilization of these rooms effectively. In this case, the emergencies get priority, and add-ons are booked on a first-come, first-served basis.

Most institutions, however, cannot afford to have one or two ORs staffed and waiting. In this case, a clear algorithm must be developed (Fig 1). Emergencies and elective add-ons are fairly straightforward. Any emergency goes to the first available room, whereas an elective add-on case goes at the end of the schedule. When there is a so-called "urgent" matter, a decision must be made on a case-by-case basis. Examples of this type of case include an ectopic pregnancy, an obstructed bowel, a fracture, and an eye injury. Each of the services must be asked to develop guidelines re- garding urgency and maximum allowable wait

GEI-IING THE SCHEDULE DONE 303

times before surgery for these cases. This informa- tion should be common knowledge at the OR desk. This will allow appropriate triage of cases should it become necessary to schedule the urgent case ahead of an scheduled elective case. The algorithm must be both fair and effective. It is of interest that a gynecologist, for example, might insist that a "rule-out ectopic pregnancy" case has the potential for imminent rupture and must go ahead of a scheduled general surgery case. Yet, the same in- dividual may be more likely to agree that this case can wait another hour or two if the elective case to be delayed for this "emergency" is another gyne- cological operation.

On-Time Starts

Morning cases must start on time. To facilitate achieving this goal, there should a common under- standing of the definition of start time. Start time should be defined as the time when the patient arrives in the OR and is placed on the operating table. The aim should be a 95% to 100% on-time start rate for the first case of the day because the morning start sets the pace for the room for the rest of the day. On-time starts for second cases should be better than 80%. It is not uncommon for a 15-minute delay in the morning to grow to a 2-hour delay by the end of the day. The following guide- lines are suggested to ensure on-time starts.

�9 The patients should be given appropriately early arrival times the night before surgery.

�9 "One-stop check in." Patient admission should be processed completely in one place, ie, one-stop check-in, by the nurse or physi- cian assistant. Avoid patient and paperwork transfers on the day of surgery.

�9 Bring the patient directly to the OR, bypass- ing the holding area. The holding area is good for subsequent cases or placement of epi- durals for pain, but for most cases, arterial lines and central venous pressure catheters, etc, can be placed in the OR while the urinary catheter is inserted and the operative site is prepared.

�9 Anesthesiologists, nurses, and surgeons should work in parallel not in series, as is usually the case--to improve efficiency.

Short Turnaround Times

Turnaround time (TAT) should be kept at a minimum. A clear definition of TAT should be

adopted. TAT is defined as the interval between the previous patient's departure from the OR to the next patient's arrival in the OR. It is suggested that TAT should be 30 minutes for inpatient ORs, 15 minutes for ambulatory centers, and as short as 5 to 10 minutes for minor cases. To minimize TAT, patient preparation for the next case must begin in the preoperative holding area. Intravenous cathe- ters can be placed and an infusion started. Prophy- lactic antibiotics can be given. Placement of arte- rial cannula, central venous catheter, pulmonary artery catheter, or epidural catheter to provide an- esthesia for surgery or pain management can be accomplished in the holding area. Instrument trays can be prepared and outside the room, ready to be opened during the turnaround time. Delays in turn- around must be examined and the causative factors remedied.

Decrease Case Times

Although avoiding morning delays and main- taining low TATs are important for an effective running schedule, intraoperative delays can wreak havoc on the daily conduct of the OR schedule. A 2-hour case that ends up taking 4 hours will not only delay subsequent cases but may result in cases being put on hold. Case time is the time from a patient's arrival in the OR to the patient's dis- charge from the OR. It includes anesthesia induc- tion, patient preparation, operative time, dressing placement, and patient emergence from anesthesia. Longer-than acceptable case times may result from the following:

�9 slow induction of anesthesia, �9 long patient preparation time, �9 slow surgery (slow surgeon, attending sur-

geon not present for long sections of the case, inappropriate teaching),

�9 delayed patient emergence from anesthesia, and/or

�9 no postanesthesia care unit (PACU) beds available.

It seems obvious that the most gain in OR time can be made by addressing the case time rather than turnaround time because the longest part of the OR cycle is usually the case time.

ORs on HoM

ORs placed on hold result in a costly waste of time. The usual reasons include nonavailahility of

304 VINOD MALHOTRA

surgeons, anesthesiologists, nurses, equipment or PACU beds.

Most of these situations can be pre-empted by careful running of the schedule. The surgeon's office must be notified well ahead of time regard- ing his or her case. Should the surgeon be unavail- able, another case can be substituted in that slot. Anesthesia coverage generally is not be a problem, but it nevertheless should be anticipated and ad- justments made as necessary.

Nursing coverage beyond 3:00 PM and 5:00 PM often can be a problem. There exists a shortage of OR nurses in the United States, which is expected to grow in the next 5 years. For some hospitals, flexible staffing of the OR may help address this problem. The individual running the schedule must communicate with the OR desk frequently throughout the day to plan for adequate staffing for cases during the late afternoon and evening hours. Although nurses are routinely requested to put in overtime to complete cases, overtime is an expen- sive way to staff the OR. The ratio of registered nurses and OR technicians may have to be adjusted during the day to provide coverage.

Unavailability of equipment (eg, microscopes, laparoscope, laser) can generally be avoided by rearranging the OR schedule ahead of time. How- ever, if one case runs unexpectedly long, the equip- ment may not be available for another case. Rear- ranging the order of a surgeon' s own cases may be the easiest and least disruptive solution to this problem. Once again, a morning review of the schedule should alert the OR director of this pos- sibility. Subsequent patients can then be called in time to come earlier than planned, permitting the rearrangement of cases.

Occasionally the PACU is full and no beds are available for OR patients. To prevent this prob- lem, a review of the schedule with the PACU head nurse must be done in the morning to anticipate the extent of this problem, which usu- ally occurs in the late morning and afternoon, and plan PACU discharge strategy for the day. All patients who have met PACU discharge cri- teria must be discharged promptly. Any patients kept in the PACU while waiting for laboratory results can be discharged to the ward after dis- cussion with the surgical service. All patients scheduled for postoperative transfer to the inten- sive care unit should bypass the PACU. Occa- sionally, even the hospital beds are full so that

PACU patients cannot be discharged to a hospi- tal bed, causing a further back-up in the PACU. In such instances, we have found it useful to transfer these patients to the holding area where one nurse can monitor up to eight patients who are ward-ready. This frees up beds in the PACU. Beyond this, the hospital admissions office and a hospital administrator must be consulted. If it is likely that no more beds will be available, some of the surgeries scheduled on the OR list will have to be postponed. It is much better to make this decision early so that the patients can be informed before they leave home and the sur- geons can be informed in time.

PACU discharge criteria should be established if they do not already exist. This will allow faster patient passage through PACU. Patients who meet PACU discharge criteria on emergence in the OR do not need to be sent to the PACU and can be directly transferred to the second-stage recovery a r e a .

Use of Data and Benchmarking in Running the Schedule

Available data about the functioning of the OR regarding start times, TATs, case times, cancella- tion rates, etc, will be helpful in daily running of the ORs. One glance at the schedule for any room will predict whether that room will realistically run as planned. This will also help in staffing the OR appropriately for the planned schedule and any added cases. For example, a surgeon wants to add a case starting at 3:00 PM and insists that she will be done in 2 hours. You are concerned about running beyond 5:00 PM with a lack of available nursing staff and possibly having to pay overtime to present staff. If you know that the average duration for that case for this surgeon is 2 hours, you are taking a 50:50 chance on finishing in time. How- ever, if her average time is 1 l/2 hours and the 95th percentile is 2 hours, there is 95% surety that she will be done on time.

Conflict Resolution and Follow Up

Despite well-made OR schedules and well-run scheduling boards, conflicts arise on a daily basis. Effective conflict resolution requires leaders with excellent interpersonal and communications skills. Each conflict must be resolved with discussion among all individuals concerned. A follow-up as-

GEl-rING THE SCHEDULE DONE 305

sessment of decisions will help in making urgent choices the next time. All emergencies, cancella- tions, and complications must be reviewed on an ongoing basis.

For those who have accepted the responsibility of running the OR schedule, challenges abound. Leadership, organizational skills, quick thinking on one's feet, improvisation, interpersonal skills, decisiveness, and--above all--remaining calm and collected amidst crisis will just be a few of the attributes tested.

SUGGESTED READING*

1. OR Manager (a monthly newsletter, published in Boulder, CO, for OR managers)

2. The American Journal of Anesthesiology (official journal of the Association of Anesthesia Clinical Directors)

3. AORN Journal (official publication of the Association of Operating Room Nurses)

* Articles pertaining to effective OR management appear regularly in these journals.