When numerous demands like surgeon requests, changing staffing requirements and capacity issues compete for OR time and space, the surgical schedule can take on a life of its own. Yet, the surgical schedule doesn't have to be hard to manage. Studies clearly show that schedulers should consider five key guiding principles in the following order: patient safety, access, OR efficiency, patient service and physician satisfaction. In this article, I'll show you how these five principles will help you get your surgical schedule under control.

Efficient Staff Allocation: Do The Math In daily practice, creating an efficient OR schedule means maximizing productive surgical time. That is, accept as many cases as you safely can and minimize delays between cases. When it comes to longer-term planning of OR time and staff allocation, however, the meaning of efficiency becomes more complicated. In the long run, the manager must consider both under- and overutilization of the OR because the most efficient OR employees are neither idle nor overworked. Shift Number of Under-Utilized Hours Number of Over-Utilized Hours x 1.75 Cost (Hours) 8-hour 5 (0 3 2 0) 8.75 (1.75x3 0 0 2) 13.75 (5 8.75) 9-hour 7 (0 4 3 0) 5.25 (1.75x2 0 0 1) 12.25 (7 5.25) 10-hour 9 (0 5 4 0) 1.75 (1.75x1) 10.75 (9 1.75) 11-hour 12 (0 6 5 1) 0 (1.75x0) 12 (12 0) Historical data analysis is key to striking the best balance between under- and overutilization. Research shows that, by allocating staff based on past OR utilization, surgery managers can come closer to pinpointing the number of daily OR hours they'll need and thereby improve efficiency by as much as 19 percent. Importantly, overutilization is more costly than underutilization in the long run because of overtime pay and the added inconvenience of both recruiting staffers and actually working the extra hours. Mathematically, managers can account for this by assigning a 1.75 relative cost of over- to underutilized hours. This includes 1.5 for ?time and a half' plus a value of 0.25 for the added frustration. Suppose, then, that on four Mondays last month your surgical service performed 11, 5, 6 and 10 hours of surgery (including turnover times). The staff works eight-hour shifts. The following table shows that your OR will run most efficiently if you arrange for 10 standard hours of OR time every Monday. You can accomplish this in a number of ways (for example, two 5-hour shifts). - Franklin Dexter, MD, PhD

1. Patient safety first
Although surgical schedulers intuitively make decisions based on clinical need, many do not have a clear sense of why they do what they do. It is important to articulate the principle that patient safety (and quality of care) is preeminent. That is, the staff should satisfy every clinical need (such as preoperative evaluation, documentation and infection control) regardless of the resulting workload. This means accepting additional cases as long as it is safe to do so and moving cases when needed to satisfy clinical needs (you may need to schedule a patient with diabetes first to avoid prolonged NPO, for example). Similarly, schedulers should refuse to add or move cases whenever doing so compromises patient safety.

The following scenario illustrates the common-sense guiding principle of ?safety first':

You have an add-on case and are trying to decide if and where you can accommodate it. The last case in OR #1 is scheduled to finish at 1 p.m. The case in OR #2 is scheduled to finish at 2:30 p.m. The usual shift runs from 7 a.m. to 3 p.m. The staff in OR #1 could probably handle the add-on case, but the staff working in OR #2 is clearly qualified. Although it would be more efficient to schedule the case in OR #1 to prevent overtime, you schedule the case in OR #2 because you will not compromise patient safety. You also know that, given the nature of the patient and procedure, this later start time will not hinder the patient's ability to be discharged on an outpatient basis.

2. Access
The next consideration in the scheduling decision is access. As long as it is possible to have an OR, staff and equipment available so the case can proceed safely, schedule it in. In essence, access is secondary only to safety, and the scheduler should not refuse cases based on an arbitrary time of day. In the earlier scenario, for example, the scheduler should not refuse this new case simply because it will end after 3 pm.

Although some hospitals may allocate fixed OR time based on financial criteria as a part of a long-term strategic plan, it is counterproductive to attempt to limit the daily cases just to adhere to a fixed-hours schedule. The only realistic (and most economically sound) surgical scheduling approach is to live by the philosophy that everyone is there to get cases done as efficiently as possible. This principle promotes flexibility and growth of the surgeons' practices and the outpatient facility.

Types of Scheduling When surgery managers describe their approach to scheduling, the most common response is "block time." While most schedules are based around predetermined blocks of OR time, nearly all of them will accept "add-ons" daily to meet the needs of surgeons. Such an approach makes economic sense. The more often you fill your ORs to capacity, the more profitable the facility is likely to be. This holds true even if you have to extend work hours, as added variable costs like labor and supplies are incremental compared with the increased contribution to the bottom line. In general, once a facility covers its fixed costs, the remaining revenue contributes greatly to profitability. The flip side of this accommodating approach: It can be difficult to balance flexibility and efficiency in the face of clinical, staffing and other demands. When more than one person is responsible for creating the schedule, there is an even greater potential for inefficiency. Fortunately, it is easy for any surgical facility to articulate a sound algorithm that everyone can follow when making daily scheduling decisions, because scheduling priorities are the same whether the setting is hospital-based, office-based, or freestanding. - Franklin Dexter, MD, PhD

3. OR Efficiency
The scheduler should consider efficiency only after satisfying the more important principles of safety and access. When scheduling daily procedures, OR efficiency means moving cases to minimize delays and thereby minimize surgery after 3 p.m. Consider the following scenarios:

You have two ORs. The cases in OR #1 are scheduled to finish at 2 p.m., whereas the cases in OR #2 are scheduled to finish at 3:30 p.m. The order of cases will not affect safety. There is adequate access because you have appropriate staffing for both ORs, but you need to decide which OR to open first because you have just one housekeeper. You open OR #2 first to minimize the potential that surgery will be delayed beyond 3:30 p.m.

Suppose now that the cases in both ORs are scheduled to finish at 2 p.m. You have six patients scheduled in OR #1 and two patients undergoing longer procedures in OR #2. You opt to open OR #1 first because the potential for surgical or turnover delays increases with caseload.

4. Patient service
The next consideration is patient convenience; that is, trying to minimize patient waiting time. This simply means scheduling the most predictable cases first, provided this approach is safe, does not hinder access and maintains efficiency. For example, consider the following scenario in a rural hospital setting in which in- and outpatient procedures are done in the same ORs:

Dr. Smith has scheduled three cases within his block time: Inguinal hernia repair, laparoscopic cholecystectomy and a combination tracheotomy/gastrostomy tube placement in an ICU patient. Schedule the ICU patient last, as this case may be highly unpredictable.

5. Physician satisfaction
Once the principles of safety, access, efficiency and patient service are satisfied, make an attempt to maximize physician efficiency. Provided there are no clinical consequences, inefficiencies or patient delays associated with moving the cases, the scheduler should accommodate the surgeon's requests to alter the sequence of cases.

Remember that when your schedulers understand their priorities, they can reduce the amount of time it takes to schedule cases, and they can better ensure safety, profitability, OR efficiency, and patient and surgeon satisfaction.

Dr. Dexter ([email protected]) is Associate Professor at the University of Iowa's Department of Anesthesia.