Author’s Accepted Manuscript

Operating Room Efficiency

David H. Rothstein, Mehul V. Raval

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DOI: https://doi.org/10.1053/j.sempedsurg.2018.02.004
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To appear in: Seminars in Pediatric Surgery
Cite this article as: David H. Rothstein and Mehul V. Raval, Operating Room
E f f i c i e n c y , Seminars in Pediatric Surgery,
https://doi.org/10.1053/j.sempedsurg.2018.02.004
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Operating Room Efficiency

David H. Rothstein, MD, MS1*, Mehul V. Raval, MD, MS2

1
Department of Pediatric Surgery, John R. Oishei Children’s Hospital, and Department of
Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo,
N.Y.
2
Department of Pediatric Surgery, Children’s Healthcare of Atlanta, and Department of Surgery,
Emory University School of Medicine, Atlanta, Ga.

Corresponding author:
David H. Rothstein, MD, MS
Pediatric Surgery
1001 Main St, 3rd Floor
Buffalo, NY 14203
drothstein@kaleidahealth.org
716-323-6110 (o)
716-323-6683 (f)

Abstract
The operating room is the financial hub of any hospital, and maximizing operating room
efficiency has important implications for cost savings, patient satisfaction, and medical team
morale. Over the past decade, manufacturing principles and processes such as Lean and Six
Sigma have been applied to various aspects of healthcare including the operating room. Although
time consuming, process mapping and deep examinations of each step of the patient journey
from pre-operative visit to post-operative discharge can have multiplicative benefits that extend
from cost savings to maintaining the focus on improving quality and patient safety.

Introduction

The operating room (OR) is the financial nexus of the modern hospital, accounting for up to 40%
of a hospital’s costs and 60-70% of revenue (1). It also represents an important interface between
surgeon, patient, consultants and the community. With significant revenue at stake and operating
costs conservatively estimated at $15-$50/minute (2, 3), we all have a strong vested interest in
maximizing OR efficiency. Beyond simple financial savings, improving OR efficiency can have
myriad salutatory secondary benefits including improved patient safety, increased OR
throughput, and improved patient, surgeon and staff satisfaction (Figure 1). These benefits may
translate into a competitive advantage in the healthcare market.

What drives OR efficiency? Or, perhaps better asked, what factors lead to OR inefficiency? This
list is long, but includes human resource and material issues, limited availability and application
of information technology, schedule variation, and impaired process flow. Variety in patient
types, operation types, and multiplicity of surgeons and other proceduralists can make the task of
maximizing efficiency daunting. In pediatric surgery, one must add the variability introduced by
patients of a wide range of sizes and ages, congenital comorbid conditions, specialized surgical
procedures, and the addition of parents as a special form of “co-patient.”

And how can we affect OR efficiency in a positive manner? The past decade has seen the wide
adoption of manufacturing industry principles aimed at reducing waste, standardizing production
steps, and lowering personnel costs. Probably the most commonly applied principles are those of
the Lean and Six Sigma methodologies, but other processes have been applied to the healthcare
industry, including lessons learned from aviation safety (Team STEPPS), computerized
scheduling, and eliminating constraints (avoiding “bottlenecks”).

This review will examine the major industry lessons that have been applied to healthcare, look at
some successful approaches to increasing efficiency, discuss some of the challenges particular to
pediatric surgery, and make some recommendations for consideration by individuals interested in
improving any aspect of OR efficiency.

Operating Room complexity

The OR is a complex environment comprising multi-layered social interactions, unpredictability,

low tolerance for mistakes, and high expectations (1). It is at once inconceivable that the OR
environment allow for an efficient, streamlined perioperative experience and paradoxically
completely unacceptable that it not approach perfection.

A major part of an OR’s complexity stems from unpredictability. Patient factors unexpected
violations of preoperative instructions about timeliness of presentation, fasting periods, or
medical clearance may prompt last-minute cancellation. As in any type of pediatric care, viral
respiratory illnesses can raise concerns regarding pulmonary health of a child and increase risks
of anesthesia. In addition, a case itself will often produce surprise delays due to complexity,
intraoperative complications, or even such mundane things such as difficulty in obtaining
intravenous access that is common in young or recidivist patients. Surgeon factors include case
start delays due to conflicting tasks and poor communication with staff about equipment needs.
These same factors are applicable to anesthesiologist, with the added possibility of the
individual’s being responsible for supervising multiple ORs at once and being unavailable for an
on-time case induction. System factors include myriad challenges from delayed transport,
missing paperwork, inability to locate preoperative laboratory tests, missing equipment, and case
flow interruption due to staff turnover for meal or other breaks (see Wakeman and Langham’s
comments on this topic in the Team Dynamics chapter of this Seminars in Pediatric Surgery
issue).

OR efficiency also requires that cases be booked appropriately, with case length and complexity
appropriately predicted, and available block time used to capacity to avoid leaving OR staff
unused and OR rooms lying idle. A large literature on OR room utilization points to the need for
adequate communication between surgeon and office staff in the time period before an operation,
as well as minute-to-minute communication between the control desk and surgeons, staff and
patients on the day of surgery. In addition, several studies in OR utilization have suggested that
using surgeon-specific metrics to predict OR case time may not be as effective in pediatric
surgery as in adult surgery (4).

Last is the challenge of appropriate staffing. The OR must be overstaffed to allow provide
flexibility for unanticipated crises or the addition of an emergent case. Yet financial restraints
may dictate understaffing to avoid paying staff who are not actively engaged in patient care or
OR preparation. In this aspect, there is a clear parallel to trauma triage to maximize specificity
and sensitivity of anticipated staffing requirements.

Metrics of OR efficiency

Multiple measures of OR efficiency have been proposed, although no single one appears to
represent every aspect of efficiency from the perspectives of the multiplicity of stakeholders
including nurses, surgeons, anesthesiologists, patients/families, hospital administrators,
regulatory bodies and payors. Most institutions will select different combinations of metrics
based on local custom and requirements. The Canadian Paediatric Wait Times Project, launched
at 15 pediatric centers in 2007, identified the following metrics (5), many of which are familiar:
 Off-hours surgery – may result from urgent add-on cases or case over-runs, each
requiring different solutions
 Same-day cancellation rate – it can be helpful to classify cancellations by cause as well as
time of day in seeking to reduce this rate
 First case start-time accuracy – most hospitals allow a 5-minute grace period for this
metric; a more accurate reflection of start time accuracy is probably incision time, a
measure of true patient readiness (5), although this can be influenced both by patient
complexity and lack of OR team preparedness (e.g., when one or more of the members
are not physically present when the patient is ready for incision)
 OR use – one can distinguish between overall utilization (time something is occurring in
the OR, whether actual operation or turnover activities) and operating-specific utilization
(time spent between first incision and final closure as a percentage of the room’s overall
“open” period
 Percentage of unplanned closures – these may occur due to unanticipated staff or
equipment deficits, cleaning requirement for infection control, or equipment malfunction
(such as oxygen supply deficit, or overhead light malfunction)
 Case duration accuracy – it is useful to distinguish between true case time (the interval
between patient entry and exit) and turnover times in order to find intervention targets
 Turnover time – the interval between patient exit and next patient entry, although this
assumes that a patient is always available for immediate entry once a room is cleaned and
ready
 Excess staffing costs – unanticipated staffing costs can result from both over-utilization
(a case goes beyond a planned OR day, requiring that either additional nurses be called in
or the existing nurses be paid overtime salary) and underutilization (paying nurses to fill a
scheduled shift when too few cases are booked or the case times are inappropriately long)

Approaches to evaluating the OR process

Various methods to evaluate OR processes exist, all centering on data collection, analysis,
evaluation with iterative correction, and dissemination to staff and institution. Process mapping
is the method by which each large process is broken down into component parts, which are in
turn dissected for areas for improvement. Multiple groups have described this process, including
Russ and colleagues, who created the Metric for Evaluating Task Execution in the Operating
Room (METEOR) tool to measure task completion in the perioperative process for basic
procedures (6). METEOR is comprised of 80 tasks that were felt to represent well-established
processes of care, broken down into three tasks – patient, equipment/provision, and
communication – for each of the familiar OR phases of care –preoperative, intraoperative, and
postoperative. Although not yet validated in prospective larger studies to measure its impact on
the OR efficiency, the described breakdown offers a comprehensive taxonomy typical of most
operations and provides opportunities for improvement.

Another approach to assessing processes in healthcare is time-driven activity-based costing

(TBABC) (7). Traditionally, activity-based costing was challenging in healthcare as each
activity must have a cost assigned. One can imagine that in an OR, there are dozens of activities
being performed simultaneously and many of these activities do not have a discrete price tag.
TBABC simplifies the process of cost accounting in healthcare by using more streamlined
estimates of costs and incorporating time spent caring for a patient. Thus, TBABC is as much a
metric of efficiency as it is for costs. TBABC has been used to help improve efficiency in clinics
and with overall operating room utilization. (8-10)

The Preoperative Phase

Preoperative medical clearance is among the most important modifiable factors that can help
avoid unnecessary cancellations and delays (see Tobias’ discussion of the Perioperative
Anesthetic Evaluation in this issue of Seminars in Pediatric Surgery). It is most helpful when the
anesthesia team is independently involved in this process, as well, although can risk creating
systematic redundancy. Another modifiable factor is the communication between surgeon and
patient/family, as well as the patient’s primary care physician and relevant consultative
specialists, and may be reinforced with additional written or web-based instructions (see Heiss
and Raval’s discussion of patient engagement in this issue of Seminars in Pediatric Surgery). In
addition, several authors have stressed the utility of a pre-operative phone call in the day or days
prior to planned operation to be sure that the patient’s parents are aware of relevant nil per os
instructions and the correct arrival time (3).

The process of patient flow from admission to the OR offers multiple opportunities for efficiency
improvement. (11) These include minimizing patient travel and transport with optimal hospital
design, having patient hospitality companions available to greet and accompany patients, and
having adequate interpretative services for the hearing impaired or non-English-speaking patient
and family. Improving patient registration and coordination of nursing and anesthesia
preoperative tasks has been shown to improve OR efficiency (12). For inpatients, adequate
staffing of transporters and automated systems of transport notification can streamline the
movement of patient to the pre-operative area.

The Intraoperative Phase

Opportunities for improving efficiency in the intraoperative phase begin with having adequately
trained staff, proper instrumentation, and equipment and materials. While performing a surgical
time-out can help identify and avoid possible sources of delay, time-outs are not comprehensive.
In terms of instruments and equipment, preference cards are a consummate source of angst for
most surgeons (13). One approach is to streamline instrumentation and equipment used for
common procedures for all surgeons at a given center. Skarda et al. were able to use a single
preference card for all appendectomy patients and demonstrated cost savings without negatively
impacting operative times or patient outcomes. (14)

Prolonged operative time has been shown to be associated postoperative complications across a
spectrum of children's surgical procedures.(15) To this end, various groups have explored
modifying surgical approach and technique in order to improve efficiency. Toro et al broke
down a complex procedure, laparoscopic right hepatectomy, into seven discrete, standardized
steps. Video review of surgeons performing each step provided opportunity to understand
intraoperative variation in care and improve efficiency.(16) Similarly, intraoperative coaching
has gained attention as a method to improve operative efficiency. (17)

The Postoperative Phase

Parallel processing once a surgical procedure is completed can help reduce turnover times and
maintain OR flow. Examples include having environmental services staff start cleaning
procedures in the room’s periphery, automation of communication to locate parents for a post-
operative discussion with the surgeon, and perhaps most effectively moving the process of
extubation to the post-anesthesia recovery unit in appropriate patients (18). For same-day surgery
patients, clinical practice guidelines and nursing-driven discharge pathways allow for relatively
automated discharge flow, removing barriers caused by historic reliance on phone calls to and
order entry by residents or mid-level providers (see Shah and Kenney’s discussion on same-day
discharge in this issue of Seminars in Pediatric Surgery). Similarly, for patients of any stay
duration, allowing point-of-service staff to make independent decisions can enhance recovery,
and recent work on computer modelling has supported the incorporation of electronic-medical
record-based automation into the post-operative pathway (19). Although the full spectrum of
post-operative and post-discharge care is not the topic of this review, it is important to recognize
that freeing up surgical beds through efficient discharge practices can reduce the possibility of
holding up operative cases due to lack of available beds; this may be most applicable at busy
institutions, during “surge” respiratory infection seasons, and for patients who may require an
intensive care unit bed.

Industry streamlining processes

Lean

“Lean” is the word originally used to describe a manufacturing process of the Toyota motor
corporation in the 1980s. Its principles were to eliminate any waste that absorbs time or
resources that do not add product value (20) (Figure 2). The Lean process has five steps (21):
 Identify value
  Map the process (identify all steps in the value stream, eliminating whenever possible
those steps that do not create value)
 Create flow (so the product will flow smoothly toward the customer)
 Establish flow (allowing the customer to pull value from the next upstream activity)
 Create perfection (repeat above step in an iterative process, improving each time)

Six Sigma

Developed in 1986 by the Motorola Corporation, Six Sigma uses statistical methods to make
processes more uniform (20). The name refers to the requirement that manufacturing achieve
perfection beyond six standard deviations of the mean (i.e., achieving a 99.99966% success rate).
The process is achieved through a system called DMAIC (D = Define, M = Measure, A =
Analysis, I = Improvement, C = Control) (Tagge), following the general principles of continuous
quality improvement through data collection, analysis, application and re-evaluation.

Lean Six Sigma

Most efficiency improvement processes take advantage of multiple different approaches, and
Lean is often combined with Six Sigma and simply named Lean Six Sigma. Ultimately, although
there are ample single institution reporting improvements after adoption of the Lean and Six
Sigma principles, no study has definitely shown causality, and sustainability of changes is not
always apparent (22-24).

Theory of Constraints

Made popular by Eliyahu M. Goldratt in 1984, the Theory of Constraints (25) hold that system
performance can be improved by identifying process bottlenecks and focusing all efforts at
relieving these bottlenecks (26). The cyclical process has five components:

 Identify: Identify the current constraint (where the rate of the process is limited)
 Exploit: Make immediate improvement to the throughput by mitigating the constraint
(using available resources)
 Subordinate: Ensure that all other activities are in support of removing the current
constraint
 Elevate: Continue all efforts at removing the constraint, even if this requires investment
of new capital
 Repeat: These five steps are part of a continuous, iterative cycle. Once one constraint is
resolved the next constraint should immediately be addressed.

Others

TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) was
designed by the Department of Defense and the Agency for Healthcare Research and Quality) to
provide an evidence-based approach to team training (27). With roots in military and aviation
industry application, this model has been used in some hospitals in an effort to improve
perioperative communication and minimize errors (see also Wakeman and Langham’s article on
team dynamics in this issue of Seminars in Pediatric Surgery). Forse and colleagues
demonstrated improvements in some markers of OR efficiency by comparing first case on-time
start percentages and other quality indicators in time periods before and after TeamSTEPPS
training (28). While they were able to demonstrate initial improvement, these were not sustained
in later time period analyses. Broader field improvement – including those in turnover time and
case length – were reported in a different study of the impact of TeamSTEPPS training, with
these outcomes sustained at one year (29). By introducing a standardized and rigorous – although
not onerous – briefing and debriefing process, TeamSTEPPS appears to offer secondary benefits
to the patient care process that ultimately improve OR efficiency, patient safety and patient
satisfaction (29-30).

Lessons learned from literature review

Fong and colleagues performed a systematic review of OR efficiency papers, and categorized
summative recommendations based on scale of intervention (31):
 Small (applicable to single surgeons or small surgical groups, ready for rapid
implementation)
o Surgical workflow redesign – use of surgical checklists and parallel processing,
process mapping (Figure 3), improved staff briefing
o Standardizing instruments and supplies – including removal of rarely used
instruments to speed counting at the beginning and end of cases (32)
o Team huddles – pre- and post-op huddles that can optimize workflow and reduce
errors
 Medium (to be applied to larger surgical groups and entire OR environments, require
more time and a larger degree of surgeon and staff buy-in for implementation)
o Checklists – with the risk of checklist “fatigue” there appear to be data supportive
of the use of intra-operative checklists to reduce error in routine cases, as well as
outside of the OR to streamline patient flow
o Teaming – working with the same team can improve operating speed and
engender esprit du corps with secondary safety and quality benefits through staff
engagement and flattening of hierarchy, which in turns may improve
communication
o Data tracking – can be particularly beneficial in identifying causes of OR
inefficiency and promote a transparency that is essential to team buy-in
o Awareness of costs – the benefits of educating surgeons and nurses on disposable
item costs are principally financial with little direct influence on OR efficiency
 Large (requiring cooperation across an institution and often necessitating capital
investment)
o Supply-chain management – this comprises a large swathe of OR operations, but
specific examples include minimizing stock shelving (just in time delivery,
particularly of less frequently used items), carefully tracking opened-but-not-used
items to avoid waste, and simplifying stock room appearances to allow rapid
localization of needed supplies by nursing staff
 o Specialization – creating dedicated teams to specific cases requires that a hospital
have a large enough volume to justify the effort
o Space redesign – intelligent design that minimizes patient, surgeon and staff
movement can require massive capital investment, but the return on this
investment by improving flow and reducing intraoperative time lost to fetching
equipment and supplies can be substantial
o Parallel processing – perhaps less applicable in the pediatric surgery, parallel
processing identifies processes (particularly around anesthesia induction but also
including documentation and pre-operative evaluation) that can be done during
the closing phases of the prior case to augment throughput (33)

Longevity/Sustainability

Dissemination of data through a transparent process of staff and corporate suite engagement is
vital to the acceptance of OR efficiency quality improvement initiatives (3). Sustainability is the
true mark of success in such initiatives, but requires constant vigilance and an iterative process as
described in the Lean Six Sigma literature.

Another key to sustainability is having buy-in from all levels of staff, including surgeons, nurses,
custodial staff, supply chain managers, central supply/sterilization workers, and so on (34).
Engaging staff in the processes of improving efficiency is empowering and rewarding. Over
time as more innovative, efficient, and improved care systems are designed, the staff involved in
these transformations evolve from being participants and facilitators to being empowered
consultants and being to train and coach others. (35)

The Future

In a fashion similar to that in which car company robots today do much of the work previously
done by humans on the Ford Model T assembly line, one might imagine that computer-driven
automation will continue to take on an ever-increasingly important role in optimizing the
perioperative experience. At the same time, surgery is not a faithfully reproducible methodology,
and human processes are subject to myriad unpredictable variations that affect outcomes. We
suspect that computerized linkage to medical records, transfer of information between pre-
operative and perioperative encounters, patient and family tracking and automated intraoperative
updates that both families and ancillary services informed will continue to improve the
throughput process. As an example, some systems have put in place radio frequency
identification tags to help follow patient and staff flow (36-37), while others have incorporated
electronic medical record-linked paging systems to update all parties automatically (26)

Recommendations

1. Pre-operative phase
a. Pre-operative process: Adequate evaluation of a patient’s operability is of paramount
importance, and unanticipated case delays or cancellations can be minimized through
the robust use of pre-anesthesia testing. A phone call confirmation of case time and
required hospital arrival time, nil per os status, and other relevant scheduling issues
 on the day prior to operation can be a valuable reminder to parents and similarly
avoid case delays.
b. OR scheduling: Case scheduling should be performed in a manner that balances the
need to maximize OR utilization while at the same time maintaining a sense of team
cohesiveness and continuity. Surgeon-specific “historical” times may be less
important than service-specific times when calculating anticipated case lengths.
c. Admission process for outpatients: Streamlining the admission process through
automated demographics/insurance data confirmation, adequate staffing and
intelligent flow design can minimize delays and mitigate parental frustration.
d. Inpatients: For inpatients, automation of the multiple steps involved in the preparation
and transport of patients from floor to pre-operative area can remove the burden of
unnecessary phone calls between circulating nurses and other OR staff and floor staff,
as well as speed up the transport process. Adequate staffing, again, is critical to allow
for efficient patient transport. Pre-operative anesthesia evaluation, preferably the day
prior to operation, is perhaps even more important for inpatients than ambulatory
patients, given overall higher complexity and comorbidity that can be anticipated in
the inpatient population.
2. Operative phase
a. Case carts and preference cards: Standardization of equipment to match service needs
rather than individual surgeon preferences can reduce cost as well as wasted time.
b. Supply chain/storage: Simplifying storage schemes, minimizing travel distances
within the operating room environment, including automated re-stocking reminders,
and avoiding overstocking may help increase OR efficiency by decreasing waste and
allowed for quicker picking of needed supplies. (38)
c. OR: In the OR itself, myriad small steps can have an additive effect to streamline the
time spent between room entry and exit. This begins with adequate staff preparation,
through direct attending presence (39-40) and briefing (“team huddle”), to
communication between attending, staff and anesthesia, to accurate case booking and
case cart selection, to intra-operative communication about unanticipated
findings/needs and anticipated case completion. Case checklists, similar in concept to
the safety timeout, can avoid dropped steps (41), and minimization of nursing staff
turnover/breaks during cases can similarly reduce time wasted on handoffs, redundant
instrument counts, and loss of inertia (37). Standardization of instrument trays and
reducing inclusion of generally unused instruments has multiple benefits (32).
Automated, electronic medical record-initiated updates to families can decrease time
burden on the circulating nurse, and have a secondary beneficial effect of improving
parent satisfaction through effective communication (see Calabro and Rothstein’s
review in this issue of Seminars in Pediatric Surgery).
3. Post-operative phase
a. Turnover time: this metric is commonly a source of frustration to all involved, and
can be address specifically as a highlighted component of OR efficiency. Automated
communication to cleaning staff as the prior case is coming to a close, tying turnover
time goals to case complexity rather than case/service type, and surgeon engagement
are some strategies that have had success in decreasing TOT.
b. Parallel processing: Although parallel processing has perhaps less application in
pediatric surgery than in adult surgery because pre-operative (awake) intravenous line
 placement and regional anesthesia are less often feasible in younger patients, the
concept is still applicable and should be applied as often as possible. This would
include concepts such as pre-operative next case anesthesia evaluation by midlevel
providers or anesthesia fellows/residents/attending colleagues during late phases of
the previous operation, patient induction during the case opening and instrument
counting phase, staggered case starts, and anesthesia emergence in the post-anesthesia
care unit rather than OR.
c. Discharge pathways: The use of electronic medical record-based clinical pathways
and enhancing the role of point-of-service providers (i.e., nurses and advanced
practice providers) in independent decision-making can markedly increase the
efficiency of diet advancement, mobilization, pain control and general discharge
planning.

4. OR general
a. OR management: Personal experience and formal study both validate the need for an
efficient and agile room management to allow for continuous reevaluation and
adjustment to the minute-to-minute scheduling. Although there are clearly benefits to
maintaining a consistent nursing and technician team, the ability to move surgeons
and cases around to available rooms is likely a greater benefit to OR efficiency.
Dedicating an experienced person to control the flow of delayed or prolonged existing
cases as well as add-on cases is likely a worthwhile investment.
b. OR staff engagement: Circulating nurses are perhaps the most critical components of
the perioperative efficiency process. Staff engagement, education and inclusion are
critical to any efficiency improvement process. End-of-operation debriefs, best
performed on-line, can be rapid and promote team engagement while identifying
sources of delay (42). Dissemination of results to staff in a timely and transparent
fashion is also useful (43). Lastly, the important of leadership by example by
surgeons cannot be overstated. If the patient remains at the center of an idealized
quality improvement construct, it is perhaps the surgeon who reaps the second most
obvious rewards of improved OR efficiency as it is she or he who can be most
productive, avoid sitting idle and free up time for other activities, be they
administrative, academic, or simply finishing a scheduled OR day on time. Attarian
and colleagues listed these recommendations for surgeon engagement: 1) restating
project goals regularly; 2) sharing data transparently; 3) proposing constructive
solutions when able; 4) expressing gratitude daily to OR staff and colleagues; 5)
promoting high-achieving employees; 6) participating actively alignment projects
with the hospital; and 7) looking for new ideas to help improve efficiency (44).
c. Incentives: The literature is mixed on the value of positive or negative incentivization
(28, 42, 45). Typical examples include bonus payments to staff for meeting OR
efficiency metrics consistently and taking way block time from surgeons who display
non-conforming behaviors (e.g., non-punctual, non-participatory in briefs/debriefs,
etc.). Incentive in general, whether in the form of praise, engagement, finances, or
public sharing of successes, appears sensible in any case. Most high-level staff, such
as surgeons are often incentivized based on the intellectual stimulation and feeling for
 worth gained from being a part of a highly efficient system. Financial incentives
typically help motivate front-line, task driven staff (46).

Conclusions
In the end, all OR efficiency has a local component, and while many strategies discussed in this
manuscript are generalizable, each institution must review its particulars and adapt these
strategies. It is helpful to foster a team attitude through active engagement of all relevant
stakeholders – at least including surgery, anesthesia, nursing, OR management, and other
administration. – Regularly scheduled release of data can maintain transparency and encourage
participation of key stakeholders. More work remains to prove the value and sustainability of any
of the multiple business methodologies currently being applied in healthcare.
Legends

Figure 1. Value cost proposition

Figure 2. Process mapping

Figure 3. Key steps in work flow evaluation

 Implement
Dissemination
of results to
Pilot with surgeons and
single surgeon OR staff

Formulate
revised
process
Process
map

Unplanned
Employee surgical
engagement volume
variation

Reducing the collection and

Streamlining the
documentation of redundant
preoperative process
patient information

Reducing
operating room
nonoperative
time Adapted from Cima et al.
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