Pieter S. Stepaniak

Modeling procedure and surgical times for current procedural terminology-anesthesia-surgeon combinations and evaluation in terms of case-duration prediction and operating room efficiency: a multicenter study.

BACKGROUND: Gains in operating room (OR) scheduling may be obtained by using accurate statistical models to predict surgical and procedure times. The 3 main contributions of this article are the following: (i) the validation of Strum’s results on the statistical distribution of case durations, including surgeon effects, using OR databases of 2 European hospitals, (ii) the use of expert prior expectations to predict durations of rarely observed cases, and (iii) the application of the proposed methods to predict case durations, with an analysis of the resulting increase in OR efficiency. METHODS: We retrospectively reviewed all recorded surgical cases of 2 large European teaching hospitals from 2005 to 2008, involving 85,312 cases and 92,099 h in total. Surgical times tended to be skewed and bounded by some minimally required time. We compared the fit of the normal distribution with that of 2- and 3-parameter lognormal distributions for case durations of a range of Current Procedural Terminology (CPT)-anesthesia combinations, including possible surgeon effects. For cases with very few observations, we investigated whether supplementing the data information with surgeons’ prior guesses helps to obtain better duration estimates. Finally, we used best fitting duration distributions to simulate the potential efficiency gains in OR scheduling. RESULTS: The 3-parameter lognormal distribution provides the best results for the case durations of CPT-anesthesia (surgeon) combinations, with an acceptable fit for almost 90% of the CPTs when segmented by the factor surgeon. The fit is best for surgical times and somewhat less for total procedure times. Surgeons’ prior guesses are helpful for OR management to improve duration estimates of CPTs with very few (<10) observations. Compared with the standard way of case scheduling using the mean of the 3-parameter lognormal distribution for case scheduling reduces the mean overreserved OR time per case up to 11.9 (11.8–12.0) min (55.6%) and the mean underreserved OR time per case up to 16.7 (16.5–16.8) min (53.1%). When scheduling cases using the 4-parameter lognormal model the mean overutilized OR time is up to 20.0 (19.7–20.3) min per OR per day lower than for the standard method and 11.6 (11.3–12.0) min per OR per day lower as compared with the biased corrected mean. CONCLUSIONS: OR case scheduling can be improved by using the 3-parameter lognormal model with surgeon effects and by using surgeons’ prior guesses for rarely observed CPTs. Using the 3-parameter lognormal model for case-duration prediction and scheduling significantly reduces both the prediction error and OR inefficiency.

The effect of the Operating Room Coordinator's risk appreciation on operating room efficiency.

BACKGROUND: The Operating Room Coordinator (ORC) is responsible for filling gaps in every operating room (OR) schedule. We have observed differences among the personalities of the four ORCs with regard to their willingness to agree to assume more risk concerning their daily planning. The hypothesis to be tested is that the relationship between the personality of each of the four ORCs and the risk an ORC is willing to take of cases running late affects OR efficiency. METHODS: In order to judge the personality of an ORC in relation to risk-taking in planning schedules, we applied the Zuckerman-Kuhlman Personality Questionnaire in our study. Seven anesthesiologists were asked to score every ORC on willingness to take risks in planning. To analyze which risk attitude creates more OR efficiency, the daily prognosis of the ORC compared with the actual OR program outcome was registered during a 5-mo period in 2006 and 2007. We analyzed whether, in the opinion of hospital management, the costs of reserving too much OR time balances with the costs of reserving too little OR time, and whether this result is consistent with the assignment of the management tasks of the ORC. RESULTS: Seven anesthesiologists classified the four ORCs into the risk-averse group (n = 2) and the nonrisk-averse group (n = 2). The Zuckerman-Kuhlman Personality Questionnaire results for risk-seeking indicate that there is a difference in risk appreciation among the different ORCs. The main finding in our study is that the nonrisk-averse ORC plans to fill the gaps in more cases in the OR program than the risk-averse ORC does. The number of extra cases performed by the nonrisk-averse ORC as compared to a risk-averse ORC is 188 in 2006 and 174 in 2007. The average end-of-program-time per OR/day for the nonrisk-averse ORC is 34 min (±19 min, P = 0.0085) later than for the risk-averse ORC. We find that this hospital on average reserves more OR time for procedures than is actually required. The nonrisk-averse ORC takes more advantage of that extra OR time than the risk-averse ORC does by scheduling extra cases during office hours. The success of the nonrisk-averse ORC can be linked to the fact that there is usually time available due to this over-reserving. CONCLUSIONS: The conclusion of this study is that a nonrisk-averse ORC creates significantly less unused OR capacity without a great chance of running ORs after regular working hours or canceling elective cases scheduled for surgery compared to a risk-averse ORC.

Working With a Fixed Operating Room Team on Consecutive Similar Cases and the Effect on Case Duration and Turnover Time

HYPOTHESIS If variation in procedure times could be controlled or better predicted, the cost of surgeries could be reduced through improved scheduling of surgical resources. This study on the impact of similar consecutive cases on the turnover, surgical, and procedure times tests the perception that repeating the same manual tasks reduces the duration of these tasks. We hypothesize that when a fixed team works on similar consecutive cases the result will be shorter turnover and procedure duration as well as less variation as compared with the situation without a fixed team. DESIGN Case-control study. SETTING St Franciscus Hospital, a large general teaching hospital in Rotterdam, the Netherlands. PATIENTS Two procedures, inguinal hernia repair and laparoscopic cholecystectomy, were selected and divided across a control group and a study group. Patients were randomly assigned to the study or control group. MAIN OUTCOME MEASURES Preparation time, surgical time, procedure time, and turnover time. RESULTS For inguinal hernia repair, we found a significantly lower preparation time and 10 minutes less procedure time in the study group, as compared with the control group. Variation in the study group was lower, as compared with the control group. For laparoscopic cholecystectomy, preparation time was significantly lower in the study group, as compared with the control group. For both procedures, there was a significant decrease in turnover time. CONCLUSIONS Scheduling similar consecutive cases and performing with a fixed team results in lower turnover times and preparation times. The procedure time of the inguinal hernia repair decreased significantly and has practical scheduling implications. For more complex surgery, like laparoscopic cholecystectomy, there is no effect on procedure time.

Bariatric surgery with operating room teams that stayed fixed during the day: a multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration.

BACKGROUND: Bariatric surgery durations vary considerably because of differences in surgical procedures and patient factors. We studied the effects on patient outcomes, teamwork and safety climate, and procedure durations resulting from working with operating room (OR) teams that remain fixed for the day instead of OR teams that vary during the day. METHODS: Data were collected in 2 general teaching hospitals, consisting of patientrelated demographic and intraoperative data and of staffrelated survey data on team work and safety climate. The procedure durations of fixed and conventional OR teams were analyzed by comparison of means tests and by regression methods to control for the effects of surgeon, surgical experience, and procedure type. RESULTS: For both hospitals, we obtained the following 4 results for working on bariatric procedures with OR teams that remained fixed for the day. First, patient outcomes did not worsen. Second, teamwork and safety climate (both measured on a 5-point scale) improved significantly, for teamwork + 0.86 (95% confidence interval [CI], 0.54 to 1.18) and for safety climate + 0.75 (95% CI, 0.40 to 1.11). Third, the procedures were performed significantly faster, as both the mean and the SD of procedure durations decreased. After correcting for learning effects, the average reduction of durations was 10.8% (99% CI, 5.0% to 15.3%, or 4 to 13 minutes). This gain was mainly realized for surgical time (12%; 99% CI, 5% to 18%, or 3 to 11 minutes). The effect on peripheral time, defined as procedure time minus surgical time, is not significant (3%; 99% CI, −6% to 12%, or −1 to 3 minutes). Fourth, additional gains were obtained by performing the same type of procedure multiple times within the same day (5% per every next procedure of the same type; 99% CI, 3% to 7%, or 3 to 6 minutes). CONCLUSIONS: Working with fixed teams in bariatric surgery reduced procedure durations and improved teamwork and safety climate, without adverse effects on patient outcomes.

Monitoring anesthesiologists' and anesthesiology departments' managerial performance.

June 2013 • Volume 116 • Number 6 In the current issue of Anesthesia & Analgesia, Kynes and colleagues1 describe patient complaints about anesthesiologists reported during postoperative phone calls. Among pediatric patients, tardiness from scheduled start times accounted for more complaints than any other factor under our control. Among adult patients, the use of regional anesthesia or IV sedation (as opposed to general anesthesia) resulted in more complaints than other factors under our control.1 There were large differences in the rate of complaints among the anesthesiologists.1 However, these differences were not evident once the analysis adjusted for risk factors such as the use of general anesthesia.1 Anesthesiologists differ in their clinical performance.2–4 Anesthesiology residents can assess differences among supervising faculty anesthesiologists in the quality of their operating room supervision.3 Similarly, anesthesiologists can assess differences among residents in the quality of their clinical care.4 In both cases, the assessments are reliable and valid.4,5 The same is not true regarding management skills. For example, neither anesthesiologists nor anesthesiology residents can accurately assess even their own turnover times.5 As shown in Kynes’ study and others, waiting on the day of surgery matters to patients.1,6 However, there do not appear to be differences among anesthesiologists in the minutes of patients’ waiting past scheduled start times, frequency and minutes of add-on patients waiting following submission of the request for surgery, or complaints about the care provided.1,7–8 Complaints about intraoperative anesthesia care are principally a managerial outcome, not clinical, because the incidence of satisfaction with anesthetic care is just as high among the population of patients with adverse anesthetic events as patients without such events.9 Complaints are principally related to waiting.9 The reason anesthesiologists have similar waiting from scheduled start times, waiting for add-on cases, and patient satisfaction is that they make managerial decisions using common rules-of-thumb (i.e., “heuristics”). For example, multiple studies have shown that anesthesiologists make decisions that increase their own clinical work during the hours to which they are assigned.8–11 When working in a single room (e.g., as an anesthesiology resident), this good work ethic reduces the hours worked late and the minutes that cases start late, both of which are good.12–13 Such activity can be sustained both by other physicians’ perceptions of efficiency and of (positive) team activity.5,14–15 The paper by Wang et al.11 in this issue also reaches this conclusion. Anesthesiologists should make managerial decisions to run operating rooms as efficiently as possible. Yet, neither monitoring patient complaints,1 first case starts,7 nor patient waiting8 is useful. What should an institution monitor to assess managerial performance?