The Elephant in the Operating Room

To the Editor:—In the August 2005 issue of ANESTHESIOLOGY, Sandberg et al. describe an Operating Room of the Future (ORF) that includes extensive physical and workflow redesigns for “optimal support of advanced minimally invasive surgery.” The ORF enhancements incorporate increased capital costs for advanced equipment and increased personnel costs as compared with their standard operating room. These costs are justified by their findings that they are more than offset by increased revenues resulting from increased efficiency in the ORF. Several points should be carefully considered before any institution attempts to replicate such a model. Insurance mix: Revenues are strongly affected by the “insurance mix” of the patient population. In California, Medi-Cal (Medicaid) covers only approximately 46% of fully allocated hospital costs, whereas some preferred provider organization plans cover as much as 120% of those same costs. Sandberg et al. do not reveal the insurance mix of their study population. Given that capital and personnel costs are entirely independent of fluctuations in insurance mix, a hospital with an unfavorable insurance mix could easily fail to offset the increased costs of the ORF model with increased revenue. Operating Room of the Future utilization: Sandberg et al. use a model for utilization that places only one surgeon working within the ORF each day. In work at our institution, we found that, using single surgeon utilization, similar daily enhancements in operating room throughput could be achieved with extensive workflow redesign. However, when multiple surgeons were scheduled within a single operating room on a given day, all time savings gained through enhanced efficiency were lost awaiting next surgeon arrival. Seventy-four percent of all delay codes during a study period were under the heading of “awaiting surgeon arrival,” whereas 83% of total delay minutes were under that same heading (R. A. Dritz, M.D., Berkeley, California, unpublished data, 1997: data gathered by assigned observational nurse in the operating room). At our institution, only 8–12% of all operating rooms are scheduled with only a single surgeon on any given day. Given that Sandberg et al. further note that, even when only using a single surgeon, not all surgeons and surgical case mixes benefit from the inclusion in the ORF (see Sandberg et al., table 2); one can see that extreme care must be taken in managing operating room utilization patterns if one is to achieve the financial enhancements they describe. Capturing productivity gains: It is important that time savings resulting from increased efficiency be filled with other productive activities and not lost to downtime. For example, if a surgeon required a full 8-h shift to perform a surgical caseload in a standard operating room setting but successfully completed those same cases in 6 h in the ORF, it is essential that the 2 h saved not be squandered either awaiting another surgeon’s arrival or enhancing coffee break times. Because of the increased costs per hour in the ORF, time savings lost to nonproductive activities in the ORF could make it a net loss when compared with the standard operating room. In summary, Sandberg et al. present an intriguing model to enhance operating room efficiency. However, extreme care must be exercised before choosing to replicate such a model in another hospital setting. Given the current realities of hospital economics, the Operating Room of the Future may not be economically viable in the present.