HISTORY
The OR has undergone an evolution in its role within the hospital.
The organized structure and daily management of the OR are markedly different today
than it was 20 to 30 years ago.[2]
In the past,
ORs generated large profits.[3]
The priority during
this era was to maximize convenience for surgeons and attract a greater market share.
Controlling costs was of low importance because it was assumed that any new investment
in the OR would lead to increased revenue. During this period, revenue for the hospital
was plentiful, so when new equipment or expanded ORs were desired, they were provided.
Surgical procedures were scheduled at the desire of the surgeon, usually on a first-come-first-served
basis. In this era, the authority for OR management was dispersed between hospital
administrators and the OR nursing leaders. OR nurse managers were expected to manage
all the complex activities in making the OR run.[4]
Many of the supporting
services (housekeeping, admitting, materials management, and laundry) had separate
administrative reporting structures. The low procedure complexity of ORs allowed
for these simplified support services. Usually, a hospital administrator, often
with little direct OR experience, had authority for the OR as well as several other
areas of the hospital. This hospital administrator left daily control of OR functions
to the OR head nurse, who became the de facto leader of the unit. Physicians often
had a limited role in directing OR function.
As surgical procedures became more complex and competition for
available OR time increased, surgeons began to become dissatisfied with the hospital
administrator's control of OR management. OR committees were formed to allow physicians
an avenue to voice their thoughts to hospital leadership. The hospital and OR committees
created rules and policies governing OR function. Dedicated rooms for complex procedures
and increasing scheduling demands led to the development of guaranteed reserved OR
times called "blocks." These blocks allow better predictability for surgeons to
perform their procedures, as well as to allow the hospital to provide the necessary
support for the cases. The authority for daily OR management still resided primarily
with nursing.
As Diagnosis-Related Group (DRG) reimbursement and capitative
payment for care became more common, ORs began to experience reduced revenue. Hospital
administrators noted that ORs were very expensive to furnish and run. The overall
hospital operating margin (profit) began to shrink, going from 6.3% in 1997 to 2.7%
in 1999.[5]
By 1999, 43% of not-for-profit hospitals
actually lost money. Such losses forced hospital leaders to rethink how they ran
their ORs. If the ORs consumed 9% to 10% of the institution's annual budget, these
costs needed to be analyzed and controlled.[6]
With the advent of general medical restructuring and primary care "gatekeepers,"
predictions of reduced demand for specialists and surgical services were made. Hospitals
reduced inpatient beds and limited OR growth. The net effect of these changes was
that frustration with OR function and management increased.
Hospitals set targets for performance, and regulatory organizations
set quality measures for the OR. To complicate matters even more, the predictions
of reduced surgical caseload volume proved to be untrue. Surgical demand began to
increase faster than the OR infrastructure, OR nursing, and anesthesia services could
match. Shortages of hospital beds, intensive care units (ICUs), and personnel to
staff ORs have now led to increased pressure to manage ORs with maximum efficiency
while at the same time controlling costs. The hospitals expected all these OR changes
to occur simultaneously while maintaining high OR customer and patient satisfaction.
Hospital administrators began to realize that they needed more direct physician
leadership in these complex OR matters. In some hospitals, medical directors were
appointed and more voice and authority were given to physicians in OR leadership
roles. This physician leadership structure began in a few academic departments but
has now expanded to many public and private organizations throughout the United States,
Europe, and elsewhere. The focus on not only leadership structure but also management
techniques that improve OR function has led to a organized approach to OR management
as set forth in this chapter.
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