MEDICAL MANAGEMENT IN THE OPERATING ROOM

Operating rooms are complex and expensive entities, similar to large corporations. To make an enterprise of this magnitude function, a well-defined governance structure must be in place. Because medical needs and regulatory requirements are constantly changing, this governance structure must be designed to be able to rapidly adapt and bring about change in the organization. The earlier style of top-down management, centered in a distant and often unfamiliar hospital administrator with an OR nursing director as the floor manager, often failed to meet the changing needs of the OR. In addition, the diverse groups working within the OR (nursing, surgery, anesthesiology) had different incentives and goals, which at times created a battle zone atmosphere.^[7] From these challenges, the concept of appointing a medical director in the OR came about in an attempt to align the forces working in the OR. There are many advantages to this structure. By centralizing authority in one knowledgeable individual with control and authority for global OR matters, an organization can more effectively adapt to changing needs and make critical improvements. The original concept was to create an "OR czar"; however, this implies a ruling style by force or a dictatorship. Neither of these characteristics will prove to be successful in actual practice. An organization structure that describes how the medical director may fit into the system is shown in Figure 86-1 . Operating rooms have four distinct groups that have a stake in its function: surgeons, anesthesiologists, nurses, and hospital administrators. All these groups have their own interests, directions, and goals. Surgeons want maximum convenience and service, easy OR access, and the latest and newest equipment. Nursing wants predictable hours and standardization of cases. Anesthesiology wants high utilization during peak business hours and adequate support for starting procedures and for turnovers. Hospital administration wants ORs to have high utilization with the lowest possible cost for personnel and equipment. The trick for the OR director in making an OR function well is to find a balance where these groups can work together to produce an effective operation.

Formalizing the position of the OR medical director will help pull these diverse entities together and address their changing needs. The hospital's goals in creating an organizational structure for the OR director are improved OR performance; increased physician, nursing, and patient satisfaction; rapid adaptability to changing market forces; improved communications throughout the system; and accountability and enforcement of OR rules and regulations. Some personal characteristics for such a person are listed in Table 86-1 .

Anesthesiologists are good candidates for this position for a variety of reasons. They have a more global view of the OR and understand the overall workings of the OR process. Anesthesiologists and hospital administrators share the desire for a smooth-running and cost-effective

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Figure 86-1 Organizational structure that describes how the medical director may fit into the operating room system. CEO, chief executive officer; OR, operating room; PACU, postanesthesia care unit; SDS, same-day surgery.

There are challenges for an individual in this position. A great deal of time must be spent away from clinical practice, attending meetings, planning projects, and coordinating OR productivity. The physician's group or department chair must give time to this individual to be able to accomplish the OR's mission. Additional financial support must come from the hospital to pay for the time spent on medical director functions. Likewise, the chairs of surgery and anesthesia must cede to the medical director some of their departmental control and authority

TABLE 86-1 -- Characteristics of the medical director of an operating room

Experienced individuals, usually in the middle of their careers

Respected for clinical skills

Strong interpersonal skills

Integrity and trust by all groups

Perceived neutrality and balanced views on issues

Leadership style by consensus development

Strong analytic and problem-solving skills

Detailed data management traits

Ability to commit significant time and focus to operating room

Appreciation of hospital's goals

Good long-range planning development

Ability to address regulatory and oversight controls

involving OR matters. The time and energy demands may limit medical directors from advancing within their own departments, organizations, or academic institutions. Because some decisions will not be agreeable to all parties, medical directors must be able to withstand criticism and challenges to their role. In addition, limitations in business training and data processing may require added background building to meet these needs. Guidelines for the role of medical director can be found in Appendix 1 or on the AACD website at AACDhq.org.

In 2002, a survey was conducted by the AACD of its membership ( Table 86-1 ).^[8] Some of the data are found in Table 86-2 . The survey noted that the position of medical director started in academic organizations but has

TABLE 86-2 -- American Association of Clinical Directors 2002 survey of operating room medical directors

Hospital Type
University teaching	44%
Community hospital	33%
University affiliated	33%
No. Hospital Beds	Size
<50	5%
50–100	4%
100–200	13%
200–500	54%
>500	25%
Hospital Compensation for Medical Director (per Year)
None	40%
0–$10,000	25%
$10,000–$25,000	18%
$25,000–$50,000	13%
$>50,000	4%

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If an organization wishes to create a new position of medical director of the OR, the director's responsibilities, expectations, and support should be clearly defined beforehand. Frequently, the motivating factors for creating an OR medical director position are that the organization is frustrated with the functioning of the OR and there is poor satisfaction among all parties working in the OR. Before accepting the role of medical director, the job description, organizational chart, and financial support must be clearly defined. Medical directors should look for issues that can be remedied fairly easily to gain momentum and acceptance by those working in the OR. Coordination with the OR head nurse and OR business manager will unite the resources necessary to bring about change. Regular communication to hospital superiors, as well as those working in the OR, will help define how the projects are going, as well as identify future plans. OR directors need to involve other physicians in setting goals and priorities. Success will require hospital administration and physicians to partner together to bring about change, and both sides may need to compromise to find workable solutions. The OR committee along with hospital administration needs to create rules and definitions for the OR that are fair and equitable. These rules should be evenly enforced and peer pressure used to help maintain improvements. Individualistic views should be discouraged and a team approach created. An understanding of how "game theory" applies to the OR is also useful.^{[9] [10]}