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RUNNING THE DAILY SCHEDULE

Frequently, an anesthesiologist is partnered with an OR nursing leader to make decisions regarding "running" the daily surgery schedule. As most large departments have come to realize, some individuals are better at this task than others. The schedule runner must be able to make fair decisions regarding moving cases, dealing with add-on cases, and using the nursing and anesthesia workforce in the most efficient manner to complete the surgical list.

Getting the schedule done is a complex job.[42] Making the flow of cases go smoothly requires many steps ( Table 86-16 ). The initial step is to review the schedule of cases the evening before, as well as early the morning of surgery. Look for potential obstacles to patient flow and for opportunities to deal with add-ons or changes. An accurate and realistic schedule is probably the most important factor in making the surgical day go well. The schedule runner should also frequently walk the "floor" in the OR to check on the status of room starts, case progression, and turnovers. Because surgical procedures have
TABLE 86-14 -- Operating room assessment report
Surgeon Cases Collection Avg Collection/Case OR Minutes Avg Minutes/Case Collection per OR Minute
Green 53 $43,116  $813 1150 22 $37.49
Jones 17 $16,802  $988  989 58 $16.99
Smith 10 $17,179 $1718  588 59 $29.22
Rogers 19 $11,947  $629  800 42 $14.93
Wilson 12 $13,341 $1112 1052 88 $12.69
Lynch 13  $7,398  $569  883 68  $8.38

a high degree of variability, plans on how cases should proceed are frequently changed, and adaptation is paramount. Create a tracking system to allow quick reference to how the day is progressing. This system may be something as simple as a handwritten grease board in the surgical core to more complex electronic displays. Regardless of the style, it is important for people working in the OR to be able to rapidly see where things are going, who is finished, and what add-ons are posted.

Every OR has add-ons and case cancellations. Obviously, the higher the number of add-ons and cancellations, the more complicated running the schedule becomes.[43] [44] [45] Although no true national benchmarks exist for schedule changes, it may be desirable to have add-on rates less than 12% and cancellation rates less than 4% to effectively
TABLE 86-15 -- Keys to increasing operating room throughput
Schedule full-day blocks rather than half-day blocks.
Surgeons should follow themselves in the same operating room.
Verify schedule accuracy to decrease delays in case completion.
Streamline preoperative processes and standardize testing.
Use specialty teams of nurses and anesthesiologists.
Organize supply and equipment needs for easy room setup.
Focus attention on room starts and turnover to create a culture of timeliness and efficiency.
If you have a significant number of add-on cases, plan for an open room or be able to move cases to available time slots.
Ensure that the communication pattern throughout the perioperative area informs all necessary individuals of case progression.

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TABLE 86-16 -- Ten steps to completing the daily schedule
Recheck the schedule the afternoon before surgery to look for potential difficulties and to identify opportunities.
Review the schedule early in the morning on the day of surgery and note cancellations and add-ons.
Ensure that rooms are starting on time by walking through the operating room suites.
Set expectations for surgical case progress by using benchmark case times if available.
Organize the turnover process to manage peak room changes from midmorning until early afternoon.
Develop a well-understood policy for working add-on cases into the schedule.
Look for open room time to move cases from late-running rooms or to move add-on cases into.
Identify cancellations early and redeploy the room and personnel resources to complete other cases.
Set realistic staffing patterns to meet the surgical caseload demand. Use nonstandard shifts so that rooms do not have to be closed in the early afternoon.
Use a case-tracking system so that others can see where resources are needed to complete the caseload.


TABLE 86-17 -- Common case cancellation issues
Patient Self-cancellation or no-show

Desired second opinion

Preferred transfer to another institution
Surgeon Not available; busy with an emergency or another case

Decided surgery was not indicated

Patient needed further workup
Anesthesiologist Patient not NPO

Patient needed further workup
Hospital Nursing staff not available

Lack required equipment or implants for case

Scheduling error; wrong date for surgery

Lack beds; ICU at capacity

manage the schedule. If an OR has higher rates, a close look should be taken to identify why these changes are taking place. Some of the issues common in case cancellations are shown in Table 86-17 . [46] Add-on cases should also have a well-understood system for triage so that they can be performed efficiently. Generally, the scheduled elective cases take precedence over add-on cases. Managing urgent or emergency cases must also follow a well-understood system.[42] Regardless of the best plans and attempts to control add-ons, situations will arise in which an urgent or emergency case will delay or "bump" a planned elective case from the schedule. One algorithm used to deal with
TABLE 86-18 -- Add-on case management
Emergency Urgent Elective
Come to the OR within 30 min Come to the OR within 2 hr No time constraints
Example: gunshot to the abdomen Example: appendectomy or ectopic pregnancy Example: revision dialysis shunt
Place in any open room Place in available staffed open block room or in room with cancellations Follow elective cases in first available room

If no room is open, bump the posting surgeon's elective cases

If posting surgeon has no room, bump same surgical division

If no cases within same surgical division, bump room with the shortest surgical list

this problem is shown in Table 86-18 . A factor that often helps control add-on placement is the manner of the surgeon's practice. If a group or division of surgeons is very busy, they may have set OR days when they are present for surgical procedures and other days when they are committed to clinic visits and are unavailable for the OR. Often, the surgeons' add-on cases are self-channeled into days that they are already in the OR. In this situation, the add-ons would naturally follow into that surgeon's preexisting room. Of course, if a hospital system has a large number of add-ons and surgeons must perform these later in the day, the OR schedule should be constructed to properly staff and support these times. Nursing shifts using the traditional 8-hour (7 AM to 3 PM) period may need to be modified to cover late rooms with regularly scheduled personnel working 12-hour shifts (7 AM to 7 PM) or staggered shifts (10 AM to 6 PM).

Despite the best planning, the daily schedule may still have challenges because of the unpredictable nature of cases and the motivation of surgeons to meet their own targets for their day's activities. An interesting analogy with how these interactions play out can be found in Alan Marco's articles on game theory as it applies to the OR.[9] [10] These perspectives can be helpful in achieving the goal of making the schedule run efficiently and seeking support for overall organizational success.

Utilization reports and periodic review of the schedule should be performed to look for opportunities for improvement. These measures may easily show where opportunities for improved efficiency remain, such as

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Figure 86-3 An example of schedule utilization.

decreasing unused OR time ( Fig. 86-3 and Fig. 86-4 ). Regardless of plans and desires to make a schedule go efficiently, remember that when a patient is in the OR, the quality of that patient's care is the main focus.

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