Operating room management: what goes wrong and how to fix it.

Operating rooms are probably the most difficult of all hospital areas to manage. This article describes a number of common management problems in operating rooms and identifies four broad management areas that must be adequately addressed to ensure an effectively run O.R. It also suggests possible approaches for dealing with the four areas.

Many factors contribute to O.R. management difficulties. For example, the numerous services that interact closely in the O.R.--multiple surgical specialties, anesthesiology, and nursing--have different motivations and cultures that frequently do not work well together on a team. At times, depending on how strong or weak the O.R. manager is, no one has the authority to make the many operational decisions needed each day in this area, such as which elective cases will be delayed to accomodate an emergency. Also, strong personalities, long work hours, interpersonal conflicts, and many critical ill patients make the O.R. an area of high stress. To compound matters, problems are frequently dealt with by staff who are promoted to management positions because of excellent technical skills but who lack management expertise or, depending on who is available on a given day, whose qualifications are minimal in all areas.

In addition, the different driving forces in for-profit institutions (where more surgical cases make more money) and prepaid managed care systems (more cases cost more money) can interfere with satisfactory O.R. functioning. Finally, the O.R. is a high-cost center; both personnel and equipment costs are high, and supply costs can become excessive if not carefully monitored.

Common Management Problems

In various projects in O.R. management, we have done surveys of O.R. personnel to identify management problems. We have found that O.R. staff are often proud of their ability to deliver high-quality work and believe that they are dedicated and hard working. However, our data also revealed many areas of significant dissatisfaction and a large number of management areas that need improvement. Issues that were frequently identified as problematic include:

* There may be ineffective leadership of the O.R.

There may not be an effective, agreed-upon leader for the entire O.R. Alternatively, an individual may be designated "leader" by title, but the staff may not accept the person as leader. The leader may not be effective because of a lack of management skills. In addition, O.R.s frequently have strong informal leaders who can promote harmony or create major management problems. Finally, a person who is an effective and accepted leader may be away from the O.R. a great deal of the time in meetings and in fulfilling other responsibilities.

* The various departments working in the O.R. may be functionally leaderless.

Leaders may be in place but may lack authority, interest in leading a particular function, or management skills. An example is surgical chiefs who do not hold physicians accountable for utilizing their block times effectively or for persistently overbooking. This disregard of a basic management principle (that scarce resources, in this situation O.R. time, must be utilized effectively) affects every one working in the O.R. suite. Overbooked rooms run late, causing delays in starting cases and causing unplanned overtime for nursing and anesthesia staff.

* Interpersonal conflicts are all too common in O.R.s.

The high level of stress, the personalities of surgeons and anesthesiologists, and the feeling of powerlessness common in the nursing staff lead to frequent conflicts.

* There may not be enough information to manage the O.R. satisfactorily.

Typical examples would be not having room utilization by service or by surgeon or not knowing average times for typical operations, all necessary for appropriate scheduling.

* The O.R.'s physical layout and location may seriously interfere with its functioning.

The location, layout, and staffing of the O.R. desk as well as the ease of use and location of the O.R. communication system are vital to satisfactory functioning. The location of the O.R. in relation to support functions, such as radiology and pathology or the ICU, and the location and availability of equipment such as microscopes and lasers may interfere with efficient functioning.

* Long room turn-over time is a common problem.

Inadequate turnover results from a lack of effective coordination. For example, housekeeping personnel may not be available when an O.R. needs cleaning. This may be due to poor scheduling, an inadequate O.R. communication system, or poor supervision of housekeeping staff.

* Systems problems in preparing patients for surgery are frequent.

The chart may not be complete, the patient may not show for surgery, there may not be enough transport staff to get patients promptly, and so on.

* The various groups working in the O.R. may be reluctant to assume responsibility for improving inefficiencies. This provides misguided justification for maintaining a less than satisfactory status quo.

Management Issues That Need to Be Addressed

We have found four major themes that encompass O.R. management problems: the system's rewards, ineffective logistical and system design, lack of responsibility or reluctance to accept responsibility, and lack of effective teamwork and a common goal.

System Rewards

There is a marked difference between a prepaid managed care system and a for-profit facility in terms of O.R. system rewards. In for-profit organizations, greater O.R. efficiency results in quicker turnaround, more patients, and more income for the organization, surgeons, and anesthesiologists. In a prepaid system, there is little incentive to do more cases; the reward for increased efficiency would be increased work. For most people in the O.R., this is not a reward. Indeed, one of the common ways surgeons and O.R. staff in a prepaid managed care system gain control over their work day is, paradoxically, by maintaining inefficiencies. A typical example would be a slowdown by staff, with a consequent delay in room turnover toward the end of the day. Staff would then get to leave on time rather than start another case for which they might not get relief. In addition, staff members get longer breaks if turnaround time is longer. In a prepaid environment with lower individual financial incentives, such as a county hospital, a typical method used by personnel to control the pace of their work is to arrive late.

Organizational System Design

Many logistical or system design issues contribute to difficulties in effectively managing an O.R. For example, when equipment is inefficiently stored or sterilized or is not available, delays and frustrations result. The same is true if there is lack of direct communication between operating rooms and departments such as pathology. Additionally, if radiology technicians are not readily available to the O.R., delays occur. Whatever the cause of a delay, one of its consequences is prolonged anesthesia, resulting in increased risk for the patient and further delays in completing the O.R. schedule.

Recovery room problems may contribute to case backup in the O.R. Anesthesiologists may not be able to return quickly to start the next case if a recovery room nurse cannot accept an incoming patient promptly. There may not be enough ICU beds or even hospital beds to send recovered patients to, especially in managed care systems. The recovery room can become full and unable to accept new patients, which results in back up in the O.R. Another logistical/system design problem arises if housekeepers are not present when rooms break to facilitate efficient room turnover.

Reluctance to Accept Responsibility

Blaming co-workers is all too common in O.R.s. Surgeons frequently blame anesthesia for delays in initiating cases, for long turnaround time, and for wasting surgeon's time by not communicating on last-minute cancellations. Surgeons also often blame O.R. staff for inefficiencies that occur late in the day, which is frequently perceived as a way to enable the staff to go home on time rather than start a new case late in the shift. O.R. staff gets blamed for equipment unavailability (i.e., not set up properly or missing). Surgeons also blame radiology for equipment failure and/or lack of skill with equipment.

Anesthesiologists, on the other hand, blame surgeons for late starts on the first case of the day (because "surgeons always arrive late"). They also blame O.R. staff for late starts on the first case of the day, frequently stating that the circulating nurse is not ready due to morning reports. O.R. staff is blamed for changing rooms after the anesthesiologist has already set up for a case in an O.R.

O.R. managers, too, point fingers of blame. They blame anesthesiologists for late starts on the first case of the day. They blame surgeons for late starts and for not notifying the O.R. in advance about special equipment needs. They also blame central supply for not always having equipment ready.

Common Goals and Teamwork

With all this blame around, it's no surprise that effective teamwork remains more a goal than a reality in many O.R.s. Different motivations and cultures drive the different groups that interact in the O.R. For example, surgeons have traditionally been powerful players in hospitals and come from a tradition of assertiveness (we also hear "agressiveness") and authority. This is even more true today because of the economic benefit that can result to an institution from a well-known surgeon's reputation and the many patients, and their expensive operations, that follow.

Nursing staff members have traditionally been the "surgeons' hand-maidens" and are still often treated as such even though they are highly trained professionals. Anesthesiologists have in the past been another group that "waits on" the surgeon. The increasing use of technology by anesthesiologists, such as the financially rewarding Swan-Ganz catheter insertion, has changed this situation somewhat. Increased financial rewards, however, have not changed anesthesiologists' traditional culture. They are frequently "loners" and have a reputation, at least, of not wanting to work together.

The power and status of the different O.R. groups follows economic lines. Surgeons are the highest paid medical specialty and exercise the greatest power and status in the O.R. Anesthesiologists, second in rank in the O.R., are also one of the nation's highest paid medical specialties. Nursing, the third profession involved in the O.R., occupies the lowest place both economically and in power status. Nonprofessional O.R. staff members (e.g., housekeeping) are so low in status that they may not feel they are valued members of the O.R. team, but obviously they are vital to smooth O.R. functioning.

Possible Solutions to O.R. Management Problems

Although specific solutions to O.R. management problems at particular institutions depend on circumstances and resources available, some general principles for O.R. problem solving can be defined.

There must be a commitment from the leaders of the multiple O.R. services to improve the situation. Such commitment is necessary to overcome lethargy and the sense of being overwhelmed with a hopeless number of problems and to help develop enough energy to begin the process of change. Getting this commitment from everyone is not easy. It might come from one of the three service leaders. If not, a high-level administrator may need to champion the effort and hold individuals accountable for improvement. In either case, outside expertise may need to be called in to objectively diagnose the problem and facilitate the process of change.

It is a crucial for the chiefs of surgery and anesthesiology, along with the O.R. manager, to discuss and resolve the major issues between themselves and their departments. Such an effort might best be accomplished with the assistance of professional facilitation. Without a good working relationship between the key players, any efforts to improve or enhance the effectiveness of an O.R. system will be mediocre at best and will certainly not be long-lasting.

A follow-up step may be to have a small group with representatives from surgery, anesthesia, and the O.R. nursing staff discuss and work out day-to-day conflicts. A group of this sort will work best if the individuals involved truly have the support of, and fully represent, the professional areas from which they are drawn.

O.R. management decisions are usually made in the worst possible way: by a large committee whose members don't work well together or by a committee led by someone who doesn't know how to run an effective meeting. The problem is compounded when the committee meets infrequently. The typical O.R. committee is scheduled to meet once a month, though in practice may miss regular meetings. The group is usually large, due to the presence of subspecialty surgeons, and the chair is usually a surgeon who lacks skills in running a productive meeting and/or who has a parochial view of the issues. This kind of committee can be useful in establishing O.R. policy issues but is usually ineffective in solving problems.

Essential to successfully run O.R.s are frequent small meetings of people who have the power to get things done, led by an agreed upon leader who knows how to run an effective meeting. This might be called the O.R. Management Group, Committee, or Task Force. Our experience has shown that whatever it is called, the committee is most effective if attended by the leaders or seconds-in-command of the three O.R. services and the administrative liaison for the O.R.

There are fundamental guidelines for ensuring a successful process for problem identification and resolution within the O.R. committee framework. The principles of effective meetings must be known, valued, and adhered to. The method of appointment and the roles of the chair and committee members must be clearly defined. There must be clear committee goals (i.e., what is the committee to accomplish and in what time will it be accomplished?). A rotation system for the committee chair can be effective in balancing power among the groups on the committee.

To begin the process of change, committee meetings should probably be held on a weekly basis. Once momentum is gained, meetings can be held less frequently. It is useful to keep individual meetings under one hour. We have found that with an agreed upon agenda distributed beforehand, regular, frequent, and short meetings will create a stimulus to get the work done in a timely manner and result in concrete steps being taken. If this process is to be effective, sufficient time must be built in to get the priority work done that arises from the meetings.

Prompt distribution of brief minutes, with clearly assigned and defined action items and deadlines, is important so people can be reminded of their assignments in enough time to get jobs done before the next meeting. Invited guests (such as the head of facilities, central services, or laundry) may need to be part of the meeting. Frequently they can provide solutions to aggravating O.R. problems.

It's easy to be overwhelmed by the number and complexity of O.R. management problems. As a first step, those problems should be identified, clarified, and prioritized. It is a good idea to begin with small issues so that the O.R. management group does not become overly discouraged and can achieve an early success. Continued momentum for change is achieved once the process begins.

When working on information systems problems, we have found that one area where change can be made relatively easily is in the scheduling/information area. A useful set of diagnostic questions to ask includes:

* Does the person who runs the O.R. have enough information and data to do it properly?

* Does your information system have O.R. utilization by room, service, surgeon, and so on?

* Is the system working well?

* What are the system's strengths and weaknesses?

* Do you have average times for standard procedures for different surgeons?

* How much work is taking place in other shifts?

Many scheduling and statistical programs are available commercially or could even be developed in-house. A surprising number of O.R.s still do not have a computerized data collection system and rely solely on hand counts. Once a good information base is established, realistic scheduling can be done. Unrealistic scheduling is a source of great aggravation to supporting services. A method for dealing with emergencies can be developed once proper scheduling is in place.

As management begins the change process by providing leadership and resources, it is imperative that input from the O.R. staff be obtained. The staff should be surveyed to provide an opportunity for them to identify problems and make suggestions for improvement early on. Without that involvement, it will be difficult to have management's plans implemented successfully. Once goals are established and agreed upon, senior administration must ensure that individuals at all levels are held accountable and are fully supported.

Administration can provide support in a number of ways. For example, administration should ensure that all staff members who need to learn basic and specialized management practices and principles, such as how to deal with difficult people, conflict management, and effective communications skills (including meetings management skills), have opportunities to learn them. Once individual and O.R. committee goals are set, administration should provide broad support to see them implemented. If support in an area is not possible, specific reasons should be given to the appropriate people/committee. Finally, administration should let O.R. committee members know how the improvement program will be evaluated and that individuals will be held accountable for outcomes.

Another possibility for managed care facilities is to develop, with input from the different O.R. groups, a system of incentives to provide motivation for increased efficiency. This system might be based on the premise that efficiency depends as much on teamwork as on individual efforts. It's critical that incentives be developed by the individuals who will be affected. Change will be limited unless there are incentives and rewards for the people on the line doing the work.

If the process of change in O.R. management proves to be too difficult, obtaining assistance from specialists with O.R. management expertise may be useful to help ensure the success of the change process. Professional management assistance can provide accurate and unbiased analysis. They can, for example, point out and analyze the different cultures and driving forces between the various groups analyze the situation in a more neutral way than those working in the organization might be able to or be perceived as able to. Individuals selected to provide the extra support should be knowledgeable of O.R. systems and dynamics and skilled in obtaining an accurate organizational diagnosis. That diagnosis should include interviews with physicians, RNs, administrators, and other appropriate people who work in the O.R. Such consultants should be skilled in working with managers and administrators as well as professional medical staff. In addition, they should have demonstrated expertise in planning and implementing a successful organizational intervention plan that will be successful.

If any movement is to be made toward more effectively managed O.R.s, it is essential to ensure a human systems environment that fosters collaboration between the key stakeholders. Much has been written recently about empowerment, partnership, and continuous quality improvement in the workplace. Nowhere is understanding and effective implementation of these concepts more crucial to successful management than in the O.R.