Why can't we start the OR schedule on time?

I've spent a lot of time in the OR. One thing you learn is that the problems never seem to change, just the attempted solutions. Like noxious weeds, you can spray them, pull them, or ignore them or try to lean them to death, but they always seem to come back each July with the arrival of new residents and fellows.

Delays in OR start time and turnover is a vast finger pointing exercise involving nurses, surgeons, anesthesiologists and patients. Much like getting an airplane to take off on time, the flight attendants, pilots, maintenance crews, baggage handlers and air traffic controllers all play a role.

In California, 1 minute of operating room (OR) time costs an average $36 to $37 per minute, according to a study published in JAMA Surgery.

Here are the efficiency issues:

1. Building support among physicians to reduce supply costs A lot of money can be saved by lowering the implant buy, particularly in high priced cardiovascular and orthopedic implants. We are talking millions a year. The ritual of buying implants is a negotiation between the hospital purchasing authority, the vendor and the surgeons so you can imagine what a meeting of the Value Added Committee looks like. What seems to be ignored are the millions wasted on unnecessary instruments that have to be bought, cleaned, inventoried, transported and tracked that sit on the back table unused in 90% of the cases. 

2. Blocking time. There are two things that belong to surgeons that you never, ever, want to touch-their wallets and their block time. The new OR Golden Block Time Rule is that the surgeons who make the gold get the most block time. Loss leaders in the OR are more dangerous than an antibiotic resistant strain of E. Coli in the PACU. However, hospitals are rethinking block time. Roughly 51 million surgeries are done in more than 10,000 hospitals and surgery centers in the U.S. each year. Yet the corresponding utilization of operating rooms across these centers is, at best, 55 percent to 60 percent, based on estimates from the Medical Group Management Association. Given that a minute of utilized OR time is easily worth more than $70 in revenue and a minute of staffed OR time can cost $50 or more, having underutilized OR time is a huge problem.

3. Adjusting OR block time and releases I think OR demand management is too complicated for even the best trained, most experienced nurse sitting at a white board with three cell phones. Maybe it's time to install automated OR traffic control systems and offer a Masters degree for docs who want another pathway to the C-suite. Machine learning might be answer.

4. Proactively avoiding gaps due to equipment problems. 

Surgeon: Can I have that superexpensive retractor I designed please?

Scrub nurse: Sorry, doctor. We loaned that to Colorado General last night for an emergency case. It has to be gas sterilized, so it won't be available until the end of the week. Is there something else I can hand you?

5. Case start times. Like the first flight of the day that does not start on time, the dominos start to fall when the surgeon does not make the incision on time. While getting the staff to start the first case on time is the ultimate exercise in herding cats, it has bought a lot of second homes for Lean Methodology consultants who are sipping vodka tonics on the deck in their house in Vail while you are waiting for someone to get the consent signed. AI might be answer to improve start times.

6. Controlling turnover times. The basic rule is that excessive turnover time is always someone else's fault and, generally, the volume of the complaints is related to your place in the food chain while the ultimate power to make change is inversely related. 

One company thinks it has the solution, creating a hospital air traffic control system.

Suppose United Airlines ran your OR? I prefer an aisle seat even if the table and the pitch angle is getting smaller and smaller.

Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on Twitter@ArlenMD and Co-editor of Digital Health Entrepreneurship