Successful Strategies for Improving Operating Room Efficiency at Academic Institutions

To the Editor: I greatly enjoyed reading the article by Overdyk et al. 1 on operating room (OR) efficiency. They have aggressively pursued identification and correction of many sources of case delay. Presumably, virtually every academic center in the country is attempting to improve OR efficiency, and the 46-min per OR per day time-savings achieved by Overdyk et al. should attract a great deal of deserved attention. Unfortunately, the authors of this article fail to address or even mention what is probably the most significant barrier to real competitive perioperative cost-reduction; namely, academic surgical operating times. They state that surgery-controlled time is 4.5 times greater than anesthesia-controlled time but conclude from this that, "OR efficiency might be well served by streamlining OR scheduling." No doubt, but what about the actual procedure time? Academic surgery times are generally 130%-150% higher than those in private practice, and not simply because of case complexity. The academic surgical culture allows for large amounts of unsupervised resident activity during positioning, preparing, opening, closing, and, in some cases of prolonged head and neck cases, during the mid-portion, as well. Efficiency improvements have led anesthesiology teaching time to become progressively squeezed. Overdyk et al. 1 do not note the effect of their activities on anesthesia training, but it cannot have been made better. Real progress in cost-reduction requires that attending surgeons be brought further into the process. The issue is far deeper than showing up on time, although certainly that is an important element. The question is what do they do during opening and closing and how they guide housestaff during the procedure. The inevitable prolongation of technical procedures in a teaching facility is a little discussed factor in determining the true cost of medical education. Our challenge, in both anesthesiology and surgery, is to revise traditional teaching styles so that they retain effectiveness while promoting recognition by all parties of the cost-intensive nature of the operating suite. Presumably, teaching by abandonment or trainee subcuticular closure of a long incision, will become unusual events. It is important to note the psychology of team behavior. It is our observation that sustained success of efficiency-improving endeavors requires ongoing surgical commitment and leadership. A few minutes per day can be hammered out of nursing and anesthesia procedures, but premature departure by the surgery attending physician, adding 20-30 min to a closure, will quickly drain the energy from a complex collaborative effort. Charles Beattie, Ph.D., M.D. Department of Anesthesiology; Vanderbilt University Medical Center; The Vanderbilt Clinic; Nashville, TN 37232-2125