Operating room management: what goes wrong and how to fix it - Clinical Services

Physician Executive, Nov-Dec, 1992 by Selma Harrison Calmes, Kurt M. Shusterich

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.