The Impact of OR booking lists on patient flow

In our current surgical system blocks of OR time are assigned to surgeons in which patients are booked from the surgeon’s office based on time available and time required for the particular procedure. These blocks might be either half-day or full day blocks, and the assignment of blocks usually would be established at time of recruitment of the surgeon with evolution as the surgeon’s seniority progressed. The surgeon would then build their ambulatory office or clinic time around their OR time. Hence making adjustments to OR days and time is complex within surgical services, with impacts on clinic and office utilization, unit staffing and schedules, impacts on the schedules of other surgeons, impacts on anaesthesiology schedules, and impacts on OR staffing among other factors. All of this leads to deep entrenchment of OR days and times. Few surgeons relish OR time at the end of the week for a variety of reasons. The result has been a strong tendency to bunch up cases in mid-week on the OR lists.
This ‘bunching’ effect predictably increases pressures on patient flow during mid-week days with increased utilization of ward beds and ICU beds which in turn affects the ED and other services across the hospital. Surgical services have managed their own needs within surgical units by staffing up mid-week and staffing down on the weekend and shoulder days within surgical services. However in the healthcare system in which we work, bed occupancy is close to 100% in “non-surge” seasons and most often is in excess of 100% in “surge” seasons (November through April). As such, there is minimal flexibility to manage the mid-week surgical peaks, and patient flow is negatively impacted.

“Smoothing out” the surgical schedule has been challenging for different administrations and medical leadership over the years, however we are now prepared to have a fresh look at the issues underlying the problem and seek new approaches.


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Participant comments on The Impact of OR booking lists on patient flow

  1. I know, this can be a real problem. At our institution, we don`t have any surgeon specific slots, so called fixed OR day for certain surgeon. We don´t have this ambulatory office problem, because there is only one queue, such for very specific procedures, there are surgeon specific queue OR plans are done for 1 week at a time. I think surgeon specific OR days are a better system because it enhances the utilization rate of the OR time. Our unit aims to focus the baseline cases at the beginning of the week because the intensive care stay is key element for patient flow. If we operate very complicated cases at first two days of the week, we will have cancellations by the end of the week because of ICU beds.
    The surgical flow should be maintained evenly, but problems would be caused by emergency cases etc. (dissections, rupture, TX etc.). If the OR requires a bit of other support services and there is no need for an ICU stay, the weekly program can be better planned. You can also change the week program easily after certain time or have two week –three week plan with different OR slots. The proposal is that you will give them, certain slots, which be changed after certain time frame.
    Also the unit staffing would cause difficulties, but it is manageable when you have more freedom to do that (strong unions etc). So you should have more moveable staffing. We have also “hired” beds from other departments for a busy season.

  2. Surgeon behavior is a strong factor in your equation. All surgeons want to get the in-patietn elective cases early in the week so there are no cases over the weekend. One way to optimize the OR schedule is to have block time for in-patient surgery and ortho spread through the week and mix with outpatient cases that don’t need beds/ICU. You can incentives surgeons that have complex cases (need ICU or more than 2 days in the hospital) to operate on Mondays and Fridays (provided the weekend team are good enough to take care of such cases).

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