Keys to optimize the operating room efficiency | Revista Española de Anestesiología y Reanimación (English Edition)

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Abad-Gurumeta, R. Casans-Francés, J.M. Calvo-Vecino" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M.A." "apellidos" => "Gómez-Ríos" "email" => array:1 [ 0 => "magoris@hotmail.com" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Abad-Gurumeta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 2 => array:3 [ "nombre" => "R." "apellidos" => "Casans-Francés" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 3 => array:3 [ "nombre" => "J.M." "apellidos" => "Calvo-Vecino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Departamento de Anestesiología y Medicina Perioperatoria, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo Español de Vía Aérea Difícil (GEVAD), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Grupo de Investigación Anestesiología y Tratamiento del Dolor, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Departamento de Anestesia, Complejo Asistencial Universitario de Salamanca, Universidad de Salamanca (CAUSA), Salamanca, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Claves para optimizar la eficiencia de un bloque quirúrgico" ] ] "textoCompleto" => "IntroductionConstant transformations in health care due to the fast pace of scientific and technological progress in medicine and population ageing constitute a continuous challenge for health systems.<a class="elsevierStyleCrossRefs" href="#bib0275">1,2</a> This growing complexity coupled with rising costs compels health services to constantly reorganise in order to adapt their resources to meet today's demands and maintain quality of care, clinical efficiency and sustainability.<a class="elsevierStyleCrossRef" href="#bib0285">3</a> The success and continuity of healthcare depend on the capacity of an organisation to adapt its structures and practices to this changing reality.Surgery is the main source of revenue and costs in hospitals worldwide.<a class="elsevierStyleCrossRefs" href="#bib0290">4–6</a> The organisation of this service is particularly complex, since the surgical suite is the epicentre of a multidisciplinary care process involving multiple hospital services and different groups of health professionals.<a class="elsevierStyleCrossRef" href="#bib0305">7</a> The need for all hospitals to maximise the efficiency of their surgery suite<a class="elsevierStyleCrossRefs" href="#bib0300">6,8</a> has prompted an increase in research on this topic in recent decades. However, surgical resources are often considered underutilised.<a class="elsevierStyleCrossRefs" href="#bib0295">5,6</a> The aim of operating room management is to replace these ineffective organisational structures with other, more competent frameworks<a class="elsevierStyleCrossRef" href="#bib0290">4</a> conducive to the achieving the main goals of 21st century surgical practice: safety, effectiveness and efficiency.<a class="elsevierStyleCrossRef" href="#bib0315">9</a> The aim of this article is to analyse the current principles of organisation, optimisation and clinical management of the surgical suite and their repercussion on the quality and safety of care.Operating room managementPlanning surgery is a highly complex task,<a class="elsevierStyleCrossRefs" href="#bib0280">2,10</a> because it involves coordinating different professionals, at times with conflicting interests, in order to maximise effectiveness and achieve common goals.Surgical suites must be managed under a defined organisational structure. The introduction of an operating room manager, the creation of operating room committees, and management by objectives<a class="elsevierStyleCrossRefs" href="#bib0325">11,12</a> can improve both performance and patient and staff satisfaction, while good communication facilitates change management and the ongoing implementation of rules and regulations.<a class="elsevierStyleCrossRef" href="#bib0290">4</a>The position of operating room manager is best filled by a doctor. Anaesthesiologists are particularly suited to this role.<a class="elsevierStyleCrossRefs" href="#bib0290">4,5</a> In fact, more than half of all operating rooms are managed by anaesthesiologists.<a class="elsevierStyleCrossRef" href="#bib0290">4</a>The creation of an operating room committee is fundamental for efficient management. The committee is usually made up of the surgeons, anaesthesiologists and nurses that head their respective services, together with hospital leaders, and a small number of physicians undergoing their required rotations.<a class="elsevierStyleCrossRef" href="#bib0335">13</a> It should be small enough to ensure functionality,<a class="elsevierStyleCrossRef" href="#bib0335">13</a> and one of its tasks in to develop priority-based algorithms. Effective management requires integrated decision-making: (a) strategic (long-term), to address the physical structure of the surgical area; (b) tactical (medium term), to provide enough resources to meet the suite's needs. This includes the allocation of operating time, staff scheduling and allocation of specialised equipment, and (c) operational (short-term), involving the day-to-day administration of the surgical suite, starting with assigning personnel and equipment 24h in advance, and coordinating medical and non-medical support units.<a class="elsevierStyleCrossRefs" href="#bib0295">5,14</a>The surgical suite, as a multidisciplinary unit, requires a set of rules in order to coordinate its activity and deal with conflicts while preserving a professional working environment. The committee draw up, in writing, a “framework statute” of the surgical suite that will include, among other things, the composition, function and responsibilities of the committee and the manager, operating room rules (schedules, patient pathways or safety), programming rules, and management concepts or rules of behaviour that will foster a culture of unity and teamwork. The work of health professionals should not be limited to providing health care, as in the past; they should be involved in management issues, and take joint responsibility for efficacy and efficiency outcomes.<a class="elsevierStyleCrossRef" href="#bib0345">15</a>The diversity of procedures, urgent or scheduled, and their relative priority, dependence on other structures with limited capacity, such as postoperative care units, and the large number of services competing for a limited number of operating rooms, mean that programming and efficiency parameters are paramount in operating room management.ProgrammingOperating room performance depends on the number of surgeries performed; therefore, management is mainly focused on scheduling,<a class="elsevierStyleCrossRef" href="#bib0300">6</a> in parallel with waiting list management and organisation of the personnel and instruments needed for a particular intervention.<a class="elsevierStyleCrossRef" href="#bib0290">4</a> A surgical intervention involves several human resources that must be programmed for immediate action (surgeons, anaesthesiologists, nurses, porters, etc.) or set on stand-by (radiology technicians, pathologists for diagnostic biopsies, a second surgical team for complementary interventions).<a class="elsevierStyleCrossRef" href="#bib0280">2</a> Good scheduling is essential to provide an effective service, while scheduling shortcomings are the source of delays and both staff and patient dissatisfaction. Operating schedule rules should be established, operating timetables should be drawn up and personnel assigned to each case. Both the timetable and the personnel assigned will be modified if emergency cases and imbalances between registered and real cases arise.<a class="elsevierStyleCrossRef" href="#bib0300">6</a> Many institutions have automated their programming systems in an attempt to limit bias in surgery duration estimates, overlapping cases that require specific resources, and to guarantee, as far as possible, that scheduled surgeries go ahead by relocating patients and avoiding cancellations.<a class="elsevierStyleCrossRefs" href="#bib0290">4,5</a> Most hospitals plan their surgery schedule on a weekly basis, leaving enough flexibility for the management of beds and seasonal demands. Patients undergoing anaesthesia procedures outside the surgical suite should be included in the general surgical schedule, since they require perioperative resources, such as anaesthesia service personnel or beds in post-anaesthesia care units.Programming systems“Open” programmingEach operating room is available for any intervention. This system has many limitations: it is impossible to estimate which operating rooms and which resources will be available at a given time, and makes it difficult to allocate these elements. It also involves transferring specialised equipment from one operating room to another without the possibility of advanced planning. The result is general inefficiency, which is why this system is only used in a small number of operating rooms that are available for emergency cases, thus avoiding altering the programmed surgery schedule. The number and availability of operating rooms will depend on the volume of urgent cases added.“Block time” programmingThis is the most widely used programming system,<a class="elsevierStyleCrossRefs" href="#bib0290">4,13</a> and involves allocating a specific operating room and surgery time to a specific surgical team for a certain time, depending on demand or hospital priorities.<a class="elsevierStyleCrossRef" href="#bib0295">5</a> This organisation system creates specialised operating rooms and personnel, it avoids the constant transfer of resources between operating rooms, and reduces turnover times and case variability.<a class="elsevierStyleCrossRef" href="#bib0300">6</a> This system works best when allocation is service-based instead of surgeon-based, and organised around full days instead of time slots, since patient flow and case start times are more predictable,<a class="elsevierStyleCrossRefs" href="#bib0290">4,6</a> and allocation can be changed in accordance with factors such as waiting lists or block times. Unused block times are available for any service, on a first-come, first-served basis. The centre must establish, through the surgical committee, schedule allocation rules to ensure that the process is equitable, taking into consideration advanced programming, hold times or release times, which will vary in each hospital and each service, depending on the volume of urgent surgeries.<a class="elsevierStyleCrossRefs" href="#bib0290">4,16</a>Hospitals in which block time is used to the full and an increase in demand is expected should take the strategic decision of either increasing surgical activity or the number of operating rooms. The per-hour profit margin, the growth potential, and limited need for additional resources, such as critical care beds for each service, are a good basis on which to take tactical decisions regarding the allocation of the new block times.<a class="elsevierStyleCrossRef" href="#bib0355">17</a>Emergency managementThe impact of emergency surgery cases should be factored in to any analysis of surgery suite resources. Management of these cases depends on the characteristics of each surgical suite, the expected flow of cases,<a class="elsevierStyleCrossRef" href="#bib0295">5</a> and the established priorities. In hospitals with a low volume of unscheduled surgeries, emergency cases can be incorporated into the elective schedule by scheduling “open rooms” or by rescheduling elective cases. Hospitals with a higher volume of emergency cases can allocate certain operating rooms exclusively for emergency surgery.<a class="elsevierStyleCrossRef" href="#bib0300">6</a> Good management of emergencies surgeries improves the efficiency and general use of the surgical suite by limiting their impact on the elective schedule and assigning the appropriate resources to the unscheduled case load.<a class="elsevierStyleCrossRef" href="#bib0295">5</a> An exceptional case would be delayed emergency trauma surgery, which may have an allocated operating room with a flexible schedule that allows managers to group certain interventions and optimise patient care.Predicting surgery timesGood surgery planning depends on making reliable estimates of the time needed for each procedure.<a class="elsevierStyleCrossRefs" href="#bib0320">10,18</a> Underestimating surgery times will disrupt the start time of subsequent cases, which might need to be postponed or cancelled, while overestimations result in empty operating rooms.<a class="elsevierStyleCrossRef" href="#bib0320">10</a> Both situations can lead to suboptimal use of the operating room, and should be avoided.Predictions should not be based solely on the surgeon's estimate or on average surgery times taken from clinical records, which are inaccurate and highly variable, but should also take into account the specific characteristics of each patient.<a class="elsevierStyleCrossRef" href="#bib0365">19</a> Different studies have attempted to develop predictive tools based on statistical models.<a class="elsevierStyleCrossRef" href="#bib0320">10</a> Those that provide improved estimates of surgical time and block planning are those that base their calculations on real, most recent surgery times extracted from the hospital's computer system and specific patient indicators.<a class="elsevierStyleCrossRefs" href="#bib0320">10,20,21</a> Gathering surgeon-specific data is fundamental, since surgical times vary widely between surgeons and hospitals.<a class="elsevierStyleCrossRef" href="#bib0380">22</a> In the absence of documented surgery times of a specific surgeon, the average of times of other surgeons or the surgeon's own estimate, adjusted for bias, can be used.<a class="elsevierStyleCrossRef" href="#bib0385">23</a> The use of prediction models reduces the variability of time estimates, increases the operating room use rate, and limits overtime by planning of the start of the last operation in relation to the end of the working day,<a class="elsevierStyleCrossRef" href="#bib0320">10</a> although flexible planning on the day of surgery, transfer of cases, and extra cases minimise the impact of predictions on the number of extra hours.Dexter et al.<a class="elsevierStyleCrossRef" href="#bib0390">24</a> showed that surgical times can be predicted from the duration of previous cases and current information using Bayesian analysis.<a class="elsevierStyleCrossRef" href="#bib0385">23</a> This would allow real-time decision-making, such as transferring cases to other operating rooms, knowing when to prepare the next patient, or when to make the necessary material resources available.<a class="elsevierStyleCrossRef" href="#bib0365">19</a> The analysis does not predict delays caused by intraoperative complications or other unforeseen events. In short, different software will facilitate surgery programming according to estimated surgical times for each pathology, surgeon and patient.SchedulingAccurate programming is a key factor in completing the daily surgical schedule.<a class="elsevierStyleCrossRef" href="#bib0290">4</a> Despite this, daily programming can be complex, given the inherent uncertainty of surgery times, and the constant flow of patients with their particularly characteristics and priorities. This means that surgery timetables need to be revised constantly up to the day before the intervention.<a class="elsevierStyleCrossRef" href="#bib0280">2</a> Surgery programming is significantly influenced by decisions made in the days prior to the intervention, but does not affect the efficiency of block time until the day before surgery,<a class="elsevierStyleCrossRefs" href="#bib0395">25,26</a> since cancellation rates are highest among patients hospitalised 24h before the scheduled surgery.<a class="elsevierStyleCrossRef" href="#bib0405">27</a> Last minute cancellations add more interruptions to planning and call for surgery re-scheduling.<a class="elsevierStyleCrossRef" href="#bib0400">26</a> Emergencies can further disrupt the elective surgery schedule, even when the hospital has allocated a specific operating room for such cases. Other independent variables to take into account are the availability of beds in the postoperative care unit, or of porters to transfer patients; lack of both these factors can cause bottlenecks.<a class="elsevierStyleCrossRef" href="#bib0280">2</a>Efficiency indicatorsThe efficiency of the surgical suite depends, among other factors, on programming, allocation of resources and operating room preparation times, anaesthetic induction, surgery, anaesthetic education, and preparation of the operating room for the next patient. Poor management cause cancellations and overloaded waiting lists, while a well-managed operating room permits high surgical turnover, improves clinical outcomes, reduces postoperative complications, and is associated with increased patient satisfaction.<a class="elsevierStyleCrossRef" href="#bib0410">28</a> Each hospital must define its own efficiency indicators to determine which phases of the process need to be optimised. Punctuality, turnover times, operating room workload, and cancellation rates are the best performance indicators of a surgical suite.<a class="elsevierStyleCrossRef" href="#bib0295">5</a>PunctualityThe starting time of the first case of the day is defined as the moment in which the patient is wheeled into the room. First-case punctuality is an easy parameter to measure, as it is not determined by delays in previous cases, and it reduces over-utilisation of the operating room. All these factors make it a benchmark for surgical efficiency.<a class="elsevierStyleCrossRefs" href="#bib0290">4,12</a> However, it is a difficult goal to achieve, and first-case delays occur in 40–90% of operating rooms.<a class="elsevierStyleCrossRefs" href="#bib0415">29,30</a> This has a negative effect on the surgery, and causes dissatisfaction among patients and operating room staff. Punctuality depends on multiple factors, such as the timing of hospital admission or correct preoperative workup and preparation.Several studies have evaluated different strategies to avoid first-case delays, such as taking patients to the surgical suite 15min before surgery start time, staff punctuality, having the staff of the previous night shift prepare the material for the next day, immediate entry to the operating room after patient identification, and speedy performance of the surgical checklist, i.v. placement, and monitoring.The direct economic benefit of reducing such delays depends on the hospital's size and case load<a class="elsevierStyleCrossRef" href="#bib0330">12</a>; however, it is usually minor, because little time is saved with these measures,<a class="elsevierStyleCrossRef" href="#bib0425">31</a> and costs are often high, because efforts need to be applied to multiple operating rooms simultaneously.<a class="elsevierStyleCrossRef" href="#bib0420">30</a> Nevertheless, in hospitals with a large number of operating rooms and a high workload, reducing delays reduces over-utilisation and costs.Ending surgery on time is essential, as it reduces extraordinary costs, and prevents friction and even conflicts among staff. Wachtel and Dexter<a class="elsevierStyleCrossRef" href="#bib0430">32</a> describe a mathematical model to recalculate the surgical timetable and reduce delays in previous cases in order to avoid follow-on patient and surgeon waiting time and reduce dissatisfaction.TurnoverTurnover is the time from exit of the outgoing patient to entry of the incoming patient. Turnover depends on many factors, such as cleaning and preparation of the operating room for the new procedure, transfer of the outgoing patient to the recovery unit and preoperative workup and transfer of the incoming patient to the surgical suite.<a class="elsevierStyleCrossRef" href="#bib0300">6</a> The more complex the surgery, the longer the turnover time, given the need for special operating room and patient preparation. Dexter et al.,<a class="elsevierStyleCrossRef" href="#bib0435">33</a> reviewed 1 year of data from 4 tertiary level hospitals, and found an average turnover time of 34–66min. Mazzei<a class="elsevierStyleCrossRef" href="#bib0440">34</a> and Patterson<a class="elsevierStyleCrossRef" href="#bib0445">35</a> presented average turnovers times for different interventions.Reducing turnover time is necessary from a business perspective, since empty operating rooms are not profitable. Unfortunately, even increasing turnover efficiency to the maximum will not allow more patients to be included in the schedule,<a class="elsevierStyleCrossRef" href="#bib0435">33</a> except in operating rooms catering for a large number of patients that require many turnovers.<a class="elsevierStyleCrossRef" href="#bib0450">36</a> Either way, efficient turnover can decrease overtime, and it associated costs, and also improve staff satisfaction.<a class="elsevierStyleCrossRef" href="#bib0300">6</a> Excessive focus on turnover is counterproductive, as staff can focus efforts on achieving this target to the detriment of other more important goals.<a class="elsevierStyleCrossRef" href="#bib0290">4</a>Operating room utilisationOptimising operating room utilisation is a priority goal for the surgical suite manager and the hospital management board. Unfortunately, there is no universally accepted optimal level of use.<a class="elsevierStyleCrossRef" href="#bib0455">37</a> Strum et al.<a class="elsevierStyleCrossRef" href="#bib0460">38</a> defined the concepts of “over-utilisation” and “under-utilization”. Under-utilisation is defined as the programmed activity time in which the operating room is not used, while over-utilisation is the time used for elective cases after exceeding the scheduled time. Using these concepts, we can estimate the cost-effectiveness of an operating room, as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, both involves costs. Under-utilisation means less revenue to compensate for fixed costs, while over-utilisation entails overtime, with costs 1.5–2 times higher than those generated by under-utilisation. In addition, staff may be prompted to quit due to dissatisfaction with long working hours, and the need to hire new personnel also increases costs. This is why controlling over-utilisation is far more important than under-utilisation.<a class="elsevierStyleCrossRef" href="#bib0355">17</a> Operating room managers must aim to limit over-utilisation to less than one third of operating rooms, and tolerate under-utilisation in the remaining two thirds by ensuring all procedures have finalised before the end of the nursing shift. This would limit expenses, yet increase economic performance.<a class="elsevierStyleCrossRef" href="#bib0290">4</a> Finding the right balance between over- and under-utilisation of operating rooms involves offsetting fixed operating room costs against the combination of variable costs and revenue.<a class="elsevierStyleCrossRef" href="#bib0290">4</a> Tyler et al.<a class="elsevierStyleCrossRef" href="#bib0455">37</a> used a simulation model to show that a target utilisation of 85% is the highest that can be achieved within their operational goals (start-time delays of no more than 15min, and no more than 15min end-of-day overtime). In practice, this is the percentage used to maximise profits and reduce system overload,<a class="elsevierStyleCrossRefs" href="#bib0290">4,39</a> although there is a tendency is to increase overall raw utilisation to meet the increase in volume, due to diminishing availability of operating rooms. Decisions to allocate an operating room time for a particular surgeon or a particular service are based on this parameter. A service that consistently exceeds 80% of block time will generally have problems in scheduling cases, so this number is used to indicate when more block time should be allocated to a particular service.<a class="elsevierStyleCrossRef" href="#bib0300">6</a> Hospitals need to reschedule operating room allocation every 3–6 months in order to optimise the distribution of block times to the different services, depending on demand. Different authors have proposed strategies to maximise the percentage of use. However, their use in real practice may be limited given that they have been tested under ideal simulation conditions.<a class="elsevierStyleCrossRef" href="#bib0470">40</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Utilisation time depends on adjusting the schedule to the procedures to be performed, the surgeons who will perform them, and pre-established turnover times. For example, “long” surgical interventions will be associated with better surgical performance than a greater number of “short” interventions, which will accumulate more down time. This indicator cannot be measured in isolation, because maximised performance must take into account the number of surgery cancellations or hours of overtime, which reduce efficiency by increasing costs.<a class="elsevierStyleCrossRef" href="#bib0335">13</a> The concept of utilisation is merely a measure of resource consumption, so it should not be used to analyse operating room efficiency.Cancellation rateA low cancellation rate, in addition to being an efficiency requirement, is an indicator of care quality and respect for the patient.<a class="elsevierStyleCrossRef" href="#bib0335">13</a> Cancellations have a significant economic impact due to loss of up to $1430–1700 in revenue in hospitals in the United States, and due to the costs associated with under-utilisation, in addition to the emotional impact on patients and families.<a class="elsevierStyleCrossRefs" href="#bib0475">41–43</a>Cancellation rates vary widely in the literature, from 2% to 27%.<a class="elsevierStyleCrossRefs" href="#bib0490">44–47</a> Different studies suggest that the more efficient hospital achieve cancellation rates of less than 5%.<a class="elsevierStyleCrossRef" href="#bib0475">41</a> The current target is a rate of 3–4%, which does not include patients who refuse surgery or do not show up on the scheduled day. Case cancellations are divided into patient-related causes, structural and planning-related causes, and procedural-related causes.<a class="elsevierStyleCrossRef" href="#bib0480">42</a> Thus, institutional, cultural, social and economic factors, or clinical changes may determine surgical cancellations.<a class="elsevierStyleCrossRefs" href="#bib0475">41,48</a> Although certain cancellations are unavoidable, up to 50% of causes could be preventable.<a class="elsevierStyleCrossRef" href="#bib0480">42</a> A cancellation should be considered a critical problem, and should be treated as a complication. It must be registered and notified, and its causes must be analysed using the Donabedian model (structure, process and results)<a class="elsevierStyleCrossRef" href="#bib0485">43</a> to identify problems and apply specific solutions. Kaye et al.,<a class="elsevierStyleCrossRef" href="#bib0515">49</a> for example, managed to reduce their cancellation rate from 15% to 5.9% within 2 years using a multidisciplinary, goal-directed organisational approach.A pre-anaesthetic workup in all patients, as well as standardised, universally agreed complementary preoperative tests, are essential. The latter must be based on scientific evidence and not on “defensive medicine”, which only causes unnecessary delays and cancellations. Tests that will optimise the patient's clinical status should be prioritised. There are also mobile applications designed to remind patients of preoperative and prehabilitation recommendations. These can empower patients and help them prevent cancellations due to non-compliance with these protocols, encourage their autonomy, and remind them of the part they play in ensuring the success of the intervention.Daily workloadThe daily workload is a marker that shows the efficiency of the system. However, it is only a variable, not an indicator of efficiency, and taken alone does not reflect utilisation or permit comparisons of operating rooms performance. Although this variable has little practical application, the average number of daily surgeries per annum is a highly stable, informative marker that can relativise the “raw” utilisation rate of the operating room, which can be very high even when the number of cases is less than ideal.Efficiency scaleEfficiency is a difficult concept to assess with a single measure.<a class="elsevierStyleCrossRef" href="#bib0300">6</a> Macario<a class="elsevierStyleCrossRef" href="#bib0520">50</a> describes a rating scale consisting of 8 efficiency metrics (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) based on variables easily obtained from the computer system used in most surgery suites.<a class="elsevierStyleCrossRef" href="#bib0300">6</a> This scale can be used by operating room managers to determine the overall efficiency of their operating rooms, and to compare their figures with those of other comparable institutions to identify areas of improvement and techniques that could optimise performance. This is the first such scoring system that has attained a certain level of acceptance.<a class="elsevierStyleCrossRef" href="#bib0300">6</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Factors that limit management effectivenessOne of the main factors that stand in the way of achieving optimal results is the introduction of incentives, priorities and conflicting expectations among the members of the operating room team (surgeons, anaesthesiologists and nurses).<a class="elsevierStyleCrossRef" href="#bib0525">51</a> This leads each individual to focus on their individual performance rather than the objectives and general priorities of the operating room, and can cause conflict and interruptions. For example, salaried or hourly employees try to control the pace of work during the working day and slow down at the end of the shift or generate long turnover times. In contrast, employees receiving bonuses per case (surgeons and anaesthesiologists) perform their work more efficiently, putting pressure on the rest of the team to speed up turnover and perform more operations. Furthermore, while the manager focuses on effectiveness and overall efficiency, surgeons apply pressure to obtain a second operating room and treat a larger number of patients, even at the expense of sacrificing overall effectiveness. The manager must use priority-based algorithms and impose his or her authority to avoid operating room interruptions due to these conflicts,<a class="elsevierStyleCrossRef" href="#bib0295">5</a> transferring cases to fill the gaps in the daily schedule in order to reduce downtime in some operating rooms and over-utilisation and waiting in others.<a class="elsevierStyleCrossRef" href="#bib0295">5</a>Special programmesAn operative surgery suite should be able to cater for special programmes, such as major ambulatory surgery, which has its own patient pathways and protocols, trauma surgery, transplant programmes and extra afternoon activities.<a class="elsevierStyleCrossRef" href="#bib0335">13</a>Trauma surgeons often have to treat patients as quickly as possible, preferably within 24h of the injury, during their initial hospital stay. These cases can be treated either within the hours reserved for the trauma service or in an operating room allocated for that purpose if the volume so requires. This operating room can function as an open-block space, in which surgery is scheduled only a few hours in advance. In these cases, adhering to the weekly block time schedule would cause delays, prolong hospital stays and disrupt the system.Organ transplantation is unpredictable, and compels managers to change the surgery schedule. In its operating room rules, the committee must specify how these disruptions should be resolved in order to minimise their impact on cancellations and the harm caused to all concerned.Finally, when the surgery suite has completed – or is in the process of completing – all its scheduled activity, it can start to manage external waiting lists. These add-on cases are usually managed by “vertical” extension, in other words, extending the working day or scheduling extra afternoon working hours.ProtocolisationSurgical care includes several phases, including surgical indication and obtaining informed consent, programming the intervention and performing the pre-anaesthetic workup. This chain of activities should be managed in accordance with protocols. The operating room committee should spearhead the initiative to standardise all this activity, seeking the help and agreement of all involved in the process.<a class="elsevierStyleCrossRef" href="#bib0530">52</a> Protocolising clinical processes and patient pathways, and using check-lists to confirm compliance, will reduce clinical variability by speeding up the intervention, increasing patient safety, and improving interdisciplinary team work and care quality and efficiency.<a class="elsevierStyleCrossRefs" href="#bib0280">2,53,54</a>Information systemsGood management depends on a constant stream of accurate, real-time information from the surgical suite. This can only be achieved with an effective computer system. The tools currently available in this regard include radio-frequency identification patient tracking systems, patient monitoring dashboards, cameras and automated notification systems, and priority-based algorithms for automating case management decisions. These allow managers to evaluate the different elements of the process and to implement ongoing improvement programmes.<a class="elsevierStyleCrossRef" href="#bib0295">5</a> The operating room committee should define which indicators should be used for that purpose. All operating rooms will soon be equipped with the technology needed to record and analyse this information. The system will automatically extract data from the computer server, such as the name of the surgeon, the scheduled procedure and the real start time of the case, and will make automatic “Bayesian” schedule readjustments for ongoing cases,<a class="elsevierStyleCrossRef" href="#bib0390">24</a> thus allowing better management of the uncertainty associated with predicting surgery times.<a class="elsevierStyleCrossRef" href="#bib0365">19</a> More and more hospitals now use this type of system and software.ConclusionsSurgery has changed dramatically in recent decades, to the extent that today's demand for surgical procedures outstrips existing resources. Safety, quality and efficiency have become the priority objectives of 21st century surgical care. Decision-making is based on goals, such as starting and ending on time, reducing turnover times, high utilisation rates, low cancellation rates, and reserve capacity and flexibility, among others. Integrated computer systems can analyse these efficiency indicators, detect shortcomings, and implement continuous improvement programmes to achieve and maintain good productivity. Protocolisation and optimal procedural programming, interdisciplinary coordination, the use of surgical checklists or mobile applications that involve patients in the surgical procedure can contribute significantly to successful management. The surgical block must function as a unit with a good working environment that is conducive to achieving the common objectives. The implementation of these strategies will optimise efficiency and guarantee sustainability.Conflicts of interestSome authors are members of the editorial team of the Spanish Journal of Anaesthesiology and Critical Care as director (AAG), secretary (RCF) and editor (JMCV). The authors have not intervened in the editorial process of the manuscript, which has been independently managed by another editor. The authors have no other conflict of interest related to the scientific content of the article." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1145540" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1075728" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1145539" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1075727" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Operating room management" "secciones" => array:5 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Programming" "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0020" "titulo" => "Programming systems" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "“Open” programming" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "“Block time” programming" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Emergency management" ] ] ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Predicting surgery times" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Scheduling" ] ] ] 1 => array:3 [ "identificador" => "sec0050" "titulo" => "Efficiency indicators" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Punctuality" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Turnover" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Operating room utilisation" ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Cancellation rate" ] 4 => array:2 [ "identificador" => "sec0075" "titulo" => "Daily workload" ] 5 => array:2 [ "identificador" => "sec0080" "titulo" => "Efficiency scale" ] 6 => array:2 [ "identificador" => "sec0085" "titulo" => "Factors that limit management effectiveness" ] ] ] 2 => array:2 [ "identificador" => "sec0090" "titulo" => "Special programmes" ] 3 => array:2 [ "identificador" => "sec0095" "titulo" => "Protocolisation" ] 4 => array:2 [ "identificador" => "sec0100" "titulo" => "Information systems" ] ] ] 6 => array:2 [ "identificador" => "sec0105" "titulo" => "Conclusions" ] 7 => array:2 [ "identificador" => "sec0110" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-04" "fechaAceptado" => "2018-08-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1075728" "palabras" => array:4 [ 0 => "Operating room management" 1 => "Goals" 2 => "Efficiency" 3 => "Quality of health care" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1075727" "palabras" => array:4 [ 0 => "Gestión del bloque quirúrgico" 1 => "Objetivos" 2 => "Eficiencia" 3 => "Calidad de la asistencia sanitaria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Healthcare is in constant transformation. Health systems should focus on improving efficiency to meet a growing demand for high-quality, low-cost health care. The operating room is one of the biggest sources of revenue and one of the largest areas of expense. Therefore, operating room management is a critical key to success. The aim of this article is to analyse the current principles of organisation, optimisation and clinical management of the operating room and its impact on the quality and safety of care." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La asistencia sanitaria está en constante transformación. Los sistemas de salud deben centrarse en mejorar la eficiencia para satisfacer la creciente demanda de atención de salud de alta calidad y bajo coste. El quirófano es una de las mayores fuentes de ingresos y una de las mayores áreas de gasto. Por lo tanto, la gestión del bloque quirúrgico es una clave fundamental para el éxito. El objetivo de este artículo es analizar los principios actuales de organización, optimización y gestión clínica del bloque quirúrgico y su impacto en la calidad y en la seguridad asistenciales." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gómez-Ríos MA, Abad-Gurumeta A, Casans-Francés R, Calvo-Vecino JM. Claves para optimizar la eficiencia de un bloque quirúrgico. Rev Esp Anestesiol Reanim. 2019;66:104–112." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program. An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page:" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Raw utilisation. For the system as a whole, this is the percent of time that patients are in the room during resource hours. For an individual service, this is the percent of its block time during which it has a patient in the operating room. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Adjusted percentage. Number of surgery hours used during block time assigned to a specific service+number of surgery hours used during block time not assigned to a specific service×100 per block time. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Service utilisation. This measures the percentage of time a service uses its block time during resource hours. It is adjusted compared with raw utilisation, in that it gives a service “credit” for the time necessary to set up and clean up a room, during which time a patient cannot be in the room. It may exceed 100% because of the inclusion of cases performed during resource hours that are outside-own block hours. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Operating room workload. The total hours of operating room case time plus turnover on that day. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Allocated time. Time reserved for a surgeon or service on a particular day (block time). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Underutilised time. Allocated time−operating room workload (if the value is <1, then default to 0). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Overutilized time. Operating room workload−allocated time (if the value is <1, then default to 0). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Operating room labour cost. 1×allocated time+1.5×overutilized time. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Inefficiency measure of operating room time. Underutilised time+1.5×overutilized time. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1955061.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Surgical suite performance concepts developed by the American Association of Clinical Directors (AACD)." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Total score 0–16; 0–5 points: poorly managed operating rooms; 13–16 points: achievable with the use of state-of-the-art management systems." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Points</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">0 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Excess staffing costs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>10% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5–10% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Start time tardiness (mean tardiness of start times for elective cases per operating room per day) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>60min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45–60min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><45min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Case cancellation rate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>10% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5–10% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PACU admission delays (% of workdays with at least 1 delay in PACU admission due to shortage of beds) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>20% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10–20% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><10% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Contribution margin (mean) per operating room hour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><$1000/h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">$1000–$2000/h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>$2000/h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Turnover times (mean setup and cleanup turnover times for all cases) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>40min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25–40min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><25min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prediction bias (bias in case duration estimates per 8h or operating room time) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>15min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5–15min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><5min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prolonged turnovers (% of turnovers that are more than 60min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>25% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10–25% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><10% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1955062.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Macario's scoring system for operating room efficiency." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:54 [ 0 => array:3 [ "identificador" => "bib0275" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Savings from reducing low-value general surgical interventions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H.T. 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Continuing education

Keys to optimize the operating room efficiency

Claves para optimizar la eficiencia de un bloque quirúrgico

M.A. Gómez-Ríosa,b,c,

Corresponding author

magoris@hotmail.com

Corresponding author.

, A. Abad-Gurumetad, R. Casans-Francése, J.M. Calvo-Vecinof

a Departamento de Anestesiología y Medicina Perioperatoria, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain

b Grupo Español de Vía Aérea Difícil (GEVAD), Spain

c Grupo de Investigación Anestesiología y Tratamiento del Dolor, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain

d Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, Spain

e Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain

f Departamento de Anestesia, Complejo Asistencial Universitario de Salamanca, Universidad de Salamanca (CAUSA), Salamanca, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Constant transformations in health care due to the fast pace of scientific and technological progress in medicine and population ageing constitute a continuous challenge for health systems&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">1&#44;2</span></a> This growing complexity coupled with rising costs compels health services to constantly reorganise in order to adapt their resources to meet today&#39;s demands and maintain quality of care&#44; clinical efficiency and sustainability&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">3</span></a> The success and continuity of healthcare depend on the capacity of an organisation to adapt its structures and practices to this changing reality&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Surgery is the main source of revenue and costs in hospitals worldwide&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">4&#8211;6</span></a> The organisation of this service is particularly complex&#44; since the surgical suite is the epicentre of a multidisciplinary care process involving multiple hospital services and different groups of health professionals&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">7</span></a> The need for all hospitals to maximise the efficiency of their surgery suite<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">6&#44;8</span></a> has prompted an increase in research on this topic in recent decades&#46; However&#44; surgical resources are often considered underutilised&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">5&#44;6</span></a> The aim of operating room management is to replace these ineffective organisational structures with other&#44; more competent frameworks<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> conducive to the achieving the main goals of 21st century surgical practice&#58; safety&#44; effectiveness and efficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">9</span></a> The aim of this article is to analyse the current principles of organisation&#44; optimisation and clinical management of the surgical suite and their repercussion on the quality and safety of care&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Operating room management</span><p id="par0015" class="elsevierStylePara elsevierViewall">Planning surgery is a highly complex task&#44;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">2&#44;10</span></a> because it involves coordinating different professionals&#44; at times with conflicting interests&#44; in order to maximise effectiveness and achieve common goals&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Surgical suites must be managed under a defined organisational structure&#46; The introduction of an operating room manager&#44; the creation of operating room committees&#44; and management by objectives<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">11&#44;12</span></a> can improve both performance and patient and staff satisfaction&#44; while good communication facilitates change management and the ongoing implementation of rules and regulations&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The position of operating room manager is best filled by a doctor&#46; Anaesthesiologists are particularly suited to this role&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">4&#44;5</span></a> In fact&#44; more than half of all operating rooms are managed by anaesthesiologists&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The creation of an operating room committee is fundamental for efficient management&#46; The committee is usually made up of the surgeons&#44; anaesthesiologists and nurses that head their respective services&#44; together with hospital leaders&#44; and a small number of physicians undergoing their required rotations&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">13</span></a> It should be small enough to ensure functionality&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">13</span></a> and one of its tasks in to develop priority-based algorithms&#46; Effective management requires integrated decision-making&#58; &#40;a&#41; strategic &#40;long-term&#41;&#44; to address the physical structure of the surgical area&#59; &#40;b&#41; tactical &#40;medium term&#41;&#44; to provide enough resources to meet the suite&#39;s needs&#46; This includes the allocation of operating time&#44; staff scheduling and allocation of specialised equipment&#44; and &#40;c&#41; operational &#40;short-term&#41;&#44; involving the day-to-day administration of the surgical suite&#44; starting with assigning personnel and equipment 24<span class="elsevierStyleHsp" style=""></span>h in advance&#44; and coordinating medical and non-medical support units&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">5&#44;14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The surgical suite&#44; as a multidisciplinary unit&#44; requires a set of rules in order to coordinate its activity and deal with conflicts while preserving a professional working environment&#46; The committee draw up&#44; in writing&#44; a &#8220;framework statute&#8221; of the surgical suite that will include&#44; among other things&#44; the composition&#44; function and responsibilities of the committee and the manager&#44; operating room rules &#40;schedules&#44; patient pathways or safety&#41;&#44; programming rules&#44; and management concepts or rules of behaviour that will foster a culture of unity and teamwork&#46; The work of health professionals should not be limited to providing health care&#44; as in the past&#59; they should be involved in management issues&#44; and take joint responsibility for efficacy and efficiency outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">15</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The diversity of procedures&#44; urgent or scheduled&#44; and their relative priority&#44; dependence on other structures with limited capacity&#44; such as postoperative care units&#44; and the large number of services competing for a limited number of operating rooms&#44; mean that programming and efficiency parameters are paramount in operating room management&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Programming</span><p id="par0045" class="elsevierStylePara elsevierViewall">Operating room performance depends on the number of surgeries performed&#59; therefore&#44; management is mainly focused on scheduling&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a> in parallel with waiting list management and organisation of the personnel and instruments needed for a particular intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> A surgical intervention involves several human resources that must be programmed for immediate action &#40;surgeons&#44; anaesthesiologists&#44; nurses&#44; porters&#44; etc&#46;&#41; or set on stand-by &#40;radiology technicians&#44; pathologists for diagnostic biopsies&#44; a second surgical team for complementary interventions&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">2</span></a> Good scheduling is essential to provide an effective service&#44; while scheduling shortcomings are the source of delays and both staff and patient dissatisfaction&#46; Operating schedule rules should be established&#44; operating timetables should be drawn up and personnel assigned to each case&#46; Both the timetable and the personnel assigned will be modified if emergency cases and imbalances between registered and real cases arise&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a> Many institutions have automated their programming systems in an attempt to limit bias in surgery duration estimates&#44; overlapping cases that require specific resources&#44; and to guarantee&#44; as far as possible&#44; that scheduled surgeries go ahead by relocating patients and avoiding cancellations&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">4&#44;5</span></a> Most hospitals plan their surgery schedule on a weekly basis&#44; leaving enough flexibility for the management of beds and seasonal demands&#46; Patients undergoing anaesthesia procedures outside the surgical suite should be included in the general surgical schedule&#44; since they require perioperative resources&#44; such as anaesthesia service personnel or beds in post-anaesthesia care units&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Programming systems</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">&#8220;Open&#8221; programming</span><p id="par0050" class="elsevierStylePara elsevierViewall">Each operating room is available for any intervention&#46; This system has many limitations&#58; it is impossible to estimate which operating rooms and which resources will be available at a given time&#44; and makes it difficult to allocate these elements&#46; It also involves transferring specialised equipment from one operating room to another without the possibility of advanced planning&#46; The result is general inefficiency&#44; which is why this system is only used in a small number of operating rooms that are available for emergency cases&#44; thus avoiding altering the programmed surgery schedule&#46; The number and availability of operating rooms will depend on the volume of urgent cases added&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">&#8220;Block time&#8221; programming</span><p id="par0055" class="elsevierStylePara elsevierViewall">This is the most widely used programming system&#44;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">4&#44;13</span></a> and involves allocating a specific operating room and surgery time to a specific surgical team for a certain time&#44; depending on demand or hospital priorities&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">5</span></a> This organisation system creates specialised operating rooms and personnel&#44; it avoids the constant transfer of resources between operating rooms&#44; and reduces turnover times and case variability&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a> This system works best when allocation is service-based instead of surgeon-based&#44; and organised around full days instead of time slots&#44; since patient flow and case start times are more predictable&#44;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">4&#44;6</span></a> and allocation can be changed in accordance with factors such as waiting lists or block times&#46; Unused block times are available for any service&#44; on a first-come&#44; first-served basis&#46; The centre must establish&#44; through the surgical committee&#44; schedule allocation rules to ensure that the process is equitable&#44; taking into consideration advanced programming&#44; hold times or release times&#44; which will vary in each hospital and each service&#44; depending on the volume of urgent surgeries&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">4&#44;16</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Hospitals in which block time is used to the full and an increase in demand is expected should take the strategic decision of either increasing surgical activity or the number of operating rooms&#46; The per-hour profit margin&#44; the growth potential&#44; and limited need for additional resources&#44; such as critical care beds for each service&#44; are a good basis on which to take tactical decisions regarding the allocation of the new block times&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Emergency management</span><p id="par0065" class="elsevierStylePara elsevierViewall">The impact of emergency surgery cases should be factored in to any analysis of surgery suite resources&#46; Management of these cases depends on the characteristics of each surgical suite&#44; the expected flow of cases&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">5</span></a> and the established priorities&#46; In hospitals with a low volume of unscheduled surgeries&#44; emergency cases can be incorporated into the elective schedule by scheduling &#8220;open rooms&#8221; or by rescheduling elective cases&#46; Hospitals with a higher volume of emergency cases can allocate certain operating rooms exclusively for emergency surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a> Good management of emergencies surgeries improves the efficiency and general use of the surgical suite by limiting their impact on the elective schedule and assigning the appropriate resources to the unscheduled case load&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">5</span></a> An exceptional case would be delayed emergency trauma surgery&#44; which may have an allocated operating room with a flexible schedule that allows managers to group certain interventions and optimise patient care&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Predicting surgery times</span><p id="par0070" class="elsevierStylePara elsevierViewall">Good surgery planning depends on making reliable estimates of the time needed for each procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">10&#44;18</span></a> Underestimating surgery times will disrupt the start time of subsequent cases&#44; which might need to be postponed or cancelled&#44; while overestimations result in empty operating rooms&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">10</span></a> Both situations can lead to suboptimal use of the operating room&#44; and should be avoided&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Predictions should not be based solely on the surgeon&#39;s estimate or on average surgery times taken from clinical records&#44; which are inaccurate and highly variable&#44; but should also take into account the specific characteristics of each patient&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">19</span></a> Different studies have attempted to develop predictive tools based on statistical models&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">10</span></a> Those that provide improved estimates of surgical time and block planning are those that base their calculations on real&#44; most recent surgery times extracted from the hospital&#39;s computer system and specific patient indicators&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">10&#44;20&#44;21</span></a> Gathering surgeon-specific data is fundamental&#44; since surgical times vary widely between surgeons and hospitals&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">22</span></a> In the absence of documented surgery times of a specific surgeon&#44; the average of times of other surgeons or the surgeon&#39;s own estimate&#44; adjusted for bias&#44; can be used&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">23</span></a> The use of prediction models reduces the variability of time estimates&#44; increases the operating room use rate&#44; and limits overtime by planning of the start of the last operation in relation to the end of the working day&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">10</span></a> although flexible planning on the day of surgery&#44; transfer of cases&#44; and extra cases minimise the impact of predictions on the number of extra hours&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Dexter et al&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">24</span></a> showed that surgical times can be predicted from the duration of previous cases and current information using Bayesian analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">23</span></a> This would allow real-time decision-making&#44; such as transferring cases to other operating rooms&#44; knowing when to prepare the next patient&#44; or when to make the necessary material resources available&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">19</span></a> The analysis does not predict delays caused by intraoperative complications or other unforeseen events&#46; In short&#44; different software will facilitate surgery programming according to estimated surgical times for each pathology&#44; surgeon and patient&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Scheduling</span><p id="par0085" class="elsevierStylePara elsevierViewall">Accurate programming is a key factor in completing the daily surgical schedule&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> Despite this&#44; daily programming can be complex&#44; given the inherent uncertainty of surgery times&#44; and the constant flow of patients with their particularly characteristics and priorities&#46; This means that surgery timetables need to be revised constantly up to the day before the intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">2</span></a> Surgery programming is significantly influenced by decisions made in the days prior to the intervention&#44; but does not affect the efficiency of block time until the day before surgery&#44;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">25&#44;26</span></a> since cancellation rates are highest among patients hospitalised 24<span class="elsevierStyleHsp" style=""></span>h before the scheduled surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">27</span></a> Last minute cancellations add more interruptions to planning and call for surgery re-scheduling&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">26</span></a> Emergencies can further disrupt the elective surgery schedule&#44; even when the hospital has allocated a specific operating room for such cases&#46; Other independent variables to take into account are the availability of beds in the postoperative care unit&#44; or of porters to transfer patients&#59; lack of both these factors can cause bottlenecks&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">2</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Efficiency indicators</span><p id="par0090" class="elsevierStylePara elsevierViewall">The efficiency of the surgical suite depends&#44; among other factors&#44; on programming&#44; allocation of resources and operating room preparation times&#44; anaesthetic induction&#44; surgery&#44; anaesthetic education&#44; and preparation of the operating room for the next patient&#46; Poor management cause cancellations and overloaded waiting lists&#44; while a well-managed operating room permits high surgical turnover&#44; improves clinical outcomes&#44; reduces postoperative complications&#44; and is associated with increased patient satisfaction&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">28</span></a> Each hospital must define its own efficiency indicators to determine which phases of the process need to be optimised&#46; Punctuality&#44; turnover times&#44; operating room workload&#44; and cancellation rates are the best performance indicators of a surgical suite&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">5</span></a></p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Punctuality</span><p id="par0095" class="elsevierStylePara elsevierViewall">The starting time of the first case of the day is defined as the moment in which the patient is wheeled into the room&#46; First-case punctuality is an easy parameter to measure&#44; as it is not determined by delays in previous cases&#44; and it reduces over-utilisation of the operating room&#46; All these factors make it a benchmark for surgical efficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">4&#44;12</span></a> However&#44; it is a difficult goal to achieve&#44; and first-case delays occur in 40&#8211;90&#37; of operating rooms&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">29&#44;30</span></a> This has a negative effect on the surgery&#44; and causes dissatisfaction among patients and operating room staff&#46; Punctuality depends on multiple factors&#44; such as the timing of hospital admission or correct preoperative workup and preparation&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Several studies have evaluated different strategies to avoid first-case delays&#44; such as taking patients to the surgical suite 15<span class="elsevierStyleHsp" style=""></span>min before surgery start time&#44; staff punctuality&#44; having the staff of the previous night shift prepare the material for the next day&#44; immediate entry to the operating room after patient identification&#44; and speedy performance of the surgical checklist&#44; i&#46;v&#46; placement&#44; and monitoring&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The direct economic benefit of reducing such delays depends on the hospital&#39;s size and case load<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">12</span></a>&#59; however&#44; it is usually minor&#44; because little time is saved with these measures&#44;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">31</span></a> and costs are often high&#44; because efforts need to be applied to multiple operating rooms simultaneously&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">30</span></a> Nevertheless&#44; in hospitals with a large number of operating rooms and a high workload&#44; reducing delays reduces over-utilisation and costs&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Ending surgery on time is essential&#44; as it reduces extraordinary costs&#44; and prevents friction and even conflicts among staff&#46; Wachtel and Dexter<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">32</span></a> describe a mathematical model to recalculate the surgical timetable and reduce delays in previous cases in order to avoid follow-on patient and surgeon waiting time and reduce dissatisfaction&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Turnover</span><p id="par0115" class="elsevierStylePara elsevierViewall">Turnover is the time from exit of the outgoing patient to entry of the incoming patient&#46; Turnover depends on many factors&#44; such as cleaning and preparation of the operating room for the new procedure&#44; transfer of the outgoing patient to the recovery unit and preoperative workup and transfer of the incoming patient to the surgical suite&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a> The more complex the surgery&#44; the longer the turnover time&#44; given the need for special operating room and patient preparation&#46; Dexter et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">33</span></a> reviewed 1 year of data from 4 tertiary level hospitals&#44; and found an average turnover time of 34&#8211;66<span class="elsevierStyleHsp" style=""></span>min&#46; Mazzei<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">34</span></a> and Patterson<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">35</span></a> presented average turnovers times for different interventions&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Reducing turnover time is necessary from a business perspective&#44; since empty operating rooms are not profitable&#46; Unfortunately&#44; even increasing turnover efficiency to the maximum will not allow more patients to be included in the schedule&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">33</span></a> except in operating rooms catering for a large number of patients that require many turnovers&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">36</span></a> Either way&#44; efficient turnover can decrease overtime&#44; and it associated costs&#44; and also improve staff satisfaction&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a> Excessive focus on turnover is counterproductive&#44; as staff can focus efforts on achieving this target to the detriment of other more important goals&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Operating room utilisation</span><p id="par0125" class="elsevierStylePara elsevierViewall">Optimising operating room utilisation is a priority goal for the surgical suite manager and the hospital management board&#46; Unfortunately&#44; there is no universally accepted optimal level of use&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">37</span></a> Strum et al&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">38</span></a> defined the concepts of &#8220;over-utilisation&#8221; and &#8220;under-utilization&#8221;&#46; Under-utilisation is defined as the programmed activity time in which the operating room is not used&#44; while over-utilisation is the time used for elective cases after exceeding the scheduled time&#46; Using these concepts&#44; we can estimate the cost-effectiveness of an operating room&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; both involves costs&#46; Under-utilisation means less revenue to compensate for fixed costs&#44; while over-utilisation entails overtime&#44; with costs 1&#46;5&#8211;2 times higher than those generated by under-utilisation&#46; In addition&#44; staff may be prompted to quit due to dissatisfaction with long working hours&#44; and the need to hire new personnel also increases costs&#46; This is why controlling over-utilisation is far more important than under-utilisation&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">17</span></a> Operating room managers must aim to limit over-utilisation to less than one third of operating rooms&#44; and tolerate under-utilisation in the remaining two thirds by ensuring all procedures have finalised before the end of the nursing shift&#46; This would limit expenses&#44; yet increase economic performance&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> Finding the right balance between over- and under-utilisation of operating rooms involves offsetting fixed operating room costs against the combination of variable costs and revenue&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> Tyler et al&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">37</span></a> used a simulation model to show that a target utilisation of 85&#37; is the highest that can be achieved within their operational goals &#40;start-time delays of no more than 15<span class="elsevierStyleHsp" style=""></span>min&#44; and no more than 15<span class="elsevierStyleHsp" style=""></span>min end-of-day overtime&#41;&#46; In practice&#44; this is the percentage used to maximise profits and reduce system overload&#44;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">4&#44;39</span></a> although there is a tendency is to increase overall raw utilisation to meet the increase in volume&#44; due to diminishing availability of operating rooms&#46; Decisions to allocate an operating room time for a particular surgeon or a particular service are based on this parameter&#46; A service that consistently exceeds 80&#37; of block time will generally have problems in scheduling cases&#44; so this number is used to indicate when more block time should be allocated to a particular service&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a> Hospitals need to reschedule operating room allocation every 3&#8211;6 months in order to optimise the distribution of block times to the different services&#44; depending on demand&#46; Different authors have proposed strategies to maximise the percentage of use&#46; However&#44; their use in real practice may be limited given that they have been tested under ideal simulation conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">40</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Utilisation time depends on adjusting the schedule to the procedures to be performed&#44; the surgeons who will perform them&#44; and pre-established turnover times&#46; For example&#44; &#8220;long&#8221; surgical interventions will be associated with better surgical performance than a greater number of &#8220;short&#8221; interventions&#44; which will accumulate more down time&#46; This indicator cannot be measured in isolation&#44; because maximised performance must take into account the number of surgery cancellations or hours of overtime&#44; which reduce efficiency by increasing costs&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">13</span></a> The concept of utilisation is merely a measure of resource consumption&#44; so it should not be used to analyse operating room efficiency&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Cancellation rate</span><p id="par0135" class="elsevierStylePara elsevierViewall">A low cancellation rate&#44; in addition to being an efficiency requirement&#44; is an indicator of care quality and respect for the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">13</span></a> Cancellations have a significant economic impact due to loss of up to &#36;1430&#8211;1700 in revenue in hospitals in the United States&#44; and due to the costs associated with under-utilisation&#44; in addition to the emotional impact on patients and families&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">41&#8211;43</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Cancellation rates vary widely in the literature&#44; from 2&#37; to 27&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">44&#8211;47</span></a> Different studies suggest that the more efficient hospital achieve cancellation rates of less than 5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">41</span></a> The current target is a rate of 3&#8211;4&#37;&#44; which does not include patients who refuse surgery or do not show up on the scheduled day&#46; Case cancellations are divided into patient-related causes&#44; structural and planning-related causes&#44; and procedural-related causes&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">42</span></a> Thus&#44; institutional&#44; cultural&#44; social and economic factors&#44; or clinical changes may determine surgical cancellations&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">41&#44;48</span></a> Although certain cancellations are unavoidable&#44; up to 50&#37; of causes could be preventable&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">42</span></a> A cancellation should be considered a critical problem&#44; and should be treated as a complication&#46; It must be registered and notified&#44; and its causes must be analysed using the Donabedian model &#40;structure&#44; process and results&#41;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">43</span></a> to identify problems and apply specific solutions&#46; Kaye et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">49</span></a> for example&#44; managed to reduce their cancellation rate from 15&#37; to 5&#46;9&#37; within 2 years using a multidisciplinary&#44; goal-directed organisational approach&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">A pre-anaesthetic workup in all patients&#44; as well as standardised&#44; universally agreed complementary preoperative tests&#44; are essential&#46; The latter must be based on scientific evidence and not on &#8220;defensive medicine&#8221;&#44; which only causes unnecessary delays and cancellations&#46; Tests that will optimise the patient&#39;s clinical status should be prioritised&#46; There are also mobile applications designed to remind patients of preoperative and prehabilitation recommendations&#46; These can empower patients and help them prevent cancellations due to non-compliance with these protocols&#44; encourage their autonomy&#44; and remind them of the part they play in ensuring the success of the intervention&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Daily workload</span><p id="par0150" class="elsevierStylePara elsevierViewall">The daily workload is a marker that shows the efficiency of the system&#46; However&#44; it is only a variable&#44; not an indicator of efficiency&#44; and taken alone does not reflect utilisation or permit comparisons of operating rooms performance&#46; Although this variable has little practical application&#44; the average number of daily surgeries per annum is a highly stable&#44; informative marker that can relativise the &#8220;raw&#8221; utilisation rate of the operating room&#44; which can be very high even when the number of cases is less than ideal&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Efficiency scale</span><p id="par0155" class="elsevierStylePara elsevierViewall">Efficiency is a difficult concept to assess with a single measure&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a> Macario<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">50</span></a> describes a rating scale consisting of 8 efficiency metrics &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; based on variables easily obtained from the computer system used in most surgery suites&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a> This scale can be used by operating room managers to determine the overall efficiency of their operating rooms&#44; and to compare their figures with those of other comparable institutions to identify areas of improvement and techniques that could optimise performance&#46; This is the first such scoring system that has attained a certain level of acceptance&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Factors that limit management effectiveness</span><p id="par0160" class="elsevierStylePara elsevierViewall">One of the main factors that stand in the way of achieving optimal results is the introduction of incentives&#44; priorities and conflicting expectations among the members of the operating room team &#40;surgeons&#44; anaesthesiologists and nurses&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">51</span></a> This leads each individual to focus on their individual performance rather than the objectives and general priorities of the operating room&#44; and can cause conflict and interruptions&#46; For example&#44; salaried or hourly employees try to control the pace of work during the working day and slow down at the end of the shift or generate long turnover times&#46; In contrast&#44; employees receiving bonuses per case &#40;surgeons and anaesthesiologists&#41; perform their work more efficiently&#44; putting pressure on the rest of the team to speed up turnover and perform more operations&#46; Furthermore&#44; while the manager focuses on effectiveness and overall efficiency&#44; surgeons apply pressure to obtain a second operating room and treat a larger number of patients&#44; even at the expense of sacrificing overall effectiveness&#46; The manager must use priority-based algorithms and impose his or her authority to avoid operating room interruptions due to these conflicts&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">5</span></a> transferring cases to fill the gaps in the daily schedule in order to reduce downtime in some operating rooms and over-utilisation and waiting in others&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">5</span></a></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Special programmes</span><p id="par0165" class="elsevierStylePara elsevierViewall">An operative surgery suite should be able to cater for special programmes&#44; such as major ambulatory surgery&#44; which has its own patient pathways and protocols&#44; trauma surgery&#44; transplant programmes and extra afternoon activities&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">13</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Trauma surgeons often have to treat patients as quickly as possible&#44; preferably within 24<span class="elsevierStyleHsp" style=""></span>h of the injury&#44; during their initial hospital stay&#46; These cases can be treated either within the hours reserved for the trauma service or in an operating room allocated for that purpose if the volume so requires&#46; This operating room can function as an open-block space&#44; in which surgery is scheduled only a few hours in advance&#46; In these cases&#44; adhering to the weekly block time schedule would cause delays&#44; prolong hospital stays and disrupt the system&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Organ transplantation is unpredictable&#44; and compels managers to change the surgery schedule&#46; In its operating room rules&#44; the committee must specify how these disruptions should be resolved in order to minimise their impact on cancellations and the harm caused to all concerned&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Finally&#44; when the surgery suite has completed &#8211; or is in the process of completing &#8211; all its scheduled activity&#44; it can start to manage external waiting lists&#46; These add-on cases are usually managed by &#8220;vertical&#8221; extension&#44; in other words&#44; extending the working day or scheduling extra afternoon working hours&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protocolisation</span><p id="par0185" class="elsevierStylePara elsevierViewall">Surgical care includes several phases&#44; including surgical indication and obtaining informed consent&#44; programming the intervention and performing the pre-anaesthetic workup&#46; This chain of activities should be managed in accordance with protocols&#46; The operating room committee should spearhead the initiative to standardise all this activity&#44; seeking the help and agreement of all involved in the process&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">52</span></a> Protocolising clinical processes and patient pathways&#44; and using check-lists to confirm compliance&#44; will reduce clinical variability by speeding up the intervention&#44; increasing patient safety&#44; and improving interdisciplinary team work and care quality and efficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">2&#44;53&#44;54</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Information systems</span><p id="par0190" class="elsevierStylePara elsevierViewall">Good management depends on a constant stream of accurate&#44; real-time information from the surgical suite&#46; This can only be achieved with an effective computer system&#46; The tools currently available in this regard include radio-frequency identification patient tracking systems&#44; patient monitoring dashboards&#44; cameras and automated notification systems&#44; and priority-based algorithms for automating case management decisions&#46; These allow managers to evaluate the different elements of the process and to implement ongoing improvement programmes&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">5</span></a> The operating room committee should define which indicators should be used for that purpose&#46; All operating rooms will soon be equipped with the technology needed to record and analyse this information&#46; The system will automatically extract data from the computer server&#44; such as the name of the surgeon&#44; the scheduled procedure and the real start time of the case&#44; and will make automatic &#8220;Bayesian&#8221; schedule readjustments for ongoing cases&#44;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">24</span></a> thus allowing better management of the uncertainty associated with predicting surgery times&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">19</span></a> More and more hospitals now use this type of system and software&#46;</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusions</span><p id="par0195" class="elsevierStylePara elsevierViewall">Surgery has changed dramatically in recent decades&#44; to the extent that today&#39;s demand for surgical procedures outstrips existing resources&#46; Safety&#44; quality and efficiency have become the priority objectives of 21st century surgical care&#46; Decision-making is based on goals&#44; such as starting and ending on time&#44; reducing turnover times&#44; high utilisation rates&#44; low cancellation rates&#44; and reserve capacity and flexibility&#44; among others&#46; Integrated computer systems can analyse these efficiency indicators&#44; detect shortcomings&#44; and implement continuous improvement programmes to achieve and maintain good productivity&#46; Protocolisation and optimal procedural programming&#44; interdisciplinary coordination&#44; the use of surgical checklists or mobile applications that involve patients in the surgical procedure can contribute significantly to successful management&#46; The surgical block must function as a unit with a good working environment that is conducive to achieving the common objectives&#46; The implementation of these strategies will optimise efficiency and guarantee sustainability&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">Some authors are members of the editorial team of the <span class="elsevierStyleSmallCaps">Spanish Journal of Anaesthesiology and Critical Care</span> as director &#40;AAG&#41;&#44; secretary &#40;RCF&#41; and editor &#40;JMCV&#41;&#46; The authors have not intervened in the editorial process of the manuscript&#44; which has been independently managed by another editor&#46; The authors have no other conflict of interest related to the scientific content of the article&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Healthcare is in constant transformation&#46; Health systems should focus on improving efficiency to meet a growing demand for high-quality&#44; low-cost health care&#46; The operating room is one of the biggest sources of revenue and one of the largest areas of expense&#46; Therefore&#44; operating room management is a critical key to success&#46; The aim of this article is to analyse the current principles of organisation&#44; optimisation and clinical management of the operating room and its impact on the quality and safety of care&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La asistencia sanitaria est&#225; en constante transformaci&#243;n&#46; Los sistemas de salud deben centrarse en mejorar la eficiencia para satisfacer la creciente demanda de atenci&#243;n de salud de alta calidad y bajo coste&#46; El quir&#243;fano es una de las mayores fuentes de ingresos y una de las mayores &#225;reas de gasto&#46; Por lo tanto&#44; la gesti&#243;n del bloque quir&#250;rgico es una clave fundamental para el &#233;xito&#46; El objetivo de este art&#237;culo es analizar los principios actuales de organizaci&#243;n&#44; optimizaci&#243;n y gesti&#243;n cl&#237;nica del bloque quir&#250;rgico y su impacto en la calidad y en la seguridad asistenciales&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez-R&#237;os MA&#44; Abad-Gurumeta A&#44; Casans-Franc&#233;s R&#44; Calvo-Vecino JM&#46; Claves para optimizar la eficiencia de un bloque quir&#250;rgico&#46; Rev Esp Anestesiol Reanim&#46; 2019&#59;66&#58;104&#8211;112&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar1005">This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program&#46; An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page&#58;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; <span class="elsevierStyleItalic">Raw utilisation</span>&#46; For the system as a whole&#44; this is the percent of time that patients are in the room during resource hours&#46; For an individual service&#44; this is the percent of its block time during which it has a patient in the operating room&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#8211;10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;5&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;60<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;45<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#8211;10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PACU admission delays &#40;&#37; of workdays with at least 1 delay in PACU admission due to shortage of beds&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Contribution margin &#40;mean&#41; per operating room hour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;&#36;1000&#47;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#36;1000&#8211;&#36;2000&#47;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;&#36;2000&#47;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Turnover times &#40;mean setup and cleanup turnover times for all cases&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#8211;40<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;25<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prediction bias &#40;bias in case duration estimates per 8<span class="elsevierStyleHsp" style=""></span>h or operating room time&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;15<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#8211;15<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;5<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prolonged turnovers &#40;&#37; of turnovers that are more than 60<span class="elsevierStyleHsp" style=""></span>min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;10&#37;&nbsp;\t\t\t\t\t\t\n
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                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46;T&#46; Malik"
                            1 => "J&#46; Marti"
                            2 => "A&#46; Darzi"
                            3 => "E&#46; Mossialos"
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                      "doi" => "10.1002/bjs.10719"
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                            5 => "N&#46; Rosso"
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