published thesis

Copyright

By

Jessica Vasquez

2016

OR BLOCK UTILIZATION’S IMPACT ON PRODUCTIVITY iii

Acknowledgements

I would like to begin with thanking my precious God for provision, strength, and courage

during my time as a full time student. Lord, my aim is to give you glory in all that I do and

wherever I may be.

Secondly, I would like to thank my loving husband Shawn and our two kids, Zach

and Gianna, for their support, encouragement, understanding, and patience.

I would also like to thank Mr. Todd Henderson. By the grace of God, the door for me

to work in an operating room opened, reporting directly to Mr. Henderson, who has been a

mentor and a gracious boss. I have learned so much because of the opportunity to work in the

OR. Mr. Henderson is a champion of change and continuous improvement. Mr. Henderson is

an invisible patient advocate, striving to deliver the utmost quality and care in his

department.

To my colleague and local statistician, Jose Fuentes, who graciously reviewed my

statistical analyses for this project. Jose made himself available during off-working hours to

answer my many questions regarding statistical definitions.

Finally yet importantly, I would like to specifically recognize and thank Dr. BJ

Moore, Jesus Garcia, R. Steven Daniels, and Tony Pallitto for their outstanding tutelage.

OR BLOCK UTILIZATION’S IMPACT ON PRODUCTIVITY iv

Executive Summary

OBJECTIVE To research best practice principles application in the management of block

utilization and to find how it influences productivity. The research included a case study on

Bakersfield Memorial Hospital’s (BMH) surgery department.

DESIGN A quantitative and policy analysis design was used with pre-existing data.

SETTING Bakersfield Memorial Hospital, Bakersfield, California.

METHOD Pre-existing data collected and analyzed by the BMH hospital IT department was

reviewed to determine optimal block utilization; how first case on time starts, case add-ons,

and weekend volume is impacted by block utilization and how block utilization impacts the

productivity of the OR. Best practice models were compared against the policies of BMH

block scheduling.

MAIN FINDINGS BMH has had challenges in maintaining their productivity levels. Their

block schedule contained 34% of surgeons using less than the 60% required utilization rate to

maintain block; had a significant amount of add-ons and weekend cases. Additionally, BMH

struggled to reach their target goal of 70% First Case On-Time Starts, leading to case delays,

increased overtime costs, and surgeon dissatisfaction. BMH implemented best practice

models of block scheduling in their policies, but has struggled to comply with them. A

governance committee known as the Surgical Services Executive Committee (SSEC) had

been formed by BMH but attendance from physician leaders was very low. Block utilization

decisions were not made by the SSEC per policy. BMH has successfully controlled turnover

times and has successfully predicted case lengths at least 50% of the time.

CONCLUSION Further research is needed to determine why block time utilization is

limited to 8-hour blocks, five days a week. Additionally, if the SSEC or governance

committee does not abide by their own policies, it affects the way an OR performs, thus

affecting productivity. It is recommended for BMH to perform regression analyses to

confirm a relationship between productivity and block utilization, as this research was

limited due to time constraints.

OR BLOCK UTILIZATION’S IMPACT ON PRODUCTIVITY v

OR BLOCK UTILIZATION’S IMPACT ON PRODUCTIVITY vi

Table of Contents

Acknowledgements .............................................................................................................................................. iii Executive Summary...............................................................................................................................................iv Table of Contents ..................................................................................................................................................vi Chapter One ............................................................................................................................................................ 1 Introduction ............................................................................................................................................................ 1

Problem Statement.............................................................................................................................................. 2 Purpose of the Study ........................................................................................................................................... 3 Importance of the Study ..................................................................................................................................... 3

Chapter Two ........................................................................................................................................................... 4 Review of Literature ............................................................................................................................................... 4

The Significance of Time ................................................................................................................................... 4 Governance ......................................................................................................................................................... 7 Scheduling ........................................................................................................................................................ 11 Case Length Prediction ..................................................................................................................................... 12 Expenses ........................................................................................................................................................... 13 Questioning Best Practice ................................................................................................................................. 13

Chapter Three ....................................................................................................................................................... 15 Research Methods ................................................................................................................................................ 15

Analysis of SSEC Minutes ............................................................................................................................... 16 Block Utilization Report ................................................................................................................................... 16 Performance Management Tool ....................................................................................................................... 17 Productivity Report .......................................................................................................................................... 18 Weekend Volume Report ................................................................................................................................. 19 Conclusion of Research Methods ..................................................................................................................... 20

Chapter Four ......................................................................................................................................................... 21 Results and Discussions ....................................................................................................................................... 21

Governance Findings ........................................................................................................................................ 21 Block Scheduling Policy Findings.................................................................................................................... 23 Performance Metrics and Its Impact on Productivity ....................................................................................... 26 Weekend Volume Findings .............................................................................................................................. 27 Productivity Findings ....................................................................................................................................... 28 Summary and Conclusions ............................................................................................................................... 28 Recommendations ............................................................................................................................................ 29

Recommendation #1: Update Block Scheduling Policy. .............................................................................. 29 Recommendation #2: Update SSEC Policy .................................................................................................. 29 Recommendation #3: SSEC Recruitment ..................................................................................................... 30 Recommendation #4: Surgeon Report Cards................................................................................................ 30 Recommendation #5: Consider Saturday Elective Schedule ........................................................................ 30 Recommendation #6: Extend Block Hours .................................................................................................. 31

References ............................................................................................................................................................ 32 Appendix A .......................................................................................................................................................... 37 Appendix B........................................................................................................................................................... 38 Appendix C........................................................................................................................................................... 39 Appendix D .......................................................................................................................................................... 40

Chapter One

Introduction

Surgical admissions at a hospital generate as much as 48% of revenue (Agency for

Healthcare Research and Quality, 2014). Surgery plays a critical role in the business of

healthcare. While surgeries contribute a large portion of revenue, the operational costs must

be managed to control productivity. In order to bring in new business from recruitment of

surgeons, minimize impact to productivity, and efficiently use the hospital’s resources to

maximize revenue and reduce operational costs, block scheduling of surgical cases must be a

strategic process with measurable outcomes involving physician leadership.

Block Scheduling was created to reserve specific blocks of time assigned to specific

surgeons or surgeon groups, referred to as Block Time Assigned (BTA), on specific days of

the week. The utilization of a block schedule is defined by the percentage of total block time

used (BTU) against total block time given (BTA). Turnaround Time (TAT), which is added

to the numerator, is defined as the exact time a wound closure begins until the next patient’s

incision. Total block utilization is calculated by adding block time that is used plus

turnaround time divided by block time assigned (BTU +TAT) / (BTA). This calculation

accounts for those surgeons who result in over 100% utilization.

This research observes Bakersfield Memorial Hospital’s (BMH) surgery department,

located in the city of Bakersfield in the state of California, as they face challenges in

managing surgical block utilization, which currently dominates 98% of the entire OR

schedule (excluding block assignments) and has a grand total of 60% block utilization as of

March 2016. In addition, the administration must maintain a productivity goal of 101% per

OR BLOCK UTILIZATION’S IMPACT ON PRODUCTIVITY 2

pay period. Productivity is defined as total Full Time Employee (FTE) productive hours

(excluding PTO, sick days, holidays, etc.) against total case volume.

The BMH surgical department has ten operating room (OR) suites in the Main OR

with a dedicated Open Heart, Neurosurgery, Orthopedic, and Robotics room. The types of

surgeries performed include Plastic/Cosmetic, Gynecology, Neurology, Urology, Orthopedic,

Spinal, Cardiovascular, Open Heart, and General with an average of 650 surgical cases per

month, including emergent cases. Business hours, or Prime Time, are Monday through

Friday, from seven thirty in the morning to three thirty in the afternoon. Prime Time

Utilization is a statistical analysis measuring the total number of surgical cases booked in a

24-hour period against total cases booked during Prime Time hours. Cases that are performed

outside of Prime Time generally are at risk of incurring overtime costs. Such is the case for

BMH, where they average 23 elective cases on weekends (Saturday and Sunday) each

month.

Problem Statement

Despite holding quarterly Surgical Services Executive Committee (SSEC) meetings,

which comprise of physician leaders and executive administration making block utilization

decisions, block time utilization has not improved. The OR is supposed to be officially closed

during the weekends with staff on standby for emergency cases. However, data for 2015

show that surgeons are adding on elective cases on the weekends (add-ons), activating the

call team, requiring the hospital to pay the staff at callback premium, which is paid at time

and a half. Additionally, the staffing for callback cases are skeletal in that staff does not have

the support it would normally have during regularly scheduled weekly cases. This is

especially important, because recent studies have concluded that patient mortality increases


to as much as 82% for elective surgical cases occurring on weekends (Aylin, Alexandrescu,

Jen, Mayer, Bottle, 2013).

Purpose of the Study

This research aimed to understand why surgeons perform elective surgeries outside of

their block time and on the weekends; how block utilization and scheduling can be improved;

and how improving the entire block scheduling process can improve productivity. These

questions will have been answered by examining BMH data provided for the year 2015,

which examines block utilization, weekend volume, first case on time starts, SSEC minutes

(notes), and productivity reports.

Importance of the Study

This study is significant, because while the hospital implements their block

scheduling policy according to best practice, the outcome is not considered desirable and

potentially increases the risk of mortality. Therefore, as the Pareto Principle states that

twenty percent of the input equals eighty percent of the outcome, this study aimed at finding

out which twenty percent caused poor block utilization, impacting the productivity of the

OR. Other hospitals can learn how to effectively manage productivity and block utilization

through use of data and policy analysis as a result of this study.

Chapter Two

Review of Literature

Most surgical facilities have an overall goal to provide quality patient care, reduce

costs, and increase revenue. There is much literature on examining ways to maximize OR

utilization. In reviewing literature that consists of best practice, industry standards define best

practices that speak to the significance of time, the need for governance, and the importance

OR scheduling plays in effective management. All the literature reviewed agreed that

variables such as add-on cases, urgent cases, and emergency cases, created challenges in the

scheduling process. One observation made by several authors suggested that studies

performed prior to the year 2000 were obsolete, while studies done after the year 2000

provided the most relevant research and methods (Chu, Fei, Meskens 2009; Peltokorpi, 2011;

Guerriero and Guido, R. 2010), especially considering the Patient Protection and Affordable

Care Act implementation and Medicare’s Accountable Care programs.

The Significance of Time

Authors unanimously agree that time in an OR is the most significant resource. Time

brings in revenue or can cause expenses such as in overtime costs. Time is money. Every

operating suite should serve a purpose for every minute, otherwise idle time can result in loss

of revenue. Gamble summarizes this succinctly by stating that time is an OR's most valuable

resource and is greatly impacted by slight delays in case start times, lengthy turnovers, or

even a few minutes spent looking for a piece of missing equipment (2013). Guerriero (2010)

agrees by stating that late starts result in overtime costs, because the last surgery of the day is

pushed later than the scheduled shift end time, and so on-time surgery starts should be

strategic.


One question to consider, is who owns time in the operating room? The answer is

complex, as the landlord of OR time belongs to administration and must sufficiently provide

anesthesiologists, adequate staffing, equipment, and supplies. But revenue is dependent upon

surgeons. Practically speaking, blocks of time (in many cases entire days) are awarded to

surgeons who are considered high volume. However, time can work against productivity,

specifically in the case of delays.

A common area of struggle discussed, are the times that first cases start, also known

as First Case On-Time Starts (FCOTS). BMH’s policy defines a late start approximately five

minutes past 7:30am (or past the scheduled start time). Surgical organizations across the

country strive to start their first cases of the day at the exact time it was scheduled to start.

Otherwise, it is considered delayed and it creates a domino effect, delaying the succeeding

cases, ultimately upsetting surgeons and incurring staff overtime costs. Herrick, Horvath,

Prentiss, Powell, Walsh, Walsh, and Warner (2013) states that if OR management were able

to control on-time starts, then labor costs could also be controlled. Herrick et al (2013) used

principles of Lean methodology in an attempt to optimize case start times while decreasing

resident work hours at Dartmouth-Hitchcock Medical Center (a teaching hospital) to identify

the cause of delayed vascular surgeries for first case starts. They applied DMAIC (define,

measure, analyze, improve, control) techniques for a span of one year, with the facility

performing at the baseline of 39 percent for FCOTS. Value stream maps, Pareto, control, and

process flow charts were created. They measured two outcomes. The first, was the amount of

first cases to start on time. The second outcome measured hospital costs, times residents

rounded, and labor hours. These metrics were then compared to benchmarks.


Herrick et al found that the primary cause for patient processing delays in the

preoperative (pre-op/holding) phase were due to incomplete surgeon documentation.

However, it was the late arrival of the resident to pre-op/holding which was the identifying

primary cause of delays, in the completion of the operative consent and history and physical

update (H&P). Residents arrived late to pre-op because of their morning rounding

obligations. To minimize this, they standardized processes, got rid of nonvalue-added

activities, and implemented the use of checklists. Results showed that the FCOTS

performance improved to 71% at just six weeks after implementation and it was sustained,

ultimately jumping to 86% at the one-year mark. Herrick et al research explicitly stated that

previous studies have shown that for organizations with multiple ORs with scheduled cases

for eight hours or longer, improvement of on-time starts can have a significant financial

impact by reducing OR staffing from 10 to 8 hours, decreasing overtime labor costs that may

be incurred when staff work beyond the standard eight-hour shift. (2013).

This can be partially reproduced in a hospital setting except in the cases of residents

and morning patient rounding, as not all hospitals or surgery centers employ residents. But

best practice shows that Lean and DMAIC methodology have proven to be successful tools

when looking for root causes of delays. At BMH, the surgeon completes the H&P at his or

her office. Once a patient arrives at the hospital, the nurses obtain the consent forms

according to the doctor’s orders. While a big portion of this study involved residents and

their duties which caused the delays, BMH experiences delays of their own beginning at the

start of the very first cases of the day, though without residents.


Governance

A recommended strategy for OR business, is the implementation of governance.

Franklin Dexter is a medical doctor most commonly cited among the literature reviewed.

Dexter (2013) advocates for a committee comprised of key players selected to become

informal leaders. This committee is now considered best practice and famously known as the

Surgical Services Executive Committee (SSEC). Using the principles of Kaizen (Herrick et

al, 2013), also known as continuous improvement from the Lean process improvement

industry, the SSEC includes surgeons, anesthesiologists, OR management, OR scheduler,

hospital administration, and others for the purpose of proactively working together to address

issues of concerns and solutions, such as block time utilization.

Why is an SSEC or similar committee needed? Kindscher explains that such a

committee which includes surgeons, anesthesiologists, nurses, and hospital leadership, all

have different perspectives on what OR efficiency means. “Surgeons want convenient and

readily available OR access, anesthesiologists want smooth-running schedules, nurses desire

predictable shifts, and hospitals seek maximal profit margins for this costly unit. (Kindscher,

paragraph 4, 2015).

Kindscher further explains that, “The scope and authority of the OR committee

depend upon local facility and medical practice governance structures. Often this committee

will review performance standards, develop policies, offer budgetary guidance, and allocate

OR time to surgeons or divisions” (paragraph 2, 2015). OR Manager, a magazine publication

for operating room administrators, encourages the formation of an SSEC stating that this type

of structure is valuable because “buy-in from all of the leadership prevents end-around

games, such as when a surgeon asks the OR manager for something, doesn’t get the answer


he wants, goes to the CEO, and then the OR manager gets a call” (Torrance, paragraph 9,

2015).

Because having an SSEC is a standard for OR governance, the methods used to test

its effectiveness were by implementing such a committee in poor performing hospitals.

Blasco (2013) had implemented several committees in various organizations and has seen

block utilization increase from 48 to 73 percent, with an 8 percent increase in volume. Blasco

implemented SSEC committees in different hospitals, from large community hospitals to

teaching hospitals. He argues that while typically Ambulatory Surgery Centers (ASC), which

are generally owned by surgeons, are competitive in nature with hospitals, that they should

be looked at as a model. Blasco states that ASCs maintain high levels of quality,

productivity, surgeon satisfaction, and patient satisfaction. They also are profitable even

when receiving much lower reimbursement per case compared with hospital ORs (2013).

This was a unique concept that was not found in the literature reviewed, yet the benefits of

having governance consisting of the physician customers is repeatedly seen. Blasco believes

in a governance committee with key players, stating that the SSEC model works because it

gives surgeons a major role in the collaborative oversight of surgical operations. Most

hospitals do not provide surgeons with a sense of ownership of the OR, and so the SSEC

model sees the physician’s voice as a necessary resource, allowing them to balance their

needs for quality, access and service with the hospital's need for improved productivity. As a

member of the SSEC, surgeons begin to see themselves as both owners and valued

customers. (Blasco, 2013).

While many authors tout the benefits of OR governance, Blasco (2013) is among the

few to point out its weakness. Unfortunately, that weakness is the lack of support from senior


administration to reinforce or support SSEC decisions. This occurs when a physician

complains often enough or threatens to take business to a competing hospital. Blasco

describes an example he experienced while in the implementation process:

Not long ago, I helped a specialty hospital in the East establish an SSEC. The

committee created a collaborative environment within the surgery department and

achieved significant improvements in efficiency, productivity, costs and quality.

Pleasing everyone is impossible, of course, and one surgeon disagreed with a certain

change enacted by the SSEC. He complained stridently to hospital administrators.

Finally, instead of supporting the governance committee, the administrators backed

down and overrode the SSEC decision. Several committee leaders stepped down in

frustration, and the SSEC was nearly dissolved. (paragraph 18, 2013).

Having physician involvement means having physician leaders assisting

administration in communicating to other surgeons; peer to peer engagement. This is

especially important for BMH, as the Anesthesiologists and Surgeons are their customers.

Jackson and Stobinski (2014) argues that the SSEC should be responsible for block

utilization and must be cautious not to over-book (75-85%) and over utilize, as this reduces

flexibility of open scheduling. Additionally, they recommended to not make release times so

late that there isn’t enough time to find another case for that slot. Further recommendations

state that Block Time must be continually monitored and re-evaluated. There were also

recommendations against too much block of one specialty on any given day because it is

important to consider the limited resources and equipment (Jackson and Stobinski, slide 11,

2014).


Jackson and Stobinski (slide 24, 2014) examined 7 hospitals totaling 41 OR’s with a

total annual case volume of over 27,000, with multiple ancillary departments. The problems

they observed were: there were no clear expectations or consequences regarding block

utilization; questionable data; no interest from surgeons; more requests for block time than

available; inefficient staffing, and empty rooms in the middle of the day. Their process

improvement plan was to create an administrative position, establish a multi-disciplinary

committee, improve communication, and increase education.

Results show that block time utilization increased 30%, with the consistent block

observations and planned letters sent to surgeons monthly summarizing their block. Jackson

and Stobinski (slide 11, 2014) argued that block time must be reviewed often and blocks

should be revised where underutilization is common. This could be done monthly, every

three months, six months, or yearly. Recommendations included modification options such as

ending block at 1500 instead of 1700, avoiding half-day blocks, blocking every other week

instead of every week, and creating a group block where surgeons from same service line are

allowed to book in the block. What was learned from this study was that block time equates

with “surgeon’s pride” and that it is important to gain trust from them and important to

educate new physicians. Further recommendations included the enforcement of block policy

from the SSEC and to expect variations (slide 44, 2014).

The Jackson and Stobinski (2014) literature was actually a presentation at a

conference. It offered practical information that can realistically be applied. At the

conclusion of their presentation, they included tips for how the implementation of their plan

can work. It possibly is the most important portion of the research. “For this to work:

Surgeons must be involved; Must back up your people; Must have the support of the C-Suite;


Entire facility must be aligned; Must enforce your policies consistently and with all

surgeons” (slide 52, 2014).

Surgeon attendance for quarterly SSEC meetings at BMH has been very poor. This

may be one reason why block utilization has not significantly improved. While block

utilization is a common item on the agenda, block assignments did not change in the year

2015 even when utilization was below 25%. The phenomenon of poor physician attendance

at an SSEC was not mentioned in the literature reviewed. A study on how to retain and

recruit physicians to such a committee is needed.

Scheduling

The bulk of the research focuses on scheduling. There have been various statistical

tests to find the best scheduling model for various surgical facilities, each varying in their

results. Peltokorpi stated that previous research regarding operating room management has

focused on studying the before and after analysis of single hospital cases (p.1, 2011).

Because most studies only evaluated a single organization, Peltokorpi analyzed several

hospitals, totaling 26 units, with the goal to “analyze the synergic effect of strategic decisions

and operative management practices on operating room productivity enabling statistical

hypothesis testing with empirical data” (Peltokorpi, p. 1, 2011). There were eleven

hypotheses that assumed connections between the use of strategic and operative practices and

productivity. Among these hypotheses were the assumptions that operating rooms with

focused service have better productivity, the size of the operating room does not impact

productivity, ORs with a large number of acute surgery have better productivity, case length

prediction can improve productivity, cross-training and flexibility of staff improves

productivity, incentivizing physicians improves productivity, performance monitoring


improves productivity, and that scheduling of cases and staffing impacts productivity.

Results showed that scheduling (also referred to as “capacity-building, resource-planning, or

patient- planning practices) have a higher impact on productivity than strategic decisions.

Peltokorpi concludes that “proper operative practices are more important than correct

strategic decisions in terms of improving OR performance” (p. 1, 2011).

Case Length Prediction

Because of variation in surgery times, the majority of research studies support the

forecasting of case length by using historical surgery times (May, Sampson, Strum, Vargas,

2000). This method of statistical forecasting is known as Case Length Prediction and it is

considered best practice. Peltokorpi included case length prediction as the fifth hypothesis

arguing that the combination of accurate estimations with target filling rates leads to the

optimal utilization and thus to increased productivity (2013). Guerriero and Guido (2010)

agrees that the amount of predictable surgery durations are limited, pointing out that different

competing criteria like team waiting, OR idling, overtime, efficiency, and quality of care

should be considered in order to determine tight schedules of when surgery durations are

affected by the unknown variables. Guerriero and Guido argue for strategic management in

scheduling efficiently, because the method used-projection- is based on historical data of one

or more years. Dexter, Macario, and Traub (2002) adds that the use of historical data for long

term forecasting is not always accurate and therefore recommends to use the average of the

most recent year’s total hours of elective cases to predict future usage of OR time. Dexter et

al’s suggestions to use recent historical data, is perhaps most useful in case length prediction.


Expenses

What I found most interesting, was that few authors mentioned managing the supply

costs of surgical equipment. Gamble listed it as their first recommendation, recommending to

look at high cost items and benchmark them to national standards. Surgical equipment

consists of implants, supplies, and devices for example (Gamble, 2013). In fact, after

reviewing the 2014-15 fiscal year budget report for BMH, the findings revealed that 72% of

their expenses were spent on supplies while 22% was spent on labor. BMH has actively made

strides to communicate with surgeons on agreeing to similar or standardized, surgical

instruments. But movement in this direction has been slow. Administration faced challenges

of having surgeons who explicitly expressed their desire to use instruments from their

preferred vendors/manufacturers. Two surgeons performing the same procedure ended up

requesting the same instrument, from different manufacturers.

Scheduling, as is mentioned in the literature, is key in balancing productivity. Block

time utilization goes hand-in-hand and literature argues that block time should be reviewed

by the SSEC often, policies enforced, and block assignments revised where needed. The

purpose of reviewing the literature is to seek out best practice for scheduling and managing

of block time for application in an OR.

Questioning Best Practice

One question that arises from the literature, is why the industry’s best practice has

adopted prime-time to be between 7:30am to 3:00pm and why block assignments are limited

Monday through Friday. The current best practice model appears to make an attempt to fit a

camel through the eye of a needle. Why must the industry, which has grown and evolved into

a square peg, be forced to fit into a round hole? Why does prime-time end at 3pm and not


10pm? Why aren’t weekends counted in block time? Why force an organization to adapt to

the current best practice model instead of adapting the model to fit the needs of the

organization? In the case of BMH, it would benefit them if block hours were extended

through the weekend and prime-time hours be extended past 3pm.

Chapter Three

Research Methods

The purpose of this research was to observe BMH’s compliance to best standards by

reviewing their data and policies in the management of the OR block scheduling and to see if

best practice applications result in optimal productivity by using existing reports and data

provided by BMH for fiscal year 2015. The reports included Block Utilization data;

Productivity Reports, which included staff call-back hours (paid as overtime) to show the

costs of having elective surgeries; and Weekend Volume Data. The aggregated data from

these pre-existing reports would reveal the costs of an underutilized operating room.

Additionally, meeting minutes consisting of agenda items and discussions for SSEC meetings

were obtained for review to show challenges in the implementation of best practice

modeling.

All BMH data collected was extracted from their electronic patient charting system

called MediTech, by the Information Technicians (IT) department. The purpose for

extraction was to apply statistical analysis for performance metrics. The IT department is

comprised of experts in data analysis as well as the MediTech EHR program; had the

clearance and authorization by the hospital to extract data; and created monthly reports and

dashboards in Excel spreadsheets which were routinely submitted to the OR department

director and senior administration for review.

Managing the operating room has many challenges due to the conflicting priorities

and the preferences of its stakeholders, including the scarcity of costly resources. These

factors clearly stress the need for efficiency and necessitate the development of adequate

planning and scheduling procedures to balance staffing levels. The existing data that was


reviewed consisted of statistical reports detailing performance metrics of baseline, actual,

performance, and prediction.

Analysis of SSEC Minutes

BMH’s SSEC meets on a quarterly basis and maintains meeting minutes, detailing

member attendance, agenda items, and discussions. A review of the meeting minutes was

necessary to review agenda items that took priority; what discussions and follow-up action

was made regarding agenda items. The focus of reviewing meeting minutes was to review

any discussion, follow-up, action plans, and decisions that may or may not have been made

by the committee.

Block Utilization Report

The “Block Utilization” report summarized the utilization of room usage per surgeon,

by day of the week, month, and year. This (Block Utilization) is the report that showed the

performance of the hospital’s “Block Time Management,” but also pointed to surgeon

performance. The data served to support the research and literature. All Physician names

have been removed and replaced with a number (i.e. Surgeon 1, Surgeon 2, Surgeon 3, etc.).

The report included:

● Trend analysis

● Total Block Hours Assigned (in hours and minutes)

● Total Hours Spent in Blocks with Turn Around Time (in hours and minutes)

● Total Number of Procedures Done in Block

● Total Hours Spent Outside Blocks with Turn Around Time (in hours and minutes)

● Total Number of Procedures Done Outside Block


● Total Hours Spent in Block to Total Hours Spent Outside Block (rounded ratios

between procedures and times performed in block vs. out of block)

● Procedures in Block to Procedures Out of Block

● OR Block Scheduler Summary Graphs

● OR Turnaround Time and Prediction Bias

○ Physician Name (will be scrubbed)

○ Block Owner (yes or no)

○ Number of Actual Cases (Emergency & Non-Emergency)

○ Average Procedure Length (in hours and minutes)

○ Average TAT (turnaround time)

○ Standard Deviation of TAT

○ Number of Cases with Predicted Duration Times (Non-Emergency)

○ Percent Estimate Accurate

○ Percent Estimate Low

○ Percent Estimate High

Performance Management Tool

The BMH Performance Management Tool, a spreadsheet that listed several criteria

for measuring performance, was a pre-existing report sent out to management daily. As the

Peri-Operative Coordinator of BMH, this report is automatically sent to me on a daily basis.

The report included percent baseline data, percent daily usage data, percent quarterly average

(range is flexible. Drop Down menu allows date range to be selected), percent target. More

specifically, the data measured the following metrics for each day:

● Total Number of cases (for the current day vs baseline vs target)


● Number of first cases (for the current day vs baseline vs target)

● Percent of on-time first case starts (FCOTS)

● Number of Turnovers (for the current day vs baseline vs target)

● Turnover Time- Wheels out to wheels in (minutes) (for the current day vs baseline vs

target)

● Percent of Prime-Time OR Utilization (7am-4pm) (for the current day vs baseline vs

target)

● Percent of Cancellations within 24hrs of surgery (for the current day vs baseline vs

target)

The use of this data was important because it revealed how timely starts, delays, turnover

time, “business hours” utilization (prime-time), and cancellations affected block utilization

outcomes and how block utilization is impacted.

Productivity Report

A productivity report was also used, which is generated bi-weekly. This was a

spreadsheet which was easily downloaded from the time and attendance Business Analytics

Software program. It showed the number of FTEs used against case volume, how many FTEs

projected, and how many FTEs were paid overtime hours. More specifically, the report had

the following metrics measured:

● Percent of Productivity

● Unit of Service (UOS)

● Actual Productive Hours/UOS

● Budgeted Productive Hours/UOS

● Actual and Variance of Productive FTEs


● Actual and Variance of Paid FTEs

● Registry FTEs

● Registry Percentage

● Overtime (OT) FTEs

● OT Dollars

● OT Percentage

● Orientation FTEs

● Non Productive Percent

This report caused management to make changes in the staffing. If the report showed

overage on FTEs, then management had to adjust by “flexing off” staff (i.e. reduce their

work hours by sending them home early when cases finish or giving them days off during the

week). Because capacity-building (scheduling) and staffing is critical to all cases, literature

agreed that the key to optimal productivity among block utilization, is contingent on proper

use of human resources. The productivity report supported the research when comparing to

best practice models, and also demonstrated staffing trends and how block utilization

impacted productivity.

Weekend Volume Report

Weekend Volume was a statistical report generated to reveal how many cases were

performed on Saturday and Sundays, per week, per month, per year. It included the types of

procedures which were performed. This is important, because the Operating Room’s business

hours are closed during the weekend, with a call-team on standby for emergent cases only.

However, the Weekend Volume Report showed a trend of elective cases being performed on

Saturdays and Sundays, activating the call-team, which is paid with OT dollars. The report


also revealed which surgeons tended to do cases normally considered elective on a weekend.

This report included the following metric measurements:

● Cases-Procedures-Minutes by Physician

○ Number of cases (per month)

○ Total Minutes (per month)

○ Average Case Duration (per month)

○ Total Cases

○ Total Minutes

○ Total Average Case Duration

● Cases by Hour Started (pivot table with chart)

● Procedure Case Count, Total Minutes, Average Case Duration by Month

● Saturday and Sunday Case Count

Conclusion of Research Methods

Block Time needed to be measured for its effectiveness, as it greatly impacts the

business of the OR. It would not be possible to discuss problems or recommend solutions

without the data nor would this study be able to support the statement that block utilization

impacts productivity (either positively or negatively). The third party data access would show

how staff productivity is affected by block utilization, because when block surgeons do not

book cases and do not release their cases, staff is “flexed off” due to no work and potential

revenue is lost. And the productivity report is critical to show the costs of overtime for on-

call staff working on the weekends for surgeries by block surgeons, that are usually done

during the week and within block.

Chapter Four

Results and Discussions

The purpose of this research was to observe BMH’s compliance to best standards by

reviewing their data and policies in the management of the OR block scheduling and to see if

best practice applications result in optimal productivity. BMH follows best practices of

establishing governance, with a Surgical Services Executive Committee. Regarding OR

block scheduling, they do not apply the recommended “block -to -open” percentage, where

no more than 80% of all rooms should be blocked, leaving 20% open. The Performance

Management Tool (PMT) showed that the average percent of first cases that start on time is

51%. The Productivity Report shows that nearly $700,000 was paid out in overtime costs (to

include holiday premium, call back, overtime, and double time). The surgery department

consistently struggled to reach the productivity target of 101%. And while the department is

officially closed during the weekends, they average 23 cases a month during weekends

(Saturday and Sunday) alone. Policy also details the process of block scheduling, but BMH

did not apply the policy in practice such as in reviewing block utilization monthly when

actually it was reviewed quarterly nor was the policy applied when surgeons did not maintain

the minimum 60% block utilization.

Governance Findings

The BMH surgery department has an SSEC. They met on a quarterly basis, however,

attendance by physicians was extremely poor. Block utilization was repeatedly on the agenda

but no changes had been made. Members of the SSEC included the C-suite (Chief Nursing

Officer, Chief Executive Officer, Chief Operating Officer, Chief Medical Officer), Director


of Nursing, Manager of Central Processing Department, Surgery Scheduler, select Surgeons,

and Chair of Anesthesiology.

Review of block scheduling was on the agenda, but re-allocation of block was not

noted. However, concern regarding block assignment was mentioned, because of changes

being made without informing the SSEC and OR management; non-compliance of the

Scheduling and Block Policy; and physicians consistently arriving late for their cases,

affecting the FCOTS statistics.

In reviewing the attendance from previous minutes, surgeons were among the least in

attendance. In addition, the attendance of the entire C-suite was also incomplete. It could be

due to the time of day these meetings took place, at 6pm. However, while issues were

discussed in SSEC, there were no formal decisions made, especially regarding block time.

Best practice recommends having an SSEC firm in their decision making and in support of

policies put in place. Blasco (2013) had described how an SSEC would fail, by a lack of

support from senior administration to reinforce or support SSEC decisions. This occurs when

a physician complains often enough or threatens to take business at a competing hospital.

Blasco described an implementation attempt to form an SSEC at a hospital where one

surgeon would constantly complain to senior administration, threaten to leave, and resist

changes. Blasco revealed that at this particular hospital, instead of supporting the governance

committee, the administrators backed down and overrode the SSEC decision leading to the

loss of several committee leaders due to frustration. The SSEC at that specific hospital

almost dissolved (2013). That example mirrors BMH. However, what Blasco did not foresee,

was a lack of physician involvement, which was also a problem at BMH but not in Blasco’s

study. The literature reviewed touted governance but did not address how to retain physician


members. This is a topic that must be further discussed in order to have a successful

governance.

Block Scheduling Policy Findings

The block policy contained the purpose and process of block scheduling, stating:

To outline a consistent, effective, and systematic process for scheduling surgical

cases, creating and managing block time. The policy will support equal scheduling

opportunity for all qualifying surgeons and outline processes to maximize schedule

access by providing optimal utilization of operating room suite, time, equipment, and

available personnel. (Policy #DP-SS 129, Dignity Health BMH, p.1, 2015).

The policy was ten pages in length and specifically defined “block” as “time

guaranteed,” but it does not guarantee “specific operating room suites.” It clearly stated that

requests for block time from surgeons had to be submitted in writing to the SSEC; that a

utilization rate of 60% (over one quarter) is the minimum to maintain block, while a

minimum of 80% utilization must be maintained to increase block time. The SSEC was

tasked with block review and re-allocation and per policy, utilization was supposed to be

reviewed on a monthly basis by the SSEC. However, SSEC meetings occurred quarterly. Re-

allocation of block was mentioned in the meeting minutes, led by the director of surgery, but

no decision to re-allocate block time was ever made by the SSEC.

The policy was absent on how block was assigned to a surgeon who did not request it.

The practice for BMH has been that the Chief Executive Officer (CEO) or the Chief

Operating Officer (COO), allocate block time. However, there was no process or policy in

place to explain how, why, and on what basis surgeons were selected to receive block; nor

was there a process detailing how available block was determined to be assigned or how


block may have been re-allocated to be given to a new surgeon for a new block assignment.

This method had worked in past years, but due to the growth of the business, patient

population, and the addition of the Affordable Care Act, this is a practice that has begun to

bring conflict in the scheduling process. This is because block allocation was often made

without discussing available capacity with the SSEC and the OR Director.

Based on the loose adherence to block policies; block assignments which were not

discussed with the SSEC; and the lack of physician attendance at SSEC meetings, it appears

the critical foundation of managing block and balancing productivity is greatly impacted by a

weakened governance.

While block utilization was reviewed during SSEC meetings, the policy was not

formally referenced against actual block utilization, nor were any decisions regarding

revision of block voted on. Best practice dictates that a maximum of 80% of the surgery

schedule can be blocked. However, the findings showed that BMH’s surgery schedule has

98% blocked (see figure 2, BMH Block Utilization), leaving no room for extra business or

flexibility. Out of 41 total block assigned surgeons, 27 surgeons, or 34%, used less than the

60% required to maintain block. 16 surgeons, or 60%, utilized more than 80% of their block,

granting them the privilege to increase their block times. At least one surgeon had a 0%

utilization for six straight months. Referring to BMH’s policy, it clearly stated that in order

for block assignment to be maintained, 60% must be utilized. Overall, total block utilization

for fiscal year 2015 ended at 52.2% though corporate policy had a set target of 75% total

block utilization for BMH.

Results show that yet again, the hospital was not compliant with their own policy of

reviewing and re-allocating block. Suggestions and recommendations were made by the


Director of Nursing during SSEC meetings, for the re-allocation of block assignments for

surgeons who use less than half of their assigned time, as noted in the meeting minutes. But

no changes were made to block assignments even when utilization of several surgeons were

below 25%.

The management team of the surgery department attempted to communicate with

surgeons by mailing monthly letters containing individual block utilization statistics,

including a “release of block” form in the event a surgeon was going on vacation.

Unfortunately, these letters did not make significant impacts to block utilization however, at

least two surgeons who averaged less than 5% of block had block taken away and one

surgeon retired, opening up a slot.

Another finding was the add-on rate. At the end of the 2015 fiscal year, an average of

20% of surgical cases were added on, last minute. Add-on cases are unforeseen scheduling

requests made by surgeons that are not emergent. BMH accommodates add-ons and the

policy specifies those cases “are to follow.” This disrupts the staffing schedule, as room and

case assignments are made 24hrs prior to surgery. Add-on cases result in overtime and

double-time costs and staff burn out because of a poor work-life balance. For example, 12

hour nurses who normally work 3 days a week, are called in to work a 4th and 5th day, at

double-time pay.

Regarding on time starts, the policy had also mentioned that “all sources of delays

will be tracked and reviewed monthly by the SSEC” (BMH Policy DP-SS 129, p. 7). The

statistical analysis of the percent of on time starts is reviewed by the OR management team,

however, the SSEC meeting minutes did not include reviewing all sources of delays. In


addition, the SSEC met quarterly, and therefore did not implement the monthly review the

policy itself had set.

While it was the duty of the SSEC to make firm decisions per best practices for block

scheduling, it was the management of the surgery department that actually made the

attempts. Since there was no proper support from the SSEC, the block utilization dominated

the entire business of the OR with poor use and surgeons who used less than 60% of their

block, kept it.

Performance Metrics and Its Impact on Productivity

BMH policy dictated that physician delays of 30 minutes or more result in an adverse

effect to block scheduling privileges. The policy also defines “delay in start time” as five

minutes past the scheduled start time. The Performance Management Tool revealed that the

biggest weakness impacting productivity, was the percent of cases to start on time. BMH set

a goal to start cases as scheduled, 90% of the time. However, their fiscal year 2015 average

yielded a 49% of on-time first case starts. This was due to various reasons such as surgeon

late arrival, anesthesiologist late arrival, and even hospital rooms not ready (due to not

having special equipment or surgical instruments ready).

This in turn, affected the Prime-Time OR Utilization (cases during business hours),

where prime-time began at 7am and ended at 3pm. BMH had a target to complete 75% of

total cases within business hours. However, with cases starting late and cases being added on

to Saturday and Sunday, the results showed an average of 48% prime-time utilization. This

suggests a huge loss of potential revenue and an unbalanced schedule.

Turnover Time is defined as the minutes counted when a patient is wheeled out of the

operating room (wheels out) after completion of surgery until the minute the wheels of the


next patient are rolled into the room (wheels in). The Surgical Assistants are responsible for

cleaning the operating room suite and sterilizing equipment for the next case. Turnover time

for BMH was very good, with a target goal of 25 minutes but an actual average of 23 minutes

for fiscal year 2015. The shorter the turnover time, the higher utilization of block and prime-

time.

BMH also calculated case length prediction. That is, the educated guess of how long a

specific case will run which the scheduler makes when scheduling cases. BMH accurately

predicted case lengths an average of 50% of the time in FY2015.

Weekend Volume Findings

A practice that has been ongoing at BMH, are weekend cases. 25% of Surgeons who

are block owners were 40% of the weekend volume. Many of the procedures performed on

the weekend, were cases usually performed during the week as elective. BMH weekend

volume data revealed that they average 23 cases a month on weekends alone; 5.5 cases each

Saturday and 5 cases each Sunday. Weekends are reserved for emergency surgical cases.

Staff called in during the weekends, are paid at time and a half. The impact to productivity is

significant with the amount of weekend cases performed.

What I found interesting, was that BMH’s policy (DP-SS 129, p. 8) speaks

specifically of “elective Saturday schedule.” The policy was last updated April 29, 2015 by

the Board of Directors, however, all cases that occurred on Saturdays were considered

emergent according to the data that was collected by their IT department, even when similar

procedures were considered elective during the week. Staff was also getting paid at time and

a half. The policy itself shows that BMH does in fact have a Saturday elective schedule, but

in application, it treated all cases as emergencies. Furthermore, section 6 of Elective Saturday


Schedule states that there should be no Sunday elective schedule, yet there were consistently

5 or more cases performed on Sundays in FY2015.

Productivity Findings

At the end of fiscal year 2015, a review of the productivity report revealed that it cost

BMH $117,415 in call-back costs; $123,629 in double time costs; $15,829 for cases

scheduled during holidays; and $426,542 in overtime costs, for a total of $683,415 spent on

labor outside of business hours. If block scheduling was balanced and weekend cases

minimized or controlled (such as adding Saturday to the regular schedule), the cost in

staffing would be reduced.

Summary and Conclusions

This study aimed at researching best practice principles application in the

management of block utilization and to find how it impacts productivity. The research

included a case study on Bakersfield Memorial Hospital’s (BMH) surgery department.

Results indicate that BMH has had challenges in maintaining their productivity levels,

presumably due to an unbalanced block schedule with 34% of surgeons using less than the

60% required utilization rate to maintain block; has a significant amount of add-ons and

weekend cases. Additionally, BMH has struggled to reach their target goal of 70% First Case

On-Time Starts as shown by their PMT report, leading to case delays, increased overtime

costs, and surgeon dissatisfaction. The policy stipulated that all sources of delays in start

times would be tracked and reviewed by the SSEC, but meeting minutes do not show that

such reviews actually took place. Also the policy mentioned the reviews of delays were to be

done monthly by the SSEC, but the committee only met quarterly.


BMH implements best practice models of block scheduling in their policies, but has

struggled to comply with them. A governance committee known as the Surgical Services

Executive Committee has been formed by BMH, as best practice encourages, but attendance

from physician leaders has been decreasing over time; block utilization decisions have not

been made (no re-allocation of block); and meetings held quarterly contradict their policy

which stated that block utilization would be reviewed by the SSEC on a monthly basis.

BMH has successfully controlled turnover times, which reduces case delays and also

has successfully predicted case lengths at least 50% of the time, leading to more accurate

surgery scheduling, ultimately impacting how cases are staffed.

Recommendations

The purpose of this section is to present recommendations that were developed based

on a review of scholarly research compared to current practices. Despite the struggles BMH

has faced in FY2015, they are taking steps in the right direction.

Recommendation #1: Update Block Scheduling Policy.

It is recommended that their block scheduling policy is updated to reflect the capacity

of SSEC. Because the committee met quarterly though the policy obligated decisions

monthly, it is evident that meeting monthly is not attainable, therefore it is recommended to

change the frequency of meetings that were supposed to occur on a monthly basis to a

quarterly basis.

Recommendation #2: Update SSEC Policy

Secondly, there should be a policy establishing how, why, and when block time is

assigned to a surgeon, with the decision made by the SSEC. It is important for these

scheduling decisions to be made after consulting with the OR director (who is a member of


the SSEC), who can foresee potential conflicts and complications that administration would

not be aware of. The SSEC should make efforts in firmly implementing their written policy

to actually review and re-allocate (right size) block assignments to surgeons who do not meet

the recommended minimum block utilization rate.

Recommendation #3: SSEC Recruitment

The SSEC should implement unique ways of recruiting physicians, by announcing

invitations through newsletters and visits by physician liaisons encouraging involvement.

The SSEC is a platform where physician’s voices can be heard and where changes can be

made with their best interest. Therefore, it is important to recruit new physician members and

inquire from them as to their ideal meeting times so that attendance can be improved.

Recommendation #4: Surgeon Report Cards

While BMH follows best practice in sending surgeons a letter containing their block

utilization, I recommend implementing a report card with a letter grade, that not only visually

displays a surgeon’s summary of block utilization, but would include their individual metrics

of: Block Utilization; % of On-Time First Case Starts; Number of Turnovers; Prime Time

OR Utilization; and % of Cancellations within 24hrs of Surgery. A report card is also known

as a “scorecard,” and it is used to motivate and inform surgeons on their performance, per

best practice.

Recommendation #5: Consider Saturday Elective Schedule

Regarding weekend volume, since BMH’s policy already speaks of Saturday elective cases,

it is recommended that Saturday be added to the regular schedule; include block assignments;

and add Saturday to the data collection. Staff should be paid at regular straight time since it


would be a regularly scheduled day. This would significantly decrease overtime costs thus,

improving productivity.

Recommendation #6: Extend Block Hours

Regarding prime-time utilization, the hours should be extended past 3pm. Since a significant

amount of caseloads are add-ons, it would benefit BMH if prime-time is extended,

leaving open slots for add-on cases. This would increase prime-time utilization and make

better use of evening shift staff.


References

Agency for Healthcare Research and Quality. (February 2014). Characteristics

of Operating Room Procedures in U.S. Hospitals, 2011. Healthcare Cost and

Utilization Project. Statistical Brief #170. Retrieved from:

http://www.hcup-us.ahrq.gov/reports/statbriefs/sb170-Operating-Room-Procedur

es-United-States-2011.pdf

Aylin, P., Alexandrescu, R., Jen, M. H., Mayer, E. K., & Bottle, A. (2013, May 28). Day of

Week of procedure and 30-day mortality for elective surgery: Retrospective analysis

of hospital episode statistics. Retrieved from

http://www.bmj.com/content/346/bmj.f2424

Bakersfield Memorial Hospital. (2015). Block Utilization Report [Excel

spreadsheet]. Bakersfield, CA: Bakersfield Memorial Hospital.

Bakersfield Memorial Hospital. (2015). Performance Management Tool (PMT)

[Excel spreadsheet]. Bakersfield, CA: Bakersfield Memorial Hospital.

Bakersfield Memorial Hospital. (2015). Productivity Report [Excel spreadsheet].

Bakersfield, CA: Bakersfield Memorial Hospital.

Bakersfield Memorial Hospital. (2015). SSEC Meeting Minutes.

Bakersfield, CA: Bakersfield Memorial Hospital.

Blasco, T. (7 November 2013). Making the OR accountable. Hospitals and Health

Networks. Retrieved from:

http://www.hhnmag.com/articles/6092-making-the-or-accountable#

Chu, C., Fei, H., Meskens, N. (28 February 2009). A planning and scheduling problem for

an operating theatre using an open scheduling strategy.


Doi:10.1016/j.cie.2009.02.012.

Dexter, F., Traub, R. (April 2002). How to schedule elective surgical cases into specific

operating rooms to maximize the efficiency of use of operating room time.

Anesthesia and Analgesia, 94 (4), pp. 933-942. Retrieved from:

http://journals.lww.com/anesthesia-

analgesia/Abstract/2002/04000/How_to_Schedule_Elective_Surgical_Cases_into.30.

aspx.

Dexter, F., Macario, A., Traub, R. (February 2003). How to release allocated operating

room time to increase efficiency: predicting which surgical service will have the

most underutilized operating room time. Anesthesia and Analgesia, 96 (2),

P.507-512. Retrieved from:


analgesia/Fulltext/2003/02000/How_to_Release_Allocated_Operating_Room_Time_t

o.38.aspx.

Dexter, F., Watchel, R. (January 2008). Tactical increases in operating room block time

for capacity planning should not be based on utilization. Anesthesia and

Analgesia,106 (1), p. 215-226. Retrieved from:


analgesia/Abstract/2008/01000/Tactical_Increases_in_Operating_Room_Block_Time

.39.aspx.

Epstein, R., Dexter, F. (March 2002). Statistical power analysis to estimate how many

months of data are required to identify operating room staffing solutions to

reduce labor costs and increase productivity. Anesthesia & Analgesia, 94 (3),


640-643. Visited on April 26, 2016 from:


analgesia/Abstract/2002/03000/Statistical_Power_Analysis_to_Estimate_How_Many

.29.aspx.

Gamble, M. (18 January 2013). 6 cornerstones of operating room efficiency: best

practices for each. Becker’s Hospital Review. Retrieved from:

http://www.beckershospitalreview.com/or-efficiencies/6-cornerstones-of-operating

-room-efficiency-best-practices-for-each.html.

Guerriero, F., Guido, R. (20 November 2010). Operational research in the management

of the operating theatre: a survey. Health Care Management Science, 14,

89-114.

Herrick, D.P., Horvath, A.J., Prentiss, S.J., Powell, R.J., Walsh, D., Walsh, T., Warner,

C. (5 November 2013). Lean principles optimize on-time vascular surgery

Operating room starts and decrease resident work hours. Journal of Vascular

Surgery, 58 (5), p.1417-1422. Retrieved from:

http://www.ncbi.nlm.nih.gov/pubmed/23827339.

Kindscher, J. (2 July 2015). Operating room management. Clinical Gate. Visited on

April 29, 2016 from: http://clinicalgate.com/operating-room-management/

May, J.H., Sampson, A.R., Strum, D.P., Vargas, L.G. (May 2000). Surgeon and type of

Anesthesia predict variability in surgical procedure times. Anesthesiology, 92 (5),

1454-1167. Retrieved from:

http://www.ncbi.nlm.nih.gov/pubmed/10781292

McIntosh, C., FANZCA, Dexter, F., Epstein, R. (December 2006). The impact of


service-specific staffing, case scheduling, turnovers, and first-case starts on

anesthesia group and operating room productivity: a tutorial using data from an

Australian hospital. Anesthesia & Analgesia, 103 (6), 1499-1516. Retrieved

from:

http://journals.lww.com/anesthesiaanalgesia/Abstract/2006/12000/The_Impact_of_Se

rvice_Specific_Staffing,_Case.34.aspx.

Jackson, M., Stobinski, J. (14 February 2014). How does a block committee fit into the

Governance of the facility? OR Manager (slideshow presentation). Retrieved on April

13, 2016 From:

http://www.ormanager.com/wp-content/uploads/2014/02/Block-Scheduling-

Committees-Stobinski-Jackson-Slides.pdf

Peltokorpi, A. (4 August 2011). How do strategic decisions and operative practices

Affect operating room productivity? Health Care Management Science, 14 (4)

370-82.

Punke, H. (5 March 2013). Strategies for surgical service line success under

accountable care. Becker’s Hospital Review. Retrieved from:

http://www.beckershospitalreview.com/hospital-key-specialties/strategies-for-

surgical-service-line-success-under-accountable-care.html.

Surgery Management Improvement Group. (31 May 2012). Operating room scheduling:

best practices (video presentation). Retrieved on April 9, 2016 from:

https://youtu.be/kbRS47AWcfI

Torrance, A. (22 July 2015). Predictive modeling helps match resources with needs. OR

Manager. Retrieved from:


http://www.ormanager.com/predictive-modeling-helps-match-resources-with-needs/


Appendix A

Authorization for Protocol 16-70.


Appendix B

Authorization for use of BMH Data


Appendix C

BMH Block Utilization Report


Appendix D

BMH Performance Management Tool

published thesis

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