Journal of Postgraduate Medicine
 Open access journal indexed with Index Medicus & ISI's SCI  
Users online: 1827  
Home | Subscribe | Feedback | Login 
About Latest Articles Back-Issues Articlesmenu-bullet Search Instructions Online Submission Subscribe Etcetera Contact
 ::  Similar in PUBMED
 ::  Search Pubmed for
 ::  Search in Google Scholar for
 ::  Article in PDF (219 KB)
 ::  Citation Manager
 ::  Access Statistics
 ::  Reader Comments
 ::  Email Alert *
 ::  Add to My List *
* Registration required (free) 

  IN THIS Article
 ::  References

 Article Access Statistics
    PDF Downloaded42    
    Comments [Add]    
    Cited by others 15    

Recommend this journal


  Table of Contents     
Year : 2015  |  Volume : 61  |  Issue : 1  |  Page : 1-2

Can we improve operating room efficiency?

Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication15-Dec-2014

Correspondence Address:
Dr. J V Divatia
Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0022-3859.147000

Rights and Permissions

How to cite this article:
Divatia J V, Ranganathan P. Can we improve operating room efficiency?. J Postgrad Med 2015;61:1-2

How to cite this URL:
Divatia J V, Ranganathan P. Can we improve operating room efficiency?. J Postgrad Med [serial online] 2015 [cited 2023 Jun 7];61:1-2. Available from:

Operating rooms (ORs) are probably among the most important areas of the hospital, contributing to both the workload and the revenue. Efficiency of use of OR time depends on scheduling of cases, allocation of staff, equipment, time required for preparation and induction of anesthesia, performance of surgery, recovery from anesthesia, preparation of the OR for the next patient and other resources. Inefficient OR management can result in case cancellations and long patient waiting lists. A well-managed OR results not only in a high surgical turnover, but also in reduced postoperative complications, improved patient-centered outcomes and greater patient satisfaction. How does one improve OR utilization? The first logical step would be an audit. Several performance parameters relevant to OR utilization have been identified. [1],[2] These include 1) accurate case-duration estimate: Measures the percentage of cases where patient-in-room duration is within 15 minutes of the estimated in-room duration. This is a performance parameter for the scheduling of cases. 2) percentage of on-time first case starts: In a good OR, there should be no reason for the patient to be wheeled in late. Delayed starts may reflect inefficiencies in the hospital systems at any level from the wards to receiving the patient in the OR. 3) Pre-admission screening measures the percentage of cases that had a preanesthetic checkup prior to surgery. Inadequate prescreening may be responsible for a proportion of cancellations or delayed starts. 4) Patient-in-to-incision time: Measures the average time that elapsed between the patient entering the operating room and the first incision. This includes the time for induction of anesthesia, positioning, and surgical preparation. This is variable depending on the nature of the anesthetic and the surgery. 5) Average turnover time measures the time that elapsed between the prior patient exiting the room and the next patient entering the OR. There are many factors that drive turnover time. This can include an inefficient central processing of instruments or can be a result of a multidisciplinary problem involving nursing, anesthesia, housekeeping and the turnover team staff not working in co-ordination. Reduction in turnover times may not lead to an increase in surgical throughput unless the number of cases carried out per OR per session is high. Outcomes such as incidence of complications, infection rates, and perioperative mortality are important, but are affected by many factors other than efficiency of OR performance.

Audits of OR utilization have been criticized on several fronts; the lack of standard definitions for various OR processes, differences between studies in terms of methodology used to calculate utilization, lack of validation of these indices as performance indicators and the inability to extrapolate results from one center to another. It is difficult to set universal benchmarks for all ORs as these can vary considerably depending on the patient population, type of hospital as well as the type of surgery and anesthesia. For example, one cannot apply a benchmark set for patient-in-to-incision time for a lipoma excision done as a day-case procedure to a major hip replacement surgery. Hospitals operating on a for-profit basis would be more oriented towards a rapid turnover than academic hospitals with residents in-training. Other limitations of such audits may be a perceived bias in data collection (if surgeons, anesthesiologists or nurses with a potential for bias are responsible for data collection). The Hawthorne effect during the audit may lead to better than expected results. Despite these drawbacks, for want of better alternatives, such audits are being increasingly accepted as tools to improve OR performance.

In this issue of the journal, Talati et al. [3] analyze the utilization of OR time and cancellation of scheduled cases in a tertiary care teaching centre in North India. The principal findings of Talati's study are in keeping with published literature, both from India and elsewhere and have identified potential areas for improvement. With an OR utilization of 86%, 12% of OR time was spent on supportive services (including anesthesia) and 61% on actual surgery. Notably, 22.5% of scheduled cases were cancelled, with lack of operating time being the main factor for cancellation. This seems a rather high figure for an elective surgical list and could represent a key area for change. Unrealistic and inflexible scheduling, hospital and departmental policies and unanticipated delays in anesthetic or surgical procedure could be responsible. The cancellation rate varied from 40% in one OR to 0% in another. This wide range could help identify factors that lead to (or prevented) cancellations. Another interesting finding was that delayed OR starts were fairly common and were due to easily avoidable factors (mostly late shifting of patients from wards).

Several limitations of this study though need to be emphasized. It is unclear why the authors chose to exclude cases which were started after 1400 hrs. It has been shown that list over-runs are an important component of OR performance and contribute to decreased staff morale and delays in start of ORs the next day, due to non-availability of equipment and sterile supplies. Also, since this was a teaching hospital, it would have been interesting to note whether performance of procedures by trainees affected anesthesia and surgery times. The impact of training on OR efficiency is unclear - Eappen et al. [4] found that the administration of anesthesia by residents did not negatively impact anesthesia timings; Urman and colleagues [5] concluded that having anesthesia residents in ORs improved on-time starts but led to increased induction and emergence timings.

A few other studies have examined the appropriateness of use of OR time in the Indian scenario. Vinukondaiah [6] analyzed the utilization of ORs in the department of general surgery in a referral-hospital and identified factors that could possibly improve availability of OR time by as much as 20%. Our own audit of utilization of OR time for 828 surgeries carried out during 407 OR sessions in a tertiary-referral cancer centre. [7] showed that the median time of starting the OR list was 5 min after the scheduled list start time, with 15% (60 out of 407) first cases entering the OR more than 10 min late. Late OR start and finish times, delays in shifting patients out of the OR after recovery from anesthesia, and under-utilization of the anesthesia induction room were identified as potential areas of inefficiency.

Once the problem areas have been identified, the next step is to implement solutions. While it is vital for all concerned departments to be engaged in dialogue and discussion, it is equally important to have strong perioperative leadership. [2] It would be useful to identify an accountable, point person who runs the OR, manages scheduling, and effectively communicates with the surgical, nursing and anesthesia teams and other concerned staff. Often theatres are allocated with a particular surgeon or surgical unit. While it is effective for the first case in each OR, it may be appropriate to schedule subsequent cases into ORs in which there is a greater likelihood of starting and finishing the operation in time, rather than reserve the OR for a particular surgeon. Such flexibility in scheduling can prevent cancellations as well as delayed finishes, and result in better utilization of the OR.

As early as in 1998, Ovedyk and colleagues [8] achieved significant improvements in operating room efficiency by analyzing OR data on causes of delays, devising strategies for minimizing the most common delays, and subsequently measuring delay data. Personal accountability, streamlining of procedures, interdisciplinary teamwork, and accurate data collection were all important contributors to improved efficiency. The importance of audit as a quality improvement tool is beyond doubt. Audits help identify deficits and assess the impact of interventions. Of course, multi-disciplinary changes in practice, processes and attitudes will be needed to bring about improvements in OR utilization and consequently better patient centric outcomes.

 :: References Top

Foster T. Data for benchmarking your OR′s performance. OR Manager 2012 January; Vol 28, No 1. [about 5 pages]. Available from: [Last accessed on 2014 Oct 8].  Back to cited text no. 1
Kurtz R. 7 of the most important metric for measuring OR efficiency. Beckers Hospital Review January 19, 2012. Available from: [Last accessed on 2014 Oct 8].  Back to cited text no. 2
Talati S, Gupta AK, Kumar A, Malhotra SK, Jain A. Analysis of time utilization and cancellations of scheduled cases in the main operation theater complex of a tertiary care teaching Institute of North India. J Postgrad Med 2014;61:3-8.  Back to cited text no. 3
Eappen S, Flanagan H, Bhattacharyya N. Introduction of anesthesia resident trainees to the operating room does not lead to changes in anesthesia-controlled times for efficiency measures. Anesthesiology 2004;101:1210-4.  Back to cited text no. 4
Urman RD, Sarin P, Mitani A, Philip B, Eappen S. Presence of anesthesia resident trainees in day surgery unit has mixed effects on operating room efficiency measures. Ochsner J 2012;12:25-9.  Back to cited text no. 5
Vinukondaiah K, Ananthakrishnan N, Ravishankar M. Audit of operation theatre utilization in general surgery. Natl Med J India 2000;13:118-21.   Back to cited text no. 6
Ranganathan P, Khanapurkar P, Divatia JV. Utilization of operating room time in a cancer hospital. J Postgrad Med 2013;59:281-3.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
Overdyk FJ, Harvey SC, Fishman RL, Shippey F. Successful strategies for improving operating room efficiency at academic institutions. Anesth Analg 1998;86:896-906.  Back to cited text no. 8

This article has been cited by
1 The Economic Impact of Standardization and Digitalization in the Operating Room: A Systematic Literature Review
Christian von Schudnat, Klaus-Peter Schoeneberg, Jose Albors-Garrigos, Benjamin Lahmann, María De-Miguel-Molina
Journal of Medical Systems. 2023; 47(1)
[Pubmed] | [DOI]
2 Measuring the Performance of a Training Nurse Angiographer
Hayley Hill
British Journal of Cardiac Nursing. 2023; 18(3): 1
[Pubmed] | [DOI]
3 Audit of operation theater time utilization with perspective to optimize turnaround times and theater output
Vandana Pakhare, R Gopinath, SKalyani Surya Dhanalakshmi, Ananya Nanda, Neha Kanojia, P Venu
Journal of Anaesthesiology Clinical Pharmacology. 2022; 38(3): 399
[Pubmed] | [DOI]
4 Introducing the “Twilight” operating room concept: a feasibility study to improve operating room utilization
Bee Shan Ong, Rebecca Thomas, Simon Jenkins
Patient Safety in Surgery. 2022; 16(1)
[Pubmed] | [DOI]
5 Building a Center for Abdominal Core Health: The Importance of a Holistic Multidisciplinary Approach
Austin P. Seaman, Kathryn A. Schlosser, Daniel Eiferman, Vimal Narula, Benjamin K. Poulose, Jeffrey E. Janis
Journal of Gastrointestinal Surgery. 2022;
[Pubmed] | [DOI]
6 Assessment of Operative Time for Lip and Oral Cancers: A Tool to Improve Operative Room Efficiency
Rohit Jindal, Pinakin Patel, Kamal Kishor Lakhera, Chanchal Gulati, Suresh Singh, Raj Govind Sharma
Indian Journal of Otolaryngology and Head & Neck Surgery. 2022;
[Pubmed] | [DOI]
7 Operating room scheduling with surgical team: a new approach with constraint programming and goal programming
Seyda Gür, Mehmet Pinarbasi, Haci Mehmet Alakas, Tamer Eren
Central European Journal of Operations Research. 2022;
[Pubmed] | [DOI]
8 Trends in Surgical Patents Held by Surgeons From 1993 to 2018
Brianna L. Slatnick, Paul Truche, Kyle C. Wu, Robert Crum, Alexander Yang, Jonathan Durgin, Heung Bae Kim, Farokh R. Demehri
Annals of Surgery. 2022; 276(6): e1107
[Pubmed] | [DOI]
9 What delays your case start? Exploring operating room inefficiencies
Dimitrios I. Athanasiadis, Sara Monfared, Jake Whiteside, Ambar Banerjee, Donna Keller, Annabelle Butler, Dimitrios Stefanidis
Surgical Endoscopy. 2021; 35(6): 2709
[Pubmed] | [DOI]
10 Applying LEAN Healthcare in Lean Settings: Launching Quality Improvement in Resource-Limited Regions
Pavithra K. Rao, Aaron J. Cunningham, Daniel Kenron, Philip Mshelbwala, Emmanuel A. Ameh, Sanjay Krishnaswami
Journal of Surgical Research. 2021; 266: 398
[Pubmed] | [DOI]
11 The impact of a teaching staff availability on educational process and OR efficiency in academic hospital
Mikhail Chernov, Angela Vick, Sujatha Ramachandran, Shamantha Reddy, Galina Leyvi, Ellise Delphin
Perioperative Care and Operating Room Management. 2021; 25: 100218
[Pubmed] | [DOI]
12 Reducing Wasted Time Prior To Starting Thoracic Surgical Operations
Juan Ascanio, John Pawlowski, Bella Mikhailov, Ruiz Jorge, Jennifer Wilson, Michael Kent, Sidhu P. Gangadharan, Marianne Kelly, Marie Kaneko, Qi Ott, Pasley Shari
Seminars in Thoracic and Cardiovascular Surgery. 2021;
[Pubmed] | [DOI]
13 Efficiency benchmarks in the surgical management of primary rhegmatogenous retinal detachment: a monocentric register cohort study of operating room time metrics and influential factors
Reinhard Angermann, Anna Lena Huber, Markus Hofer, Yvonne Nowosielski, Stefan Egger, Martina T Kralinger, Claus Zehetner
BMJ Open. 2021; 11(12): e052513
[Pubmed] | [DOI]
14 Comparison of operating room inefficiencies and time variability in laparoscopic gastric bypass
Dimitrios I. Athanasiadis, Sara Monfared, Jake Whiteside, Trisha Engle, Lava Timsina, Ambar Banerjee, Annabelle Butler, Dimitrios Stefanidis
Surgery for Obesity and Related Diseases. 2020; 16(9): 1226
[Pubmed] | [DOI]
15 Impact of Digital Supported Process Workflow Optimization for Hip Joint Endoprosthesis Implantation on Hospital-Specific Process and Quality Ratios
Benjamin Lahmann, David Hampel
Acta Universitatis Agriculturae et Silviculturae Mendelianae Brunensis. 2020; 68(4): 755
[Pubmed] | [DOI]


Print this article  Email this article
Online since 12th February '04
© 2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow