The most precious resource in an OR is time. In 1758, Benjamin Franklin coined the phrase, "lost time is never found again."1 This is very true when reviewing effective block time scheduling. Therefore, using block time efficiently is paramount for a hospital's success.
Organizations must provide quality medical care to patients while using available resources competently and cost-effectively. The cost associated with an OR depends on several factors such as patient acuity, procedure complexity, provider preferences, and anticipated surgical completion time. Approximately $900 to $1,200/hour was recorded relative to OR costs, according to one study, which included overhead costs, physician fees, staffing costs, and other variables that depend on the type of surgery and the venue where it is performed.2 The balance of time and fiscal responsibility present logistical barriers, provider availability concerns, and staffing complexities. Optimizing effective block time scheduling can be approached from three different standpoints: fiscal, provider satisfaction, and patient flow logistics.
Block time scheduling
The most efficient design for block time scheduling in an OR is by the day as opposed to hourly blocks of time.3 This is especially true for surgical specialties that have longer and more complex cases because this allows one surgeon or group to use the OR all day. Hourly block time has resulted in cases exceeding the allotted time or causing room underutilization within the day, which cost the facility money and time.
Block release is a block time that is not scheduled by one provider and released to another provider to prevent OR underutilization. Block release times should vary depending on the surgical specialty or a specific surgeon.3 Certain specialties such as cardiothoracic may keep their block time until 24 hours prior to surgery, due to the nature of their procedures. Setting staggered block releases can help fill unscheduled time. Also, automatic release time can be used for surgical specialties that complement this structure (for example general surgery and gynecologic surgery).
Fiscal
Maintaining a positive profit margin is key for an organization. Traditionally, block time was based upon the providers' usage rate. Utilization rate is how efficiently an OR is being used, meaning that too many ORs are not being used, which is inefficient and does not support case volume.2 This can lead to higher costs for staffing and anesthesia provider coverage. The more cases the provider completes within the allotted block time, the higher the utilization rate.
A benchmark of 80% utilization is considered optimum, but organizations have decreased revenues, due to low reimbursement rates.3 Looking at reimbursement rates for the surgical procedures performed is a better indicator of a positive revenue flow. The profitability of cases is now a growing factor in assigning block time. If utilization is reviewed, competitive market conditions should be considered to avoid losing providers. Also, being cognizant of the payer mix ratio and the volume of services provided are useful for fiscal responsibility.
Provider satisfaction
Providers are one of the biggest revenue generators. Underutilization of block time can have a costly outcome on an organization. Providers have many options for where they will book and perform their surgical procedures. This decision can be greatly influenced by ease and ability to schedule a surgery, the coordination of block time relative to office hours, and organization resources, such as staffing, equipment, and bed availability. Therefore, it is important to consider the provider and adjust utilization time with proper notice and transparent communication. Criteria should be established whereby the providers are fully aware well in advance of time changes, modifications, or adjustments of block time.
Patient flow logistics
The dynamics of patient flow are greatly influenced by the efficiency of the OR.4 The utilization of the OR directly impacts patient bed availability and timely discharge. It is important to balance the diverse needs of all involved to move patients through their hospital experience as efficiently as possible. This will ensure better publically reported survey results and ultimately augment reimbursement for the organization from Medicare/Medicaid and private payers. Patient flow logistics can be managed by better block time utilization and decreasing underutilization during the day.
Patient cancellations need to be reviewed daily to assist in patient flow logistics. Last-minute cancellations due to an array of reasons, such as illness, change in treatment plan, or lab results, can adversely impact efficiency and patient flow.5 Tracking patient cancellations assists in trending of data to determine if efforts need to be directed to specific surgical specialties.
Automated surgical management systems
Since OR scheduling influences an entire organization, it is important to maximize the operational effectiveness. An automated surgical management system can provide schedule planning including variables such as specific room access, emergencies merged into a schedule, unanticipated cancellations, and accurate data regarding the anticipated length of specific surgeries. This type of system can provide leadership with data points regarding average cases per week, turnover times, cost per case, and annual case reporting. This aggregated information is important in establishing an efficient and effective block time scheduling in the future.
Leadership
It is imperative that leadership within any organization maintains the same principles and fairness. A pragmatic approach is required to promoting block time guidelines, analyzing utilization reports, and creating accountability regarding utilization that ensures adherence. When establishing effective block time scheduling, it is important to enforce guidelines. In order to reform a current block time schedule, an interprofessional team of perioperative leaders is vital to the success of this endeavor. Adjustments of current block time based upon utilization rates should be viewed with a cautious eye toward reimbursement rates. Also, transparent and honest communication with providers regarding reassignment of block time is an essential step. (See Practical solutions.)
Improving the effectiveness of block time scheduling can have many advantages influencing patient, organization, and provider and nursing satisfaction. Patients can be accommodated with more accurately timed surgeries and have more satisfied providers and nurses taking care of them. Organizations can increase their case volume and become more fiscally resourceful. Providers can balance their office time and surgical time better, as well as be treated in an equitable fashion when scheduling surgery. Nursing staff can be more satisfied with a more predictable schedule. Effective block time scheduling can be a successful endeavor for all involved if basic structures are applied.
Practical solutions
* Set clear guidelines with built-in accountability.
* Keep lines of communication between the perioperative leadership and provider open and clear.
* Analyze data points such as reimbursement rates and payer mix ratio.
* Be proactive in closing gaps in the schedule on a daily basis.
* Move toward full-day blocks of possibly 8 to 12 hours.
* Adjust release dates.
* Move utilization target upward depending upon competitive market.
Source: Theresa Criscitelli, EdD, RN, CNOR
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