Improving operating room efficiency
through process redesign
Maureen Harders, MD,aMark A. Malangoni, MD,bSteven Weight, MD,cand Tejbir Sidhu, MD,a
Background. Operating rooms (ORs) are important resources for patient care and revenue, yet a
significant portion of OR time is taken up by nonoperative activities. We hypothesized that redesigning
the process that occurs between operations would lead to a decrease in nonoperative time (NOT ? room
turnover time plus anesthesia induction and emergence time).
Methods. Following a 3-month multidisciplinary planning process, a prospective study to reduce NOT
was initiated in 2 of 17 ORs at a tertiary care academic medical center. Unlike previous reports, which
have limited the number of participants, we constructed a process that was restricted only by case
duration. The plan focused on minimizing nonoperative tasks in the OR, effecting parallel
performance of activities, and reducing nonclinical disruptions. Eligible cases were those with an
estimated operative time of 2 hours or less. A target NOT of 35 minutes was established. Cases of
similar duration in the remaining ORs served as a concurrent control group.
Results. Twenty-three surgeons, 13 anesthesiologists, and 11 nurses worked in the project ORs over
a 3-month period. Residents participated in all cases. There was a significant reduction in NOT
(42.2 ? 12.9 vs 65 ? 21.7 minutes), turnover time (26.4 ? 11.2 vs 42.8 ? 21.7 minutes), and
anesthesia-related time (16.9 vs 21.9 minutes, all P ? .001) in the project rooms compared with cases
of similar duration in control ORs. Process-related delays were identified in 70% of cases when NOT
exceeded the 35-minute target.
Conclusions. These results demonstrate that a coordinated multidisciplinary process redesign can
significantly reduce NOT. This process is applicable to most ORs and has optimal benefit for cases of
2 hours or less in duration. The high percentage of residual process–related delays suggests that further
improvements can be anticipated. (Surgery 2006;140:509-16.)
From the Departments of Anesthesiology,aSurgery,band Obstetrics/Gynecology,cMetroHealth Medical Center,
Case School of Medicine
Inefficiencies in an operating room (OR) can
occur during and between cases and lead to multi-
ple problems including delays in the delivery of
patient care. They also have a negative financial
impact for the institution and cause frustration for
surgeons, anesthesiologists, and other OR staff.
Ultimately, delays are associated with dissatisfaction
among patients as well as heath care providers.
Many hospitals are affected by this problem and
expend their resources to find opportunities to
Turnover time (TOT) encompasses the time to
clean and ready an OR for the next case. Several
previous studies have focused on reducing TOT.1,2
Others have approached this problem by address-
ing nonoperative time (NOT), defined as the time
from when surgical activity ends until the time that
the next patient is ready for the skin prep.3-5NOT
includes TOT and represents a broader measure of
time during which no operative activity takes place.
There are additional opportunities to increase
overall OR efficiency by using NOT to assess the
effective use of time since it is more comprehensive
Reductions in NOT are best achieved by working
faster, not harder.6Approaches to gaining efficien-
cies in NOT have included the incorporation of
new or improved technology, modification of tradi-
tional OR design, adding personnel, and improving
work flow through the use of parallel processing.
Each of these approaches has challenges and some-
times costs associated with their use. In contrast to
Presented at the 63rd Annual Meeting of the Central Surgical
Association, Louisville, Kentucky, March 10, 2006.
Reprint requests: Maureen Harders, MD, Department of Anes-
thesiology. MetroHealth Medical Center, 2500 MetroHealth Dr,
Cleveland, OH 44109. E-mail: firstname.lastname@example.org.
0039-6060/$ - see front matter
© 2006 Mosby, Inc. All rights reserved.
for most of them, it does not delay their time in the
operating room or contribute to increased nonop-
Dr Michelassi asked about our on-time perfor-
mance at the beginning of the day. We traditionally
get about 75% to 80% of our cases begun within 5
minutes of our projected start time. The perfor-
mance in these two particular rooms was slightly
better than that, and can be attributed to the com-
mitment of the anesthesiologists, nurses, and sur-
Lastly, I would be remiss not to point out that
residents were involved from both surgical and an-
esthesia services in all of these cases. So we were
able to do this in a teaching setting, which is also
516 Harders et alSurgery