There are some healthcare services that hospitals lose money on and some services that hospitals make money on. Hospitals tend to lose money on medical admissions and uninsured/Medicaid patients but make money on surgeries. Specialty hospitals, such as orthopedic surgical hospitals, take advantage of this and consequently can be quite profitable. However, for community hospitals to meet their obligation to align the healthcare resources of the hospital with the healthcare needs of the community, those community hospitals must maintain an adequate ratio of surgical to non-surgical services. But it also means that the hospital’s operating rooms must consistently function at maximum efficiency. And that is where OR scheduling can make or break a hospital’s financial bottom line.
In simplistic form, there are basically two ways to schedule surgeries: block scheduling and open scheduling. In block scheduling, a block of time is assigned to a specific surgeon or surgical group and no other surgeon can schedule cases in that particular operating room during that particular time and day. In open scheduling, surgical cases are booked in an operating room based on first-come, first-served and many surgeons may book cases in any given room in the OR area on any given day. As an analogy, block time is like a restaurant reservation – you reserve a table days in advance and you know when you walk in the restaurant that you are going to have a table at that particular time and day without having to wait. There are certain guiding principles to block time:
1. Block time belongs to the hospital
2. Block time is an extremely valuable asset
3. The hospital must designate a guardian of the block time
Block scheduling has certain advantages. It allows for specific operating rooms to be dedicated to specialized equipment (laparoscopic equipment, robotic equipment, fluoroscopy, etc.). It is allows the surgeon to make the most efficient use of his/her time by clustering cases at one time so that the surgeon does not need to be constantly racing between the office and the operating room. The surgeon can then schedule other times during the week to be seeing outpatients, thus making that surgeon’s office practice more efficient. It can allow the hospital to make most efficient use of a given operating room since the same surgeon will be physically present and ready to go as soon as the next patient is brought into the OR.
Similarly, open scheduling can have certain advantages. It allows accommodation of urgent or emergent cases. It can result in more consistent use of the operating room, nursing staff, and anesthesiology staff during regular work hours. It can result in less use of staff overtime. There is no need for a block time release policy or monitoring of block time utilization.
What really constitutes a block?
In order to maintain optimal utilization of the operating room, it is best to avoid half-day blocks and instead grant full-day blocks, whenever possible. It takes time to set up an operating room for a spine surgery case if that OR has been used for ENT surgeries all morning and therefore there is less down-time when reconfiguring a room for a second half-day block. Furthermore, no surgeon can predict with perfect accuracy how long it will take to do a particular surgery – there are inevitably unexpected delays or complications that can make a surgery go longer and there are inevitably last minute cancelations that can make the schedule shorter. If either of these happen during a morning half-day block, then it can result in either the OR going unused at the end of the morning or the surgeon with the afternoon half-day block having to wait to start her/his surgeries. It may be operationally most efficient to have some blocks end at 3:00 PM rather than at 5:00 PM.
Some surgeons may not need a full-day block each week. In these situations, scheduling an every-other-week block for that surgeon can make sense and be preferable to scheduling a weekly half-day block. Usually, you can find a second surgeon who also needs an every-other-week block to counter balance scheduling.
Surgeons frequently define their value by block time
When a hospital recruits a new surgeon, one of the first things that surgeon will ask for is block time. From the surgeon’s perspective, it is an indication of how much the hospital values her/him and the surgeon with block time will have a perception of having a greater chance of success. Indeed, to recruit the best surgeons, a hospital must be willing to offer block time. And if that surgeon can reliably fill their block time, then it is a win-win financially for both the surgeon and the hospital. However, the philosophical question will always remain: “Is block scheduling a right or a privilege?”. The bottom line is that a surgeon’s pride is often enhanced by having block time but the hospital’s financial viability is enhanced by the surgeon consistently filling that block time.
Some surgical specialties are better suited for block time
Surgeries that can be planned weeks in advance are the most efficient users of block time. For example, orthopedic joint replacements, spinal operations, and hernia repairs are elective surgeries and can be scheduled far in advance – these are best suited for block time scheduling. On the other hand, cholecystectomies, fracture repairs, and dilation & curettage procedures are often scheduled with only 24 – 48 hours notice – these are best suited for open scheduling. Sometimes, it is necessary to have a dedicated block that is not scheduled weeks in advance, for example, a trauma block. Although some trauma cases need to go to the OR emergently, most trauma cases can wait until the next morning. Having a dedicated block in the mornings for hip fracture repairs may be necessary for a hospital that is a designated trauma center.
Block vs. open scheduling is not an either/or proposition
A high-functioning hospital must use both block scheduling and open scheduling. The challenge is getting the right ratio of block to open scheduling in order to perform the maximum number of surgeries each week with the most efficient use of the surgeons’ time. To do this, there has to be rules for which surgeons get block time, how block time is released when the surgeon does not have cases to fill his/her block time, the amount of open scheduling necessary to meet the demands of urgent surgeries, and the amount of utilization that a surgeon must maintain in order to keep her/his block time. All of this means that the hospital must have good data including data on utilization, data on how accurately individual surgeons estimate it will take to do a given surgical procedure, and how often the operating room runs overtime. In order for the surgeons to believe the data, it has to be accurate, timely, and transparent.
So, what is the ideal ratio of block:open scheduling? As with most things in hospital management, it depends. For a hospital that does a lot of joint replacements and spine surgeries, a block ratio of 80% block time may be appropriate. For a hospital that depends on emergency department admissions to fill their operating rooms with trauma cases and appendectomies, then a ratio of 60% block time may be appropriate. For most hospitals, the maximum percentage of block time should not exceed 75-85%.
Not only is it necessary to have an optimal overall monthly block ratio, but it is necessary to have an optimal daily block time ratio. There are certain days of the week that are more desirable for surgeons to operate on than others. Surgeons who do inpatient surgeries tend to prefer Mondays, Tuesdays, and Wednesdays so that their patients can be discharged by Friday and so they do not have to round on the weekend. But Monday is also a day that typically has a high utilization of open schedule cases for all of the patients admitted over the weekends with fractures and acute cholecystitis. For the hospital to function at peak efficiency, it has to maintain a constant census throughout the week and so some surgeons will necessarily have to be assigned the less desirable Thursday and Friday blocks. This is often newer surgeons which allows the hospital to reward those surgeons with the highest block time utilization with the most desirable block times.
The importance of a block release policy
Sometimes, a surgeon does not need their block time. Maybe they have a planned vacation or will be attending a medical conference. Maybe they may just not have enough cases to do that week. In order to avoid the operating room being unused on those occasions, there must be a robust mechanism for releasing that surgeon’s block time so that other surgeons can schedule cases into that time. Vacation and time off for conferences needs to be communicated to the OR scheduling desk as soon as the surgeon knows she/he will be taking time off. If this is two or three months in advance, it allows another surgeon to pick up an extra day of block time that week. However, if this is only two or three days in advance, then no other surgeon will have enough notice to schedule a full block of elective cases and that OR will need to be filled by open scheduling.
Because individual operating rooms may have specialized equipment (robot, imaging capability, etc.), it may be preferable to have a staged block release policy in order to most efficiently use that operating room. So, for example, the orthopedic joint replacement surgeon’s block time gets first released to other orthopedic surgeons and then later gets released to all of the other surgeons if none of the orthopedic surgeons want that time.
Be prepared for concerns by your surgeons
- If I release my block months in advance of a conference I’ll be attending, will that be held against me?
- If a patient is unexpectedly sick or cancels an elective surgery at the last minute, will that be held against me?
- Am I going to be penalized if I operate faster than other surgeons and finish my block earlier in the day?
- Am I going to be penalized if the OR staff take excessively long to turn the room over between my surgeries so that I finish late?
- If I don’t have block time am I going to be stuck doing all of my elective cases at 4:00 in the afternoon?
Block time management requires resources
Perhaps nowhere else in the hospital does the adage “You have to spend money to make money” apply better than the OR scheduling desk. Optimized block time management requires the hospital to invest in a robust OR scheduling program, ideally one that is embedded in or communicates with the hospital’s electronic medical record. But the hospital cannot rely on a computer program alone – there has to be a human being who is overseeing the OR scheduling process. Block time optimization is a data-driven process and so there has to be a mechanism to have reliable information about individual surgeon first case start times, case duration times, block finish times, case cancelation rates, percent of blocks released, and room turnover times. There also has to be physician leadership intimately involved in block time management and data review. This will ideally involve a dedicated medical director of preoperative services but also a committee of involved surgeons in order to provide self-monitoring of block utilization. Ideally, block utilization data should be posted regularly (weekly or monthly) in a location that all of the surgeons can see.
Ideally, a given block should be utilized 80% of the time. If it is less than that, then the OR is likely to be frequently sitting idle in the afternoon. If it is more than that, then the OR is likely frequently running overtime into the evening and the surgeon may be developing a back-log of cases.
Block time management is complicated and can be costly. Within the hospital, it can be politically charged. But when done right, it can make the surgeons happy and the hospital profitable.
October 25, 2020
