It gives a sense of great accomplishment for a newly trained surgeon to be initially appointed to the medical staff of a hospital but surgeons really know when they have “arrived” when they are granted block time in the operating room. Block time is when a specific surgeon (or surgical group) is assigned an operating room for a half-day or full-day every week. That surgeon owns that particular operating room for that block of time and can schedule several surgical cases, one right after another.
Surgeons like block time because it is very efficient for them. They only have to go to the locker room to get changed into scrubs once and they can do a lot of surgeries without having to travel back and forth to the hospital. They can tell their patients with reasonable accuracy what time their operation will be starting and they can plan the rest of their week’s outpatient appointments, meetings, etc. without having a conflict. For a surgeon, it is easy to quantify their value and importance by block time. If the surgeons do not have block time and have to schedule cases in “open time”, then those surgeons often find themselves in the physician’s lounge waiting for the surgeons scheduled in that particular operating room for the hour before them to finish their cases. And a surgeon drinking coffee in the lounge instead of operating is not making money for him/herself or for the hospital. From the surgeon’s perspective, block time can be as important of an employment negotiation as vacation time and office space – if a surgeon wants block time and can’t get it at one hospital, then that surgeon will take his/her patients to another hospital that gives him/her block time.
But there is a down-side to block time. If the surgeon does not fill their block with cases, then the operating room loses money – some estimates put the cost of an OR at $15-20 per minute after factoring in staff time, equipment, administrative costs, etc. The hospital also loses money through opportunity margin, that is, the money that could have been made if some other surgeon was doing an operation in that empty room.
Another problem with block time is that if all of the operating rooms are “blocked out”, then there is no capacity for emergency cases, for example, the trauma patient who shows up in the emergency department or the patient in the ICU who needs an exploratory laparatomy. In order to accommodate these surgical cases that cannot be scheduled weeks or months in advance, there has to be sufficient “open time” when surgeons can add-on cases on relatively short notice.
Block times are not all the same duration. For example, an otolaryngologist who does a lot of tonsillectomies and septoplasties may be able to do a surgery every 30 minutes and so a 4-hour block may be appropriate. On the other hand, an otolaryngologist who does complex neck cancer surgeries with flap creation may be doing procedures that can take all day and so an 8-hour block may be appropriate. In addition, some surgeons can warrant having 2 OR rooms at a time blocked, such as the otolaryngologist doing tonsillectomies and septoplaties who can be doing a surgery in one room in about the time it takes to clean another room, allowing him/her to efficiently go back and forth between the two rooms. The otolaryngologist doing the major neck cancer surgery for 8 hours only needs one OR per block time.
Open time can be created by either purposefully keeping some operating rooms out of the block time schedule so that they are never blocked out or open time can be created by “releasing” block time when a surgeon does not have any cases scheduled for that particular day. For some specialties that normally schedule their cases electively weeks or months in the future, for example joint replacement surgery, it may be appropriate to release a surgeon’s block 4 weeks in advance if he/she has no cases on the schedule by that time. However, for other specialties, it may not be possible to release a block more than a day or two in the future, for example, neurosurgery, when once a brain tumor or aneurysm is diagnosed, it has to be operated on within a few days.
Therefore, the hospital has to have the right balance between block time and open time. Here are some of the tactics to optimize block time use:
- Develop an accurate way of measuring block time utilization for each surgeon. When a surgeon does not do any surgeries on a given block time day, it is pretty easy to define that block as unutilized. But what about the surgeon who only schedules two 1-hour surgeries in a 6-hour block? Or the surgeon who schedules six 1-hour surgeries in that same block but gets done faster than expected in only 3 hours? Distinguishing between unutilized versus underutilized blocks becomes important. It is important to get buy-in about how block time utilization will be defined from the surgeons and then to provide them with a scorecard so that there is objective data to justify any future changes to their block times. Ultimately, the goal is to identify “collectable time” which is the smallest quantum of time that another surgical case could be fit into – for a cataract surgeon, “collectable time” in a given block might be 30 minutes but for a thoracic surgeon doing coronary bypass surgeries, “collectable time may be more like 3 hours. 100% utilization is not obtainable; 75% utilization may be a more realistic goal.
- Give feedback to the surgeons regularly. Ideally, they should have a “report card” outlining their block utilization every month. If this information is only provided once or twice a year, it becomes more difficult for the surgeon to change their behavior and their practice patterns. Regular feedback brings results and makes adjusting surgeons’ block time easier. If a surgeon is consistently running over their block time, then that surgeon should reduce the number of cases scheduled in their blocks. On the other hand, if a surgeon is consistently finishing the last case long before the end of the block time, that surgeon should schedule more cases in the block.
- Know the economics of your community. The target for block time utilization will vary depending on profitability and competitiveness. For example, if your hospital is trying to attract more surgeons, you will have to accept a lower block time utilization percentage. Also, in a surgical market that is primarily affluent patients with commercial insurance, the hospital can afford to have a lower block time utilization and still be profitable whereas if most of the patients have Medicare or Medicaid (with lower reimbursement for any given surgery), the hospital will need to have a higher block time utilization to avoid losing money.
- Define the duration of one whole block. For an OR that normally runs 7:00 AM to 3:00 PM, a whole block would be 8 hours. However, if the OR has the ability to staff rooms for a longer period, a full block could be 12 hours. This would permit surgeons to schedule half blocks (e.g., 7:00 AM to 1:00 PM), 1/3 blocks (e.g., 7:00 AM to 11:00 AM), or 2/3 blocks (e.g. 11:00 AM to 7:00 PM). Blocks less than 4 hours in duration result in operating room inefficiency.
- Ensure that the first case starts on time each day. If the first case starts late then the surgeon will run past their block end time and that means that if there is another block scheduled for that operating room later in the day, the second block will not start on time.
- Control the operating room turn-over time. The faster the OR staff can clean the OR and get it ready for the next patient, the more cases you can schedule in a given block.
- Release blocks as far into the future as possible. If a surgeon has vacation or will be attending an out of town conference, that surgeon’s block time can be released many months before the scheduled vacation/conference time. It becomes much easier to reassign that block on that particular week to another surgeon who is looking to do extra cases that week. Set automatic block release times that are appropriate for how far in advance a specific surgeon typically books cases: for a joint replacement surgeon, it may be 2 weeks, for a neurosurgeon, it may be 3 days, for an orthopedic trauma surgeon, it may be 6:00 AM the day of the block. Try to average 3 weeks for block releases when including auto-released blocks plus electively released blocks.
- Develop an approach for reassigning released block time that the surgeons agree on. For example, if a gynecologist releases his/her OR block for a day 2 months in the future because of a planned vacation, will that block be up for grabs by any surgeon on a first-come, first-served basis? Or will the other gynecologists in the same practice be given the first choice about picking up the extra block?
- Develop a way of easily displaying block and open time so that a scheduler in the surgeon’s outpatient office can take a block that was released by another surgeon or schedule an individual case in an OR open time. A robust and simple to understand OR calendar that is integrated into the electronic medical record is ideal.
- Be willing to take away block time from surgeons who are not utilizing their blocks. This can be difficult when the surgeon is a senior member of the medical staff or someone who brings highly lucrative procedures to the hospital. As an example, if block time utilization falls below 65%, then the duration of that block or number of blocks could be reduced. If block utilization is > 80%, then that surgeon/service should be offered additional blocks. It is often more feasible to reduce the number of blocks rather than reduce the amount of time a surgeon has in their block since reducing the block duration means that you will have small increments of open OR time popping up during the week and it is often hard to find a surgeon to do a single short procedure in that time. As an example, reducing a surgeon’s block from 4 hours to 3 hours means that you are going to have a 1-hour time slot that you will need to find another surgeon to fill.
- Determine the correct ratio of block-to-open operating rooms that the hospital needs. If there is too little open OR time, then surgeons will hoard their block time since they know they can’t fit in extra cases on other days and the hospital can find itself with a low block utilization rate and surgeons who don’t want to give up their blocks. In this situation, new surgeons can’t get on the OR schedule. On the other hand, if there is plenty of open OR time so that surgeons can always find an acceptable time/day to put in their cases, then they will be more amenable to giving up underutilized block time. If the amount of block time is too low, then the surgeons will find themselves not being able to consistently work with the same anesthesiologists and OR staff and that can result in operational inefficiency and medical errors. Ideally, there should always be at least 2 ORs that are open and not blocked out and for most hospitals, an 80% block to 20% open time is a reasonable goal. However, that ratio will be different for different hospitals; for example, a hospital that is a trauma center and tends to do a lot of surgeries on patients admitted through the emergency department may need a ratio of 60% block to 40% open time.
Ultimately, what the surgeons want is a predictable time that they can do a lot of cases back to back. What the hospital wants is all of the operating rooms being used for surgeries as many minutes of the day as possible. Reconciling these two often conflicting goals can be challenging but successful reconciliation will ultimately lead to both surgeon satisfaction and hospital productivity.
October 5, 2018
