How Do We Define “Winning” in the OR?

OR teams are not unlike Formula One race teams—highly skilled teams who can master accuracy and collaboration. In Formula One, the goal is obvious—to be the first car across the finish line. The collaborative efforts of all members of the team, their training, and their strategy all align with that one goal. ORs are one of the most resource-intensive environments in healthcare, so understanding how to define “winning” in the OR and creating an operational model that aligns incentives, culture, metrics, technology, and performance management to achieve desired outcomes are critical.

Unfortunately, it sometimes feels that “winning” in ORs is defined not by how skilled and efficient our teams are but by being the first one to start or the last one to cross the finish line. Commonly used metrics in the OR are on-time starts, turnover time, and utilization. Utilization is frequently not measured by how much was done during a specific amount of time, but by how much of the allotted time was used. The one that finishes last or starts first gets rewarded, often with little attention paid to what goes on in between.

Often, these metrics reward one member of the team but do not recognize the talent of the rest of the team. On-time starts are easy to measure but not predictive of team performance after the first patient of the day enters the OR. If utilization refers to how many hours are spent in the OR and not the quality of the surgical results or how efficiently you performed the procedures during the day, rewarding surgeons for high OR utilization means rewarding long anesthesia, procedure, and turnover times. Paradoxically, a surgeon’s OR “utilization” is harmed by having a highly skilled anesthesia and surgical team that can masterfully turn over rooms safely and efficiently. Excellence is being penalized.

In his June Harvard Business Review article, Michael Mankins writes about how targets are not an effective guide for strategy; however, identifying the gaps between the multiyear outlook and performance ambition, including both financial objectives and strategic growth, can help to define the highest priority challenges (Harvard Business Review. https://tinyurl.com/uyryzjza). Once the gaps are identified, causes can be determined, and a range of solutions can be devised. Decisions are then made about what is to be done and NOT to be done, and why. Continued performance monitoring is fundamental to determining if interventions are successful or not, and if some metrics drive unwanted behaviors. Some companies, such as Amgen, use a platform that tracks performance using both leading and lagging indicators.

Using this method, ORs could identify challenges, set priorities, and select and track metrics informed by the identified causes of delays and poor outcomes.

It is important that we do not overprioritize efficiency, as this can lead to anxiety, errors, burnout, and a lack of time for staff and resident training and process improvement projects. However, we should reward teams that have superior outcomes in less time and train and appropriately incentivize all teams to perform at a high level. How can we change the way we think about OR “utilization” to ensure that incentives align with the goal of high-quality, efficient care by all members of the team, allowing time for training and process improvement, and not motivating unwanted behaviors? 

—Robin