PUBLISHED THESIS

Copyright
By
Jessica Vasquez
2016

OR BLOCK UTILIZATION’S IMPACT ON PRODUCTIVITY iii
Acknowledgements
I would like to begin with thanking my precious God for provision, strength, and courage
during my time as a full time student. Lord, my aim is to give you glory in all that I do and
wherever I may be.
Secondly, I would like to thank my loving husband Shawn and our two kids, Zach
and Gianna, for their support, encouragement, understanding, and patience.
I would also like to thank Mr. Todd Henderson. By the grace of God, the door for me
to work in an operating room opened, reporting directly to Mr. Henderson, who has been a
mentor and a gracious boss. I have learned so much because of the opportunity to work in the
OR. Mr. Henderson is a champion of change and continuous improvement. Mr. Henderson is
an invisible patient advocate, striving to deliver the utmost quality and care in his
department.
To my colleague and local statistician, Jose Fuentes, who graciously reviewed my
statistical analyses for this project. Jose made himself available during off-working hours to
answer my many questions regarding statistical definitions.
Finally yet importantly, I would like to specifically recognize and thank Dr. BJ
Moore, Jesus Garcia, R. Steven Daniels, and Tony Pallitto for their outstanding tutelage.

OR BLOCK UTILIZATION’S IMPACT ON PRODUCTIVITY iv
Executive Summary
OBJECTIVE To research best practice principles application in the management of block
utilization and to find how it influences productivity. The research included a case study on
Bakersfield Memorial Hospital’s (BMH) surgery department.
DESIGN A quantitative and policy analysis design was used with pre-existing data.
SETTING Bakersfield Memorial Hospital, Bakersfield, California.
METHOD Pre-existing data collected and analyzed by the BMH hospital IT department was
reviewed to determine optimal block utilization; how first case on time starts, case add-ons,
and weekend volume is impacted by block utilization and how block utilization impacts the
productivity of the OR. Best practice models were compared against the policies of BMH
block scheduling.
MAIN FINDINGS BMH has had challenges in maintaining their productivity levels. Their
block schedule contained 34% of surgeons using less than the 60% required utilization rate to
maintain block; had a significant amount of add-ons and weekend cases. Additionally, BMH
struggled to reach their target goal of 70% First Case On-Time Starts, leading to case delays,
increased overtime costs, and surgeon dissatisfaction. BMH implemented best practice
models of block scheduling in their policies, but has struggled to comply with them. A
governance committee known as the Surgical Services Executive Committee (SSEC) had
been formed by BMH but attendance from physician leaders was very low. Block utilization
decisions were not made by the SSEC per policy. BMH has successfully controlled turnover
times and has successfully predicted case lengths at least 50% of the time.
CONCLUSION Further research is needed to determine why block time utilization is
limited to 8-hour blocks, five days a week. Additionally, if the SSEC or governance
committee does not abide by their own policies, it affects the way an OR performs, thus
affecting productivity. It is recommended for BMH to perform regression analyses to
confirm a relationship between productivity and block utilization, as this research was
limited due to time constraints.

OR BLOCK UTILIZATION’S IMPACT ON PRODUCTIVITY v

OR BLOCK UTILIZATION’S IMPACT ON PRODUCTIVITY vi
Table of Contents
Acknowledgements .............................................................................................................................................. iii
Executive Summary...............................................................................................................................................iv
Table of Contents ..................................................................................................................................................vi
Chapter One............................................................................................................................................................1
Introduction ............................................................................................................................................................1
Problem Statement..............................................................................................................................................2
Purpose of the Study...........................................................................................................................................3
Importance of the Study .....................................................................................................................................3
Chapter Two...........................................................................................................................................................4
Review of Literature...............................................................................................................................................4
The Significance of Time ...................................................................................................................................4
Governance.........................................................................................................................................................7
Scheduling........................................................................................................................................................11
Case Length Prediction.....................................................................................................................................12
Expenses...........................................................................................................................................................13
Questioning Best Practice.................................................................................................................................13
Chapter Three.......................................................................................................................................................15
Research Methods ................................................................................................................................................15
Analysis of SSEC Minutes ...............................................................................................................................16
Block Utilization Report...................................................................................................................................16
Performance Management Tool .......................................................................................................................17
Productivity Report ..........................................................................................................................................18
Weekend Volume Report .................................................................................................................................19
Conclusion of Research Methods.....................................................................................................................20
Chapter Four.........................................................................................................................................................21
Results and Discussions .......................................................................................................................................21
Governance Findings........................................................................................................................................21
Block Scheduling Policy Findings....................................................................................................................23
Performance Metrics and Its Impact on Productivity .......................................................................................26
Weekend Volume Findings ..............................................................................................................................27
Productivity Findings .......................................................................................................................................28
Summary and Conclusions ...............................................................................................................................28
Recommendations ............................................................................................................................................29
Recommendation #1: Update Block Scheduling Policy...............................................................................29
Recommendation #2: Update SSEC Policy..................................................................................................29
Recommendation #3: SSEC Recruitment.....................................................................................................30
Recommendation #4: Surgeon Report Cards................................................................................................30
Recommendation #5: Consider Saturday Elective Schedule........................................................................30
Recommendation #6: Extend Block Hours ..................................................................................................31
References ............................................................................................................................................................32
Appendix A ..........................................................................................................................................................37
Appendix B...........................................................................................................................................................38
Appendix C...........................................................................................................................................................39
Appendix D ..........................................................................................................................................................40

Chapter One
Introduction
Surgical admissions at a hospital generate as much as 48% of revenue (Agency for
Healthcare Research and Quality, 2014). Surgery plays a critical role in the business of
healthcare. While surgeries contribute a large portion of revenue, the operational costs must
be managed to control productivity. In order to bring in new business from recruitment of
surgeons, minimize impact to productivity, and efficiently use the hospital’s resources to
maximize revenue and reduce operational costs, block scheduling of surgical cases must be a
strategic process with measurable outcomes involving physician leadership.
Block Scheduling was created to reserve specific blocks of time assigned to specific
surgeons or surgeon groups, referred to as Block Time Assigned (BTA), on specific days of
the week. The utilization of a block schedule is defined by the percentage of total block time
used (BTU) against total block time given (BTA). Turnaround Time (TAT), which is added
to the numerator, is defined as the exact time a wound closure begins until the next patient’s
incision. Total block utilization is calculated by adding block time that is used plus
turnaround time divided by block time assigned (BTU +TAT) / (BTA). This calculation
accounts for those surgeons who result in over 100% utilization.
This research observes Bakersfield Memorial Hospital’s (BMH) surgery department,
located in the city of Bakersfield in the state of California, as they face challenges in
managing surgical block utilization, which currently dominates 98% of the entire OR
schedule (excluding block assignments) and has a grand total of 60% block utilization as of
March 2016. In addition, the administration must maintain a productivity goal of 101% per

OR BLOCK UTILIZATION’S IMPACT ON PRODUCTIVITY 2
pay period. Productivity is defined as total Full Time Employee (FTE) productive hours
(excluding PTO, sick days, holidays, etc.) against total case volume.
The BMH surgical department has ten operating room (OR) suites in the Main OR
with a dedicated Open Heart, Neurosurgery, Orthopedic, and Robotics room. The types of
surgeries performed include Plastic/Cosmetic, Gynecology, Neurology, Urology, Orthopedic,
Spinal, Cardiovascular, Open Heart, and General with an average of 650 surgical cases per
month, including emergent cases. Business hours, or Prime Time, are Monday through
Friday, from seven thirty in the morning to three thirty in the afternoon. Prime Time
Utilization is a statistical analysis measuring the total number of surgical cases booked in a
24-hour period against total cases booked during Prime Time hours. Cases that are performed
outside of Prime Time generally are at risk of incurring overtime costs. Such is the case for
BMH, where they average 23 elective cases on weekends (Saturday and Sunday) each
month.
Problem Statement
Despite holding quarterly Surgical Services Executive Committee (SSEC) meetings,
which comprise of physician leaders and executive administration making block utilization
decisions, block time utilization has not improved. The OR is supposed to be officially closed
during the weekends with staff on standby for emergency cases. However, data for 2015
show that surgeons are adding on elective cases on the weekends (add-ons), activating the
call team, requiring the hospital to pay the staff at callback premium, which is paid at time
and a half. Additionally, the staffing for callback cases are skeletal in that staff does not have
the support it would normally have during regularly scheduled weekly cases. This is
especially important, because recent studies have concluded that patient mortality increases

to as much as 82% for elective surgical cases occurring on weekends (Aylin, Alexandrescu,
Jen, Mayer, Bottle, 2013).
Purpose of the Study
This research aimed to understand why surgeons perform elective surgeries outside of
their block time and on the weekends; how block utilization and scheduling can be improved;
and how improving the entire block scheduling process can improve productivity. These
questions will have been answered by examining BMH data provided for the year 2015,
which examines block utilization, weekend volume, first case on time starts, SSEC minutes
(notes), and productivity reports.
Importance of the Study
This study is significant, because while the hospital implements their block
scheduling policy according to best practice, the outcome is not considered desirable and
potentially increases the risk of mortality. Therefore, as the Pareto Principle states that
twenty percent of the input equals eighty percent of the outcome, this study aimed at finding
out which twenty percent caused poor block utilization, impacting the productivity of the
OR. Other hospitals can learn how to effectively manage productivity and block utilization
through use of data and policy analysis as a result of this study.

Chapter Two
Review of Literature
Most surgical facilities have an overall goal to provide quality patient care, reduce
costs, and increase revenue. There is much literature on examining ways to maximize OR
utilization. In reviewing literature that consists of best practice, industry standards define best
practices that speak to the significance of time, the need for governance, and the importance
OR scheduling plays in effective management. All the literature reviewed agreed that
variables such as add-on cases, urgent cases, and emergency cases, created challenges in the
scheduling process. One observation made by several authors suggested that studies
performed prior to the year 2000 were obsolete, while studies done after the year 2000
provided the most relevant research and methods (Chu, Fei, Meskens 2009; Peltokorpi, 2011;
Guerriero and Guido, R. 2010), especially considering the Patient Protection and Affordable
Care Act implementation and Medicare’s Accountable Care programs.
The Significance of Time
Authors unanimously agree that time in an OR is the most significant resource. Time
brings in revenue or can cause expenses such as in overtime costs. Time is money. Every
operating suite should serve a purpose for every minute, otherwise idle time can result in loss
of revenue. Gamble summarizes this succinctly by stating that time is an OR's most valuable
resource and is greatly impacted by slight delays in case start times, lengthy turnovers, or
even a few minutes spent looking for a piece of missing equipment (2013). Guerriero (2010)
agrees by stating that late starts result in overtime costs, because the last surgery of the day is
pushed later than the scheduled shift end time, and so on-time surgery starts should be
strategic.

One question to consider, is who owns time in the operating room? The answer is
complex, as the landlord of OR time belongs to administration and must sufficiently provide
anesthesiologists, adequate staffing, equipment, and supplies. But revenue is dependent upon
surgeons. Practically speaking, blocks of time (in many cases entire days) are awarded to
surgeons who are considered high volume. However, time can work against productivity,
specifically in the case of delays.
A common area of struggle discussed, are the times that first cases start, also known
as First Case On-Time Starts (FCOTS). BMH’s policy defines a late start approximately five
minutes past 7:30am (or past the scheduled start time). Surgical organizations across the
country strive to start their first cases of the day at the exact time it was scheduled to start.
Otherwise, it is considered delayed and it creates a domino effect, delaying the succeeding
cases, ultimately upsetting surgeons and incurring staff overtime costs. Herrick, Horvath,
Prentiss, Powell, Walsh, Walsh, and Warner (2013) states that if OR management were able
to control on-time starts, then labor costs could also be controlled. Herrick et al (2013) used
principles of Lean methodology in an attempt to optimize case start times while decreasing
resident work hours at Dartmouth-Hitchcock Medical Center (a teaching hospital) to identify
the cause of delayed vascular surgeries for first case starts. They applied DMAIC (define,
measure, analyze, improve, control) techniques for a span of one year, with the facility
performing at the baseline of 39 percent for FCOTS. Value stream maps, Pareto, control, and
process flow charts were created. They measured two outcomes. The first, was the amount of
first cases to start on time. The second outcome measured hospital costs, times residents
rounded, and labor hours. These metrics were then compared to benchmarks.

Herrick et al found that the primary cause for patient processing delays in the
preoperative (pre-op/holding) phase were due to incomplete surgeon documentation.
However, it was the late arrival of the resident to pre-op/holding which was the identifying
primary cause of delays, in the completion of the operative consent and history and physical
update (H&P). Residents arrived late to pre-op because of their morning rounding
obligations. To minimize this, they standardized processes, got rid of nonvalue-added
activities, and implemented the use of checklists. Results showed that the FCOTS
performance improved to 71% at just six weeks after implementation and it was sustained,
ultimately jumping to 86% at the one-year mark. Herrick et al research explicitly stated that
previous studies have shown that for organizations with multiple ORs with scheduled cases
for eight hours or longer, improvement of on-time starts can have a significant financial
impact by reducing OR staffing from 10 to 8 hours, decreasing overtime labor costs that may
be incurred when staff work beyond the standard eight-hour shift. (2013).
This can be partially reproduced in a hospital setting except in the cases of residents
and morning patient rounding, as not all hospitals or surgery centers employ residents. But
best practice shows that Lean and DMAIC methodology have proven to be successful tools
when looking for root causes of delays. At BMH, the surgeon completes the H&P at his or
her office. Once a patient arrives at the hospital, the nurses obtain the consent forms
according to the doctor’s orders. While a big portion of this study involved residents and
their duties which caused the delays, BMH experiences delays of their own beginning at the
start of the very first cases of the day, though without residents.

Governance
A recommended strategy for OR business, is the implementation of governance.
Franklin Dexter is a medical doctor most commonly cited among the literature reviewed.
Dexter (2013) advocates for a committee comprised of key players selected to become
informal leaders. This committee is now considered best practice and famously known as the
Surgical Services Executive Committee (SSEC). Using the principles of Kaizen (Herrick et
al, 2013), also known as continuous improvement from the Lean process improvement
industry, the SSEC includes surgeons, anesthesiologists, OR management, OR scheduler,
hospital administration, and others for the purpose of proactively working together to address
issues of concerns and solutions, such as block time utilization.
Why is an SSEC or similar committee needed? Kindscher explains that such a
committee which includes surgeons, anesthesiologists, nurses, and hospital leadership, all
have different perspectives on what OR efficiency means. “Surgeons want convenient and
readily available OR access, anesthesiologists want smooth-running schedules, nurses desire
predictable shifts, and hospitals seek maximal profit margins for this costly unit. (Kindscher,
paragraph 4, 2015).
Kindscher further explains that, “The scope and authority of the OR committee
depend upon local facility and medical practice governance structures. Often this committee
will review performance standards, develop policies, offer budgetary guidance, and allocate
OR time to surgeons or divisions” (paragraph 2, 2015). OR Manager, a magazine publication
for operating room administrators, encourages the formation of an SSEC stating that this type
of structure is valuable because “buy-in from all of the leadership prevents end-around
games, such as when a surgeon asks the OR manager for something, doesn’t get the answer

he wants, goes to the CEO, and then the OR manager gets a call” (Torrance, paragraph 9,
2015).
Because having an SSEC is a standard for OR governance, the methods used to test
its effectiveness were by implementing such a committee in poor performing hospitals.
Blasco (2013) had implemented several committees in various organizations and has seen
block utilization increase from 48 to 73 percent, with an 8 percent increase in volume. Blasco
implemented SSEC committees in different hospitals, from large community hospitals to
teaching hospitals. He argues that while typically Ambulatory Surgery Centers (ASC), which
are generally owned by surgeons, are competitive in nature with hospitals, that they should
be looked at as a model. Blasco states that ASCs maintain high levels of quality,
productivity, surgeon satisfaction, and patient satisfaction. They also are profitable even
when receiving much lower reimbursement per case compared with hospital ORs (2013).
This was a unique concept that was not found in the literature reviewed, yet the benefits of
having governance consisting of the physician customers is repeatedly seen. Blasco believes
in a governance committee with key players, stating that the SSEC model works because it
gives surgeons a major role in the collaborative oversight of surgical operations. Most
hospitals do not provide surgeons with a sense of ownership of the OR, and so the SSEC
model sees the physician’s voice as a necessary resource, allowing them to balance their
needs for quality, access and service with the hospital's need for improved productivity. As a
member of the SSEC, surgeons begin to see themselves as both owners and valued
customers. (Blasco, 2013).
While many authors tout the benefits of OR governance, Blasco (2013) is among the
few to point out its weakness. Unfortunately, that weakness is the lack of support from senior

administration to reinforce or support SSEC decisions. This occurs when a physician
complains often enough or threatens to take business to a competing hospital. Blasco
describes an example he experienced while in the implementation process:
Not long ago, I helped a specialty hospital in the East establish an SSEC. The
committee created a collaborative environment within the surgery department and
achieved significant improvements in efficiency, productivity, costs and quality.
Pleasing everyone is impossible, of course, and one surgeon disagreed with a certain
change enacted by the SSEC. He complained stridently to hospital administrators.
Finally, instead of supporting the governance committee, the administrators backed
down and overrode the SSEC decision. Several committee leaders stepped down in
frustration, and the SSEC was nearly dissolved. (paragraph 18, 2013).
Having physician involvement means having physician leaders assisting
administration in communicating to other surgeons; peer to peer engagement. This is
especially important for BMH, as the Anesthesiologists and Surgeons are their customers.
Jackson and Stobinski (2014) argues that the SSEC should be responsible for block
utilization and must be cautious not to over-book (75-85%) and over utilize, as this reduces
flexibility of open scheduling. Additionally, they recommended to not make release times so
late that there isn’t enough time to find another case for that slot. Further recommendations
state that Block Time must be continually monitored and re-evaluated. There were also
recommendations against too much block of one specialty on any given day because it is
important to consider the limited resources and equipment (Jackson and Stobinski, slide 11,
2014).

Jackson and Stobinski (slide 24, 2014) examined 7 hospitals totaling 41 OR’s with a
total annual case volume of over 27,000, with multiple ancillary departments. The problems
they observed were: there were no clear expectations or consequences regarding block
utilization; questionable data; no interest from surgeons; more requests for block time than
available; inefficient staffing, and empty rooms in the middle of the day. Their process
improvement plan was to create an administrative position, establish a multi-disciplinary
committee, improve communication, and increase education.
Results show that block time utilization increased 30%, with the consistent block
observations and planned letters sent to surgeons monthly summarizing their block. Jackson
and Stobinski (slide 11, 2014) argued that block time must be reviewed often and blocks
should be revised where underutilization is common. This could be done monthly, every
three months, six months, or yearly. Recommendations included modification options such as
ending block at 1500 instead of 1700, avoiding half-day blocks, blocking every other week
instead of every week, and creating a group block where surgeons from same service line are
allowed to book in the block. What was learned from this study was that block time equates
with “surgeon’s pride” and that it is important to gain trust from them and important to
educate new physicians. Further recommendations included the enforcement of block policy
from the SSEC and to expect variations (slide 44, 2014).
The Jackson and Stobinski (2014) literature was actually a presentation at a
conference. It offered practical information that can realistically be applied. At the
conclusion of their presentation, they included tips for how the implementation of their plan
can work. It possibly is the most important portion of the research. “For this to work:
Surgeons must be involved; Must back up your people; Must have the support of the C-Suite;

Entire facility must be aligned; Must enforce your policies consistently and with all
surgeons” (slide 52, 2014).
Surgeon attendance for quarterly SSEC meetings at BMH has been very poor. This
may be one reason why block utilization has not significantly improved. While block
utilization is a common item on the agenda, block assignments did not change in the year
2015 even when utilization was below 25%. The phenomenon of poor physician attendance
at an SSEC was not mentioned in the literature reviewed. A study on how to retain and
recruit physicians to such a committee is needed.
Scheduling
The bulk of the research focuses on scheduling. There have been various statistical
tests to find the best scheduling model for various surgical facilities, each varying in their
results. Peltokorpi stated that previous research regarding operating room management has
focused on studying the before and after analysis of single hospital cases (p.1, 2011).
Because most studies only evaluated a single organization, Peltokorpi analyzed several
hospitals, totaling 26 units, with the goal to “analyze the synergic effect of strategic decisions
and operative management practices on operating room productivity enabling statistical
hypothesis testing with empirical data” (Peltokorpi, p. 1, 2011). There were eleven
hypotheses that assumed connections between the use of strategic and operative practices and
productivity. Among these hypotheses were the assumptions that operating rooms with
focused service have better productivity, the size of the operating room does not impact
productivity, ORs with a large number of acute surgery have better productivity, case length
prediction can improve productivity, cross-training and flexibility of staff improves
productivity, incentivizing physicians improves productivity, performance monitoring

improves productivity, and that scheduling of cases and staffing impacts productivity.
Results showed that scheduling (also referred to as “capacity-building, resource-planning, or
patient- planning practices) have a higher impact on productivity than strategic decisions.
Peltokorpi concludes that “proper operative practices are more important than correct
strategic decisions in terms of improving OR performance” (p. 1, 2011).
Case Length Prediction
Because of variation in surgery times, the majority of research studies support the
forecasting of case length by using historical surgery times (May, Sampson, Strum, Vargas,
2000). This method of statistical forecasting is known as Case Length Prediction and it is
considered best practice. Peltokorpi included case length prediction as the fifth hypothesis
arguing that the combination of accurate estimations with target filling rates leads to the
optimal utilization and thus to increased productivity (2013). Guerriero and Guido (2010)
agrees that the amount of predictable surgery durations are limited, pointing out that different
competing criteria like team waiting, OR idling, overtime, efficiency, and quality of care
should be considered in order to determine tight schedules of when surgery durations are
affected by the unknown variables. Guerriero and Guido argue for strategic management in
scheduling efficiently, because the method used-projection- is based on historical data of one
or more years. Dexter, Macario, and Traub (2002) adds that the use of historical data for long
term forecasting is not always accurate and therefore recommends to use the average of the
most recent year’s total hours of elective cases to predict future usage of OR time. Dexter et
al’s suggestions to use recent historical data, is perhaps most useful in case length prediction.

Expenses
What I found most interesting, was that few authors mentioned managing the supply
costs of surgical equipment. Gamble listed it as their first recommendation, recommending to
look at high cost items and benchmark them to national standards. Surgical equipment
consists of implants, supplies, and devices for example (Gamble, 2013). In fact, after
reviewing the 2014-15 fiscal year budget report for BMH, the findings revealed that 72% of
their expenses were spent on supplies while 22% was spent on labor. BMH has actively made
strides to communicate with surgeons on agreeing to similar or standardized, surgical
instruments. But movement in this direction has been slow. Administration faced challenges
of having surgeons who explicitly expressed their desire to use instruments from their
preferred vendors/manufacturers. Two surgeons performing the same procedure ended up
requesting the same instrument, from different manufacturers.
Scheduling, as is mentioned in the literature, is key in balancing productivity. Block
time utilization goes hand-in-hand and literature argues that block time should be reviewed
by the SSEC often, policies enforced, and block assignments revised where needed. The
purpose of reviewing the literature is to seek out best practice for scheduling and managing
of block time for application in an OR.
Questioning Best Practice
One question that arises from the literature, is why the industry’s best practice has
adopted prime-time to be between 7:30am to 3:00pm and why block assignments are limited
Monday through Friday. The current best practice model appears to make an attempt to fit a
camel through the eye of a needle. Why must the industry, which has grown and evolved into
a square peg, be forced to fit into a round hole? Why does prime-time end at 3pm and not

10pm? Why aren’t weekends counted in block time? Why force an organization to adapt to
the current best practice model instead of adapting the model to fit the needs of the
organization? In the case of BMH, it would benefit them if block hours were extended
through the weekend and prime-time hours be extended past 3pm.

Chapter Three
Research Methods
The purpose of this research was to observe BMH’s compliance to best standards by
reviewing their data and policies in the management of the OR block scheduling and to see if
best practice applications result in optimal productivity by using existing reports and data
provided by BMH for fiscal year 2015. The reports included Block Utilization data;
Productivity Reports, which included staff call-back hours (paid as overtime) to show the
costs of having elective surgeries; and Weekend Volume Data. The aggregated data from
these pre-existing reports would reveal the costs of an underutilized operating room.
Additionally, meeting minutes consisting of agenda items and discussions for SSEC meetings
were obtained for review to show challenges in the implementation of best practice
modeling.
All BMH data collected was extracted from their electronic patient charting system
called MediTech, by the Information Technicians (IT) department. The purpose for
extraction was to apply statistical analysis for performance metrics. The IT department is
comprised of experts in data analysis as well as the MediTech EHR program; had the
clearance and authorization by the hospital to extract data; and created monthly reports and
dashboards in Excel spreadsheets which were routinely submitted to the OR department
director and senior administration for review.
Managing the operating room has many challenges due to the conflicting priorities
and the preferences of its stakeholders, including the scarcity of costly resources. These
factors clearly stress the need for efficiency and necessitate the development of adequate
planning and scheduling procedures to balance staffing levels. The existing data that was

reviewed consisted of statistical reports detailing performance metrics of baseline, actual,
performance, and prediction.
Analysis of SSEC Minutes
BMH’s SSEC meets on a quarterly basis and maintains meeting minutes, detailing
member attendance, agenda items, and discussions. A review of the meeting minutes was
necessary to review agenda items that took priority; what discussions and follow-up action
was made regarding agenda items. The focus of reviewing meeting minutes was to review
any discussion, follow-up, action plans, and decisions that may or may not have been made
by the committee.
Block Utilization Report
The “Block Utilization” report summarized the utilization of room usage per surgeon,
by day of the week, month, and year. This (Block Utilization) is the report that showed the
performance of the hospital’s “Block Time Management,” but also pointed to surgeon
performance. The data served to support the research and literature. All Physician names
have been removed and replaced with a number (i.e. Surgeon 1, Surgeon 2, Surgeon 3, etc.).
The report included:
● Trend analysis
● Total Block Hours Assigned (in hours and minutes)
● Total Hours Spent in Blocks with Turn Around Time (in hours and minutes)
● Total Number of Procedures Done in Block
● Total Hours Spent Outside Blocks with Turn Around Time (in hours and minutes)
● Total Number of Procedures Done Outside Block

● Total Hours Spent in Block to Total Hours Spent Outside Block (rounded ratios
between procedures and times performed in block vs. out of block)
● Procedures in Block to Procedures Out of Block
● OR Block Scheduler Summary Graphs
● OR Turnaround Time and Prediction Bias
○ Physician Name (will be scrubbed)
○ Block Owner (yes or no)
○ Number of Actual Cases (Emergency & Non-Emergency)
○ Average Procedure Length (in hours and minutes)
○ Average TAT (turnaround time)
○ Standard Deviation of TAT
○ Number of Cases with Predicted Duration Times (Non-Emergency)
○ Percent Estimate Accurate
○ Percent Estimate Low
○ Percent Estimate High
Performance Management Tool
The BMH Performance Management Tool, a spreadsheet that listed several criteria
for measuring performance, was a pre-existing report sent out to management daily. As the
Peri-Operative Coordinator of BMH, this report is automatically sent to me on a daily basis.
The report included percent baseline data, percent daily usage data, percent quarterly average
(range is flexible. Drop Down menu allows date range to be selected), percent target. More
specifically, the data measured the following metrics for each day:
● Total Number of cases (for the current day vs baseline vs target)

● Number of first cases (for the current day vs baseline vs target)
● Percent of on-time first case starts (FCOTS)
● Number of Turnovers (for the current day vs baseline vs target)
● Turnover Time- Wheels out to wheels in (minutes) (for the current day vs baseline vs
target)
● Percent of Prime-Time OR Utilization (7am-4pm) (for the current day vs baseline vs
target)
● Percent of Cancellations within 24hrs of surgery (for the current day vs baseline vs
target)
The use of this data was important because it revealed how timely starts, delays, turnover
time, “business hours” utilization (prime-time), and cancellations affected block utilization
outcomes and how block utilization is impacted.
Productivity Report
A productivity report was also used, which is generated bi-weekly. This was a
spreadsheet which was easily downloaded from the time and attendance Business Analytics
Software program. It showed the number of FTEs used against case volume, how many FTEs
projected, and how many FTEs were paid overtime hours. More specifically, the report had
the following metrics measured:
● Percent of Productivity
● Unit of Service (UOS)
● Actual Productive Hours/UOS
● Budgeted Productive Hours/UOS
● Actual and Variance of Productive FTEs

● Actual and Variance of Paid FTEs
● Registry FTEs
● Registry Percentage
● Overtime (OT) FTEs
● OT Dollars
● OT Percentage
● Orientation FTEs
● Non Productive Percent
This report caused management to make changes in the staffing. If the report showed
overage on FTEs, then management had to adjust by “flexing off” staff (i.e. reduce their
work hours by sending them home early when cases finish or giving them days off during the
week). Because capacity-building (scheduling) and staffing is critical to all cases, literature
agreed that the key to optimal productivity among block utilization, is contingent on proper
use of human resources. The productivity report supported the research when comparing to
best practice models, and also demonstrated staffing trends and how block utilization
impacted productivity.
Weekend Volume Report
Weekend Volume was a statistical report generated to reveal how many cases were
performed on Saturday and Sundays, per week, per month, per year. It included the types of
procedures which were performed. This is important, because the Operating Room’s business
hours are closed during the weekend, with a call-team on standby for emergent cases only.
However, the Weekend Volume Report showed a trend of elective cases being performed on
Saturdays and Sundays, activating the call-team, which is paid with OT dollars. The report

also revealed which surgeons tended to do cases normally considered elective on a weekend.
This report included the following metric measurements:
● Cases-Procedures-Minutes by Physician
○ Number of cases (per month)
○ Total Minutes (per month)
○ Average Case Duration (per month)
○ Total Cases
○ Total Minutes
○ Total Average Case Duration
● Cases by Hour Started (pivot table with chart)
● Procedure Case Count, Total Minutes, Average Case Duration by Month
● Saturday and Sunday Case Count
Conclusion of Research Methods
Block Time needed to be measured for its effectiveness, as it greatly impacts the
business of the OR. It would not be possible to discuss problems or recommend solutions
without the data nor would this study be able to support the statement that block utilization
impacts productivity (either positively or negatively). The third party data access would show
how staff productivity is affected by block utilization, because when block surgeons do not
book cases and do not release their cases, staff is “flexed off” due to no work and potential
revenue is lost. And the productivity report is critical to show the costs of overtime for on-
call staff working on the weekends for surgeries by block surgeons, that are usually done
during the week and within block.

Chapter Four
Results and Discussions
The purpose of this research was to observe BMH’s compliance to best standards by
reviewing their data and policies in the management of the OR block scheduling and to see if
best practice applications result in optimal productivity. BMH follows best practices of
establishing governance, with a Surgical Services Executive Committee. Regarding OR
block scheduling, they do not apply the recommended “block -to -open” percentage, where
no more than 80% of all rooms should be blocked, leaving 20% open. The Performance
Management Tool (PMT) showed that the average percent of first cases that start on time is
51%. The Productivity Report shows that nearly $700,000 was paid out in overtime costs (to
include holiday premium, call back, overtime, and double time). The surgery department
consistently struggled to reach the productivity target of 101%. And while the department is
officially closed during the weekends, they average 23 cases a month during weekends
(Saturday and Sunday) alone. Policy also details the process of block scheduling, but BMH
did not apply the policy in practice such as in reviewing block utilization monthly when
actually it was reviewed quarterly nor was the policy applied when surgeons did not maintain
the minimum 60% block utilization.
Governance Findings
The BMH surgery department has an SSEC. They met on a quarterly basis, however,
attendance by physicians was extremely poor. Block utilization was repeatedly on the agenda
but no changes had been made. Members of the SSEC included the C-suite (Chief Nursing
Officer, Chief Executive Officer, Chief Operating Officer, Chief Medical Officer), Director

of Nursing, Manager of Central Processing Department, Surgery Scheduler, select Surgeons,
and Chair of Anesthesiology.
Review of block scheduling was on the agenda, but re-allocation of block was not
noted. However, concern regarding block assignment was mentioned, because of changes
being made without informing the SSEC and OR management; non-compliance of the
Scheduling and Block Policy; and physicians consistently arriving late for their cases,
affecting the FCOTS statistics.
In reviewing the attendance from previous minutes, surgeons were among the least in
attendance. In addition, the attendance of the entire C-suite was also incomplete. It could be
due to the time of day these meetings took place, at 6pm. However, while issues were
discussed in SSEC, there were no formal decisions made, especially regarding block time.
Best practice recommends having an SSEC firm in their decision making and in support of
policies put in place. Blasco (2013) had described how an SSEC would fail, by a lack of
support from senior administration to reinforce or support SSEC decisions. This occurs when
a physician complains often enough or threatens to take business at a competing hospital.
Blasco described an implementation attempt to form an SSEC at a hospital where one
surgeon would constantly complain to senior administration, threaten to leave, and resist
changes. Blasco revealed that at this particular hospital, instead of supporting the governance
committee, the administrators backed down and overrode the SSEC decision leading to the
loss of several committee leaders due to frustration. The SSEC at that specific hospital
almost dissolved (2013). That example mirrors BMH. However, what Blasco did not foresee,
was a lack of physician involvement, which was also a problem at BMH but not in Blasco’s
study. The literature reviewed touted governance but did not address how to retain physician

members. This is a topic that must be further discussed in order to have a successful
governance.
Block Scheduling Policy Findings
The block policy contained the purpose and process of block scheduling, stating:
To outline a consistent, effective, and systematic process for scheduling surgical
cases, creating and managing block time. The policy will support equal scheduling
opportunity for all qualifying surgeons and outline processes to maximize schedule
access by providing optimal utilization of operating room suite, time, equipment, and
available personnel. (Policy #DP-SS 129, Dignity Health BMH, p.1, 2015).
The policy was ten pages in length and specifically defined “block” as “time
guaranteed,” but it does not guarantee “specific operating room suites.” It clearly stated that
requests for block time from surgeons had to be submitted in writing to the SSEC; that a
utilization rate of 60% (over one quarter) is the minimum to maintain block, while a
minimum of 80% utilization must be maintained to increase block time. The SSEC was
tasked with block review and re-allocation and per policy, utilization was supposed to be
reviewed on a monthly basis by the SSEC. However, SSEC meetings occurred quarterly. Re-
allocation of block was mentioned in the meeting minutes, led by the director of surgery, but
no decision to re-allocate block time was ever made by the SSEC.
The policy was absent on how block was assigned to a surgeon who did not request it.
The practice for BMH has been that the Chief Executive Officer (CEO) or the Chief
Operating Officer (COO), allocate block time. However, there was no process or policy in
place to explain how, why, and on what basis surgeons were selected to receive block; nor
was there a process detailing how available block was determined to be assigned or how

block may have been re-allocated to be given to a new surgeon for a new block assignment.
This method had worked in past years, but due to the growth of the business, patient
population, and the addition of the Affordable Care Act, this is a practice that has begun to
bring conflict in the scheduling process. This is because block allocation was often made
without discussing available capacity with the SSEC and the OR Director.
Based on the loose adherence to block policies; block assignments which were not
discussed with the SSEC; and the lack of physician attendance at SSEC meetings, it appears
the critical foundation of managing block and balancing productivity is greatly impacted by a
weakened governance.
While block utilization was reviewed during SSEC meetings, the policy was not
formally referenced against actual block utilization, nor were any decisions regarding
revision of block voted on. Best practice dictates that a maximum of 80% of the surgery
schedule can be blocked. However, the findings showed that BMH’s surgery schedule has
98% blocked (see figure 2, BMH Block Utilization), leaving no room for extra business or
flexibility. Out of 41 total block assigned surgeons, 27 surgeons, or 34%, used less than the
60% required to maintain block. 16 surgeons, or 60%, utilized more than 80% of their block,
granting them the privilege to increase their block times. At least one surgeon had a 0%
utilization for six straight months. Referring to BMH’s policy, it clearly stated that in order
for block assignment to be maintained, 60% must be utilized. Overall, total block utilization
for fiscal year 2015 ended at 52.2% though corporate policy had a set target of 75% total
block utilization for BMH.
Results show that yet again, the hospital was not compliant with their own policy of
reviewing and re-allocating block. Suggestions and recommendations were made by the

Director of Nursing during SSEC meetings, for the re-allocation of block assignments for
surgeons who use less than half of their assigned time, as noted in the meeting minutes. But
no changes were made to block assignments even when utilization of several surgeons were
below 25%.
The management team of the surgery department attempted to communicate with
surgeons by mailing monthly letters containing individual block utilization statistics,
including a “release of block” form in the event a surgeon was going on vacation.
Unfortunately, these letters did not make significant impacts to block utilization however, at
least two surgeons who averaged less than 5% of block had block taken away and one
surgeon retired, opening up a slot.
Another finding was the add-on rate. At the end of the 2015 fiscal year, an average of
20% of surgical cases were added on, last minute. Add-on cases are unforeseen scheduling
requests made by surgeons that are not emergent. BMH accommodates add-ons and the
policy specifies those cases “are to follow.” This disrupts the staffing schedule, as room and
case assignments are made 24hrs prior to surgery. Add-on cases result in overtime and
double-time costs and staff burn out because of a poor work-life balance. For example, 12
hour nurses who normally work 3 days a week, are called in to work a 4th and 5th day, at
double-time pay.
Regarding on time starts, the policy had also mentioned that “all sources of delays
will be tracked and reviewed monthly by the SSEC” (BMH Policy DP-SS 129, p. 7). The
statistical analysis of the percent of on time starts is reviewed by the OR management team,
however, the SSEC meeting minutes did not include reviewing all sources of delays. In

addition, the SSEC met quarterly, and therefore did not implement the monthly review the
policy itself had set.
While it was the duty of the SSEC to make firm decisions per best practices for block
scheduling, it was the management of the surgery department that actually made the
attempts. Since there was no proper support from the SSEC, the block utilization dominated
the entire business of the OR with poor use and surgeons who used less than 60% of their
block, kept it.
Performance Metrics and Its Impact on Productivity
BMH policy dictated that physician delays of 30 minutes or more result in an adverse
effect to block scheduling privileges. The policy also defines “delay in start time” as five
minutes past the scheduled start time. The Performance Management Tool revealed that the
biggest weakness impacting productivity, was the percent of cases to start on time. BMH set
a goal to start cases as scheduled, 90% of the time. However, their fiscal year 2015 average
yielded a 49% of on-time first case starts. This was due to various reasons such as surgeon
late arrival, anesthesiologist late arrival, and even hospital rooms not ready (due to not
having special equipment or surgical instruments ready).
This in turn, affected the Prime-Time OR Utilization (cases during business hours),
where prime-time began at 7am and ended at 3pm. BMH had a target to complete 75% of
total cases within business hours. However, with cases starting late and cases being added on
to Saturday and Sunday, the results showed an average of 48% prime-time utilization. This
suggests a huge loss of potential revenue and an unbalanced schedule.
Turnover Time is defined as the minutes counted when a patient is wheeled out of the
operating room (wheels out) after completion of surgery until the minute the wheels of the

next patient are rolled into the room (wheels in). The Surgical Assistants are responsible for
cleaning the operating room suite and sterilizing equipment for the next case. Turnover time
for BMH was very good, with a target goal of 25 minutes but an actual average of 23 minutes
for fiscal year 2015. The shorter the turnover time, the higher utilization of block and prime-
time.
BMH also calculated case length prediction. That is, the educated guess of how long a
specific case will run which the scheduler makes when scheduling cases. BMH accurately
predicted case lengths an average of 50% of the time in FY2015.
Weekend Volume Findings
A practice that has been ongoing at BMH, are weekend cases. 25% of Surgeons who
are block owners were 40% of the weekend volume. Many of the procedures performed on
the weekend, were cases usually performed during the week as elective. BMH weekend
volume data revealed that they average 23 cases a month on weekends alone; 5.5 cases each
Saturday and 5 cases each Sunday. Weekends are reserved for emergency surgical cases.
Staff called in during the weekends, are paid at time and a half. The impact to productivity is
significant with the amount of weekend cases performed.
What I found interesting, was that BMH’s policy (DP-SS 129, p. 8) speaks
specifically of “elective Saturday schedule.” The policy was last updated April 29, 2015 by
the Board of Directors, however, all cases that occurred on Saturdays were considered
emergent according to the data that was collected by their IT department, even when similar
procedures were considered elective during the week. Staff was also getting paid at time and
a half. The policy itself shows that BMH does in fact have a Saturday elective schedule, but
in application, it treated all cases as emergencies. Furthermore, section 6 of Elective Saturday

Schedule states that there should be no Sunday elective schedule, yet there were consistently
5 or more cases performed on Sundays in FY2015.
Productivity Findings
At the end of fiscal year 2015, a review of the productivity report revealed that it cost
BMH $117,415 in call-back costs; $123,629 in double time costs; $15,829 for cases
scheduled during holidays; and $426,542 in overtime costs, for a total of $683,415 spent on
labor outside of business hours. If block scheduling was balanced and weekend cases
minimized or controlled (such as adding Saturday to the regular schedule), the cost in
staffing would be reduced.
Summary and Conclusions
This study aimed at researching best practice principles application in the
management of block utilization and to find how it impacts productivity. The research
included a case study on Bakersfield Memorial Hospital’s (BMH) surgery department.
Results indicate that BMH has had challenges in maintaining their productivity levels,
presumably due to an unbalanced block schedule with 34% of surgeons using less than the
60% required utilization rate to maintain block; has a significant amount of add-ons and
weekend cases. Additionally, BMH has struggled to reach their target goal of 70% First Case
On-Time Starts as shown by their PMT report, leading to case delays, increased overtime
costs, and surgeon dissatisfaction. The policy stipulated that all sources of delays in start
times would be tracked and reviewed by the SSEC, but meeting minutes do not show that
such reviews actually took place. Also the policy mentioned the reviews of delays were to be
done monthly by the SSEC, but the committee only met quarterly.

BMH implements best practice models of block scheduling in their policies, but has
struggled to comply with them. A governance committee known as the Surgical Services
Executive Committee has been formed by BMH, as best practice encourages, but attendance
from physician leaders has been decreasing over time; block utilization decisions have not
been made (no re-allocation of block); and meetings held quarterly contradict their policy
which stated that block utilization would be reviewed by the SSEC on a monthly basis.
BMH has successfully controlled turnover times, which reduces case delays and also
has successfully predicted case lengths at least 50% of the time, leading to more accurate
surgery scheduling, ultimately impacting how cases are staffed.
Recommendations
The purpose of this section is to present recommendations that were developed based
on a review of scholarly research compared to current practices. Despite the struggles BMH
has faced in FY2015, they are taking steps in the right direction.
Recommendation #1: Update Block Scheduling Policy.
It is recommended that their block scheduling policy is updated to reflect the capacity
of SSEC. Because the committee met quarterly though the policy obligated decisions
monthly, it is evident that meeting monthly is not attainable, therefore it is recommended to
change the frequency of meetings that were supposed to occur on a monthly basis to a
quarterly basis.
Recommendation #2: Update SSEC Policy
Secondly, there should be a policy establishing how, why, and when block time is
assigned to a surgeon, with the decision made by the SSEC. It is important for these
scheduling decisions to be made after consulting with the OR director (who is a member of

the SSEC), who can foresee potential conflicts and complications that administration would
not be aware of. The SSEC should make efforts in firmly implementing their written policy
to actually review and re-allocate (right size) block assignments to surgeons who do not meet
the recommended minimum block utilization rate.
Recommendation #3: SSEC Recruitment
The SSEC should implement unique ways of recruiting physicians, by announcing
invitations through newsletters and visits by physician liaisons encouraging involvement.
The SSEC is a platform where physician’s voices can be heard and where changes can be
made with their best interest. Therefore, it is important to recruit new physician members and
inquire from them as to their ideal meeting times so that attendance can be improved.
Recommendation #4: Surgeon Report Cards
While BMH follows best practice in sending surgeons a letter containing their block
utilization, I recommend implementing a report card with a letter grade, that not only visually
displays a surgeon’s summary of block utilization, but would include their individual metrics
of: Block Utilization; % of On-Time First Case Starts; Number of Turnovers; Prime Time
OR Utilization; and % of Cancellations within 24hrs of Surgery. A report card is also known
as a “scorecard,” and it is used to motivate and inform surgeons on their performance, per
best practice.
Recommendation #5: Consider Saturday Elective Schedule
Regarding weekend volume, since BMH’s policy already speaks of Saturday elective cases,
it is recommended that Saturday be added to the regular schedule; include block assignments;
and add Saturday to the data collection. Staff should be paid at regular straight time since it

would be a regularly scheduled day. This would significantly decrease overtime costs thus,
improving productivity.
Recommendation #6: Extend Block Hours
Regarding prime-time utilization, the hours should be extended past 3pm. Since a significant
amount of caseloads are add-ons, it would benefit BMH if prime-time is extended,
leaving open slots for add-on cases. This would increase prime-time utilization and make
better use of evening shift staff.

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Appendix A
Authorization for Protocol 16-70.

Appendix B
Authorization for use of BMH Data

Appendix C
BMH Block Utilization Report

Appendix D
BMH Performance Management Tool

PUBLISHED THESIS

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