1.
Dr. Prahlada N.B
MBBS, MS(PGI), MBA, MHA
Karnataka ENT Hospital & Research Center,
Chitradurga

2.
What is time?
 Time is capital and not renewable income!
 Time and Tide waits for no man!
 Time is the only thing which cannot be stretched
beyond 24 hours!
 Time is the most valuable gift, which can be offered by
one to another!
 Give time for children, be good parents!
 Have time for subordinates good superiors!
 We can not make time but surely we can find time.

3.
Advantages of Time Management

4.
Advantages: Surgeon
 Time is money
 More Consultation time
 More surgeries in less time
 More time for other academic activities
 More time for extra-curricular activities
 More time for family!

5.
Advantages: Patient
 Economical
 Less discomfort
 Less chance of operating wound infection
 Less anaesthesia risk
 Less OT risk
 Less hospital stay

6.
Advantages: Hospital
 Efficient use of OT Time
 Efficient use of OT Staff
 Less hospital borne infection rate
 Less OT Risk for the patient
 Less Hospital stay
 More turnover
 Economical
 Reputation

7.
My average timing!
 CM + Tympanoplasty - 26 minutes
 MRM + Tympanoplasty - 52 minutes

8.
Why?
 Al Shifa Hospital, Perinthalmanna

9.
Why?
 Surgical Camps

10.
Why?
 MBA
 Father of Scientific Management
 Frederick Taylor (1856-1915)
 Taylorism

11.
Taylorism
 Analyzed and synthesized workflows
 Improving economic efficiency &
 Enhancing labor productivity
 Standardization of process steps
 Time and motion studies

12.
Surgical Time audit
 Recording all events in OT
 Classification of events
 Analysis of events

13.
Surgical time audit
 Recording of all events in OT
 Pre-operative
 Intra operative
 Post-operative

14.
Surgical time audit
 Intra-operative events analysis
 Divide the steps
 When you have large task on hand – divide them into
small pieces and perform!
 Prepare a Time-audit chart.

15.
Time audit chart
Surgical Steps Time in mins.
Local Infiltration 3 mins
End-aural incision 4 mins
Post-aural incision and Harvesting TM Fascia graft 5 mins
Tympanomeatal flap elevation 2 mins
Denuding the malleus 2 mins
Cortical mastoidectomy and canaloplasty 4 mins
Check ossicular mobilty & round window reflex 30 secs
Check E-tube patency 30 secs
Grafting & Stabilizing 3 mins
Closure 3 mins
Total time taken 28 mins

16.
Surgical time audit
 Classification of events
 Very important
 Not particularly important
 Worthless

17.
Surgical time audit
 Analysis of events
 What is the best of way doing particular task in least
possible time?
 Can you dedicate more time to high-value steps?
 Can you spend less time with low-value steps?
 Are there any distractions you can avoid?
 Can you modify the technique?
 Can you delegate the task?

18.
Surgical time audit
Surgical Steps Before Now
Local Infiltration 10 3 mins
End-aural incision 10 4 mins
Post-aural incision and Harvesting TM Fascia graft 20 5 mins
Tympanomeatal flap elevation 20 2 mins
Denuding the malleus 20 2 mins
Cortical mastoidectomy and canaloplasty 30 4 mins
Check ossicular mobilty & round window reflex 5 30 secs
Check E-tube patency 5 30 secs
Grafting & Stabilizing 20 3 mins
Closure 20 3 mins
Total time taken 2 Hrs 40
mins
28 mins

19.
Factors affecting Surgical time

20.
Patient factors
 General physical condition
 Risk factors
 Type of pathology
 Intra-op bleeding

21.
Surgeon factors
 Attitude
 Training
 Philosophy
 Planning
 Execution
 Delegation
 Team work

22.
Practice makes man perfect!

23.
SWOT Analysis

24.
TQM – Six Sigma

25.
Anaesthetist
 Attitude
 Training
 Philosophy
 Team work

26.
Type anaesthetist
 Superficial
 Gas Man!
 Freelancer

27.
Staff factors
 Attitude
 Training
 Team work

28.
Staff Motivation
 Discipline
 Participation and involvement
 Time management
 Morale
 Skill development
 Communication

29.
Learn the Kaizen way!

30.
Operation theatre
 Design
 Lighting
 Air conditioning

31.
Operation theatre

32.
Equipment
 Right equipment
 Working equipment
 Serviced!
 Multi-use

33.
Microscope

34.
Equipment
 Micro-instruments – double ended
 High speed micro drill
 Good burrs
 Patent suction tips!
 Scissors which cut!

35.
Surgical technique
 Plan! Plan! Plan!
 Investigate appropriately
 Communicate plan to the team
 Right surgical technique
 Right approach
 Right surgical step
 Complement surgical steps
 Do only what is necessary

36.
Surgical Approach
 Transcanal
 Endomeatal
 End-aural
 Post-aural

37.
Surgical Approach
 Trans-canal approach
 Post-traumatic perforation - < 3 months

38.
Surgical Approach
 Endomeatal approach – Wide canal
 Post-traumatic perforation - > 3 months
 Central perforation – other aetiology
 < 3 months.

39.
Surgical Approach
 End-aural approach – Narrow Canal
 Posterior Central perforation
 When Cortical mastoidectomy is not planned

40.
Surgical Approach
 End-aural incsions for Koerner’s flap/Post-aural
approach
 Anterior perforation/Anterior bony overhang
 Large perforation/Subtotal/total perofrations
 When Cortical mastoidectomy is contemplated
 All Cholesteatoma surgery

41.
Cholesteatoma – Decision making
 Only Canal wall down
 Obliterate when possible
 Single stage ossicular reconstruction
 Modified Bondy’s mastoidectomy with obliteration
 Minimal cholesteatoma
 Ossicular chain intact