Improving Operating Room Efficiency

  • Daniel J. LeeEmail author
  • James Ding
  • Thomas J. Guzzo
Endourology (P Mucksavage and B Somani, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Endourology


Purpose of Review

Operating rooms are critical financial centers for hospital systems, with surgical care representing about a third of all health care spending. However, not all of the costs are appropriate or necessary, as there are sometimes significant inefficiencies in how operating rooms are utilized.

Recent Findings

Recent innovations utilizing patient-centered data, systems principles from manufacturing industries, and enhanced communication processes have made significant improvements in improving operating room efficiency.


By focusing on improving communication, standardizing processes, and embracing a learning health system with innovations, significant improvements in operating room efficiency can be seen to improve outcomes and costs for the health system and patient.


Operating room efficiency Operating room costs Six sigma Lean Cost efficiency 


Compliance with Ethical Standards

Conflict of Interest

Daniel J. Lee, James Ding, and Thomas J. Guzzo each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. 1.
    Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory surgery data from hospitals and ambulatory surgery centers: United States. Natl Health Stat Report. 2010;2017:1–15.Google Scholar
  2. 2.
    NQF-Endorsed Measures for Surgical Procedures, 2015–2017. Department of Health and Human Services. National Quality Forum. Accessed on January 3, 2019.
  3. 3.
    Muñoz E, Muñoz W, Wise L. National and surgical health care expenditures, 2005-2025. Ann Surg. 2010;251:195–200.CrossRefGoogle Scholar
  4. 4.
    McDermott KW (IBM Watson Health), Freeman WJ (AHRQ), Elixhauser A (AHRQ). Overview of Operating Room Procedures During Inpatient Stays in U.S. Hospitals, 2014. HCUP Statistical Brief #233. December 2017. Agency for Healthcare Research and Quality, Rockville, MD.
  5. 5.
    Macario A. What does one minute of operating room time cost? J Clin Anesth. 2010;22:233–6.CrossRefGoogle Scholar
  6. 6.
    Cerfolio RJ, Ferrari-Light D, Perry N, et al. Improving operating room turnover time in a New York City Academic Hospital via Lean. Ann Thorac Surg 2019.Google Scholar
  7. 7.
    •• Childers CP, Maggard-Gibbons M. Understanding costs of Care in the Operating Room. JAMA Surg. 2018;153:e176233 Thorough investigation into the actual costs of running an operating room.CrossRefGoogle Scholar
  8. 8.
    Brodsky JB. Cost savings in the operating room. Anesthesiology. 1998;88:834.CrossRefGoogle Scholar
  9. 9.
    Tsai M. The true cost of operating room time. Arch Surg. 2011;146:886 author reply −7.CrossRefGoogle Scholar
  10. 10.
    Stey AM, Brook RH, Needleman J, et al. Hospital costs by cost center of inpatient hospitalization for medicare patients undergoing major abdominal surgery. J Am Coll Surg. 2015;220:207–17.e11.CrossRefGoogle Scholar
  11. 11.
    Brown JK, Campbell BT, Drongowski RA, Alderman AK, Geiger JD, Teitelbaum DH, et al. A prospective, randomized comparison of skin adhesive and subcuticular suture for closure of pediatric hernia incisions: cost and cosmetic considerations. J Pediatr Surg. 2009;44:1418–22.CrossRefGoogle Scholar
  12. 12.
    Ting NT, Moric MM, Della Valle CJ, Levine BR. Use of knotless suture for closure of total hip and knee arthroplasties: a prospective, randomized clinical trial. J Arthroplast. 2012;27:1783–8.CrossRefGoogle Scholar
  13. 13.
    Sah AP. Is there an advantage to knotless barbed suture in TKA wound closure? A randomized trial in simultaneous bilateral TKAs. Clin Orthop Relat Res. 2015;473:2019–27.CrossRefGoogle Scholar
  14. 14.
    Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N, Copeland J, et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal Cancer: the ROLARR randomized clinical trial. JAMA. 2017;318:1569–80.CrossRefGoogle Scholar
  15. 15.
    Coughlin GD, Yaxley JW, Chambers SK, Occhipinti S, Samaratunga H, Zajdlewicz L, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled study. Lancet Oncol. 2018;19:1051–60.CrossRefGoogle Scholar
  16. 16.
    Childers CP, Maggard-Gibbons M. Estimation of the acquisition and operating costs for robotic surgery. JAMA. 2018;320:835–6.CrossRefGoogle Scholar
  17. 17.
    Jeong IG, Khandwala YS, Kim JH, Han DH, Li S, Wang Y, et al. Association of robotic-assisted vs laparoscopic radical nephrectomy with perioperative outcomes and health care costs, 2003 to 2015. JAMA. 2017;318:1561–8.CrossRefGoogle Scholar
  18. 18.
    Bochner BH, Dalbagni G, Sjoberg DD, Silberstein J, Keren Paz GE, Donat SM, et al. Comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: a randomized clinical trial. Eur Urol. 2015;67:1042–50.CrossRefGoogle Scholar
  19. 19.
    Fixler T, Wright JG. Identification and use of operating room efficiency indicators: the problem of definition. Can J Surg. 2013;56:224–6.CrossRefGoogle Scholar
  20. 20.
    McIntosh B, Cookson G, Jones S. Cancelled surgeries and payment by results in the English National Health Service. J Health Serv Res Policy. 2012;17:79–86.CrossRefGoogle Scholar
  21. 21.
    Pratap JN, Varughese AM, Mercurio P, Lynch T, Lonnemann T, Ellis A, et al. Reducing cancelations on the day of scheduled surgery at a children’s hospital. Pediatrics. 2015;135:e1292–9.CrossRefGoogle Scholar
  22. 22.
    Kaye AD, McDowell JL, Diaz JH, Buras JA, Young AE, Urman RD. Effective strategies in improving operating room case delays and cancellations at an academic medical center. J Med Pract Manage. 2015;30:24–9.PubMedGoogle Scholar
  23. 23.
    •• Argo JL, Vick CC, Graham LA, Itani KM, Bishop MJ, Hawn MT. Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement. Am J Surg. 2009;198:600–6 Example of a data driven implementation for quality improvement within the Veterans Health Administration system.CrossRefGoogle Scholar
  24. 24.
    Schofield WN, Rubin GL, Piza M, Lai YY, Sindhusake D, Fearnside MR, et al. Cancellation of operations on the day of intended surgery at a major Australian referral hospital. Med J Aust. 2005;182:612–5.PubMedGoogle Scholar
  25. 25.
    Kaddoum R, Fadlallah R, Hitti E, El-Jardali F, El Eid G. Causes of cancellations on the day of surgery at a tertiary teaching hospital. BMC Health Serv Res. 2016;16:259.CrossRefGoogle Scholar
  26. 26.
    Pohlman GD, Staulcup SJ, Masterson RM, Vemulakonda VM. Contributing factors for cancellations of outpatient pediatric urology procedures: single center experience. J Urol. 2012;188:1634–8.CrossRefGoogle Scholar
  27. 27.
    Al Talalwah N, McIltrot KH. Cancellation of surgeries: integrative review. J Perianesth Nurs. 2019;34:86–96.CrossRefGoogle Scholar
  28. 28.
    Lopez RN, Jowitt S, Mark S. The reasons for cancellation of urological surgery: a retrospective analysis. N Z Med J. 2012;125:17–22.PubMedGoogle Scholar
  29. 29.
    Fernando BS, Cannon PS, Mohan M. Cancellation of surgical day cases in an ophthalmic centre. Acta Ophthalmol. 2009;87:357–8.CrossRefGoogle Scholar
  30. 30.
    Nelson SE, Li G, Shi H, Terekhov M, Ehrenfeld JM, Wanderer JP. The impact of reduction of testing at a preoperative evaluation clinic for elective cases: value added without adverse outcomes. J Clin Anesth. 2018;55:92–9.CrossRefGoogle Scholar
  31. 31.
    Luo L, Zhang F, Yao Y, Gong R, Fu M, Xiao J. Machine learning for identification of surgeries with high risks of cancellation. Health Informatics J 2018:1460458218813602.Google Scholar
  32. 32.
    The Health Literacy of America’s Adults. National Assessment of Adult Literacy. U.S. Department of Education. Accessed 3/15/2017.
  33. 33.
    Robinson JR, Davis SE, Cronin RM, Jackson GP. Use of a patient portal during hospital admissions to surgical services. AMIA Ann Symp Proc. 2016;2016:1967–76.Google Scholar
  34. 34.
    Haufler K, Harrington M. Using nurse-to-patient telephone calls to reduce day-of-surgery cancellations. AORN J. 2011;94:19–26.CrossRefGoogle Scholar
  35. 35.
    Phieffer L, Hefner JL, Rahmanian A, Swartz J, Ellison CE, Harter R, et al. Improving operating room efficiency: first case on-time start project. J Healthc Qual. 2017;39:e70–e8.CrossRefGoogle Scholar
  36. 36.
    Halim UA, Khan MA, Ali AM. Strategies to improve start time in the operating theatre: a systematic review. J Med Syst. 2018;42:160.CrossRefGoogle Scholar
  37. 37.
    Cox Bauer C, Greer D, Vander Wyst KB, Kamelle S. First-case operating room delays: patterns across urban hospitals of a single health care system. J Patient Cent Res Rev. 2016;3(3):125–35.CrossRefGoogle Scholar
  38. 38.
    Overdyk FJ, Harvey SC, Fishman RL, Shippey F. Successful strategies for improving operating room efficiency at academic institutions. Anesth Analg. 1998;86:896–906.CrossRefGoogle Scholar
  39. 39.
    Tagge EP, Thirumoorthi AS, Lenart J, Garberoglio C, Mitchell KW. Improving operating room efficiency in academic children's hospital using Lean Six Sigma methodology. J Pediatr Surg. 2017;52:1040–4.CrossRefGoogle Scholar
  40. 40.
    Mason SE, Nicolay CR, Darzi A. The use of lean and six sigma methodologies in surgery: a systematic review. Surgeon. 2015;13:91–100.CrossRefGoogle Scholar
  41. 41.
    McNamara R, Butler A, Baker C, Mullen J, Lenehan B, Grimes S, et al. Use of lean principals to improve flow of patients with fractured neck of femur—the HOPE study. Ir Med J. 2014;107:70–2.PubMedGoogle Scholar
  42. 42.
    Weld LR, Stringer MT, Ebertowski JS, Baumgartner TS, Kasprenski MC, Kelley JC, et al. TeamSTEPPS improves operating room efficiency and patient safety. Am J Med Qual. 2016;31:408–14.CrossRefGoogle Scholar
  43. 43.
    St Jacques PJ, Patel N, Higgins MS. Improving anesthesiologist performance through profiling and incentives. J Clin Anesth. 2004;16:523–8.CrossRefGoogle Scholar
  44. 44.
    Bethune R, Sasirekha G, Sahu A, Cawthorn S, Pullyblank A. Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre. Postgrad Med J. 2011;87:331–4.CrossRefGoogle Scholar
  45. 45.
    Mathews L, Kla KM, Marolen KN, Sandberg WS, Ehrenfeld JM. Measuring and improving first case on-time starts and analysis of factors predicting delay in neurosurgical operating rooms. J Neurosurg Anesthesiol. 2015;27:203–8.CrossRefGoogle Scholar
  46. 46.
    Martin L, Langell J. Improving on-time surgical starts: the impact of implementing pre-OR timeouts and performance pay. J Surg Res. 2017;219:222–5.CrossRefGoogle Scholar
  47. 47.
    Laskin DM, Abubaker AO, Strauss RA. Accuracy of predicting the duration of a surgical operation. J Oral Maxillofac Surg. 2013;71:446–7.CrossRefGoogle Scholar
  48. 48.
    Tuwatananurak JP, Zadeh S, Xu X, Vacanti JA, Fulton WR, Ehrenfeld JM, et al. Machine learning can improve estimation of surgical case duration: a pilot study. J Med Syst. 2019;43:44.CrossRefGoogle Scholar
  49. 49.
    Saha P, Pinjani A, Al-Shabibi N, Madari S, Ruston J, Magos A. Why we are wasting time in the operating theatre? Int J Health Plann Manag. 2009;24:225–32.CrossRefGoogle Scholar
  50. 50.
    Sultan J, Charalambous CP. Theatre time utilisation in elective orthopaedic surgery. J Perioper Pract. 2012;22:262–5.CrossRefGoogle Scholar
  51. 51.
    Delaney CL, Davis N, Tamblyn P. Audit of the utilization of time in an orthopaedic trauma theatre. ANZ J Surg. 2010;80:217–22.CrossRefGoogle Scholar
  52. 52.
    Harnett MJ, Correll DJ, Hurwitz S, Bader AM, Hepner DL. Improving efficiency and patient satisfaction in a tertiary teaching hospital preoperative clinic. Anesthesiology. 2010;112:66–72.CrossRefGoogle Scholar
  53. 53.
    Sun EC, Dutton RP, Jena AB. Comparison of anesthesia times and billing patterns by anesthesia practitioners. JAMA Netw Open. 2018;1:e184288.CrossRefGoogle Scholar
  54. 54.
    Rebuck DA, Zhao LC, Helfand BT, Casey JT, Navai N, Perry KT, et al. Simple modifications in operating room processes to reduce the times and costs associated with robot-assisted laparoscopic radical prostatectomy. J Endourol. 2011;25:955–60.CrossRefGoogle Scholar
  55. 55.
    Souders CP, Catchpole KR, Wood LN, Solnik JM, Avenido RM, Strauss PL, et al. Reducing operating room turnover time for robotic surgery using a motor racing pit stop model. World J Surg. 2017;41:1943–9.CrossRefGoogle Scholar
  56. 56.
    Fairley M, Scheinker D, Brandeau ML. Improving the efficiency of the operating room environment with an optimization and machine learning model. Health Care Manag Sci 2018.Google Scholar
  57. 57.
    Krasner H, Connelly NR, Flack J, Weintraub A. A multidisciplinary process to improve the efficiency of cardiac operating rooms. J Cardiothorac Vasc Anesth. 1999;13:661–5.CrossRefGoogle Scholar
  58. 58.
    Bender JS, Nicolescu TO, Hollingsworth SB, Murer K, Wallace KR, Ertl WJ. Improving operating room efficiency via an interprofessional approach. Am J Surg. 2015;209:447–50.CrossRefGoogle Scholar
  59. 59.
    Chalian AA, Kagan SH, Goldberg AN, Gottschalk A, Dakunchak A, Weinstein GS, et al. Design and impact of intraoperative pathways for head and neck resection and reconstruction. Arch Otolaryngol Head Neck Surg. 2002;128:892–6.CrossRefGoogle Scholar
  60. 60.
    Lee BT, Tobias AM, Yueh JH, Bar-Meir ED, Darrah LM, Guglielmi CL, et al. Design and impact of an intraoperative pathway: a new operating room model for team-based practice. J Am Coll Surg. 2008;207:865–73.CrossRefGoogle Scholar
  61. 61.
    Casaletto JA, Rajaratnam V. Surgical process re-engineering: carpal tunnel decompression—a model. Hand Surg. 2004;9:19–27.CrossRefGoogle Scholar
  62. 62.
    Cassera MA, Zheng B, Martinec DV, Dunst CM, Swanström LL. Surgical time independently affected by surgical team size. Am J Surg. 2009;198:216–22.CrossRefGoogle Scholar
  63. 63.
    Stockert EW, Langerman A. Assessing the magnitude and costs of intraoperative inefficiencies attributable to surgical instrument trays. J Am Coll Surg. 2014;219:646–55.CrossRefGoogle Scholar
  64. 64.
    Farrokhi F, Gunther M, Williams B, Blackmore C. Application of lean methodology for improved quality and efficiency in operating room instrument availability. J Healthc Qual. 2013;00:1–10.Google Scholar
  65. 65.
    Lunardini D, Arington R, Canacari EG, Gamboa K, Wagner K, McGuire KJ. Lean principles to optimize instrument utilization for spine surgery in an academic medical center: an opportunity to standardize, cut costs, and build a culture of improvement. Spine (Phila Pa 1976). 2014;39:1714–7.CrossRefGoogle Scholar
  66. 66.
    Chin CJ, Sowerby LJ, John-Baptiste A, Rotenberg BW. Reducing otolaryngology surgical inefficiency via assessment of tray redundancy. J Otolaryngol Head Neck Surg. 2014;43:46.CrossRefGoogle Scholar
  67. 67.
    Morris LF, Romero Arenas MA, Cerny J, Berger JS, Borror CM, Ong M, et al. Streamlining variability in hospital charges for standard thyroidectomy: developing a strategy to decrease waste. Surgery. 2014;156:1441–9 discussion 9.CrossRefGoogle Scholar
  68. 68.
    Gitelis M, Vigneswaran Y, Ujiki MB, Denham W, Talamonti M, Muldoon JP, et al. Educating surgeons on intraoperative disposable supply costs during laparoscopic cholecystectomy: a regional health system’s experience. Am J Surg. 2015;209:488–92.CrossRefGoogle Scholar
  69. 69.
    Xu R, Carty MJ, Orgill DP, Lipsitz SR, Duclos A. The teaming curve: a longitudinal study of the influence of surgical team familiarity on operative time. Ann Surg. 2013;258:953–7.CrossRefGoogle Scholar
  70. 70.
    Doherty C, Nakoneshny SC, Harrop AR, Matthews TW, Schrag C, McKenzie DC, et al. A standardized operative team for major head and neck cancer ablation and reconstruction. Plast Reconstr Surg. 2012;130:82–8.CrossRefGoogle Scholar
  71. 71.
    Al-Hakim L, Gong XY. On the day of surgery: how long does preventable disruption prolong the patient journey? Int J Health Care Qual Assur. 2012;25:322–42.CrossRefGoogle Scholar
  72. 72.
    Yeoh C, Mascarenhas J, Tan KS, Tollinche L. Real-time locating systems and the effects on efficiency of anesthesiologists. J Clin Anesth Pain Manag. 2018;2:37–40.PubMedPubMedCentralGoogle Scholar
  73. 73.
    Park KW, Dickerson C. Can efficient supply management in the operating room save millions? Curr Opin Anaesthesiol. 2009;22:242–8.CrossRefGoogle Scholar
  74. 74.
    Basto J, Chahal R, Riedel B. Time-driven activity-based costing to model the utility of parallel induction redesign in high-turnover operating lists. Healthc (Amst) 2019.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Urology, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.Perelman Center for Advanced MedicinePhiladelphiaUSA

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