Organising Operation time for Surgery
The operating theatre, to me, is the actual “engine” of a hospital.
It is the place where the most revenue (per unit time spent) is made by the hospital and the surgeons. Optimal running of the operating theatre is vital for the success of any private hospital. Every private hospital has its own system for booking cases for surgery. It is very important to have a proper system because the employment and engagement of staff is vital for the successful and profitable running of an operation theatre. I will describe what I have experienced at the hospital I work in and then present some suggestions as to how to optimize your work flow to fit into the system.
When we first started at Mahkota Medical Centre, 5 operation theatres were opened. There were 12 surgeons and 2 anaesthetists. The hospital decided to allocate one morning session and one afternoon session for each surgeon. For example, they gave me Wednesday afternoon from 1pm till 5 pm and Friday morning from 8 am to 1 pm. My cases were given preference during these allocated times. Other surgeons wanting to operate during my allocated time, would have to wait for me to finish my list first before they were allowed to operate. Each operating theatre was allocated to one surgeon for that session. An anaesthetist took care of each operating theatre. As we only had 2 anaesthetists but 5 operating theatres, at times one anaesthetist had to run 2 operation theatres, which thinking back now was not optimal nor ethical. However, this only rarely occurred at that time.
As more and more surgeons joined the hospital, more anaesthetists also joined our team. The system was still the same. Every new surgeon who joined the hospital was allocated a morning and an afternoon session to book their surgeries.
Unfortunately, most surgeons did not operate during their allocated time slots. Mornings were generally quiet. There was usually a rush to book cases during lunch time that is from about 12.30pm to 2 pm and in the late afternoons after about 3 pm. The reason was obvious. Surgeons would run their outpatient clinics in the mornings and early afternoons. Lunch time and late afternoons were times when most of us were free to perform surgeries.
In those days, there was no appointment system in the clinic. Everyone was consulting patients on a first come first serve basis. This was compounded by the fact that foreign patients, especially from Indonesia always turned up at the clinic without appointment, demanding immediate surgery. Therefore, it was in the best interest of all doctors to be in their respective clinics during office hours to “catch” these walk-in patients and then post them for surgery the next day.
Obstetricians face another problem. Patients who are posted for elective Caesarean sections always ask for a good time and date to undergo the delivery of their babies. I call this “Horoscopic Caesarean sections” and we have to arrange this with the operating theatre. Fortunately, in my hospital this is allowed and this again complicates scheduling.
There is also a cut off booking time for surgeons who were allocated the surgical sessions. In my hospital the cut off time for booking a case is 4pm the day before. Leaving the booking time open can lead to problems. A surgeon can book a case late at night to perform the surgery the next morning on his operating list when the surgical list for the next day has already been prepared. This can mess up the operating list.
This system at times led to chaos in the operating theatre. If a surgeon booked a case outside his/her allocated time, then the surgery will be done according to the time of booking: the first to book were allowed their surgery to be done first. Organising the list was a very difficult task for the operation theatre staff and they frequently had to face the wrath of surgeons who were under pressure to do their cases and rush back to the clinic to see other patients. Surgeons had to resort to this in order to appease patients who are waiting for them in their clinic and to prevent them from moving to their competitors. It was also always better to book the cases for surgery, as soon as possible, to prevent their patients from changing their minds and choosing a different surgeon. As such, very few surgeons actually booked their cases on their operating theatre allocation time because this would involve a patient waiting a few days to get to the list. Mondays were always busy clinic days and this was a good time to “catch” patients and post them for surgery on Tuesdays which was usually the busiest operating theatre day.
There were some flaws in this system. Firstly, all new surgeons who joined the hospital were given exactly the same 2 sessions to book their cases. We all know that new doctors take time to build their practice and have fewer cases to operate. The senior and busiest surgeons also had the same allocation. This was totally unfair because many of the busy surgeons had more cases to do than the time allocated. When a busy surgeon asked for more operating time allocation, it was denied. The reason given was that the management had to be fair to everyone. So when their allocated time was used up these busy surgeons were forced to operate during unallocated times. Some busy surgeons were in the operating theatre everyday. There was no “punishment” for surgeons who persistently booked outside their OT allocation time but also no incentive for surgeons who follow the rules and book cases only during their allocated times. There is also this problem of surgeons coming in late to perform their surgery thus delaying the operating list and causing wastage of operating time.
Having a cut off time leads to another problem. The problem is that although surgeons booked their cases in advance, the operation theatre staff would only sort out the next day’s operating lists at 4pm the day before the surgery, this being the cut off time. This is not optimal, as there is no time to warn the surgeons if the theatre is going to be too busy for all the operations, the next day. Patients were already admitted for surgery. A computer system to track the bookings and warn if too many cases had been booked would be a better system.
There is also this problem of surgeons booking cases at peculiar times. Let me explain. When the allocated time for surgery is 8 am till 1 pm, a surgeon who has only one case the next day may post it at 12pm. This may be a 2-hour surgery and so he will be operating past his allocated time. This may lead to problems of scheduling other cases. The operating theatre will also have to schedule some other cases from 8 am till 12 pm. If this scheduled cases overrun, the surgeon will scold them.
Another problem is that some surgeons book cases that they have not even consulted yet. This may be an outstation or an international patient who was promised surgery over the phone or internet. Cancellation at the last minute had occurred if the patient do not turn up for surgery.
Despite all these shortfalls the operation theatre somehow managed to run smoothly except on occasions, when workload was so heavy and all the operating theatres were running at full speed. The operation theatre staff who were overworked, on a few rare occasions, started a small mutiny by taking emergency leave or medical leave causing cases to be delayed, postponed or cancelled.
The Management of a hospital must have the responsibility of providing the optimal number of staff for the optimal running of an operation theatre. Too many staff is a waste of resources and loss of money. With too few staff, there is a danger of losing patients because of the unavailability of operation theatres. This can be a difficult balance as there are always uncertainties as to what the future work-load is going to be. The pandemic time was a good example where the number of cases were reduced drastically and there were too many staff sitting around doing nothing. Fortunately, no one was retrenched and now that the cases are coming back, the investment of keeping all the staff, will pay off.
There are many things that a management can do to optimize utilization of the operating theatre time. However this will involve penalizing errant surgeons and this is something a hospital management shuns away. For example penalizing surgeons who are persistently late to start their cases or always booking their cases outside their allocated time. Again giving incentives to surgeons who always book their cases on their allocated time is also something that the management does not have the courage to implement.
The above is my experience working in a private hospital. I had a discussion with other surgeons in other hospitals in various parts of the country. The general consensus is that surgeons are not really allocated time slots for surgery. They book their elective cases with the operating theatre either using a booking slip, computer programme or the internet and emergency cases via phone. They then, rearrange their clinic consultation hours so that they are free to perform the surgery. There is, however, a risk of waiting for an earlier surgeon to finish his case before starting their cases. This may lead to time wastage. This is especially so for visiting surgeons who will have to travel from their respective clinics to the hospital and have to wait to start their case.
So what advise can I give to doctors joining private hospitals?
- For good time management, it is wise to stick to working in one hospital only. Operating in many hospitals can lead to time wastage, waiting to start your case.
- It will be good to have a particular date and time allocated to you to perform surgeries. This will enable you to plan your time properly.
- If you have a choice, it may be better to choose a not so busy hospital to work in so that you have the privilege of choosing a good time to perform your surgeries. Choosing a busy hospital may lead to frustration in not being able to operate at your preferred time.
- Communicate with your hospital management to help them optimize time utilization in the operating theatre.
I would like to thank
My wife Sarojini for editing this article
Dr. Gunasegaran for reading through this article and giving good suggestions for its improvement.