The traditional training model for anesthesiology residents is a one-on-one apprenticeship with an attending physician, with little opportunity for the residents to learn supervisory responsibilities and team management skills.a,b In 2010, our department created an elective rotation in operating room (OR) management for senior anesthesiology residents where 1 author provided weekly 1-hour lectures during the month. Until this year, 1 author provided all the lectures for the residents during the month. The lectures covered the following topics: basic definitions in OR management, OR efficiency metrics, and the concept of an OR dashboard. In 2014, under the auspices of the American Society of Anesthesiologists, we developed a web-based module covering the basics of finance, accounting, and OR management. We hypothesized that the new web-based module would be as effective as one-on-one lectures covering the basic concepts of OR management.
In 2010, we developed a new, 4-week OR management rotation designed to replicate the management responsibilities for a supervisory anesthesiologist and an individual charged to operationalize an anesthesia health care service line. In week 1, the resident managed 2 ORs staffed by Certified Registered Nurse Anesthetists and Anesthesia Assistants respectively. In week 2, the resident’s responsibilities increased to the supervision of 3 ORs. In weeks 3 and 4, the resident worked side-by-side with the charge anesthesiologist. The charge anesthesiologist serves as the de facto OR coordinator for the anesthesia services on the day of surgery. The charge attending is responsible for making operational decisions (e.g., how should an urgent appendectomy be staffed, when should an urgent magnetic resonance imaging scan with sedation occur), assigning staffing needs for the next day, serving as a liaison among the surgical and nursing services, and overseeing the telephone patient interview-based preoperative assessment center. Each resident completed a pre- and postrotation test consisting of multiple-choice, open-ended, and definition questions at the beginning and end of the rotation. In 2013, we changed the curricular requirements for the residency program, and all senior residents now complete the rotation.
In 2015, we replaced the lectures with a 1-hour web module, “OR Management Basics: Right Case, Right Time, Right Cost,” which is a component on the continuing education section of the Web site for the American Society of Anesthesiologists.c We reviewed the pre- and postrotation examinations of participating residents for the 2010 to 2015 academic years. We identified 8 questions on the pre- and postrotation examinations that had already been incorporated as knowledge checks in the web module (Appendix 1). The questions specifically assessed basic concepts in OR management, and we used the answers to these questions to calculate the following statistics using SPSS (IBM, Armonk, NY) software: the pre- and postrotation examination scores within each group (analyzed with paired t tests), the change of scores between groups, and the pre- and postrotation examination scores between each group (examined with independent t testing).
Seven residents completed the online module and 13 participated in the classroom didactic. The online group had a mean (SD) prerotation examination score of 56% (11%) and a mean postrotation examination score of 86% (8%). The classroom group had a mean prerotation examination score of 51% (22%) and a mean postrotation examination score of 81% (13%). When comparing the postrotation scores in each group, the residents who took the online module had a mean score of 86% on their postrotation examination, and the residents who took the classroom style course had a mean postrotation examination score of 81%. A comparison of their postrotation examination means demonstrated no significant difference between the groups (P = 0.36; 95% confidence interval, −0.06 to 0.16). These results and comparisons of all groups are shown in Table 1.
Traditionally, most anesthesiologists confront the basics of OR management “on-the-job” during their transition-to-practice period. Because the American Society of Anesthesiologists is promoting the Perioperative Surgical Home as a platform to position our specialty in the future, current and future anesthesiologists will need management and leadership skills to confront the changing landscape.1,2 We believe that an OR management rotation that teaches residents the basics of managing an anesthesia health care team and service line is essential because the effective, efficient management of an OR is a large component of the Perioperative Surgical Home. However, for academic programs, a myriad of institutional, financial, and departmental constraints may make it difficult to add an OR management rotation to a resident’s training. With the increasing depth and breadth of clinical anesthesia, the increased number of mandatory rotations, and the balance of case numbers, program directors may have a difficult time finding room in a rigid curriculum. Previously, Dangler et al.3 showed that these nontechnical skills are transferable during residency. In turn, we have shown that our residents are able to acquire the knowledge covered in a web-based tutorial, and we believe that this teaching modality could serve as a platform to build an OR management rotation for academic programs without the local faculty expertise. Future studies could validate the web-based tutorial at other institutions.
Questions from the OR management pre- and postrotation examinations used for comparisons between the 2 study groups. These 8 (of 27) questions had been previously incorporated as knowledge checks in the web module.
- Define underutilized OR time.
- Define overutilized OR time.
- Define OR tardiness.
- What is the approximate “cost” of overutilized OR time?
- Define raw and adjusted utilization rates.
- First case of the day start delays are a popular hospital management tactic when it comes to OR management. Often, the metric followed is the percentage of on-time starts. From a financial perspective, which scenario results in greater institutional costs?
A general surgeon at your institution has approached your anesthesiology group and asked to implement a high-throughput OR. He believes that he can perform an extra laparoscopic cholecystectomy each day by scheduling consecutive laparoscopic cholecystectomies on the same day. He argues that by performing the same type of surgery sequentially, he will reduce the variation in OR setup for the nurses and perioperative management for the anesthesiologists. He currently has a scheduled block from 07:00 to 15:00. His surgical time (skin incision, dressing applied) on average is 75 minutes, and he is able to complete 5 laparoscopic cholecystectomies in a scheduled day. He approaches you, the Vice Chair of Clinical Affairs, and believes that he can perform an additional surgery each day because the new system will save him 15 minutes per case (5 cases multiplied by 15 minutes time savings/case equals 75 minutes). How do you proceed?
The CEO of the hospital is interested in creating an OR dashboard to measure the “efficiency” of the OR. He believes that the current metric using surgeon satisfaction has created a poor, deflated organizational culture and that raw utilization rates have resulted in gaming by certain surgeons. He would like your group to create a set of OR metrics that would be objective, applicable to all individuals in the OR, and serve to ensure the financial footing of the institution. List at least 5 metrics that would enable you to gather data and implement focused, directed changes in the perioperative process.
- a. Three ORs are scheduled for 10-hour days (07:00–17:00). OR 1 and OR 2 each start their first case at 08:00, but both rooms end at 17:00. OR 3 starts at 07:00 and ends at 17:00. This is calculated as a 33% on-time start for the day.
- b. Three ORs are scheduled for 10-hour days (07:00–17:00). OR 1 and OR 2 each start at 07:00 and the rooms finish at 17:00. OR 3 starts at 07:00, but ends at 19:00. This is calculated as a 66% on-time start for the day.
- c. Three ORs are scheduled for 10-hour days (07:00–17:00). OR 1 starts at 08:00 and finishes at 17:00. OR 2 and OR 3 both start at 07:00 and end at 17:00. This is calculated as a 66% on-time start for the day.
a Cooper L, Cobas M, Sinclair D, Boeru M. Transition to practice—PGY4 rotation improves resident understand of practice management skills. Presented at the 2010 Annual Meeting of the American Society of Anesthesiologists. San Diego, CA.
b Busso VO, Mon KS, Mirrer M, Xie YJ, Schwengel D, Mark LJ. Implementation of a novel CA3 assistant coordinator rotation that embraces ACGME core competencies with focus on practice-based learning and improvement and systems-based practice. Presented at the Annual Meeting of the International Anesthesia Research Society. May 2011, Vancouver, British Columbia, Canada.
c https://www.asahq.org/shop-asa/detail?productId=133929. Accessed December 7, 2015.
1. Alem N, Ahn K, Cannesson M, Kain ZN. Perioperative medicine and the future of anesthesiology training. ASA Newsletter. 2015;79:32–4
2. Prielipp RC, Morell RC, Coursin DB, Brull SJ, Barker SJ, Rice MJ, Vender JS, Cohen NH. The future of anesthesiology: should the perioperative surgical home redefine us? Anesth Analg. 2015;120:1142–8
3. Dangler L, Wilkhu H, Mace J, Young E, Daly T, Avigne G, Good M, Mahla M. Transition to practice: a pilot PGY-4 private practice clinical simulation designed to refine and assess ACGME core competencies. J Clin Anesth. 2005;17:676