Predictors of operative time during radical retropubic prostatectomy and robot-assisted laparoscopic prostatectomy.

OBJECTIVES: To better predict operative time using patient/surgical characteristics among men undergoing radical retropubic prostatectomy or robot-assisted laparoscopic prostatectomy in order to achieve more efficient operative scheduling and potentially decrease costs in the Veterans Health System. METHODS: We analyzed 2619 men treated with radical retropubic prostatectomy (n = 2005) or robot-assisted laparoscopic prostatectomy (n = 614) from 1993 to 2013 from six Veterans Affairs Hospitals in the Shared Equal Access Regional Cancer Hospital database. Age, body mass index, race, biopsy Gleason, prostate weight, undergoing a nerve-sparing procedure or lymph node dissection, and hospital surgical volume were analyzed in multivariable linear regression to identify predictors of operative time and to quantify the increase/decrease observed. RESULTS: In men undergoing radical retropubic prostatectomy, body mass index, black race, prostate weight and a lymph node dissection all predicted longer operative times (all P ≤ 0.004). In men undergoing robot-assisted laparoscopic prostatectomy, biopsy Gleason score and a lymph node dissection were associated with increased operative time (P ≤ 0.048). In both surgical methods, a lymph node dissection added 25-40 min to the operation. Also, in both, each additional operation per year per center predicted a 0.80-0.89-min decrease in operative time (P ≤ 0.001). CONCLUSIONS: Overall, several factors seem to be associated with quantifiable changes in operative time. If confirmed in future studies, these findings can allow for a more precise estimate of operative time, which could decrease the overall cost to the patient and hospital by aiding in operating room time management.

Your scarcest resource.

Most companies have elaborate procedures for managing capital. They require a compelling business case for any new capital investment. They set hurdle rates. They delegate authority carefully, prescribing spending limits for each level. An organization's time, by contrast, goes largely unmanaged. Bain & Company, with which all three authors are associated, used innovative people analytics tools to examine the time budgets of 17 large corporations. It discovered that companies are awash in e-communications; meeting time has skyrocketed; real collaboration is limited; dysfunctional meeting behavior is on the rise; formal controls are rare; and the consequences of all this are few. The authors outline eight practices for managing organizational time. Among them are: Make meeting agendas clear and selective; create a zero-based time budget; require business cases for all initiatives; and standardize the decision process. Some forward-thinking companies bring as much discipline to their time budgets as to their capital budgets. As a result, they have Liberated countless hours of previously unproductive time for executives and employees, fueling innovation and accelerating profitable growth.

Working women households and time-saving consumption: empirical evidence from Kerala.

This article explores the impact of labour force participation of Indian women on the consumption expenditure of their households. Field survey data were collected from working-wife and non-working wife households in Kerala, the state in India with the highest labour market participation of women in the organised sector. Differences in time-saving consumption expenditures of working and non-working wife households and different variables influencing consumption expenditures were researched. The study shows that among the variables which positively affect the time-saving consumption expenditure of the households, non-economic factors influence the time-saving consumption expenditure of the working-wife households more prominently than in non-working wife households.

Redesign of a pediatric pharmacotherapy elective course to accommodate budget reductions.

OBJECTIVE: To redesign a pediatric elective pharmacotherapy course and determine whether the redesign resulted in changes in outcome measures. DESIGN: Active learning activities were moved to an online format. Prerecorded lectures continued to be used. Peer evaluation was incorporated to give the students more feedback on their performance. ASSESSMENT; Presentation grades, average examination grades, course grades, and evaluation scores from each student who completed University course evaluations were documented for students during the 2 semesters before and the 2 semesters after the course redesign. Although for undetermined reasons a drop in examination grades occurred after the course redesign, no significant differences in presentation grades, final grades, or course evaluation grades occurred. CONCLUSIONS: A strategic course redesign successfully reduced the costs and faculty time required to offer an elective course viewed as essential to the curriculum, allowing the course to be continued in the face of state budget cuts.

The effect of the Operating Room Coordinator's risk appreciation on operating room efficiency.

BACKGROUND: The Operating Room Coordinator (ORC) is responsible for filling gaps in every operating room (OR) schedule. We have observed differences among the personalities of the four ORCs with regard to their willingness to agree to assume more risk concerning their daily planning. The hypothesis to be tested is that the relationship between the personality of each of the four ORCs and the risk an ORC is willing to take of cases running late affects OR efficiency. METHODS: In order to judge the personality of an ORC in relation to risk-taking in planning schedules, we applied the Zuckerman-Kuhlman Personality Questionnaire in our study. Seven anesthesiologists were asked to score every ORC on willingness to take risks in planning. To analyze which risk attitude creates more OR efficiency, the daily prognosis of the ORC compared with the actual OR program outcome was registered during a 5-mo period in 2006 and 2007. We analyzed whether, in the opinion of hospital management, the costs of reserving too much OR time balances with the costs of reserving too little OR time, and whether this result is consistent with the assignment of the management tasks of the ORC. RESULTS: Seven anesthesiologists classified the four ORCs into the risk-averse group (n = 2) and the nonrisk-averse group (n = 2). The Zuckerman-Kuhlman Personality Questionnaire results for risk-seeking indicate that there is a difference in risk appreciation among the different ORCs. The main finding in our study is that the nonrisk-averse ORC plans to fill the gaps in more cases in the OR program than the risk-averse ORC does. The number of extra cases performed by the nonrisk-averse ORC as compared to a risk-averse ORC is 188 in 2006 and 174 in 2007. The average end-of-program-time per OR/day for the nonrisk-averse ORC is 34 min (+/-19 min, P = 0.0085) later than for the risk-averse ORC. We find that this hospital on average reserves more OR time for procedures than is actually required. The nonrisk-averse ORC takes more advantage of that extra OR time than the risk-averse ORC does by scheduling extra cases during office hours. The success of the nonrisk-averse ORC can be linked to the fact that there is usually time available due to this over-reserving. CONCLUSIONS: The conclusion of this study is that a nonrisk-averse ORC creates significantly less unused OR capacity without a great chance of running ORs after regular working hours or canceling elective cases scheduled for surgery compared to a risk-averse ORC.

Typical savings from each minute reduction in tardy first case of the day starts.

BACKGROUND: Analysts and clinicians sitting in operating room (OR) committee meetings cannot evaluate rapidly whether a suggested idea to reduce delays in first case of the day starts can be beneficial economically. METHODS: Three years of data were used from a six OR outpatient surgery facility. The cost reduction from reducing the tardiness of start of first cases of the day was calculated using the method of McIntosh et al. (Anesth Analg 2006;103:1499-516), limited to ORs with at least 8 h of cases and turnovers. Results were then reported per minute reduction in tardy first case of the day starts as an approximation for rapid use in meetings. RESULTS: Each 1.0 min reduction in the tardy starts of first cases of the day in ORs with more than 8 h of cases and turnovers resulted overall in 1.1 +/- 0.1 min reduction in regularly scheduled labor costs (mean +/- se). This result was close to the 1.2 min obtained using an entirely different (simulation) method performed previously for OR time reductions. Secondary analyses confirmed that assumptions were satisfied at the facility, thereby reducing the chance that results are biased. For example, the proportions of the variance in tardiness attributable to anesthesiologists and specialties were only 1% and 3%, respectively, and there were no significant differences in tardiness among the 85 anesthesiologists or 14 specialties. CONCLUSIONS: Typical savings for reducing tardiness of first case of the day starts at a surgical suite equal the product of four values: i) 1.1 min reduction in staffed OR time per 1 min reduction in tardiness, ii) estimate for reductions in tardiness (min) per OR, iii) number of ORs at the suite with more than 8 h of cases, and iv) sum of the average compensations per regularly scheduled minute for personnel in each OR. If small, the analyst and/or clinician can promptly speak up and refocus group conversation toward other potential interventions. If large, the full return on investment analysis would be performed.

Both bias and lack of knowledge influence organizational focus on first case of the day starts.

BACKGROUND: The economic costs of reducing first case delays are often high, because efforts need to be applied to multiple operating rooms (ORs) simultaneously. Nevertheless, delays in starting first cases of the day are a common topic in OR committee meetings. METHODS: We added three scientific questions to a 24 question online, anonymous survey performed before the implementation of a new OR information system. The 57 respondents cared sufficiently about OR management at the United States teaching hospital to complete all questions. RESULTS: The survey revealed reasons why personnel may focus on the small reductions in nonoperative time achievable by reducing tardiness in first cases of the day. (A) Respondents lacked knowledge about principles in reducing over-utilized OR time to increase OR efficiency, based on their answering the relevant question correctly at a rate no different from guessing at random. Those results differed from prior findings of responses at a rate worse than random, resulting from a bias on the day of surgery of making decisions that increase clinical work per unit time. (B) Most respondents falsely believed that a 10 min delay at the start of the day causes subsequent cases to start at least 10 min late (P < 0.0001 versus random chance). (C) Most respondents did not know that cases often take less time than scheduled (P = 0.008 versus chance). No one who demonstrated knowledge (C) about cases sometimes taking less time than scheduled applied that information to their response to (B) regarding cases starting late (P = 0.0002). CONCLUSIONS: Knowledge of OR efficiency was low among the respondents working in ORs. Nevertheless, the apparent absence of bias shows that education may influence behavior. In contrast, presence of bias on matters of tardiness of start times shows that education may be of no benefit. As the latter results match findings of previous studies of scheduling decisions, interventions to reduce patient and surgeon waiting from start times may depend principally on the application of automation to guide decision-making.

High-throughput operating room system for joint arthroplasties durably outperforms routine processes.

BACKGROUND: Recent publications have focused on increased operating room (OR) throughput without increasing total OR time. The authors hypothesized that a system of parallel processing for lower extremity joint arthroplasties sustainably reduces nonoperative time and increases throughput. METHODS: The high-throughput parallel processing strategy included neuraxial anesthesia performed in an "induction room" adjacent to the OR, patient selection, an additional circulating nurse, and end-of-case transfer of care to a recovery room nurse who transported the patient from the OR to recovery. Instruments and supplies were prepared in a dedicated sterile setup area. Data were extracted from administrative databases. Group comparisons used standard statistical methods; statistical process control was used to evaluate performance over time. RESULTS: There were 688 historic control cases from 299 days over 16 months, and 905 high-throughput cases from 304 days spanning 24 consecutive months starting September 1, 2004. Throughput increased from 2.6 +/- 0.7 (mean +/- SD) to 3.4 +/- 0.8 arthroplasties per day per room. Nonoperative time decreased by 36 min (or 50%) per case. Operative time also decreased by 14 min (12%) per case. The end time for the high-throughput OR day was only 16 min later than control. Nonoperative time, operative time, and throughput remained significantly improved after 2 yr of operation. Contribution margin increased 19.6%. CONCLUSION: Reorganizing the perioperative work process for total joint replacements sustainably increased OR throughput. Because joint arthroplasties generated a positive margin greater than the incremental cost, the high-throughput system improved financial performance.

The balancing act: patient care time versus cost.

BACKGROUND: With demands to improve patients' clinical outcomes and decrease the escalating costs of inpatient care, nurse executives are focusing on how nurses spend their time rather than just raising staffing levels to positively impact patient outcomes. Because nursing wages constitute a high proportion of a hospital's budget, understanding the costs of nursing activities is critical to managing them. METHODS: An activity-based costing approach was used in 14 medical-surgical nursing units to study nursing activities and their related costs. Time use for 4 patient care activities (assess, teach, treat, provide psychosocial support) and 2 support activities (coordinate care and manage clinical records) including the percent of non-value-added (NVA) time for each of these activities was identified through focus groups, interviews, and timed observations. Annualized wage costs were assigned to these activities to determine average wage-related costs of each activity as well as NVA-related costs. RESULTS: More than one-third of nurses' time was considered NVA, averaging dollars 757,000 per nursing unit in wage costs annually. Nurses spent more time on support activities (56%) than in providing patient care (44%), with the least amount of time being spent on patient teaching and psychosocial support. CONCLUSION: Findings indicate a huge opportunity to both improve clinical outcomes in these units and, at the same time, reduce costs by focusing on processes to reduce the high amount time spent performing NVA and support activities and increase patient care time, particularly patient teaching and psychosocial support.