Block scheduling is a part of many operating rooms’ regular administrative business. Many surgeons work best when given predictable blocks, usually as half days or full days. This gives them the ability to group similar surgeries and personnel, manage their own schedules far in advance, and have a sense of autonomy.
Block scheduling is thus a political win and offers the entire practice some normalcy; it can even make the day-to-day scheduling process as predictable as possible. Nonetheless, the most important goal of block scheduling is to increase a practice’s efficiency (i.e. profitability). That means paying close attention to surgical block utilization: How much of your total blocked time is used for perioperative activities other than surgery? Are some blocks being consistently overbooked, while others are often released at the last minute? Are patients not showing up? These issues don’t have to be giant obstacles. You can solve them without alienating either surgeons or overstressed schedulers.
Definition and Utilization Target
First, it’s important to understand the definition and goals of surgical block utilization. Surgery accounts for around ⅓ of all healthcare spending, which means that the operating room is the profit driver for hospitals and ASCs. The “cost” of operating an OR can vary by procedure for which it is prepared; research indicates an average cost of $37 per minute. When evaluating under-utilization, you must also consider the opportunity cost of missing out on surgeries that could have been charged. Block scheduling provides a proactive solution to lost time because it consolidates cases and surgery types strategically in blocks of time that create the most number of cases possible without overtime.
Still, block scheduling is inherently imperfect because of these factors:
- Every surgery specialty has different needs
- Every surgery, even within a specialty, has different daily variables.
According to Dr. James Allen, Medical Director of Ohio State University East Hospital, all practices use some combination of block and open time to take care of emergent cases and those with less lead time as well. Because of this, he recommends that around 75-85% of total time be “blocked,” while the remaining is left for open scheduling. A common target for each block's utilization, that is total time divided by occupied time, is 80%: The American Hospital Association recommends 75%, while Johnson and Johnson recommends between 75-80%. Improving block utilization percentages is an ongoing project made much easier by new scheduling software available that can create transparency between schedulers, surgeons, and managers.
Blocks are nearly set in stone because they have far reaching consequences for practices that are already doing “okay.” So, before you go changing the macro (weekly) block arrangement, it’s best to solve problems by taking steps to better utilize the blocks as they are. Here are some key areas that affect surgical block utilization.
Surgery Estimates vs. Reality
According to a 2017 OR Manager article on scheduling accuracy, “Surgeons often underestimate total case duration, without incorporating needed time for patient induction, positioning, preparation, patient emergence, room cleanup and subsequent room setup.” Having accurate case estimates is an important KPI because it affects much of the planning, staffing, and utilization of blocks.
According to this research, surgeons often focus on surgical control time (start incision to end incision) when making estimates. Other factors they identified that cause inaccurate scheduling are exacerbated by outdated scheduling processes:
- A procedure code or description may not accurately reflect the details of the surgery
- The forms used to communicate desired surgery times may not be standardized
- Surgeons may be too busy or find it too difficult to double check the schedule in advance (especially if it is not a practice-wide shared interface)
- Day-of-surgery changes can create chaos and may not precipitate changes to the above issues
Monitoring case times and regularly reviewing them can give surgeons a better idea of where they may make estimating errors or simply not account for perioperative activities. Explore this and other ways to create a more efficient operating room here.
Use Release Time
All blocks cannot be full 100% of the time, but if a block is unscheduled, it shouldn't be completely sacrificed. Block releases can help restore balance between over and under-scheduling and catch up on cancelled or emergent cases. One problem for block utilization is that this time is released too late to be usable. The root cause is often inefficient scheduling communication (this can be addressed by real time scheduling software). For example, joint replacement surgery blocks could often be released two weeks in advance because they have such a long lead time. Cardiac surgery blocks, which are obviously more time critical, may not be released until one day prior to surgery.
Fill Open Time by Implementing Better Scheduling Processes
Release time becomes part of “open time” or the remaining blocks of time that are not designated for any particular surgeon. Some open time is regularly blocked into schedules as a way to give new surgeons or infrequent surgery types a slot. Dr. Allen recommends that open time available in an automated way. That means there aren’t messy communication threads and negotiations, but perhaps an interface with forms and rules. He also emphasizes the need for open time to be accessible to newer surgeons to prevent out-migration.
Scheduling software can provide a master view of the statuses of both pending cases (to help schedulers determine when to release time) and availability of newly opened blocks. Automated messages are triggered when statuses change. This takes the inefficiency out of open-time requests. In a busy practice with many surgeons, each with independent block release rules, without real-time visibility of available operating room time, it can be very challenging to optimize operating room resources.
Give Surgeons Agency in Scheduling
Although surgeons may underestimate total case duration, they can, in fact, overestimate their own surgical control time. This can be confounding, as they are either incurring overtime or leaving a good portion of a block unused because of other variables. If surgeons have better access to the surgical schedule, they can be partners in creating solutions. A point-of-care scheduling tool is one way they can communicate nuances of cases and make notes to guide future scheduling in real-time. Communicating relevant knowledge to PACU staff, nurses, equipment vendors, and schedulers earlier in the process increases opportunities for optimization. Surgeons and their schedulers may gain insights into better sequencing of cases by reacting to data made available.
Prep Reliable Patients
Endoscopy no-shows can range from 12 to 24% This is one of the inevitabilities of elective surgery. No-shows are a persistent revenue loss for surgical practices. Although they plague block time scheduling accuracy, the rates can be improved. According to Marbough's article Evaluating the Impact of Patient No-Shows on Service Quality, “ Forgetting about the appointment, patient scheduling conflicts, and miscommunication were found to be the most common causes of patient no-shows in various healthcare settings.” It would be a shame to alter the block of a surgeon because of preventable no-shows. The same study noted previous research in which no-shows were reduced from 20% to around 7% simply by using pre-scheduled telephone reminders.
Scheduling software automates AI-based patient messaging through email, text or phone, depending on the patient’s preferences. This can alert the scheduling staff to patient confusion, at which time they may be able to answer critical questions and gauge the potential for no-shows. Software can also help mark the risk of a no-show in the schedule.
Start At Start Time
Full-day blocks are carefully planned with little margin for error. A recent study from Pediatric Quality and Safety noted that reviews found 50-85% of first cases don’t start on time and are delayed by around 30 minutes on average. The common causes are logistics and communication: surgeon/staff availability, delayed patient registration, congestion in preoperative areas, and transportation issues. It can be difficult to outwork a late first case. Improve start times, and you can improve block utilization rates. Communication is inherently difficult among the many stakeholders of an OR, but new software tools integrate communication with scheduling and make all relevant knowledge a click away in the operating theatre.
If your practice could stand to improve surgical block utilization, consider implementing our scheduling and communication software to multiply your efficiency efforts.