Nobody Owns the OR
resource allocation without turf wars

Dennis Jeanes
Special to the Canadian Orthopaedic Association

Relaxing in early April, after an afternoon round of golf in the Florida sunshine, Dr. Joe Hyndman doesn't take much prodding to air his views on a favourite topic: how to allocate OR resources in an equitable and accountable fashion. For the past five years, he and his surgical colleagues have been doing just that at the IWK Medical Centre in Halifax. Turns out "it's a very complicated problem that isn't so complicated."

Although Hyndman is the first to say that what works for his relatively small paediatric hospital may not be easily transferable to other larger institutions, he notes, "things get just as emotional, I can assure you, as in the biggest hospitals. Surgeons are advocating for their patients. I understand that, having done it for years, myself. But the fact is, we're not helping the system, and the system is going down the tubes."

With more than 30 years' experience as an orthopaedic surgeon, Hyndman can take the long view on the "system" and its shortcomings. While he remains a strong supporter of public health care , he faults many of the major institutions managing it - governments, medical faculties, hospitals - for failing to do due diligence, for spending millions based on poor assumptions, political pressure and following the path of least resistance.

How else to explain why newly graduated orthopaedic surgeons (of which there are too few) can't find a job in Canada - despite the fact that joint arthroplasty is undoubtedly one of the most effective treatments in modern medicine and that hospitals are swamped by patient demand for joint replacement?

And why is it, Hyndman asks, that almost all the priority wait-time areas involve access to surgical services? It's because "cutting surgery is the easiest thing to do. Surgery is predictable and expensive. You can save money. Why, you'd make your budget every year if you didn't have to do any surgery."

According to Hyndman, the current paradigm of reducing patient wait times to meet pre-set benchmarks needs to be turned around: "It doesn't matter how many cases are on a surgeon's wait list, it's how many OR hours are available. That's what we need to measure and plan for." Long wait times, he says, get their start in the OR, since how long a patient waits is really determined by allocation of OR resources. And, as everyone knows, there is no more hotly contested piece of turf than an OR.

"I was the chair of the peri-operative group at IWK," Hyndman recalls, "and it was chaos. Every single person - and this happens everywhere, I'm sure - wanted more. They were convinced that they needed more. The meetings were passionate, and people would get upset. And yet, they had no data whatsoever to support their claims. I couldn't stand that."

So Hyndman set out to convince his fellow surgeons to grasp the nettle and admit it was their collective responsibility to show leadership and serve their patients better: "You can't manage surgical resource allocation unless it's done by all the surgeons, or at least their division chiefs, otherwise there's no buy-in." Eventually everybody agreed on a number of governing principles. First and foremost, nobody owns the OR. It's a resource that responds to the needs of the community. Second, the wait lists must be centralized, and they must be clean: "All the paperwork had to be done. And the patient had to be waiting for surgery. Period. It couldn't be that the patient might need surgery some day, or that the braces were coming off some time next year."

Next a working group of surgeons began collating and anayzing the hospital's OR utilization data - the type of surgery, when the patient entered the OR, when the surgeon entered the OR, what time the anesthesia was applied, when the first cut was made, when the surgeon left the OR, when the patient left the OR -"all that data that nobody looks at unless there is an issue." With retrospective OR data, they were able to determine the actual time the patient waited as opposed to the predicted time they were going to wait. They could also establish how long the surgeons actually took to perform a procedure. As a result, surgeons were only allowed to book OR time according to their historical record. If a surgeon claimed he could do a given procedure in an hour but the data showed otherwise, he was obliged to book the OR for the actual time. Some feathers were ruffled to be sure, but it's difficult to argue with the record. Ultimately the benefits of the new approach to allocating OR time compensated for the bruised egos.

Hyndman started routinely presenting quarterly OR data to the peri-operative group. Resources were then allocated for the next quarter according to OR data, community need and surgeon consensus. He stresses that for this approach to work, "it has to be the surgeons taking responsibility. They have to be committed. They have to believe the data and in the fairness of the process. And if they are burned - if we made a mistake or created a new problem by fixing an old one - they have to believe that the OR time will soon come back to them if they need more."

One of the pleasant surprises from this approach, Hyndman notes, is that meetings are now very collegial, with surgeons offering up OR time because they will be travelling or going on holidays. Another unexpected outcome is that, after five years, "we've never had to go to the institution to say that we cannot manage with the resources we have. We're very close to the edge. We're very efficient, and I think we'll probably need more resources soon. But when we do make that request, we'll know how many FTEs we need and in what fields they're needed. We'll have utilization data that speak volumes."