Surgical operating rooms are operationally quite complex, so it's a challenge for nonclinician executives to get an accurate picture of performance. However, deploying as a lens Leo Tolstoy's famous observation that: "Happy families are all alike; every unhappy family is unhappy in its own way," executives with different backgrounds readily can benchmark their own facilities against the top performers.

To get started, then, the critical questions are: "What is meant by ‘top performer'?" and "What do all top-performing operating rooms have in common?" Although my experience working with ORs nationwide has demonstrated the value of applying metrics to performance, as well as choosing metrics, many of the steps below start with a simple eyeball test of whether an OR operates like a top performer.

In ORs, top performance may relate to indicators of operational excellence, fiscal performance, growth (in market share), clinical outcomes and, in academic hospitals, even teaching or research excellence. Here we focus on operational excellence, because fiscal performance and growth often accompany operational excellence. We'll leave the matter of clinical outcomes performance to the medical staff.

The three foundations for operational excellence in top performers are leadership, management and core processes.


If executives imagine for a moment that their OR is a major "business within a business" (with annual revenues in the tens or perhaps hundreds of millions each year, with perhaps hundreds of professional employees), shouldn't a business on this scale have an equally impressive leadership structure? Unfortunately, many hospitals can't answer yes.

Thus, top-performing OR leadership begins with a board, i.e., an interdisciplinary group of leaders with a fiduciary orientation, including surgeons and anesthesiologists, OR nursing directors and managers, and hospital administrators. The board members should be role models: flexible thinkers, good negotiators, individuals who are able to see the big picture and who avoid getting mired in details.

Like any successful company's board, the OR board should conduct the following: establish and enforce policy, set and monitor OR capacity, support OR management's plans (not tear them down, as happens so often!), focus on process improvement and, above all, communicate with a single voice. The board should meet as frequently as the OR's size and importance dictates. Leaders also must set targets for key performance metrics and perhaps even adopt an OR dashboard — the specific panel of operational, safety and service metrics that typify a top-performing OR.

The OR board should be forward-thinking, define a set of goals for the year and welcome discussion about longer-term issues. Above all, the board must act in unison; there naturally will often be differences of opinion, but once a consensus is reached, the entire board must be supportive.


Managers focus on maintaining OR functions as efficiently and safely as possible. Top-performing ORs, however, understand that there are two distinct varieties of OR management. The first often is called the daily OR charge team. This team handles real-time, short-range decision-making in the ORs, much like the fast-moving, fluid management of air traffic controllers or basketball coaches. The charge team executes the daily OR schedule, which involves making decisions about early morning staff "call-offs" (days off on short notice) and add-on cases, coping with midday demands such as lunch and other staff breaks, and avoiding the "witching hour," when OR capacity appears to shrink at the end of a work shift.

The charge team members should be metrics-driven, have a strong working knowledge of OR policies, and possess high-level negotiating skills so their judgments are highly respected by the numerous stakeholders. Charge teams typically include a nurse, anesthesiologist and, more recently, even a surgeon to collaborate on these real-time decisions.

The second variety of OR management involves an OR director and clinical and departmental managers who are making more long-range decisions. Their responsibilities include developing job descriptions, making performance evaluations, recruiting and educating staff (including subspecialty RNs and support staff), and managing core processes (see below).

Top-performing ORs recognize the differences between these two varieties of OR management and place separate emphases on each. Clearly, the skills required to manage real-time issues are quite different from managing long-range issues and staffing. Leaders of top-performing ORs understand that it's unusual for a single individual to be suited to both types of management and will recruit accordingly.

Core Processes

Certain core processes are common to every OR, including case scheduling, preoperative preparation, materials management, sterile processing, and staff recruitment and education. Top-performing ORs aggressively manage these processes, even though their functions may fall, at least in part, under the jurisdiction of managers who work outside of the OR.

Take scheduling. A top-performing OR recognizes that the scheduling office also may book non-OR procedures as well as connect each case to the materials management group (to order the necessary supplies), preoperative clinic appointments (to prepare each patient medically), insurance pre-certifications, and hospital bed management (to prepare for proper postoperative care). With such heterogeneous responsibilities, top-performing ORs invest enormous energy in identifying and preventing potentially critical disconnects. Similarly, in the preoperative preparation clinic, top-performing ORs meticulously define who is responsible for clearing patients for surgery (the person who reacts to abnormal lab tests, decides on the need for consultants or responds to changes in patient status).

Using these leading practices as a template, executives can systematically evaluate their own OR's strengths and weaknesses. The return on investment will be substantial, and though the journey may have some challenges, your first step is as simple as following the leaders.

Len Firestone, M.D., is the medical director of perioperative services at Health Inventures in Boulder, Colo.