OVERLAPPING SURGERIES Room flipping lets your surgeons do more cases and, if managed properly, can decrease your staff overtime rates.

Not long ago, flip was a four-letter word at our surgery center, but that's all many of our busier surgeons wanted to do: flip cases in a second operating room. For them, it was all about doing more cases in less time — not sitting in the doctor's lounge waiting for a room to turn over.

We resisted letting our surgeons run 2 rooms for as long as we could, concerned that the long days and the late hours would take a toll on our staff. But we knew that if we didn't let our docs flip rooms, we'd be in danger of losing them to a competitor willing to accommodate them. Two years ago, we finally conceded, but not before working with our docs to set up strict guidelines on when we'd flip rooms. Rather than rush in, we wanted to ensure that overlapping surgeries would be efficient for us as well as for our doctors. Our overriding principle: Be selective. You don't want to flip every doc and every case. Here are 5 factors that help us decide.

1Is case length equal to turnover time? We prioritize flipping for cases where the turnover time is similar to the case duration. It makes sense to flip a 15-minute hand case that has a 10- to 15-minute turnover time because a surgeon can do another hand case in OR 1 while OR 2 is being turned over. On the other hand, it wouldn't make sense to flip knee arthroscopies where case duration is 60 to 90 minutes and turnover time is about 30 minutes. There'd be too much standing around. Our surgeons have learned to book cases that fit our flipping criteria on days when we are most likely to have a second room available. When the surgery is considerably longer than the turnover, they know to book them for the start or end of the day.

2Exceptions to the rule. In general, we don't allow flipping if the team will be more than 90 minutes between cases, for cases longer than 60 minutes or for cases with significant variability in duration, but we'll make exceptions.

We'll consider flipping longer (more than 60 minutes) cases when we place a regional block. When you factor nerve block placement into turnover time, adding the 10 to 20 minutes it takes to place a block in pre-op extends the turnover long enough for us to consider a room flip. We can also adjust case duration expectations if a physician assistant is available to close, freeing the surgeon up earlier for another room.

3Schedule pacing. Don't let your doctors drive room flipping; they'll flip at all times and under any circumstance. Our medical director and team lead meet Thursday afternoon to review the next week's schedule and identify the flip days. Before the flipping begins, book longer cases as the first or last case of the day (bonus staff savings: If you do a 90-minute case to start the day, team No. 2 doesn't have to come in until 15 minutes before the second case starts), and then schedule a bunch of "flippable" cases throughout the day. Flip long cases together and short cases together. For example, we schedule all of our short cases for Monday afternoon because we know we're going to be able to flip them.

4Hybrid room flips. You can use different types of room flipping for different situations. When available, a full team can flip in a new room. If a second anesthesia provider is not available, a full second team of facility staff may set up in a new room with the anesthetist flipping along with the surgeon. Finally, if the case duration is longer or staff are not available, you can use a partial room flip where just one staff member sets up a new room while the procedure is going on in the first.

5Staff mentality. The most important part of our success has been a mindset shift amongst our staff. Staff used to go home early if they were lucky enough to get a short room, while their unhappy co-workers had to finish out a long night in the OR. While this worked out great for staff when they had the short room, nobody liked the days they had the long rooms. Our protocols changed to keep staff in the facility to flip cases in the late room once the early rooms finish. This helped us transition from a me-first mentality where some staff had easy days and some had incredibly hard ones, to a team-first mentality where everyone works together so that nobody has to have a terrible day. Over the course of 2 years, the number of ORs running past 5 p.m. fell from 26% to 9%.

Why'd we wait so long?
It's been 2 years since we started room flipping. It has let our surgeons do more cases, but to do so within the hours that we could provide staff. We dramatically increased our daytime block utilization while decreasing our after-hours work and cutting our overtime rates almost in half — all while our case volume rose by more than 300%. Best of all, we've done it without increasing room wait times, having actually cut our turnover times by 14%.

We don't flip every surgeon for every case. There's always the danger that improperly scheduled room flipping can create wait times for anesthesia and facility staff, or that the other case takes longer than anticipated. Room flipping is an art form that requires delicate balance and a deft touch. If done correctly, though, it can improve your operations, and be a huge satisfier for your physicians. OSM