I am not of the opinion that block scheduling, ingrained as it may be at most surgical facilities, is the be-all and end-all of effective OR management. While block scheduling is theoretically designed to bring order to the chaos of the typical OR, it may produce the unintended consequence of dampening growth in the room.

Case in point: Recently a hospital administrator invited me to join the professional staff of his well-respected, recently updated and expanded hospital. What I subsequently learned, though, is that virtually all of his hospital's OR time is blocked and therefore only the least attractive OR starting times (2 p.m. and later) are available — and only on short notice as well — to any new surgeon, such as myself. While most surgeons are happy to operate anytime (since most surgeons are happiest when operating), I suspect that few surgeons would be attracted to a facility that eliminates any possibility of an early OR starting time.

Block scheduling, as it is traditionally structured, is not as elastic as it probably should be to accommodate the diversity of today's surgical practices. Let me suggest the following considerations to those of you who are charged with assigning blocks of OR time to surgeons:

• Block by surgeon or by specialty? To what does the nature of the surgical specialty better lend itself: block scheduling by individual surgeon or block scheduling by specialty? At a hospital with which I am associated, the cardiac surgeons are extremely busy, in need of OR access literally 24/7. Yet the clinical activities of any individual cardiac surgeon fluctuate from week to week: busy this week, not so busy next week and so on. Consequently, blocks of OR time are reserved for cardiac surgery but not for individual cardiac surgeons. Time is always available to any cardiac surgeon, but on a first-come-first-served basis.
• When to release a block? Is the release time for blocks of OR time, whether surgeon-specific or specialty-specific, realistic? And should it be uniform across the board? As a plastic and primarily cosmetic surgeon, I tend to schedule surgery two weeks or more in advance, virtually never scheduling surgery at the last minute. Holding OR time for me until one or two days beforehand really doesn't benefit me and may prevent another surgeon from using OR time I won't use, leading in turn to reduced OR productivity. On the other hand, a general surgeon whose caseload includes patients whose surgical needs are urgent or emergent would benefit by a ???release time' much, much closer to his block of OR time.
• Is a safety valve built into the OR schedule? By "safety valve," I mean a way to accommodate last-minute emergencies, patients whose medical conditions necessitate a specific OR time (for example, early a.m. for diabetic patients) or patients who are able to proceed with surgery only on a specific day (for example, college students home on vacation). Most of the facilities with which I am associated maintain an open room, scheduled on a first-come-first-served basis (with allowances for last-minute emergencies, of course), to accommodate such patients.
• Out with the old, in with the new. Surgeon seniority has its privileges, but OR viability and growth depend on the influx of new surgeons and new surgical procedures. The ability to integrate them into an existing OR schedule benefits everyone. Are already-assigned blocks of OR time subject to modification as new surgeons and new technologies impact the OR?

A happy medium
The OR can be a profit center if well-managed or a black hole if mismanaged. Simply stated, OR time should be scheduled to maximize productivity of OR personnel (including and especially surgeons) and use of OR space, instrumentation and equipment, with equal regard to the comfort and concerns of patients, who, after all, are the OR's true customers.