Block Scheduling Diplomacy

Anesthesia

By: John Olmstead

Published: 2/9/2008

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A 3-step plan to keep your ORs busy - and your surgeons happy.


Routinely reserving blocks of OR time for selected surgeons is a great idea. A surgeon can operate efficiently on one day as opposed to over several days, getting patients into the OR without a maze of scheduling. Block time also financially benefits your facility, since easy access to the OR encourages a surgeon to perform more cases there.

It's a win-win situation - unless the time you've committed to a surgeon ends up persistently misused or underused. Then it's a drain on your facility and a hindrance to other surgeons. Here's my strategy for releasing and reallocating block time, through realistic measurement and trial schedules, without antagonizing your surgeons or jeopardizing your employment.

The dream and the headaches
In concept, block-time scheduling is as simple as it is efficient. You hand out blocks to high-volume surgeons and monitor their OR usage. If usage consistently drops below 80 percent, you erase the surgeon's standing reservation. Case closed: the OR time will be available for other surgeons' use, and the surgeon losing the time won't care, since he wasn't using it. Right?

Wrong. You can't afford to ignore block time's value as one of your facility's perks. Would you strip a physician of his assigned OR locker or parking privileges? I don't know where you work, but at our community hospital, physicians won't take too kindly to a use-it-or-lose-it policy.

You'd be better served by adopting a policy of accuracy and diplomacy. In dealing with block time over the past seven years, I've developed a process that I've found to be 100 percent successful. I've been able to rescind every schedule block that I wanted to remove without generating a single complaint.

Get a handle on measurement.
Measure block-time usage weekly, with setup and teardown turnover times included, since surgeons shouldn't be penalized for the minutes involved in their undertaking. Have your surgery schedulers routinely call surgeons' offices to find out their vacation schedules as soon as possible. That way you can release the affected blocks early for first-come-first-served use, and not record the unused time as unused block time.

It's not a good idea to publicize a usage quota. Also, be realistic about block time measurement. You won't be able to identify every surgeon's vacation time, which will unintentionally reduce the measured percentage of filled block time. Cancelled cases will do the same thing. With these measurement inaccuracies, you can't in good conscience employ a high-usage expectation to dole out block times to your surgeons.

Careful When You Touch That Block Time

The simple view of setting usage expectations and rearranging block time doesn't take into account the clashing aims of surgeons, surgical services directors and administrators or the misuse of block time allocation. Here are some common problems:

  • The poorly created schedule. Block time is a sales tool used to increase business. However, it is often used as a political tool, with the most influential surgeons granted blocks while others are left off the list. In many instances, the influential surgeons are in fact the highest-volume ones, but some blocks are given to surgeons with slower practices or commitments elsewhere.
  • Incorrectly monitored usage. Recording a surgeon's scheduled OR time instead of the actual time it takes to complete a case, neglecting to note a surgeon's vacation as the reason for an unused block and failing to factor in case cancellations and turnover times are just a few ways in which surgeons can be unfairly penalized.
  • The busy surgeon with low block-time usage. He schedules cases in advance, but not in his block time slot, which he saves for any possible urgent cases that would otherwise have to be performed as add-ons later. Given the business he brings to your facility, he'll object to plans that make his scheduling more difficult.
  • The politically connected surgeon. He holds three blocks a week, each one with an average use of 45 percent. The OR director pitches a plan to consolidate his time down to two blocks a week. The surgeon phones the administrator. At best, the decision is reversed. At worst, the OR director's longevity is now on the table.
  • Surgeons exempt from usage expectations. Sometimes the OR director knows the block time will go unused but arranges it anyway, as in the case of a traveling specialist or a new surgeon building a practice alongside a soon-to-retire surgeon.

— John Olmstead, RN, MBA, FACHE

Identify and approach low-percentage users.
Due to measurement inaccuracies and the delicate politics of revoking block time, focus on surgeons using less than 50 percent of their block time over a period of three to six months. Pay particular attention to obvious non-users who reside in the 30 percent to 40 percent zone.

The successful revocation of block time is fully dependent on your approach, which must be framed as an attempt to improve service to the surgeon. The surgeon is going to be defensive, no matter what, since he has no real incentive to change practice, so your approach must be as inoffensive as possible.

Meet with the surgeon face-to-face in a private setting.
Ensure that he understands that his business is appreciated by you and your staff. Explain your role in meeting his needs and address the possibility that his needs might be better served by an alternative scheduling arrangement.

Propose a four-week trial during which you convert his reserved block time to first-come-first-served OR time. The surgeon will still be able to schedule cases with morning start times. He'll also have better access to same-day, add-on start times, as cases that would normally interfere with add-on cases could be performed earlier, freeing OR teams to attend to the surgeon's add-on cases.

For your part, commit to speaking with the surgeon's scheduler several times a week, to gauge her level of ease or difficulty in scheduling cases. At the end of the four-week trial, if the scheduler reports difficulties in scheduling, end the trial and return the surgeon's block time. If the scheduler hasn't experienced difficulties, on the other hand, you and the surgeon should agree to remove his reserved block or at least enter into another four-week trial.

What Doesn't Work

Duck and cover. Ignoring the problem and hoping it goes away is simple and clears your plate for other issues. Why take the risk of insulting a low-usage surgeon? This works fine as long as no other surgeons have trouble accessing the OR schedule. If they do, however, they'll be plenty irate at surgeons wasting precious OR time, and the facility that allows them to do so. Then you're insulting your more productive surgeons.

The surgeon council. Gather the busiest surgeons together, let them dictate the block time usage percentage expectation and give them the responsibility for dealing with low-usage surgeons, absolving the OR director and administrator of any blame for block removal. I'll admit, this solution works well in an ASC, where surgeon-partners control partnership expectations. In the community hospital setting, though, it works about as well as letting staff regulate their own attendance policy. Even if a group of hospital surgeons could agree on usage expectations, they'd be hard-pressed to penalize a colleague. Net result: it's still the OR director's problem. Learn to deal with it.

John Olmstead, RN, MBA, FACHE

Why this works
In my experience, I've found that this approach avoids insult, since most surgeons will feel that the trial seems like a reasonable idea. It also guarantees your success, regardless of the outcome.

The surgeon won't notice any decrease in access to the OR schedule during this trial. After all, his lack of use led to this planned intervention in the first place. But you haven't just yanked his block away from him. And if the surgeon does happen to have scheduling difficulties, you can simply end the four-week trial, which will solidify your facility's commitment to the surgeon and prevent the surgeon from complaining to you.

While no process is guaranteed to be 100 percent risk-free, this one has let me remove all the unused block time I wanted to revoke and has generated zero administrative complaints. You'll serve your facility's mission while preserving good relations between the surgeon, you and your facility.

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