title: Enhancement opportunities in operating room utilization; with a statistical appendix.
abstract: BACKGROUND
  The purpose of this study was to assess the direct and indirect relationships between first-case tardiness (or "late start"), turnover time, underused operating room (OR) time, and raw utilization, as well as to determine which indicator had the most negative impact on OR utilization to identify improvement potential. Furthermore, we studied the indirect relationships of the three indicators of "nonoperative" time on OR utilization, to recognize possible "trickle down" effects during the day.
  
  
  METHODS
  (Multiple) linear regression analysis and mediation effect analysis were applied to a data set from all eight University Medical Centers in the Netherlands. This data set consisted of 190,071 OR days (on which 623,871 surgical cases were performed).
  
  
  RESULTS
  Underused OR time at the end of the day had the strongest influence on raw utilization, followed by late start and turnover time. The relationships between the three "nonoperative" time indicators were negligible. The impact of the partial indirect effects of "nonoperative" time indicators on raw utilization were statistically significant, but relatively small. The "trickle down" effect that late start can cause resulting in an increased delay as the day progresses, was not supported by our results.
  
  
  CONCLUSIONS
  The study findings clearly suggest that OR utilization can be improved by focusing on the reduction of underused OR time at the end of the day. Improving the prediction of total procedure time, improving OR scheduling by, for example, altering the sequencing of operations, changing patient cancellation policies, and flexible staffing of ORs adjusted to patient needs, are means to reduce "nonoperative" time.
authors.affiliation: Department of Operating Rooms, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands. Electronic address: e.berkx@erasmusmc.nl.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: van Veen-Berkx
authors.affiliation: Institute for Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
authors.forename: Sylvia G
authors.initials: SG
authors.lastname: Elkhuizen
authors.affiliation: Department of Pulmonary Services, Diaconessen Hospital Utrecht, Utrecht, The Netherlands.
authors.forename: Sanne
authors.initials: S
authors.lastname: van Logten
authors.affiliation: Division of Anesthesiology and Pain Therapy, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: Wolfgang F
authors.initials: WF
authors.lastname: Buhre
authors.affiliation: Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Cor J
authors.initials: CJ
authors.lastname: Kalkman
authors.affiliation: Department of Operating Rooms, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands.
authors.forename: Hein G
authors.initials: HG
authors.lastname: Gooszen
authors.affiliation: Department of Surgery, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
authors.forename: Geert
authors.initials: G
authors.lastname: Kazemier
mesh_terms: D006801:Humans; D016014:Linear Models; D009873:Operating Rooms / Q000706:statistics & numerical data*; D061646:Operative Time
keywords: Benchmarking; Nonoperative time; Operating rooms; Performance indicators; Utilization