Building a Functional OR Culture: Getting It Done Chapter 12


The Operating Room (OR) is:

  • An economic engine for the hospital that needs to run efficiently and effectively for the hospital to carry out its mission
  • The employer of choice for a significant number of employees and physicians who, if they are good at what they do, have options to work anywhere; satisfied employees and surgeons strengthen administrators’ standing with the Board
  • Hallowed ground where patients lay their lives on the line and people need to work as a team to achieve outstanding clinical outcomes

A well-functioning system of operating rooms, in which people communicate well with one another, enjoy coming into work, and achieve outstanding outcomes is in everyone’s self-interest.

Case Presentation

In September 2005, the anesthesiology department was bankrupt. Overall, operating room morale was at an all-time low. The wagons of surgery, anesthesia, and surgical services were tightly circled for self-preservation:

  • The chairman was on a sabbatical, and one-third of the anesthesiology faculty had resigned.
  • The number of ORs available for elective surgery had been reduced from 35 to 31 due to a shortage of anesthesia and nursing services.
  • Surgeons were angry because they could not perform their cases during prime time, and their incentive plan was linked to the volume of operations.
  • The hospital ORs generate $126 million in net revenue annually—approximately 14 percent of the hospital’s net operating revenue.

The hospital persuaded an anesthesiologist and a surgeon to postpone retirement to turn the situation around.  They decided to develop a more functional OR culture with a three-part strategy:

  • They used the slogan “Get on the bus” to promote the concept of teamwork—everyone traveling on a bus toward a common purpose and destination: quality care and patient safety in surgical treatment. If a staff member did not get on the bus, it would leave without him. They were surprised and pleased to see how quickly this simple concept caught on.
  • They adopted the Japanese philosophy of kaizen: “the relentless pursuit of incremental improvement.” For comic relief, they purchased a flag from a marina and hung it in the medical director’s office: “Beatings will continue till morale improves.”
  • They developed two committees. The first was the Surgical Operation Leadership Group (SOLG), which had executive committee powers. Members of SOLG were permanent or elected. The permanent members were the vice president of surgical services, the chair of anesthesiology, and the OR medical director. The elected members were the chair of orthopedics and the chair of surgery. SOLG made key decisions and presented them for adoption by the larger, more representative second committee, the Surgical Operations Governance Group (SOGG). SOGG had elected members from division of surgical services, anesthesiology, and all surgical school of medicine departments. Engaging and enabling a larger group were valuable in establishing buy-in. SOLG could make decisions without the approval of SOGG, but they were always able to develop consensus based on data, especially in allocating precious resources, such as OR block time.


Over the last six years, they have arrested the unsustainable downward surge in productivity and boosted performance outcomes:

  • case volume has increased by an average of 5.6 percent per year, from 20,600 to 26,500
  • staff turnover has dropped, from 18% to 10% per year
  • first-case on-time starts have climbed from 48% to 66% in the main OR and to 82% in the ambulatory surgery center
  • OR turnover time has decreased from 45 minutes to 39 minutes.


Dr. Mandel, the first author of this chapter, believes that the ideal OR medical director to build and sustain a functional OR culture:

  • should be a full-time contract employee of the hospital and not have a career path dependent on an academic department that works in the OR. Whether the medical director is an anesthesiologist or surgeon, if promotion and salary are dependent on his/her department, there are obvious perceived conflicts of interest
  • is “a retired surgeon or anesthesiologist who likes surgeons and has a background as a high school teacher with a degree in psychiatry,”

As always, I welcome your input to improve healthcare collaboration and get it done.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure: I have not received any compensation for writing this content.

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