The three articles1–3addressing improved operating room (OR) efficiency plus the accompanying editorial4skirt an important determinant of OR efficiency. At many institutions, different surgeons performing the same procedure in the same ORs on the same acuity of patient vary more than threefold in times to perform operations.

Anesthesiologists, perioperative nurses, OR schedulers, and hospital architects can improve OR times by minutes per case. Surgeons may potentially improve times by hours per case. Clearly, the savings are in surgical techniques and behaviors.

Hospital administrators are reluctant to embrace this approach. In my former hospital, the anesthesia service met several times with the hospital chief executive officer to discuss means of shaving minutes off turnover and induction times. The chief executive officer had no conversations with surgeons about sharing surgical techniques that might save hours of time.

Administrators, services chiefs, and clinicians avoid the elephant in the operating room: The biggest determinant of OR efficiency is the facility of the surgeons who work there.

Hospitals might consider rewarding surgeons who can, for example, perform a routine laparoscopic cholecystectomy in 45 min and retraining surgeons taking 3 h for the same procedure. This simple alteration in OR scheduling, giving preference to faster surgeons, carries far more likelihood of allowing one or two extra procedures per OR per day than intubating patients in an induction room.

Oregon Anesthesiology Group, Portland, Oregon.

Hanss R, Buttgereit B, Tonner PH, Bein B, Schleppers A, Steinfath M, Scholz J, Bauer M: Overlapping induction of anesthesia: An analysis of benefits and costs. Anesthesiology 2005; 103:391–400
Torkki PM, Marjamaa RA, Torkki MI, Kallio PE, Kirvela OA: Use of anesthesia induction rooms can increase the number of urgent orthopedic cases completed within 7 hours. Anesthesiology 2005; 103:401–5
Sandberg WS, Daily BM, Egan M, Stahl JE, Goldman JM, Wiklund RA, Rattner D: Deliberate perioperative systems design improves operating room throughput. Anesthesiology 2005; 103: 406–18
Dexter F: Deciding whether your hospital can apply clinical trial results of strategies to increase productivity by reducing anesthesia and turnover times. Anesthesiology 2005; 103:225–8