James C. Eisenach, M. D., Editor

Operating Room Management: Structure, Strategies, and Original Investigations. Edited by Andrew P. Harris and William G. Zitzmann, Jr. St. Louis, Mosby-Year Book, 1998. Pages: 298.

Despite the inclusion of the word “strategies” in the title of this volume, what unfolds is not a “how-to” book for those faced with the challenges of undertaking operating room (OR) management. The editors state in their preface that their goal was to “create a resource book” relative to OR management. The majority of the material presented is background information without specifics regarding day-to-day management analysis or a specific framework, or both, to assist the practitioner who needs to rise to the challenge of OR management.

The chapter authors are almost entirely drawn from the Johns Hopkins University School of Medicine and its affiliated and neighboring health-care institutions. Physicians and nurses with administrative or educational responsibilities and administrators with degrees in business and public health have made contributions to this book. Each chapter begins with what is titled a “case study,” consisting of an organizational problem that is more or less a topic of interest related to the chapter. In the majority of cases, with the exception of chapter 1, an analysis or resolution of the problem is presented at the conclusion of the chapter as a “case discussion.” Because the material in the chapters is frequently of a “background” nature, the mechanisms and pathways for the decision-making and problem-solving, presented as a fait accompli in the case discussion, do not necessarily flow from the material presented in the corresponding chapter.

Chapters 1, 2, and 3 are rather dry and compressed treatments of business theories of “Management and Organizational Dynamics”;“Power, Influence, and Team Dynamics”; and “Negotiation,” respectively. The space allotted is too limited to thoroughly discuss the available material regarding the numerous evolving managerial theories for readers who lack a business background. Particularly in chapter 1, specific management theories could be described more practically for a “lay” reader. Chapter 2 has useful reflections regarding team function, including team creation, maintenance needs, and leadership requirements. Chapter 3 concentrates on negotiation in the framework of “distributive bargaining,” in which one party has something to gain and the other has something to lose. The addition of a discussion of “integrative bargaining,” in which both parties cooperate and are willing to entertain wins and losses, and a discussion about those circumstances in which integrative bargaining cannot be undertaken and distributive bargaining techniques must be used would have been helpful.

The next three chapters, 4, 5, and 6, provide additional background information for those without business training regarding, respectively the concepts and execution of an institutional strategic plan of which the OR would be one component; the structure, purpose, and necessary applications of an OR scheduling/data management system; and finally, an introduction to the major cost-components of OR operation (i.e., supplies, capital equipment, and personnel) with some basic aspects regarding their successful management. These chapters are more readable, perhaps because they are more descriptive and include recommendations regarding “musts” for a successful OR, rather than comprising all theoretical considerations.

Chapters 7-10 follow and describe the historical, contemporary status and changing requirements being imposed by rapid economic changes in health care on the major professional personnel groups that work in perioperative care. Successive chapters concern nursing, surgical, and anesthesiology practice and the roles of ancillary professional services (e.g., perioperative screening, radiology, and pathology). Despite stylistic differences in the composition of these chapters resulting from differing authors, it is clear that all components of the overall OR professional workforce have been under considerable pressure to refine their roles and interactions with each other to adapt to externally imposed pressures to reduce costs and increase efficiency while maintaining excellent patient care in an environment in which autonomy of decision-making and autonomy in task-time allocation increasingly is reduced.

The succeeding three chapters, 11-13, revert to education/information dissemination for the newly initiated OR executive regarding, in order, current concepts of restructuring OR management; principles of Continuous Quality Improvement 101; and an exhaustive listing of the 1995 Joint Commission for Accreditation of Health Care Organizations (JCAHO) standards that influenced perioperative care, along with superficial annotations following some of the standards. The authors acknowledge that JCAHO standards are updated and republished yearly; therefore, as time progresses past 1995, more current JCAHO documents must be referenced by readers to obtain the most up-to-date requirements and interpretations of JCAHO intent. In addition, the material in this cluster of chapters, similar to other chapters, is not sufficient to provide a new OR executive with detailed knowledge on which to base organizational action. Rather, this material serves to stimulate various considerations that will be dependent on local circumstances and that will necessitate further reflection, study, and consultation to be directly applicable.

The final two chapters are devoted to introducing the functional principles of two subsets of perioperative venues: academic medical centers and free-standing surgical centers. Perhaps these were chosen because of the opportunities that are rapidly presenting themselves for nontraditional administrative structures to evolve that include large measures of physician participation. Many of the facts and insights presented seem self-evident to anyone already working in those environments. What group is the intended audience for these particular two chapters? Perhaps they are meant for potential OR executives transitioning from more conventional community or environments to prevent an underestimation of the influence of the peculiar OR dynamics and customer relationships extant in these environments, or alternatively, meant for someone emerging from those environments to new managerial responsibilities who needs to be reminded of the reasons why traditional solutions may not be easily applicable in academic centers or free-standing centers.

In summary, although individuals entirely new to considering issues relevant to OR management challenges may find this book to be of interest, those with considerable previous OR management experience will not discover many new insights in this volume. Current research regarding the impact of recovery paradigms on overall perioperative costs is relatively ignored. Continuous quality improvement is similarly relegated to a side issue, rather than an overall driving force that can be applied to management structure, staff deployment and education, resource management, and others. Cooperative, employee-driven, consensus-based problem-solving is minimized in the early chapters in favor of rigid, somewhat dated, management theories. Case discussions could be more helpful to elucidate generalizable principles to assist readers to be able to apply principles in their environments. Even for the novice in OR management, this work is an intellectual background survey of potentially relevant concepts, rather than a practical guideline for action or strategy.

Patricia Ann Kapur, M.D.

Professor and Chair; Department of Anesthesiology; UCLA School of Medicine; Los Angeles, California 90095;pkapur@mednet.ucla.edu

(Accepted for publication October 3, 1998.)