The operating room is one of the most resource-intensive environments in healthcare — and one of the most quietly underutilized. Late starts, turnover creep, misaligned block schedules, behavioral inefficiencies, and bottlenecks upstream and downstream of the OR itself can collectively cost a health system hours of productive surgical time. The challenge is not always visible, and that is precisely what can make it so costly.
What is emerging among perioperative leaders is a growing recognition that solving for OR capacity requires looking beyond the familiar metrics. First case on-time starts and turnover times matter, but they do not capture the full picture of where time is truly being lost. From the way block schedules are designed to how accountability for delays is assigned, the leaders driving change in surgical services are asking harder questions — and finding that the answers often lie in the intersection of data, culture and workflow design. Becker’s asked eight perioperative leaders to share where OR capacity is being silently lost, and what it will take to get it back.
The leaders featured below are speaking at Becker’s Perioperative Summit, set for Sept. 14-15 at the Hilton Chicago.
If you would like to join the event as a speaker, please contact Scott King at sking@beckershealthcare.com.
As part of an ongoing series, Becker’s is connecting with healthcare leaders who will speak at the event to get their perspectives on key issues in the industry.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: Where is OR capacity being silently lost?
David Kwak, BSN, RN. Director of Surgical Services for Northwest Health (Valparaiso, Ind.): Operating room capacity is often evaluated through familiar metrics like first case on time starts, turnover time and case length accuracy, and while those matter, they don’t tell the whole story. An area that deserves more attention though it’s often an uncomfortable conversation is how we’re using double blocks and swing room models and whether a provider should in fact continue to practice in this model. These setups can work well in the right environment, but when variability in case flow or readiness exists, they can also lead to staffed OR time sitting idle. That raises a necessary question: are we truly maximizing capacity for patients, or are we allocating resources in a way that creates gaps we don’t always acknowledge? When unused OR time exists alongside access challenges, it points to a deeper misalignment between how we design our schedules and the care we’re trying to deliver. If we want to move the needle, we must be willing to look beyond traditional metrics and critically assess whether our current models are delivering the value we assume they are. These areas carry significant opportunities but will take a team approach to find a solution to benefit everyone.
Stephen Estime, MD. Associate Chair of Anesthesiology and Critical Care for UChicago Medicine: A less commonly discussed source of capacity loss is behavior and incentives. OR capacity is lost when there is unclear accountability for delays and inefficiency. In many large systems, responsibility is diffuse and inefficiency is absorbed by the system rather than owned by any one person. Some of the best levers are behavioral. For example, when proceduralists follow themselves during the day, they have more control over their schedule and its outcome rather than being dependent on those before them. When staffing models are designed to limit end-of-day inefficiencies, teams naturally adjust to stay on track. Patterns are harder to ignore when delay attribution is more visible. Designing OR schedules with these behavioral dynamics in mind can reinforce accountability in ways that encourage better habits without being punitive. Clinicians are doing their best with good intentions, and the goal is to align the system so the easiest path is also the most efficient.
Aubrey Pepper, RN. Senior Director of Nursing Surgical Services for St. Jude Children’s Research Hospital (Memphis, Tenn.): From my perspective as a pediatric perioperative director in a research-driven environment, OR capacity is often silently lost in the margins around cases rather than in the schedule itself. Trial-related requirements, longer anesthesia induction for complex patients, multiple research-related labs and coordination with pathology for critical diagnostic information — can quietly extend both case and turnover times. Additionally, coordinating with highly specialized providers who are contracted on an as-needed basis can also reduce efficiency, given the low-volume, high-complexity nature of their work. When patients experience clinical changes that require cancellation, there isn’t the elective volume most facilities can use to backfill available space.
Chris Hunt, BSN. Associate Vice President of Perioperative Services for MultiCare (Tacoma, Wash.): OR capacity is being silently lost when traditional block management practices are in place. When you approve too much surgeon block, you’re effectively blocking OR access. For example, you could see good individual block utilization because of lenient release policies but still have terrible primetime utilization. Our teams use data to help sort prime time into three buckets: allocated time, open time, and urgent/emergency time. Avoiding a “block out” can unlock access and greatly improve overall utilization.
Nadine Simmons-Ziegler, BSN, RN. Vice President of Perioperative Services for South Shore University Hospital (Bay Shore, N.Y.): OR time isn’t “lost” in one big recognizable way; it slips away in tiny amounts that don’t show up as a cancellation but still eat up minutes and create delays later in the day. Places where it can be shown are:
- Late starts: Wheels-in happens later than scheduled (team not ready, patient not in pre-op, consent/site marking not done, missing labs/imaging). A quick day-before readiness check and a first case start dashboard usually help.
- Turnover creep: Turnovers slowly get longer because of emergence/transport, room cleanup, instrument issues, missing supplies or slow setup. Parallel processing and a simple turnover checklist can keep this from snowballing.
- PACU/bed availability holds: No PACU space or inpatient beds (or transport delays) can back things up either the next patient can’t come to the OR, or anesthesia gets tied up longer than planned. PACU bed huddles and clear “PACU hold” triggers can help.
- Surgeon/vendor readiness: Surgeon running late, rep not on site yet, implant trays not complete, or preference cards that don’t match what the team needs.
- Make it easier to spot: review the trends monthly on a dashboard so the same issues don’t keep repeating.
Daniel Elinskas, DNP, RN. Director of Surgical Services for St. Mary’s Healthcare (Amsterdam, N.Y.): Speaking strictly about community hospitals, OR capacity is being silently lost through referrals to larger facilities. Many community providers are capable of far more than appendectomies and cholecystectomies. Primary care providers may not be aware of the surgeries that a local surgeon is able to perform with the resources available in a community hospital—procedures that could be done significantly closer to home than at the academic medical center to which the patient is often referred. That volume is unfortunately lost to larger institutions including follow-up visits and testing.
Grace Lim, MD. Chair of Anesthesiology, Perioperative and Pain Medicine Department for University of Utah Health (Salt Lake City):
- Edges of the schedule: Delayed starts, slow turnovers, and uneven emergence times accumulate. Small delays across multiple rooms add up to entire cases that never occur.
- Mismatch between staffing and demand: Rooms may appear open on paper, but without the optimized staffing models to support concurrency and relief, they are functionally unavailable. This loss is often invisible because cases are never scheduled rather than formally canceled
- Variability in case flow: Add-on cases, unpredictable case durations, service-specific inefficiencies create unusable fragments of time. These gaps are too short or uncertain to reliably fill.
- Inpatient capacity, coordination gaps across the system: Preoperative readiness issues, PACU bottlenecks, and inpatient bed constraints slow throughput. These are often labeled as throughput problems but represent true OR capacity loss.
- Behavioral and cultural factors: If teams anticipate inefficiency or delays because that’s the norm, then they stop attempting to optimize the schedule. Surgeons do not add cases, schedulers leave gaps, and underutilization becomes normalized.
Neil Tanna, MD. Senior Vice President of System Perioperative Services and Strategy for Northwell Health (New Hyde Park, N.Y.): Operating room capacity is silently lost through operational inefficiencies like prolonged turnaround times, late starts, inaccurate case lengths, and same-day case cancellations. Further erosion stems from clinical variation, a lack of instrument and product standardization, and fragmented supply chain management. These unfortunate issues collectively prevent the optimal utilization of the operating room.
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