The impact of planning and communication on unplanned costs in surgical episodes of care: Implications for reducing waste in hospital operating rooms

• Author: David Dreyfus,Claudia Rosales,Anand Nair
• Date: 01 January 2020
• Published date: 01 January 2020
• DOI: http://doi.org/10.1002/joom.1070

RESEARCH ARTICLE

The impact of planning and communication on unplanned

costs in surgical episodes of care: Implications for reducing

waste in hospital operating rooms

David Dreyfus

1

| Anand Nair

2

| Claudia Rosales

2

1

Department of Supply Chain

Management, Rutgers Business School,

Rutgers, The State University of New

Jersey, Newark, New Jersey

2

Department of Supply Chain

Management, The Eli Broad College of

Business and The Eli Broad Graduate

School of Management, Michigan State

University, North Business College

Complex, East Lansing, Michigan

Correspondence

David Dreyfus, Department of Supply

Chain Management, Rutgers Business

School, Rutgers, The State University of

New Jersey, 1 Washington Park, Newark,

NJ.

Email: ddreyfus@business.rutgers.edu

Handling Editors: Lawrence Fredendall,

Anand Nair, Jeffery Smith and Anita

Tucker

Abstract

This ethnographic study of more than 90 surgeries (referred to as episodes of

care) identifies the antecedents to operating room (OR) supply waste. The

study specifically considers the role of planning instances and communication

patterns among members of the surgery team on supply waste within the

OR. We operationalize planning instances in terms of the number of changes

to the physician preference card (PPC), the key document that is used to plan

items needed for surgery. Communication patterns among members of the sur-

gery team are captured by measuring the density of communication among

the OR team members during an episode of care. The unplanned costs during

an episode of care are used as a measure of OR supply waste. Hundreds of

hours were spent observing episodes of care and tracking supplies. A combina-

tion of participant-observation, survey, and secondary data were analyzed to

extract theoretical and practical insights. The results show that planning

instances have a curvilinear relationship with unplanned costs. In particular,

as the number of changes to the PPC increases, unplanned costs first increase

and then decrease. Higher density of the OR team's communication network is

associated with lower unplanned costs. This study has significant theoretical

and managerial implications that we discuss and offer directions for future

research.

KEYWORDS

econometric analysis, ethnography, healthcare, operating room, physician preference card,

planning, social network analysis, team communication, unplanned costs, waste

1|INTRODUCTION

The United States spends more on healthcare than any

other nation. A large portion of U.S. healthcare spending

is wasted. A study conducted by the Institute of Medicine

puts the amount of waste at $750 billion, or about 30% of

total health care spending in 2009 (Committee on the

Learning Health Care System in America, 2012). Thus,

understanding sources of waste is imperative. The

operations and healthcare management literature has

extensively alluded to various wastes within hospitals

(Boyer & Pronovost, 2010; Esaki & Macario, 2009;

Froehle & White, 2014; Lingard et al., 2004), but very few

studies have presented a detailed understanding of what,

where, how much, and why waste occurs. The operating

room (OR) department is a reasonable venue to examine,

as it is the highest revenue and expense generator in a

hospital, accounting for over 50% of revenues and often

Received: 28 November 2017 Revised: 4 September 2019 Accepted: 21 October 2019

DOI: 10.1002/joom.1070

J Oper Manag. 2020;66:91–111. wileyonlinelibrary.com/journal/joom © 2019 Association for Supply Chain Management, Inc. 91

more than 25% of expenses (Li, Gupta, & Potthoff, 2016).

Its role in generating supply waste—solid materials that

must be disposed of—suggests it may be an area for

potential cost savings. Supplies and materials average

47% of the OR spending (Park & Dickerson, 2009) and

they account for 70% of the 4 billion pounds of

healthcare waste produced in the United States annually

(Van Demark, Smith, & Fiegen, 2018). In the operations

management literature, we find that reductions in waste

may lead to improvements in quality and performance

(Benner & Veloso, 2008).

The OR has a social hierarchy that must function well

to avoid mistakes and meet high expectations (Healey,

El-Othmani, Healey, Peterson, & Saleh, 2015; Rothstein &

Raval, 2018). Specifically, a surgeon's role in the OR is

critical to achieving good patient outcomes while being

cost efficient with supplies and time (Gitelis et al., 2015).

Throughout an episode of care, OR personnel are com-

municating their needs for supplies, instruments, and

other items. When this occurs, the item requested will be

located, opened, and handed to the appropriate person. If

this item is on the PPC, it will be located close by and can

be quickly handed over. If the item was not on the PPC,

then the OR personnel may have brought it into the room

before the start of the episode of care. If they did not, then

time will be spent searching and obtaining the item before

it is delivered, potentially delaying patient treatment.

Our observations in the operating room during data col-

lection for this research as well as evidence presented in

extant research on surgical delays due to missing items

(Stockert & Langerman, 2014) point to an addition of

5–10minoftimetotheepisodeofcarewitheachsuch

instance that occurs after the episode of care starts. Figure 1

outlines this process. This process continues until the com-

pletion of the episode of care.

Research studies have long shown that although OR

teams have a hierarchical structure with the surgeon at

the helm of the episode of care, they rely on effective

communication to achieve positive outcomes (Burke &

Wilcox, 1969; Tushman, 1979). Both formal and informal

communications among team members occur during an

episode of care. Formal communication ensures that

information related to the procedure is appropriately

exchanged among team members, whereas informal

communication reduces stress and promotes voice and

upward communication of OR team members. Given the

importance of communication in the provision of effec-

tive healthcare (Bartunek, 2011; Levinson, Roter, Mul-

looly, Dull, & Frankel, 1997), we focus on the patterns of

verbal interaction among team members during an epi-

sode of care.

The unplanned costs considered in this study consist

of two parts. The first are costs incurred by a hospital

when the supplies that were opened and used were not

on the PPC. These relate to omissions that could have

been avoided by proper planning of PPC. The second are

costs incurred when the supplies on the PPC were

opened but were not used. These relate to costs that could

have been avoided by pruning the PPC through appropri-

ate planning. To better understand how medical proce-

dure planning and communication patterns among team

members within the OR influence unplanned costs, we

seek answers to the following research questions:

(a) What is the relationship between the number of plan-

ning instances and the unplanned costs in an episode of

care? (b) What is the relationship between the communi-

cation pattern during an episode of care and unplanned

costs?

The rest of this article is organized as follows. In the

following section, we review the literature and develop

research hypotheses. In the Section 3, we present our

research design, including a description of the data, the

operationalization of variables, and the research method-

ology. The Section 4 presents the results. In Section 5, we

discuss the theoretical and managerial implications and

conclude by presenting the limitations and directions for

future research.

2|HYPOTHESIS DEVELOPMENT

2.1 |Surgical workflow

In this study, we explore the role of planning and com-

munication by the OR team within the surgical setting

on OR waste. Henceforth, we refer to a surgery or a pro-

cedure within the OR as an “episode of care,”which

begins when the surgeon arrives in the room and ends

Item is needed

On PPC? Was item

anticipated?

Supply item

Yes

No No

Yes

Search for item

Obtain item

FIGURE 1 Operating room item search process [Color figure

can be viewed at wileyonlinelibrary.com]

92 DREYFUS ET AL.