Anaesthesia, 2009, 64, pages 473–486 doi:10.1111/j.1365-2044.2008.05854.

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Measuring the quantitative performance of surgical

operating lists: theoretical modelling of ‘productive
potential’ and ‘efficiency’
J. J. Pandit,1 D. Stubbs2 and M. Pandit3
1 Consultant, 2 Medical Student, Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford OX3 9DU,
UK
3 Consultant, Department of Obstetrics & Gynaecology, Milton Keynes, Hospital Foundation Trust, Milton Keynes,
MK6 5LD, UK

Summary
We previously defined surgical list ‘efficiency’ as: maximising theatre utilisation, minimising over-
running, and minimising cancellations. ‘Efficiency’ maximises output for input; ‘productivity’
emphasises total output. We define six criteria that any measure of productivity (better termed
‘quantitative performance’) needs to satisfy. We then present a theoretical analysis that fulfils these
by incorporating: ‘speed’ of surgery (with reference to average speeds), ‘patient contact’ (synon-
ymous with minimising gaps between cases), and ‘efficiency’ (as previously defined). ‘Speed’ and
‘patient contact’ together constitute a ‘productive potential’. Our formula satisfies the pre-set
criteria and yields plausible results in both hypothetical and real data sets, To be productive in these
quantitative terms, teams in any specialty need to achieve minimum quality standards defined by
their sub-specialty; to plan their lists to utilise the time available with no cancellations or over-runs
and to work at least as fast as average with minimal gaps between cases. ‘Productive potential’
combined with ‘efficiency’ yielding ‘actual productivity’ in our theoretical analysis more compl-
etely describes quantitative surgical list performance than any other single measure.
. ......................................................................................................
Correspondence to: Dr Jaideep J. Pandit
E-mail: jaideep.pandit@dpag.ox.ac.uk
Accepted: 26 November 2008

With nearly seven million hospital operations performed of performance [5]. However it would seem challeng-
each year in England and Wales and an annual NHS ing to develop a measure encompassing all surgical
budget of > £1 billion, operating theatres are a significant teams, undertaking as they do different combinations of
expense [1]. As all stakeholders – patients, politicians, procedures.
staff, managers – seek to maximise benefits from them, The word ‘productivity’ has various connotations in
proper measurement of processes and outcomes becomes economics, engineering, or administration. The Orga-
necessary. nisation for Economic Co-operation and Development
Previously, we concluded that surgical operating list (OECD) offered more than 20 meanings, recognising
‘efficiency’ is the completion of all the scheduled that ‘productivity’ and ‘efficiency’ are often confused
operations (that is, with no cancellations) whilst utilising and emphasising that each industry needs to develop its
properly the time available (that is, no under- or over- own measures [6, 7]. For surgical operating lists, we
runs) [2, 3]. In response, Sanders et al. observed that this therefore use the engineering sense: ‘efficiency’ mea-
notion of ‘efficiency’ was possibly incomplete [4]. It is sures how well the service functions (that is, work
theoretically possible for two teams to be equally efficient, output for costs or effort); ‘productivity’ measures the
fully utilising their time without over-runs or cancella- output. It is theoretically possible for a service to be
tions, but one team consistently completes more work highly efficient but have low total work output, and
than the other. Thus, there is a need to define ‘produc- conversely to work at high output, but extremely
tivity’ in addition to ‘efficiency’ to complete the picture inefficiently [4, 5].

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An objective measure of productivity would enable

Methods
healthcare professionals to confirm they work as hard and
effectively as reasonable within the time available, and Terminology
help them achieve this aim. Other stakeholders such as The duration of an operation is the time from the start of
patients, managers or politicians also need to be satisfied anaesthesia to the time the anaesthetist completes hand-
that the investments they make and the reliance they over to recovery staff. The gap time is the sum of the ‘idle
place in operating theatres are used as effectively as is times’ between completion of handover of one patient to
reasonable. recovery staff to the start of anaesthesia in the next patient.
Two measures of productivity that have been applied The actual duration of a list is the time from the start of
to hospital settings are ‘balanced scorecard’ and ‘data anaesthesia in the first patient on the list to the arrival of
envelopment analysis’ (DEA). The former consists of the last patient in recovery (minus any established breaks,
first listing all relevant, desirable or possible (that is, if any, for rest ⁄ lunch). The scheduled duration of a list is the
quantitative and qualitative) measures of performance time available for the list (for example, lists are usually
(such as utilisation, cancellation rates, complication rates, scheduled for a half day, 4 h, or a full day, 8 h). A list over-
satisfaction, etc) and then assigning to each a score. run occurs when the actual duration of the list exceeds its
While this encompasses a wide range of performance scheduled duration. A list under-run occurs when the
criteria, the scoring systems are necessarily arbitrary and actual duration of the list is less than its scheduled
weighting factors need to be employed, which may not duration. An over-booked list is one in where the sum of
be the same across all hospitals or even across different estimated durations of individual operations (plus any
surgical teams [8, 9]. expected gap time) on that list exceeds the scheduled
DEA is a very detailed mathematical process that duration of the list. An under-booked list is one where this
attempts to quantify the performance of teams or units sum of estimated durations is smaller than the scheduled
across a range of chosen indices with reference to the duration of the list.
‘best performing units’. However, the analysis requires Efficiency as used throughout this paper specifically
conceptualisation of abstract ‘efficient frontiers’ and refers to the notion of a team utilising its scheduled list
complex linear programming. Although some authors duration fully, without over-running or cancellation.
have argued for the validity of DEA in the context Quantitative performance is a general term we use to
of healthcare [10, 11], it does suffer from important describe the overall ‘output’ or ‘actual productivity’ of the
limitations. First, DEA yields results only relative to the surgical list, distinct from quality measures such as patient
currently best-performing teams, i.e., there is no absolute satisfaction, communication, teamwork, etc (accepting
reference point or ideal. Thus a team only knows its implicitly that these can contribute indirectly to overall
performance if all other teams have themselves been performance). Productive potential is a term used to refer to
analysed by DEA: it is not meaningful to conduct DEA the activity (speed and degree of active anaesthetic-
for one team in isolation. Second, the mathematical surgical contact with the patient), which ‘enables a team
complexity of DEA means its results are often expressed to be productive’. We explain these concepts further
in terminology that makes it difficult to strive for a simple below.
goal. Applying DEA and solving the required mathe-
matical equations is generally outside the scope of most Core criteria that an ideal measure of quantitative
surgical-anaesthetic teams. performance needs to satisfy
The broad aim of this paper is to develop a simpler, yet The first step of our analysis was to define the general
still rational alternative to balanced scorecard or DEA criteria that any mathematical descriptor needs to satisfy.
approaches to measure surgical productivity. In a step-by- Where two teams undertake the same operation (for
step approach we (1) first define the core criteria that any example, knee replacement) without over- or under-run
ideal measure needs to satisfy. Then (2), we develop a or cancellations, then an acceptable measure of their
theoretical measure that fulfils these. Finally (3), we assess relative productivity is simply the number of operations
the utility of this theoretical measure by application to undertaken on the list (‘operations per hour’). However,
hypothetical and real data sets. The step from (1) to (2) is a this is not a universal measure as teams rarely undertake
logical process: that is, if the criteria are acceptable, then just one operation and do not all work equally efficiently
the measure is deducible from them. However, the step (one team may complete more cases but cancel more
from (2) to (3) is a practical one: i.e., a test of the patients). It also biases in favour of shorter operations
measure’s ability to apply in practice. Thus, ours is (other measures such as ‘income’ favour operations –
primarily a theoretical analysis, which we extend to apply arbitrarily – priced highest): and avoiding bias enables
meaningfully to real surgical lists. comparison of teams across specialties.

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474 Journal compilation  2009 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2009, 64, pages 473–486 J. J. Pandit et al. Æ Measuring performance of operating lists
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These preliminary considerations led us to define – a booking and completing just two nephrectomies within
priori – the following six core criteria for an ideal the scheduled time. But – as a matter of policy – it is the
quantitative performance measure: latter that is properly better performing.
1 the measure should not be influenced by casemix: We emphasise another caveat already alluded to:
the type of operations conducted – or co-morbidities measuring quantitative performance is only meaningful
prolonging surgery commonly present in associated where predefined quality or safety standards are met. An
patient groups – should not influence whether a team is increasing number of specialties, most notably cardiac
regarded as ‘productive’. Thus, intrinsic procedure surgery, now define minimum standards for risk-adjusted
duration should not be influential (that is, short and mortality rates [14]. It is a deficiency that few sub-
long procedures are equally potentially productive) [12]; specialties offer such clear standards, but applying pro-
2 adoption of new techniques to achieve the same ductivity measures is inappropriate for teams that fail to
surgical aim should not be influential. For example, meet existing criteria. By analogy, a factory making more
even after any ‘learning curves’, laparoscopic tech- televisions than any other is unproductive if its televisions
niques (argued to improve safety, pain scores or do not work.
postoperative stay) often take longer to perform [13].
A team which previously completed, say, three open A formula describing quantitative list performance
nephrectomies per list and which now completes two If each of the above criteria is accepted then, logically, it is
laparoscopically does not automatically make it less possible to fulfil them all by the following empirical
productive; formula:
3 notwithstanding point (2), for any given surgical
quantitative performance (actual productivity) index
procedure, productive potential should partly be
related to the speed with which the operation is ¼ 111  ½efficiency  10ð0  productive potentialÞ  ð1Þ
completed: the faster the team operates, the more
productive it is likely to be. Thus, a team consistently in which ‘productive potential’ (as used by Schmenner
completing a hernia repair in 30 min should correctly [12, 15] to refer to ‘flow’ of activity within a service
be viewed as having a higher productive potential than industry) is:
a team that always takes 1 h undertaking exactly the productive potential ¼ ðspeedÞ  ðpatient contactÞ ð2Þ
same procedure. A team wishing to be more produc-
tive should rationally try to operate more quickly (so In these formulae, ‘patient contact’, ‘efficiency’ and
long as this preserves quality of care); ‘speed’ are each expressed as decimal fractions, the first
4 the total anaesthetist-surgeon contact time with the from 0–1, the last two can be > 1. Multiplying the result
patient should be reflected in the measure of quanti- in large square brackets by the constant 111, as shown,
tative performance. Although other aspects of the yields an index of performance (actual productivity)
surgical process (such as cleaning theatre, stocking expressed in %, in which an ‘ideal’ team (one with
sutures, preparing equipment) are undeniably impor- efficiency, speed and patient contact all equal to 1.0) has
tant, maximising anaesthesia-surgical contact minimises an actual productivity of 100%. We now consider each of
any idle gaps; the terms of the equation in detail.
5 where time savings might be made by improved
practices, reducing idle gaps or greater speed, these Efficiency
should only contribute to performance if extra cases are This is as detailed in our previous paper [2], where:
accommodated into the saved time. Earlier finishes in efficiency
themselves do not yield extra income (which accrues    
from cases) nor generally save staffing costs (if staff are fraction of scheduled fraction of scheduled
¼ 
employed for fixed base units of time); time utilised time over-running
 
6 quantitative performance is only meaningful in the fraction of scheduled
context of efficiency (the latter being the notion that all  : ð3Þ
operations completed
scheduled list time is utilised, with no over-runs or
cancellations). The reason is that high levels of apparent The ‘fraction of scheduled time utilised’ means that for
‘productivity’ are easily achieved by overwork and a list scheduled for 8 h which finishes in 6 h, this
over-expense. Overbooking a 4 h list with, say, five quantity = 0.75 and the ‘fraction of scheduled time
nephrectomies (each taking 2 h), over-running by over-running’ = 0. The ‘fraction of scheduled time
> 4 h to complete four cases (but cancelling the over-running’ means that for a list scheduled for 8 h
remaining patient) certainly achieves more work than which over-runs by 2 h, this quantity = 0.25, and the

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Journal compilation  2009 The Association of Anaesthetists of Great Britain and Ireland 475
J. J. Pandit et al. Æ Measuring performance of operating lists
. ....................................................................................................................................................................................................................
fraction of scheduled time utilised = 1. Thus, the first
two terms operate mutually exclusively; a single list
cannot be at once both under- or over-utilised. The
finish time of the list is the time of arrival of the last
patient in recovery; the start time of the list is the
scheduled start of anaesthesia for the first patient on the
list. The ‘fraction of scheduled operations completed’
means that if four out of five of the patients booked
onto the list have their operations (that is, one patient is
cancelled), this quantity = 0.80.
Productive potential
It is the product of ‘speed’ and ‘patient contact’ (Equation
(2)), implying that any team consistently working fast
with few or no gaps is potentially more productive than a
team that is always slower and ⁄ or has long gaps between
cases. The emphasis is on potential productivity because
the factors detailed in the equations will determine if this
is translated into actual productivity.
Speed
If an operation normally takes 1 h to complete and a
team’s average for this is 30 min, the team is twice as fast
as the norm and its relative speed is 2.0 (200%). If the
team takes 2 h to complete the procedure, its speed is just
0.5 (50%). For each operation, the relevant formula for
speed is thus:
relative speed for an operation
reference duration of operation
¼ :
team’s duration of operation
To obtain the speed for the team, the above relative
speeds for individual operations are averaged across all
operations undertaken. Thus if a team undertakes n1
operations with a relative speed X and n2 operations at
relative speed Y in the time period under consideration,
then:
ðn1 :XÞ þ ðn2 :Y Þ þ    þ ðnx ZÞ
speed ¼
n1 þ n2 þ    þ nx
The source of the ‘reference duration of operation’ in
Equation (4) is undefined, and could be variously from
national databases, published literature [16–18], or from
local data (such as the team’s own past operating times).
Calculating average speed means that prolonged surgery
due to occasional patient co-morbidity has little influence
on ‘team speed’. Co-morbidity inherent to the type of
surgery (such as cardiac disease needing invasive moni-
toring in cardiac surgery) is automatically taken into
account by the longer reference times for those opera-
tions. However, if data is unobtainable for reference
476
Anaesthesia, 2009, 64, pages 473–486
times, it is also possible to assume that the team operates at
‘average’ speed, with a value of 1.0.
Patient contact
This is the time actually spent conducting anaesthesia and
surgery, expressed as a proportion of the total actual list
time. If a list started promptly at 09.00 h and the last
patient arrives in recovery at 17.00 h the actual list
duration has been 8 h. If six operations each of which
lasted 1 h were completed, the patient contact is thus
6 ⁄ 8 = 0.75 (that is, 75% of the list time was spent with
anaesthetist and ⁄ or surgeon in contact with the patient).
The formula is:
patient contact
P
ð each individual operation durationsÞ
¼ :
time from scheduled start time to actual end of list
ð6Þ
The converse of patient contact index is the ‘gap time’; in
the example above, 25% of the list involved no patient
contact.
Equation (6) correctly recognises late starts as gaps. In
the example above, if the scheduled list start time was
08.00 h, then the denominator in Equation (6) is 9 h (the
first hour was a ‘gap’), then patient contact is 6 ⁄ 9 or 0.67
(67%), with a corresponding gap time of 33%. In addition
to reducing gaps, patient contact could be increased by
(a) maximising cases on a list (which should also increase
utilisation and so increase efficiency); (b) parallel process-
ð4Þ
ing of anaesthesia (as we describe further below), or
(c) operating more slowly (a strategy which is perverse,
and which would adversely influence the ‘speed’ term of
the formula).
Overview of the quantitative performance index
Equation (1) reflects that the potential to be productive
(embedded in a team’s operating speed and degree of
contact with the patient) is translatable into actual
productivity by an efficient system. We can draw analogy
: ð5Þ
with oxygen partial pressure, which can only be translated
into actual oxygen content of blood if there is sufficient
haemoglobin.
The six criteria defined and Equation (1) have some
analogy with measuring performance quantitatively in
companies that undertake skilled, complex tasks (for
example, antique clock restoration [19, 20]), as opposed
to unskilled, repetitive tasks. High productivity results
when the company estimates its workload accurately, for
example by accepting enough clocks for repair to fill its
time, but not too many that it needs to cancel or postpone
orders or pay staff overtime. This is akin to sensible
booking of patients onto operating lists. Staff should
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Journal compilation  2009 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2009, 64, pages 473–486 J. J. Pandit et al. Æ Measuring performance of operating lists
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spend as much of their time working on the clocks, rather

than in gaps or breaks (a notion akin to maximising
patient contact). Finally, for any given clock, staff should
ideally take no longer than the average time in repair for
the complexity of the task. This is akin to our notion
of speed.

Measuring quantitative performance in

hypothetical and real data sets
We applied the formulae described above to some
hypothetical but realistic scenarios to assess if they fulfilled
the criteria required. We applied Equation (1) to the data
from five arbitrarily-selected surgical teams in the region
(three gynaecology, one urology and one cardiac team).
For each list we identified the scheduled and actual start
time, the number of cases scheduled and completed (and
so the cancellation rate), the duration of each case
performed (which we compared against mean ⁄ median
published duration of those cases [12, 16–18] using
Equations 4 and 5), and the time of the last patient’s
arrival in recovery. This data enabled us to apply
Equations (1)–(6). For each team we examined ten
consecutive lists. We combined both half-day and full-
day lists for the teams as we [2, 15] and others [3] have
previously shown that timing data from such lists are
proportional and equivalent.
These applications of the formulae to the hypothetical
and real data sets were not a test of the ability of the Figure 1 (a) Plot of Performance Index against Productive
formulae to meet the predefined criteria. Rather, they Potential as yielded by Equation (1) in text. (b) The curve for
85% Efficiency and vertical line for Productive Potential of 0.9
were designed to probe the limits of the formulae when divides the plot into four quadrants, as discussed in text.
applied to practical scenarios. We were especially inter-
ested in discovering any internal contradictions created by
applying the formulae (such as a list that has a high steep part of the curve. Similarly in our plot, increasing
cancellation rate appears to perform well, etc). speed and ⁄ or patient contact is very beneficial if prevail-
ing speed ⁄ patient contact are low, but less beneficial if
these are already high. The mechanistic interpretation of
Results
this limiting ‘diminishing return’ is that any time savings
Graphical representation of quantitative through increasing speed or reducing gaps need to be of
performance sufficient magnitude as to be able to accommodate an
Figure 1a shows the theoretical distributions for the index extra case.
of quantitative performance as a family of parallel ‘Ideal’ or desired performance objectives may be
efficiency curves when plotted against a wide range of displayed. We previously suggested a minimum desirable
productive potentials. A list or team represented as a point efficiency of 85% [2]. If teams are expected to work at
can move from one efficiency curve to another by least as fast as average (speed = 1.0), and if patient contact
changes in its utilisation (that is, over- or under-running) should ideally represent > 0.9 (< 10% of list time should
or cancellation rate; it can move along any given be idle gaps) then the productive potential is 0.9
efficiency curve by changing its speed and ⁄ or patient (Equation (2)). Notwithstanding the imprecision of these
contact. Thus, performance increases as speed and ⁄ or goals, the efficiency curve and the vertical line repre-
patient contact increase, but asymptotes to a value senting these divide the graph into four quadrants (of
ultimately determined by the prevailing efficiency. unequal size; Fig. 1b). A team that is efficient and
Recalling the analogy with oxygen transport, a rise in productive lies in the top right quadrant. An efficient
oxygen partial pressure only increases content if there is team which is not potentially productive will lie in the
sufficient haemoglobin, or if the starting point is on the top left. A potentially productive but inefficient team lies

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J. J. Pandit et al. Æ Measuring performance of operating lists Anaesthesia, 2009, 64, pages 473–486
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in the bottom right. An inefficient and potentially operating per se only yields ‘credit’ by opportunity for
unproductive team lies in the bottom left. Improvements more patient contact.
in efficiency drive the points and curves upwards while In summary, consideration of hypothetical scenarios
increases in productive potential drive the point to the yields very plausible and reasonable results which fulfil the
right, along a given efficiency curve. criteria defined. These hypothetical scenarios are not
dependent upon (or require any knowledge of) the
Hypothetical scenarios surgical subspecialty of the teams or the details of the
A hypothetical team operates slowly (50% expected operations they perform.
speed) and suffers long gaps (patient contact 80%). It is
also inefficient (75%) due to overbooking, over-runs and Analysis of real data sets
cancellations. The team’s quantitative performance is low Table 1 shows one example list and how data were
(X1, Fig. 2, index = 44%). Simply accepting its own extracted to construct Table 2. If we crudely plot simply
slowness and more realistically scheduling fewer patients the ‘number of cases scheduled per list’ (as do some
onto lists, this team would finish on time, reduce hospitals, [21]) then Team C appears to perform well,
cancellations and move higher to point X2 (Fig. 2). while Teams A, B and E less so (Fig. 3a). Since this
Further gains could then be made by increasing speed measure might be affected by 8 h vs 4 h list allocations or
and ⁄ or reducing gaps (to point X3, Fig. 2). However, casemix (for example, Team E is cardiac), a perhaps more
from its original situation X1, increasing speed or reducing relevant plot is ‘cases ⁄ hour completed’ (Fig. 3b). This
gaps alone achieves relatively little as movement is along increases the apparent performance of all teams except
the efficiency curve (point X4 index << X2). Teams B and E whose performance remains ‘poor’.
If by adopting a new, inherently slower surgical Table 2, however, shows more detailed data in which
technique a team continues to complete all its cases and Team B (although weakest on start times) appears to
accomplish similar list utilisation as it did before the new perform considerably better across a range of measures,
technique, then Equation (1) will yield it the same especially cancellation rate. Team E (though poor on
performance, regardless of the number of patients or cases cancellation rate in percentage terms) shows utilisation
completed on the list (data not plotted). If a team has high closest to 100% and acceptable efficiency. It also has the
operating speed and ⁄ or minimal gaps between cases, it highest patient contact index due to ‘parallel processing’
will have spare time. Accommodating extra cases into of anaesthesia, in which anaesthetic induction and
this time will increase patient contact and so increase invasive monitoring is started while the previous patient’s
performance. If, however, the team chooses instead to surgery is being completed [22, 23]. These disparate
finish early regularly then Equation (3) will reflect this as measures can now be combined meaningfully into a
consistent ‘under-utilisation’ and low performance. Faster single measure using our formulae.
First, the plots of efficiency vs utilisation (Fig. 4)
indicate that Teams B and E (the worst-performing in
Fig. 3) generally complete all booked cases on time, with
no over-run yet near-full utilisation. Team A (which also
performed rather poorly in Fig. 3) is also quite efficient,
perhaps with a slight tendency to under-run. The teams
performing apparently well in Fig. 3 (Teams C and D)
are, in fact, inefficient. Team C suffers cancellations on
every single list and also consistently under-runs. It is
most probably over-booking its lists and then managing
this by prompt cancellation of cases to avoid over-run.
This interpretation is supported by its high rates of
booking (Table 2). The main problem with Team D is
prolonged and consistent over-runs. Like Team C, it
likely over-books its lists but manages them with gross
over-running to complete the list rather than cancellation.
Figure 5 offers further detail. Teams A, B and E show
generally acceptable performance (Team A efficiency
is very slightly < 85% threshold; Team E productive
Figure 2 Plots of Performance Index vs Productive Potential for potential is slightly < 0.9). For Teams A and B, significant
one hypothetical team as discussed in text. improvements in performance will not be achieved by

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478 Journal compilation  2009 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2009, 64, pages 473–486 J. J. Pandit et al. Æ Measuring performance of operating lists
. ....................................................................................................................................................................................................................

Table 1 Example of analysis of one of

the urology (half day cystoscopy) lists. Operation Gap Reference time for Relative
Time Activity time (min) (min) operations (min) speed
The columns show, in turn, the time
(scheduled start time = 09.00 h), the
operations conducted or activity taking 09.00 5
09.05 Start of cystoscopy 25 33 1.32
place, operation time, duration of any
09.30 End
gaps between cases, the reference times Gap 5
for the operation (from references 09.35 Start of cystoscopy 34 33 0.97
[16, 17]) and thus the relative speed for 10.09 End
the operation. Note that start time = Gap 1
start of anaesthesia; end time = arrival 10.10 Start of cystoscopy 45 33 0.73
of patient in recovery. Below the table 10.55 End
are the calculated indices for this list, Gap 10
using Equations (1)–(6) in text. 11.05 Start of cystoscopy 30 33 1.10
11.35 End
Gap 5
11.40 Start of cystoscopy 25 33 1.32
12.05 End
Gap 5
12.10 Start of cystoscopy 40 33 0.83
12.50 End

Summary data

Scheduled time for list = 09.00 h–13.00 h 240 min

Number of patients scheduled ⁄ cancelled 6⁄0
Late start 5 min
Under-run 10 min
Gap time = 31 min = 31 ⁄ 240 = 13%
Patient contact index 87%
Weighted mean speed 1.05 (105%)
Efficiency 95.8%
Productivity index 0.93 (93%)

their working any faster or reducing gaps as they lie on over-runs and help both improve efficiency and produc-
the flat part of the relationship (that is, their speed is tive potential.
already better than average for the operations they In summary, neither the hypothetical nor the real data
perform and the gaps are broadly acceptable). Team A sets revealed any internal contradictions when subjected
could do better instead by improving its cancellation rate to our formulae. Instead, the interpretations seem
(Table 2). Team E could, by contrast, improve by reasonable and could be applied to compare teams within
working slightly faster (though its patient contact time is and across specialties.
already high). As a cardiac team it has a low absolute
number of cases, so the percentage impact of even the
Discussion
occasional cancellation is magnified in Table 2: nonethe-
less it is desirable to prevent even these. The six core criteria properly reflect what is required of a
Team C’s performance is quantitatively very poor, quantitative measure of performance, and they apply to
despite its misleadingly impressive plot in Fig. 3. Like any surgical list. We present formulae that fulfil these
Teams A and B, it also cannot improve by simply criteria. Finally we demonstrate that this analysis can apply
working faster or eliminating gaps as it also lies on the flat to a range of hypothetical and actual scenarios.
part of its relationship (that is, its speed is faster than the
average and it has few gaps). Since Team C books the Comments on the mathematical aspects
most cases onto its lists and has the highest cancellation To its credit, our measure avoids complex variables or
rate (> 21%), scheduling fewer cases is rational improve- misleading surrogates such as ‘numbers of operations
ment. done’. It is, however, possible that we failed to identify
The main problem for Team D may be its low average additional criteria beyond the six we defined, which
speed (Table 2), which might be due to teaching or more should be met by an ideal measure of quantitative
complex surgical methods needing further investigation. performance. The Audit Commission and related bodies
Increasing speed would also reduce the magnitude of suggested 100 individual measures of ‘performance’,

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Journal compilation  2009 The Association of Anaesthetists of Great Britain and Ireland 479
J. J. Pandit et al. Measuring performance of operating lists Æ
Anaesthesia, 2009, 64, pages 473–486
. ....................................................................................................................................................................................................................

Teams A and D are half-day (4 h) lists; Teams B and C are full-day (8 h) lists; Team E is a full-day (10 h) list. Values are medians (interquartile range) [range], except where indicated. Start time is
given with reference to the scheduled start time (+ indicates late start, ) early start). Efficiency is calculated using Equation (3) in text; Speed using Equation (4); Patient contact index using
(47–108) [32–111]
(73–107) [56–128]
(22–84) [14–96]
(23–79) [14–89]
(62–88) [6–95]
Peformance
index (%)

84
88
68
63
79
(cancellation rate, %)
Cases completed ⁄
Table 2 Data from five actual teams (Teams A, C, D in gynaecology; Team B in urology; Team E cardiac: ten consecutive lists for each team).

cases booked

(21.4)
(7.6)
(2.4)

(6.5)
(9.5)
⁄ 39
⁄ 42
⁄ 84
⁄ 46
⁄ 21
36
41
66
43
19

Equation (5) and Performance index using Equation (1). Cases completed are shown as a fraction of those booked (with cancellation rate %).
(89–100) [80–100]
(88–97) [67–100]

(97–99) [72–100]
(89–93) [84–99]
(85–96) [64–98]
Patient contact
index (%)

96
92
93
94
98
(108–153) [84–187]
(91–148) [58–247]
(99–116) [88–122]

(69–97) [39–103]
(83–95) [65–124]
Speed term (%)

117
111
120
78
88

Figure 3 (a) Boxplots of the number of cases booked by each

of the actual teams (A–E) from which data was analysed: the
[48–95]
[25–99]
[36–89]
[45–90]
[28–95]

horizontal line represents the median, the edges of the box

Efficiency (%)

the interquartile ranges, the error bars (where different from the
(60–93)
(88–93)
(39–82)
(58–83)
(73–92)

latter) the 10th and 90th centiles, and the symbols any outlier
data. On this measure, the rank order of performance is: Team
C > D > B > A > E. (b) Boxplots of the number of cases
84
89
69
75
85

completed per hour on lists of the teams (A–E): On this mea-

sure, the rank order of performance is: Team A > D > C >
B > E.
(108–131) [85–144]
(80–106) [64–127]
(88–99) [86–101]

(83–95) [55–130]
(65–93) [58–98]
Utilisation (%)

combining these by a ‘balanced scorecard’ [1, 24–26].

While 100 indicators outnumber six, the complexity of
many end-points – and the inevitable arbitrariness of any
scorecard – makes the methodology unwieldy, without
91
91
88
120
92

necessarily increasing its power to describe performance.

The real gains of adding further end-points may be small.
()11–+1) [)25–+15]
()8–+6) [)10–+15]

()18–+3) [)30–+5]
(+4–+15) [)5–+23]

Although the individual variables contributing to

()4–+4) [)5–+20]

‘efficiency’ and ‘productive potential’ are relatively easily

Start time (min)

obtained, combining these is non-linear, which may limit

the ‘popularity’ of our approach. Some complexity is
inevitable, as simple combinations (such as product or
)3

)8
)8
0
+9

sum) of efficiency and productive potential just do not

yield sensible results. Nonetheless, Equation (1) is much
simpler than attempts to incorporate 100 performance
Team

measures, or than DEA methods. The non-linearity we

A

D
B
C

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480 Journal compilation  2009 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2009, 64, pages 473–486 J. J. Pandit et al. Æ Measuring performance of operating lists
. ....................................................................................................................................................................................................................

Figure 4 Plots of Efficiency vs Utilisa-

tion of lists (see Formula (2) in text).
The ‘triangle’ represents the ‘isopleth’
where no cancellations occur: thus, any
points lying on the lines of triangle
represent lists where no cancellation has
occurred; any point lying within the
triangle represent lists where a cancella-
tion has occurred. The horizontal line
represents the desirable objective of at
least 85% efficiency [1]. Points < 100%
on the x-axis represent under-utilisation
of the list; points lying at > 100% on the
x-axis represent over-utilisation. Each
data point represents a single list.

propose is no more complex than, say, equations involved
in oxygen delivery calculations (including the oxyhaemo-
globin dissociation curve).
We do not know if an alternative, simpler formula
exists. Strictly, our primary aim was simply to demon-
strate that the six criteria could be described mathemat-
ically to satisfaction. Even if only a close approximation of
what ‘quantitative performance’ means, our formula is a
significant advance on the use of colloquial terminology
in which efficiency, productivity, utilisation, etc are
synonymous.
Limitations and utility of our analysis
It is in the application of our measure, rather than in
its mathematical construct, that we encounter certain
practical limitations. Perhaps the weakest part of our
measure is accuracy with which ‘speed’ of surgery can be
measured. Our regret that so little publicly-accessible data
exists on how long operations take to perform is shared by
Macario who argued that lack of data was a key factor in
poor scheduling of cases to fit the available time [9]. A
hospital could use its own local data sets, but statistical bias
will favour the team as its own data generate the reference
times. Also new hospitals may be disadvantaged as they
have no historical data. Thus how ‘reference times’ are
acquired might critically influence the results of the
formula, and ideally each team’s ‘reference times’ must be
collected in the same manner or from equivalent sources
to make them comparable. For example, they should
reflect subtle variants in procedure and significant co-
morbidity in patient groups (even very closely-coded
operations could differ in duration by as much as 1 h [9]).
If the ‘aim’ of the productivity calculation is to compare
teams (perhaps within a hospital to generate internal
competition or as ‘league tables’ across hospitals) it is
essential that the ‘reference times’ are robust. This will be

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Journal compilation  2009 The Association of Anaesthetists of Great Britain and Ireland 481
J. J. Pandit et al. Æ Measuring performance of operating lists
. ....................................................................................................................................................................................................................
Figure 5 Performance Index vs Productive Potential (from
Equation (1) in text) for data from each of the real teams A–E
(each team’s efficiency is stated in %). As in Fig. 1b, the vertical
line and the curve for 85% Efficiency divide the graph into
quadrants. The point for a ‘perfect team’ (efficiency 100%, speed
1.0 and patient contact 1.0) is also shown (see text).
difficult to achieve, but may develop [27] as more precise
data is needed to inform changes in hospital funding to
activity-based measures such as Payment-by-Results [28].
If, on the other hand, the aim of the productivity score
is to engender self-reflective team improvement (akin to a
golfer working on a handicap) reference times might
usefully be based on teams’ own historical averages. These
data may have little or no external validity, but should
nonetheless focus local efforts on performance improve-
ment.
One potential criticism of our notion of relative speed
is that, by definition, 50% of teams will be ‘below
average’. Although potentially contentious (no team likes
to be ‘slow’), speed does need to be modelled. We think
that in practice actual differences in speed will be quite
small because speed is averaged over the whole range of
the team’s operations over a sustained period of time. The
team will have to be consistently slow by a large margin
and if so, then perhaps this is something important to
identify. Finally, the 50% cut-off is unreasonable: it is
teams lying beyond, say, the 95% or 99% confidence
intervals for speed that might reasonably be judged
‘outliers’. At worst (for example, if speed data proved too
difficult to obtain), the ‘speed’ element in Formula (1)
could be ignored by assigning it a value of 1.0 and so
assume that all teams, speeds are average.
We cannot factor in quality criteria any more precisely
than by emphasising that teams must meet any minimum
482
Anaesthesia, 2009, 64, pages 473–486
levels set by their own sub-specialty. We cannot stipulate
that a complication rate of, say, 3% is inherently better
than, say, 5% because sub-specialties themselves (at best)
only define a minimum threshold or range for such
measures (for example, ‘complication rates should be
< 6%’) [29, 30]. It is beyond the scope of this paper to set
quality criteria for specialties, but automatically assigning
‘zero performance’ to any team that fails to meet its own
specialty’s standards ensures that teams are not encouraged
to place speed above quality.
Our notion of ‘patient contact’ is less novel than it might
first seem. The American Association of Anesthesia
Clinical Directors describe the proportion of time on a
list that a patient is physically in the operating room
(including induction of anaesthesia) as a ‘productivity
index’ [31]. A small bias exists as patient contact (or
conversely gap time) is related to the number of cases
performed on a list. Thus, a list consisting entirely of one
long (8 h) case has by definition zero gaps, in contrast to a
list of many small cases where gaps are inevitable. But, as
we discuss later, focussing on long cases introduces its own
problems for achieving high productivity by our measure,
such that the two effects broadly balance each other.
Our assumption that all relevant operation times are
taken from the start of anaesthesia to the arrival of patient
in recovery is consistent with the majority of reports in
the field [2, 16–18, 32]. While some authors have argued
in favour of simply ‘surgical’ or ‘cutting’ time as the
relevant measure [33], this clearly ignores essential
components of the surgery such as anaesthesia and
positioning.
It is implicit in our analysis that teams have the
constructive aim of improving performance, rather than
the destructive desire of simply ‘gaming’ the system. All
measures of system performance (such as waiting lists,
waiting times, utilisation, cancellation rates, efficiency,
etc) are open to cynical manipulation or frank fraud [34]
and our index is no exception. Our formulae penalise a
list with a large ‘gap’ at the end of a list somewhat more
than they do a gap of equal magnitude in the middle of
the list (utilisation is weighted more than patient contact).
Therefore, a team repeatedly suffering this ‘penalty’ might
conceivably transfer a gap from the end of the list to the
middle and therefore finish ‘on time’. This emphasises
that our measure should not be used as a means of
benchmarking activity or as a basis for reward or
punishment [35]. Instead it can only correctly be used
as a means of identifying areas for improvement. Indeed,
we anticipate that our measure will more commonly
identify teams (such as Team B; Table 2) which are
performing well and help defend them against misclassi-
fication as ‘poor performers’ or against misguided
attempts at further performance improvement.
 2009 The Authors
Journal compilation  2009 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2009, 64, pages 473–486 J. J. Pandit et al. Æ Measuring performance of operating lists
. ....................................................................................................................................................................................................................

Interpreting the quantitative performance index last conclusion surprising, but it underlines the difficulty
Whether the graphical presentation of our formulae adds in showing objectively that late starts have a detrimental
further insight than simple perusal of the raw data as impact in the face of other, more influential adverse
spreadsheets (for example, Table 2) probably depends on factors [40–42].
the experience of the analyst. An experienced physiol- Similarly, by our formulae gaps between cases have
ogist need only glance at individual values for haemo- only a modest effect on performance. Gaps are subjec-
globin, saturation, partial pressure, cardiac output, etc, to tively felt to be important [37] but objective analysis
understand an aberration in oxygen delivery. But this suggests that gap (turnover) times are in practice
experience itself derives from knowledge of the inter- modest, so that even eliminating these has little overall
relationships. A novice on the other hand often finds effect [38, 42–45]. Some authors have gone as far as
it helpful to perform the calculations consciously step- describing analysis of turnover times as ‘meaningless’,
by-step (for example, starting with a plot of oxygen implying that the effort is rarely worth the expense [46].
saturation vs partial pressure, etc). Similarly, our process We found that even the poorest performing teams (C
formally describes a method of how to analyse the data in and D in our data) had gap times < 10% of scheduled
Table 2. list time (Table 2) which is similar to that reported by
Even experienced analysts may be misled by cursory Cook [38] and the ideal objective suggested by Macario
inspection of spreadsheets. From Table 2 it does not seem [9]. This is close to the Audit Commission’s suggested
obvious that the late starts of Team B are in fact trivial; or target for gaps of < 8% of list time, and represents a
that Team A cancellation rate (though needing improve- maximum of 40 min [1, 24–26]. Even if all this time
ment) little impairs overall performance; or that slow were ‘saved’ it is difficult to see which procedures could
operating speeds of Team D (but not Team E) are be comfortably accommodated. Thus, the way we
significant; or that the cancellation rate of Team E is modelled gap ⁄ patient contact time appropriately reflects
simply a function of a small absolute number of cases, as the limited impact of reducing modest gap times, while
expected in a cardiac team. at the same time reflecting the utility of reducing very
Targets or objectives can result in perverse outcomes. A large gap times.
well-intentioned policy of never over-running theatres Previous work has indicated that faster operating can
may lead to an undesirable increase in cancellations [36]. improve throughput of cases, but only relatively modestly
A focus on operating speed may raise complication rates. [47, 48]: consistent with the notion that the lists in these
Maximising theatre utilisation alone may lead to over- studies lay near the top of the asymptotic curve (Fig. 1).
run and ⁄ or cancellation. In contrast to single aims, our
formula balances relevant variables to provide a summary Comparison with economic measures of
statistic, without creating perverse incentives. productivity
Our analysis can only be meaningfully applied in It is beyond the scope of this article to consider our
healthcare systems that are fundamentally rational and notion of productivity in the context of formal economic
ascribe to the six core criteria we defined. Hospitals are measures. Nonetheless, there are some parallels. Sumanth
free instead to choose alternative priorities. If the only distinguished ‘efficiency’ (that is, how well the business
outcome judged important were, say, completing as many works) from ‘production’ (that is, how many goods are
cases as possible (regardless of case type), or to start on produced) [49]. Scott argued that ‘productivity’ and
time (regardless of how subsequent time is utilised), then ‘profitability’ should be distinct, as the latter can be
our analysis is irrelevant to achieving such isolated influenced by demand and complex pricing issues (for
objectives. example, price-fixing) [50]. By avoiding the latter, our
approach seems consistent with Scott’s view. Our graph-
Consistency of our formula with other data ical plot of Equation (1) closely resembles an asymptotic
Our approach is consistent with – and extends the results function used by Wen in plotting ‘business productivity’
of – a number of other studies. In our model, late starts against ‘input’. Wen demonstrated a family of curves
have only modest influence on performance. We were (similar to our efficiency curves), each representing a
surprised to find that so many lists started on or before discrete pattern of economic growth or institutional
time (Table 2). Although often blamed for inefficiencies, organisation [51]. Increasing ‘input’ (for example through
objective studies indicate that factors such as overbooking faster or greater work) could increase business produc-
dwarf any measurable impact of late starts [4, 5, 37, 38]. tivity only up to curve’s asymptote. Further increases in
Starts as late as by 15 min have no discernible impact productivity could then only be achieved by major
[39–41] and some authorities have suggested that even structural change in the business (or as we describe it,
delays of < 45 min are classed acceptable [9]. We find this ‘efficiency’).

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Journal compilation  2009 The Association of Anaesthetists of Great Britain and Ireland 483
J. J. Pandit et al. Æ Measuring performance of operating lists Anaesthesia, 2009, 64, pages 473–486
. ....................................................................................................................................................................................................................

Summary: how teams can perform well subjected to our measure will assess any unforeseen
To perform well in quantitative terms by our measure, weaknesses or features that require modification. Second,
teams need to achieve the following: first, to satisfy any wider publication of operating times will assist in the
minimum quality or safety criteria defined by their own development of ‘reference times’. Finally, more accurate
sub-specialty; next, to plan lists to utilise the time available, information on costs involved in each team’s operating
with no cancellations or over-runs; then – and best only lists will enable the hypothesis to be tested that our index
then – to focus on working at least at average speeds with of performance is related to financial success. Any
minimal gaps between cases, using any time saved to disparity between these two might indicate perverse
accommodate extra cases. These appear very reasonable incentives within the system, which would be important
aspirations, independent of type of surgery, institution or to rectify.
healthcare system in which the work takes place. Science works by future work adapting past hypoth-
Fitting in an extra case may be (inevitably) somewhat eses. We hope to stimulate readers to offer alternatives as
easier for surgical subspecialties where short procedures better descriptors of productivity. Perhaps crude in some
are common than it is for those with long cases. minor details, our formula seems to work rather well for a
However, this does not bias against the latter, for the range of hypothetical and real lists. We suspect any
following reason. Our measure is able to distinguish a improvement in accuracy will require very complex
well- from a poorly-performing cardiac team. We can mathematics, but we think the only way of finding out if
also distinguish a well- from a poorly-performing day case this is so is for others, on viewing our analysis, to set about
hernia team. Furthermore, we can make direct compar- trying to improve it.
isons of any of these four teams. However, it is generally
more difficult for the already well-performing cardiac
Acknowledgements
team to perform even better, than it is for an already well-
performing hernia team. This is because (as implicit in our We thank Professor Alex Macario, Professor of Anesthesia
measure) cardiac teams generally need to save > 2 h of & Health Research Policy, Stanford University, CA,
time to accommodate an extra case, while hernia teams USA and Mr Andrew Vincent, Director, Medicology
need to save only 30 min. The bias is not large because Ltd, Specialists in Organisational Performance Through
both teams, already performing well, lie on the flat part of People, for their helpful comments on the manuscript.
the performance curve (Fig. 5). So any real gains for the
hernia team over the cardiac team are necessarily small.
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