Dr Holger Otto,
OR Coordination, Kreiskrankenhaus Rendsburg,
Email: [email protected]
On Theatre Management, Conflict and Potential Solutions
Criticism of hospitals is a common theme in the ongoing debate on German health policy. While critics frequently accuse the health service of being too expensive, inefficient and hampered by hierarchical structures, they seldom mention the high standards of medical care available and overlook the fact that these high quality services are available to every German citizen. Will this situation continue indefinitely? Professor Rainer Saalfeld, a senior executive at McKinsey & Co. in Munich notes that new treatments are emerging at a much faster rate than our ability to finance them. Mounting constraints on financial resources call for new ideas and approaches and this applies equally to the hospital sector.
To survive in the era of diagnosis-related groups (DRGs), hospitals must increase productivity, adopt leaner processes and reform organisational structures without abandoning their ethical responsibility towards patients. Having been identified as an area of high cost, structural change is also necessary in operating theatres where highlyqualified staff from many disciplines co-operate in a confined area and consume substantial material resources. The unwritten rules that have applied in theatres have in some cases caused problems such as long idle periods, high levels of overtime and excessive inpatient stays. In the current climate, treatment processes in operating theatres must be optimised. Alongside high-quality nursing and medical care, the efficiency of a hospital is significantly enhanced when operating room processes are tightly organised. Good surgeons, anaesthetists and nurses are essential for high quality, but a new type of employee, operating theatre co-ordinators and managers, are needed to assume responsibility for ensuring operating theatre processes are efficiently organised.
Who is best suited to fullfil this new role?
Anaesthetists appear to be a particularly good choice because they have an interdisciplinary insight into the operating theatre environment. In addition, their medical role allows them to assess organisational requirements in medical matters. It has become clear, however, that the new posts do not need to be filled by clinicians. Many nurses have acquired the appropriate advanced training to make them perfectly suited to the role. The fundamental pre-requisite for candidates is an excellent knowledge of operating theatre procedures.
Co-ordinators and Managers
The theatre co-ordinator plans and directs the day-to-day activities of the operating theatre. He/she is responsible for the smooth running of the unit and the integration of emergency cases. Capacity utilisation must be maximised, and personnel and material needs planned in a manner appropriate to requirements. Hospitals with decentralised surgical units may employ several theatre co-ordinators. The theatre co-ordinator position may be filled by a clinician or a qualified nurse. They must however have excellent knowledge of operating theatre procedures.
The theatre manager, in most cases a doctor or member of nursing management, is directly accountable to the hospital board and is responsible for developing long-term strategy for the surgical unit. His function includes all tasks associated with managing and directing an operating theatre.
Besides day-to-day management functions, these include supply management (stores, orders, equipment and personnel), administration (service statements and cost control), quality management and ensuring compliance with legal requirements. When budgetary responsibilities are transferred to the theatre manager, the unit becomes a separate cost centre in the hospital. Management outcomes also improve when hospital management and theatre managers agree a set of specific goals.
and Potential Solutions
The new responsibilities created by the deployment of theatre managers may cause conflict, sometimes of a serious and/or personal nature. For theatre management to be successful, it is vital therefore that senior management lends its full support to the theatre manager long after he assumes his duties. Management must state in no uncertain terms that it is fully behind the theatre management concept and must also define how it is to function.
Power is often confused with hierarchy. Conflicts related to status should not arise because the theatre manager does not enjoy a higher position in the hospital hierarchy than the surgeon. He/she is responsible for ensuring activities in the operating theatre run smoothly and has, therefore, the power to issue instructions. He/she allocates the personnel and material resources available to the department, compiles statistics and evaluates and optimises work processes.
The hospital should draft a charter codifying the rules governing routine co-operation in the operating theatre. This should be circulated among all relevant staff who must accept it as binding in terms of how they perform their function.
Drawing on operating theatre procedures, the charter codifies the precise tasks, competences and responsibilities of all those engaged in theatre activities. It also stipulates the course of action to be adopted in the event of conflicts arising.
To help win widespread acceptance, the charter should specify a timeframe for revisiting and updating its provisions. Consultants and nursing managers should have a role in drafting the charter and should sign it together with senior hospital management.
Successful operating theatre management requires the establishment of clearly-defined organisational structures as a basis for the unit’s activities. This includes an explicit statement that a single individual may assume overall responsibility for the operating theatre. An organisational chart may help clarify at what levels decisions are to be taken and implemented.
Some hospitals have established an operating theatre steering group, usually consisting of representatives from anaesthesia, surgery and nursing. The advantage of this approach is that it inhibits the emergence of sectional interests and encourages the various actors to work as a single unit. Under this model, staff tend to be more receptive to decisions. One of its drawbacks is that the large number of people involved is not conducive to quick decision-making.
For some years now, Rendsburg Hospital has been successfully managed by one of Germany’s leading private hospital management companies, SANA Kliniken GmbH & Co KGaA, Munich. Two years ago, as part of a restructuring project in its operating theatres, the hospital established the position of theatre co-ordinator. As no applications for the post were forthcoming, management decided to advertise the position externally. The job requirements, which include management functions, were: completion of specialist medical training; several years experience in an operating theatre setting; proven organisational, conflict resolution and team skills; assertiveness; analytical ability; and computer literacy.
Besides technical competence, theatre managers must be able to foster harmonious co-operation between the various occupational groups engaged in theatre work. The successful candidate in Rendsburg was a specialist in anaesthesiology who had acquired an excellent insight into theatre processes in his previous role and had some experience in a co-ordination role. Evidence of advanced training in medical quality and theatre management completed his skills profile. The chosen candidate is answerable to the board of the hospital, to which he reports regularly, and is employed in a full-time capacity as theatre manager. Since he took up the post, improvements in the hospital’s operating theatres have been measurable. Procedures are better coordinated, changeover times have been cut and theatre planning is characterised by clear targets and certainty. When theatre slots become free, this information is communicated to specialist departments for planning purposes. As a result, capacity utilisation is maximised, delivering an overall improvement in cost terms. Nevertheless, conflicts have persisted, although there have been conspicuous and acknowledged improvements in this regard. Taking into consideration the aforementioned problem-solving approaches, continuous efforts are being made to improve theatre procedures and foster greater co-operation.
Theatre management is always a balancing act, both at a human and technical level. It requires sensitivity and resolve, a willingness to compromise and learn, insight and assertiveness as well as a fully transparent approach to decision-making. It is also vital that theatre staff are regularly briefed on developments in the hospital. In Rendsburg for example, internal statistics are provided to senior consultants and heads of department during departmental meetings, while monthly meetings of the operating theatre team are held to encourage theatre nurses and other staff to share ideas and information, and participate in the ongoing improvement process.
Efficient operating theatre management is becoming an increasingly important issue in surgical units, a high-cost hospital area whose resources are constantly being squeezed. For theatre management to be successful, transparency is vital, clear targets must be set, and staff must have confidence in the theatre manager. In addition to being professionally competent, managers must be able to integrate, possess conflict management skills and have the full support of hospital management.
Well-structured theatre management can make a major contribution to the economic success and future viability of a hospital.