“The operating room should be at the disposal of the surgeons 24/7, no questions asked.”

“Every day at 3 p.m. it’s like rats scurrying off the deck of the Titanic, and we can’t get any work done.”

“1:30 p.m. is the bewitching hour. That’s when everyone slows down and starts watching the clock.”

We have all heard these types of comments in some form or another. While these statements are really meant to be questions, when posed in this way they can be frustrating to those who hear them and those who say them because they often go unanswered. More often than not, these statements are made by those with an inaccurate or deficient understanding of perioperative utilization both financially and logistically. Anesthesiologists, as perioperative leaders, should arm themselves with an understanding of perioperative utilization so they can not only accurately and factually respond to this verbiage but also effectively manage the ORs to create an efficient, profitable, and cohesive system. The challenge that remains is a fundamental difference in the global vision across perioperative physicians and staff. As such, precipitating evolution of the perspectives of OR personnel continues to be a challenge.

As we stand in the present and step into the future, I’ve (Dr. Locke) often said in response to “Periop should be at the beck and call of the surgeon” that if you truly believe such a sentiment, you will not survive the next five to seven years of surgical practice. It’s important to recognize that this was an actual setting many have experienced; however, the personnel who supported this model are now nonexistent. Simply have a 10-minute conversation with a nurse, tech, or anesthesiologist under 35 to see that. The institutions refusing to course correct will become inconsequential. The power pendulum has swung in favor of the employee. We are functioning in the era of “quiet quitting.” If you think that as an institution or surgeon you can strongarm people into working past their shifts, or move efficiently when being utilized during emergency hours for routine cases, you will quickly have an exodus of people with no replacements, unless you are now willing to pay double.

This mismatch in vision is partly due to generational differences. Addressing the multigenerational gap is critical to developing successful OR teams. Each generation has different wants and needs. Across generations, the importance/value that we place on loyalty, mode of communication, trust, skill sets, work-life balance, and expectations for hours, compensation, and benefits varies significantly and can directly impact the scheduling structure within the perioperative suite. So how do we leverage those differing value systems to effect long-term change? How do we align understanding of perioperative operations with generational differences, while driving home the need to address challenges and stressors in a very different way than we have done in the past?

Ultimately, the question becomes, how do you counter these prevailing, yet outdated, attitudes and bring about wholesale change to the OR? It’s more likely that surgeons recognize that the perioperative landscape has changed; however, their practice model has not, which is understandably frustrating. Kotter’s 8-step model to foster meaningful change can be used as a tool to help bring about successful change in and acceptance of OR utilization and management.

“The concept of a burning platform comes from the analogy of standing on an oil platform at sea that’s on fire – the urgency to save yourself is so great you take action and jump off” (Leading Change. 1996).

We know innovation, and change, for that matter, are crucial in any organization. But how do we motivate people to, in effect, “jump”? How do we communicate that to not change is dire? A great start to creating a sense of urgency is asking a few questions. Do we struggle to fill our ORs during normal business hours? Why or why not? Do we struggle in recruiting and retaining perioperative staff? Is this a great place to work? If not, why not? Can it be changed?

Most importantly, in answering these questions we need honest and compelling dialogue about where your organization stands in the greater landscape. Honest conversations about the need for change and the threat to the organization that the lack of change represents fuel that urgency. The hope is that this will feed on itself and spread.

It goes without saying that an OR is a tough place to work. You need powerful allies who can assist you in driving meaningful change for everyone, not just for themselves. It’s helpful to have surgeons who have a consistent presence in the OR and a great working relationship with administration. Once you gain a critical mass of stakeholders, it’s time to find an executive champion. The question to be raised is “are we capable of bringing about this change using our current resources, or do we need external help?” The answer to this question is almost always yes, we need additional and a reallocation of capable resources.

Consider revisiting committee membership with an eye for people who truly desire change. Remember that any group or committee formed that does not have at least one person under the age of 40 is selling itself short. Step away from utilizing people who are on these committees as a departmental duty and/or folks who simply have seniority in age or academic standing. What we aim for is someone capable of ushering in a new vision. Younger physicians often see the same problem from a completely different lens and thus can offer solutions that did not appear as possibilities to others.

Sometimes you need help from an outside source. There are several great consulting firms, but how do you choose? How do they create and sustain change at the OR governance level? Given the expense, the decision to engage an outside consultant is often a hospital board-level decision, so it’s important to have support of administration and your key perioperative leaders to go this route.

Once you have developed your team and garnered the necessary resources, it’s time to define your mission, image of success, and value proposition. Priority number-one must be a culture of transparency. This is often a “trust fall” scenario between surgeons, administrators, nurses, techs, and staff, who all have varied understanding and perceived barriers to mission success. Many of you may be familiar with Franklin Covey’s “Leading at the Speed of Trust” (The Speed of Trust: The One Thing That Changes Everything. 2008). High-trust organizations routinely see increased productivity and decreased cost. Decreasing trust gaps and increasing personal credibility lead to the ability to change. Where distrust and frustration are unchecked, you cannot lead, and you most certainly cannot get anyone to drink what you are selling!

Initially, gather the stakeholders and communicate the vision, but understand that the vision and the ultimate path to it must also be presented in a clear and concise fashion to all members of the perioperative team. During the initial communication of the vision with the stakeholders and/or governance team, be sure to provide the background for the change, need for the change, any anticipated barriers, and the plan for success. Keep the messaging simple and direct. Communicate with honesty, encourage questions, be open to feedback, and embrace challenges. Deliver the message through multiple avenues to ensure every member of the team receives the message.

In order to effectively empower action and implement change, it is essential to remove as many barriers as possible. While empowering action, maintaining personal credibility and requiring it of each member of the perioperative team is a fundamental element in fostering a culture of trust and authenticity during the ever-evolving process of change. Barriers may be structural, systems issues, managerial, or related to skill sets. Removing or decreasing barriers can also lessen frustration, making the process of enabling action more streamlined and less arduous.

Creating quick wins motivates stakeholders and demonstrates that the efforts are worthwhile. These wins offer encouragement and a “pat on the back” for those involved. Short-term successes can make it more difficult to block future changes, revert back to “the old ways,” and provide evidence that the transformation is on track and will likely be successful. Quick wins build momentum and engender further support for the change. Next, continue to drive the momentum forward to build on the progress and achieve sustainable change!

Generational differences coupled with evolving employment models postpandemic directly impact OR staffing and create challenges related to effective staffing and OR utilization. Effective governance is required to institute the change and “make it stick.” In order to achieve this, the governance team must develop strategies to foster collaboration and create a culture of harmony among all members of the perioperative team, and this cannot be achieved without trust between parties. An imperative outcome of creating a harmonious culture and instituting change is prevention of physician burnout. By recognizing how differences in values can impact employee burnout, the governance team can ensure that once the change is instituted, it is sustainable. To create sustainable change, it is vital to understand and address topics such as flexibility in compensation and scheduling as well as the differences in generational personalities, modes of communication, and clinical skills. An effective perioperative governance team should have open and honest dialogue, demonstrate a personal interest in the staff, present clear goals and concrete rewards, provide opportunities for growth and creativity, and offer feedback and recognition as warranted. Most importantly, leadership must ensure that changes become a part of the fabric of the organizational culture. Buy in from all members of the perioperative team is essential. As such, we must create the connection to the larger purpose and goals of the organization.