The primary challenge facing anesthesiology practices nationwide is the shortage of anesthesia providers. While efforts to address provider supply are necessary, maximizing the capacity of our current teams to provide care is essential. This requires systems and processes that optimize the combined resource capability (hospital/facility and anesthesia) for surgical and nonoperating room anesthesia (NORA) care to achieve effectiveness and efficiency. While these efforts are aligned with hospital/facility goals and support the value proposition in anesthesia care delivery, in many cases, they will require significant operational management changes. This article explores ways to focus attention on improving the utilization of available anesthesia resources through thoughtful data-driven planning and management, thereby maximizing the overall capacity of anesthesia providers to be available for patient care in our current resource-restricted environment.

Inefficient OR schedules frustrate health care providers and patients. Although efficiency will never reach 100%, it can be increased through standardizing clinical and operational protocols, creating accurate case schedules, and eliminating non-value-added tasks. In contrast, inefficient management leads to unpredictable schedules, unexpected late shifts, and increased labor costs in addition to significant job dissatisfaction and physician burnout. Anesthesia workforce risk includes increased resignations, transitions to more predictable ambulatory work settings, or a change in employment status (e.g., to locums tenens or per-diem contract physicians).

How can we work with facilities to support standardization, create efficiency, and reduce OR schedule down time?

  • Misaligned staffing and scheduling between OR and NORA sites are major sources of frustration and inefficiency. For example, anesthesiology clinicians may be idle in the late afternoon and then expected to stay into the evening to cover when a room is “reopened” after late-shift nurses and technicians arrive. Anesthesiologists should consider flexible schedules that are coordinated with nursing or other staff services. If it is known that an OR must close at 3 p.m. due to a staff shortage, then the anesthesiologist assigned to that room might be “guaranteed” an early day and thus be able to attend to personal matters more reliably.
  • Anesthesiologists need to contribute to OR room schedule development, as OR and procedure room efficiency is paramount to optimal utilization of scarce resources. Anesthesiologists are adept at viewing the entirety of a procedural schedule and identifying areas for consolidation as well as planning to relieve bottlenecks in patient flow. Strategies to consolidate rooms can enable optimizing scheduling with respect to all clinical availability.
  • Anesthesiology leaders must advocate for all necessary personnel to support the anesthesia team, including anesthesia technicians, biomedical engineers, and pharmacists. Without support staff, a greater burden is placed on anesthesia clinicians for many affiliated tasks that are crucial to patient care. Increased ancillary work in an inefficient environment leads to burnout and resignations.
  • Pre-procedure optimization programs have been found to decrease day-of-surgery cancellations, improve on-time starts, and can improve outcomes. For example, cancellation of a procedure on the day of surgery is not only a powerful cause of patient dissatisfaction, but it can also wreak havoc on an OR schedule. Anesthesiology engagement in preoperative optimization programs can drive efficiency and offer assurance that patients are appropriately prepared for a procedure.

Anesthesiologists value their ability not only to improve patient outcomes but also to contribute to perioperative case management. There is a clear association between efficient and aligned OR management, increased schedule predictability, anesthesiologist job satisfaction, and reduced burnout risk leading to anesthesiology workforce satisfaction, engagement, and retention.

Franklin Dexter, MD, PhD, FASA, maintains a definitive list of references on improving OR efficiency (see

Mitigating the impact of the nationwide anesthesia shortage on procedural case capacity is necessary to meet surgical service productivity and financial goals. Prospective service-level agreements (SLA) must be based on rational case volume and staffing pattern projections that will create efficient utilization of all resources. Simply determining the number and duration of OR availability based on assigned surgical block time almost always overestimates coverage need. Historic, actual OR use patterns can refine the coverage requirements. SLAs, by day and time, should be modeled to maximizing anesthesia teams, OR staff teams, and surgeon schedules while accounting for coverage concurrency for medically directing anesthesiologists and/or the time requirements for solo anesthesia providers.

Data-driven tactical (prospective) and operational (short term) decisions are necessary to maximally extend available resources. The data required is typically available either in surgical services data or from anesthesia billing data and, through a rules-based approach, can be utilized to optimally assign OR resources (rooms, OR nursing, and anesthesia) while consolidating unallocated OR time. In this way, workforce distribution can be based on optimizing utilization (not capacity) and will limit resource waste. Fine-tuning the process then requires OR managers to tightly manage the OR environment on the day of surgery to additionally enhance patient and clinician resource movement throughout the perioperative period. Of note, historic OR performance metrics, such as first case start performance and turnover time, can distract management teams from the overarching requirement for adjusting assigned resources. Surgical services metrics (e.g., OR utilization, staff efficiency, and cost per surgical minute) provide superior indicators of overall OR performance. Further, attention to the distribution of the anesthesia clinical workforce (solo physician, CRNA, and CAA) through variable staffing ratios can also enhance efficient resource flexibility compared to fixed staffing patterns.

Figure: Anesthesia clinician flow between OR and NORA sites of service.

Figure: Anesthesia clinician flow between OR and NORA sites of service.

It is important to understand the impact of increased nonoperating room anesthesia (NORA) cases on the capacity of anesthesia clinicians to move between case location sites and matched to other NORA proceduralist and staff schedules. The slide illustrates some of the movement need with and without accompanying patients (Anesth Analg 2017;124:292). Figure adapted from abstract presentation at International Anesthesia Research Society, Washington, DC, May 2017, with permission of M. Tsai.

Preservation of OR staff and anesthesia providers is essential in this constrained environment. Presumably, creating predictability through optimal OR management will lead to increased workplace satisfaction and retention. Further, fostering a best-in-class workplace culture requires excellent OR leadership, an environment of psychological safety, and spirit of camaraderie. Trended resource-based metrics such as staff turnover should include assessment of safety perception and staff/clinician satisfaction as early signals to predict and/or correct OR cultural concerns.

Due to the advent of techniques in minimally invasive surgery and interventional procedures, anesthesiologists have experienced a migration of work from OR to NORA sites. With the anesthesia labor shortage, many find it difficult to support the lateral expansion in staffing sites and the increased number of cases. Tactically, anesthesiologists in NORA sites often trade off operational efficiency, patient safety, and staffing ratios. The Figure illustrates the various NORA sites that an anesthesia group may be asked to staff. Of note, it has been demonstrated that as the percentage of NORA responsibilities increases, clinical productivity for an anesthesiology group decreases given the disparate locations and specialized equipment constraints (Anesthesiol Clin 2018;36:143-60). Further, there is usually a mismatch between start times for block allocations in the OR and NORA proceduralists, who start later in the day. While OR anesthesiologists and nurses are usually aligned with respect to schedules, anesthesiologists in the NORA setting are often misaligned with the nurses and ancillary staff schedules. Careful consideration of OR and NORA scheduling, anesthesia clinician and staff availability, and transit time between care settings are paramount to efficient use of critical human resources.

The migration of appropriate surgical procedures from the inpatient to hospital-associated outpatient department (HOPD) and ambulatory surgery center (ASC) settings also has profound implications for the efficiency of OR utilization and the distribution of workforce in each setting. Gains in outpatient setting (HOPD or ASC) efficiency are dependent on the case/patient appropriateness (e.g., patient comorbidities, complexity of procedure), staff readiness to care for increased patient/procedure complexity, appropriate preoperative assessment for care in the outpatient setting, the ability of a surgeon to balance inpatient and outpatient patient scheduling, and the availability of anesthesia staff who can cover multiple, disparate locations. The total cost of care, the convenience, and the quality of care from the patient point of view must also be considered. Organizations must decide how to allocate block time for surgeons who are splitting their schedule between inpatient and outpatient settings, in contrast to those dedicated to one site of service on a given date. In all cases, given the complex interplay of site of service, physician, anesthesiology, patient, and appropriate health care utilization factors, flexible and adaptive coordination is necessary to achieve optimal care in ambulatory care settings.

A specific location (site of service) with appropriate clinical and administrative staff, a surgeon or proceduralist, competent nurses and skilled technicians, and anesthesia clinicians are all necessary for any health care facility to care for surgical patients. As our population ages and increasing numbers of patients are presenting for elective surgical care after COVID delays, anesthesiology is experiencing an increasing demand for surgical and procedural coverage. However, as a specialty, our capacity to extend appropriate anesthesiology services to all requested care settings is limited due to labor shortages and OR utilization/management challenges. Careful coordination between all stakeholders is required to match anesthesiology availability to surgical schedules to the appropriate site of service in order to meet our obligation to provide the highest quality and safety of care while achieving the optimal patient experience.