June 16, 2020

The Support of (and Resistance to) the OR Flip Room


Outside of “How do I (the hospital) improve first case on-time start and room turnover?” the next most asked question for surgeries is, “Do the metrics include our flip rooms, and how is providing more than one room to physicians affecting those metrics?”

With as many hospitals that are providing flip rooms to physicians, one would think that an abundant amount of literature would be available. However, a quick google search returns very little research on the topic. Most of the articles include basic criteria for a flip room policy but not how to measure the efficiency of the flip. One article by OR Manager stood out: “Utilization in a flip room can be 30% to 40% lower than a fully scheduled operating room” (OR Manager, 2014). The same article advocates that hospitals fill the pressure to offer flip rooms to recruit and keep physicians for fear they will take their cases to a different hospital.

The consensus of all the articles found through a literature search provides some basic criteria for flip rooms.

  • Volume: The surgeon should bring in 250 cases per year and average at least six to seven cases per eight-hour block (OR Manager, 2014)
  • Metrics
    • Maintain first case on-time start in each room of at least 90%
    • Utilization in both rooms at a minimum of 70% unadjusted (doesn’t account for the release of block time)
  • Scheduling
    • To book into the second room, a physician should book at least half of the block in the first room
    • Schedule longer cases as first or last case of day and book them together; book short cases together (Peterson, 2017)
  • Procedure
    • “The ideal case is a short operation with a complicated setup…with predictable case times” (OR Manager, 2014)
    • Preference to cases where the setup time is like case duration (Peterson, 2017)
    • The ratio of set-up time to case length should be close to 1 (Azoulai, 2018)
  • Equipment: Available for both rooms
  • Assistance: Must have a designee to help with start/finish

We analyzed data from a small community hospital with six operating rooms during the prime-time hours of 7am – 3pm for the period of September 1, 2019, to February 29, 2020, for the orthopedics group. Every week the orthopedics group runs two physicians a day, and both are flipping rooms for a total of four orthopedics rooms.

Prime-time utilization varies little day over day, but individual room utilization (Figure 1) varies by day of the week. How does flipping rooms affect utilization? How does this hospital compare with the 30% to 40% reduction estimate from OR Manager?

Figure 1. Prime-Time Room Utilization

The primary metrics of inefficiency during prime time are room turnover time (TOT) and first case on-time start (FCOTS). Filtering the metrics for orthopedics shows a 38% increase in TOT (Figure 2) and a 13% decrease in FCOTS (Figure 3). That decrease in FCOTS accounted for an average 18.3-minute delay.

Figure 2. Orthopedics Room Turnover Time
Figure 3. Orthopedics First Case On-Time Start

The orthopedics group averages 93.7 minutes a case. For ease of calculation, the following analysis will use an average case length of 90 minutes and 50 and 30 minutes for TOT. For every four rooms, one case will be late by 20 minutes because of the flip. Cases start at 7am for the first room and 8am for the second room.

Table 1 shows what a schedule would look like with two physicians operating two rooms each. Without variations, the best utilization based on the hospital averages is 62.5%. Taking the same amount of cases, the physician would need to operate over two days, but the increase is 12.5% (Table 2).

Table 1. Orthopedics Flip Room Utilization
Table 2. Orthopedics Room Utilization without Flip Rooms

If operated efficiently, flip rooms can benefit the hospital in terms of physician retainment and recruitment. The time that physicians must wait for the next case is minimized, allowing them to reduce the number of days they work while increasing their office time to bring in new cases. However, there are some negatives to the flip room, such as a decrease in room utilization (revenue-generating minutes) for the hospital. While this analysis shows a reduction in room utilization of 10% to 20% (Table 1 and Table 2), not 30% to 40% as referenced in OR Manager, the biggest takeaway is how much room turnover affects room utilization. More cases mean more turnover (non-revenue-generating minutes) time that reduces from maximum room utilization.

Azoulai, B. (2018, October 2). Flip Rooms Are Nothing to Flip Out About. Retrieved from Hospital IQ: https://www.hospiq.com/blog/flip-rooms-are-nothing-to-flip-out-about/

OR Manager. (2014). Firm policies and the right procedures tip the cost-benefit balance toward flip rooms. OR Manager, 1-4.

Peterson, D. (2017). The Art of the Flip. Outpatient Surgery , 23-26.

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