Using Performance Frontiers To Evaluate Non-OR Anesthesia (NORA) Efficiency

Abstract

Introduction: In high-cost, high-revenue operating room (OR) suites, dashboards displaying key performance indicators are commonplace to optimize efficiency. Given the significant successes attained, further gains may risk compromising safety. In contrast, challenges unique to non-operating room anesthesia (NORA) sites have hindered operational efficiency. Existing productivity evaluation frameworks often fall short in guiding strategic and tactical improvements in NORA delivery. Performance frontiers have proven effective in evaluating OR systems, but their application to NORA remains unexplored. This study applies performance frontiers to assess NORA site efficiency and formulates potential operational strategies.

Methods: We evaluated anesthesia billing records at our primary hospital from 1 April 2022 to 30 March 2023. Cases from operating room and NORA locations were included, except for sites with irregular volume or financial arrangements. We included only non-holiday weekdays, defining NORA block time as 7 AM to 5 PM. For each room, we calculated under-utilized (time with no anesthesia billing) and over-utilized minutes (time billed outside of NORA block hours). Data for each location were plotted as rolling 4-week sums, normalized to scheduled NORA block time. Performance frontiers were then developed and plotted.

Results: Over 246 non-holiday weekdays, 42,424 cases had billable minutes during NORA block time, comprising 20,003 (47.2%) NORA cases and 22,421 (52.8%) OR cases. Performance frontiers revealed significant variability, with nonparametric tests confirming statistical significance and non-equivalence.

Discussion: Performance frontiers reveal substantial efficiency variability across NORA sites, underscoring the need for targeted interventions. Some sites matched OR efficiency levels, while others showed substantial differences, particularly those with high variability and urgency. Efficient sites can leverage performance frontiers to optimize resource allocation, while inefficient locations may benefit from a shared anesthesia resource pool for real-time resource allocation. Performance frontiers provide a novel approach for operational leaders to make more effective strategic decisions.

Keywords: Non-Operating Room Anesthesia (NORA); Operational Efficiency; Performance Frontiers; Strategic Decision Making.

Fig. 1

Under- and over-utilized minutes for various operating room and non-operating room anesthesia locations using normalized 4-week rolling sums on a per room basis. CT, computed tomography; CVOR, cardiovascular operating rooms; EP, electrophysiology; GI, gastroenterology; IR, interventional radiology; MRI, magnetic resonance imaging; OR, main operating rooms; TEE, transesophageal echocardiography

Fig. 2

Performance frontiers added for each location plotted in Fig. 1. CT, computed tomography; CVOR, cardiovascular operating rooms; EP, electrophysiology; GI, gastroenterology; IR, interventional radiology; MRI, magnetic resonance imaging; OR, main operating rooms; TEE, transesophageal echocardiography

Fig. 3

Performance frontiers of operating suites and highly efficient NORA locations only. CVOR, cardiovascular operating rooms; EP, electrophysiology; GI, gastroenterology; IR, interventional radiology; OR, main operating rooms

Fig. 4

Performance frontiers of inefficient, sporadically utilized anesthesia locations consistently demonstrate a large amount of both under- and over-utilized minutes. CT, computed tomography; IR, interventional radiology; MRI, magnetic resonance imaging; TEE, transesophageal echocardiography

Fig. 5

Performance frontier curves for interventional radiology (IR) cases on Mondays versus non-Mondays following the addition of a second anesthesia-covered IR room one day per week