Why changing the ‘knife-to-skin’ time doesn’t affect theatre efficiency, and what to do instead.

Productivity (activity / unit cost) continues to fall throughout the NHS and, operating theatre (room) productivity is no exception.  This does not mean that people are not working hard; indeed, they may be working harder than ever.  But, it does mean that everyone has an interest in improving the system to increase the NHS’s value for money in general, and the financial survival of your own hospital in particular.

What’s gone wrong?

Using the Theory of Constraints (see below if you’re interested), we know that the ‘constraint’ in theatre throughput is the surgeon.  In other words, actually doing the surgery is the rate-limiting step.  All other resources in theatre should be focused on how best to ‘exploit’ the surgeon’s time fully.  Put another way, any time the surgeon spends not cutting is wasted time.

So, it’s not difficult to see what’s wrong in theatre, is it?  A surgeon hanging around waiting to operate gets us nowhere.

A lesson from aviation

A good analogy is the airline industry.  The surgeon is like the engine of an aeroplane.  Any time the engine is off, the plane is going nowhere.  Everything should be geared towards getting the plane moving.  The time spent on the ground, loading the plane, refuelling and cleaning the toilets out, must be reduced to the absolute minimum.  This time is called the ‘turnaround’ time; it is literally, the time taken to turn the plane around and send it on its way.  For planes with similar engines, turnaround time is the key.

Before ‘low-cost’ airlines came on the scene, a good, highly-efficient turnaround time was 45 minutes.  Nowadays, the best can do it in 15 minutes!

Avoid the simplistic, embrace the simple!

You have heard it said that bringing forward the ‘knife-to-skin’ time to 09:00 will improve theatre efficiency.  This is like saying bringing forward the take-off time will improve the efficiency of the plane’s engines because we’ll get to our destination earlier!  You will indeed get there earlier, but not quicker!  You haven’t affected the constraint in the system at all.

Let’s take some concrete examples.  A single, long operation requiring invasive anaesthetic procedures (intravenous lines, arterial lines, epidurals, etc), may not achieve a knife-to-skin time till, say 10:30.  But, the operation will go on till it finishes, which could be 13:30 or later.  Using our analogy, the ‘flight-time’ is unaffected, though the arrival time may seem late.  The efficiency is the same regardless of what time we ‘take-off’.  The opportunity for efficiency is absent because there is no turnaround time available to reduce.

On the other hand, think about multiple, short procedures, say, an ENT list with lots of tonsillectomies.  Here, the turnaround time is crucial.  If you can reduce delay between knife-to-skin times, you can do more procedures with the operating time available.  One extra short-haul flight can make the difference between profit and loss for Easyjet!   For a surgical service provider (e.g. a hospital), it could make the difference between keeping a service or not.

Simple (not necessarily easy) solutions

In our analogy, the surgeon is represented by the engine.  The anaesthetist must be the pilot.  He/she is the one who does the clever take off and landing bits.  You shouldn’t be using the pilot to refuel the aircraft or clean the toilets!  The operation is represented by the flight and the patient by the passengers (you can have fun trying to allocate roles – I haven’t worked out who provides the in-flight entertainment yet!).

So, we reduce turnaround time by ensuring a ‘ready-to-go’ patient is always available as soon as the surgeon finishes one operation. 

Here are some examples; you will be able to think of more yourself:

  • Have a local anaesthetic patient on the table whilst another is being put to sleep.  To this end, ensure that all patients are strongly offered LA in outpatients/pre-assessment clinics, and make sure surgeons are trained in these techniques
  • Perform invasive anaesthetic procedures before the previous operation has finished.  These could be done by other anaesthetists in separate areas, e.g. epidurals could be sited in Recovery (or some other appropriate place)
  • Double-up anaesthetists and ODPs, and/or make use of Anaesthetic Practitioners
  • Use Dual-Operating, where a surgeon shuttles from one anaesthetised patient to another in adjoining theatres
  • Designate a buffer area where ‘stand-by’ patients can be waiting, rather than have to fetch them from remote areas (i.e. wards)
  • Don’t insist on an Escort nurse for every patient

All these solutions are simple and easy to monitor, most are evidence-based from elsewhere in the NHS, private medicine or other countries.  They may not be cost-neutral, but in fact, most merely require a change to the way we organise ourselves.  They will improve theatre efficiency.


By using a well-established theory and borrowing useful analogies from the airline industry, I hope I have shown that simply shifting start times in isolation will not achieve greater theatre efficiency.

But, there are efficiency gains to be had, which must be achieved.  They involve the way we organise, not how fast we work.  I would emphasise that none of what I propose means cutting corners or jeopardising patient safety (which, in my book, is paramount).

Further reading:

Dettmer H W (1998) Goldratt’s Theory of Constraints: A Systems Approach to Continuous Improvement   McGraw-Hill Education, ISBN: 0873893700

Step guide to improving operating theatre efficiency


Guard your tongue

 He who guards his mouth and his tongue keeps himself from calamity. (Proverbs 21:23)

Sometimes uncomfortable things have to be said at meetings.  However, you should consider first if they can be said in other venues, in other ways, or at other times.  Grandstanding wins few friends and is generally counter-productive.  Also, silence can be very eloquent, and it’s surprising how often other people will say what you wanted to say!

The Next Level: what insiders know about executive success

  Scott Eblin, Davies-Black Publishing, 2006

There is often a feeling of vulnerability when you find yourself in a position of high authority in an organisation.  Many new executives fail to thrive in their new role and self-doubt is common.  Scott Eblin has analysed this transition and come up with characteristics for success.  His book is built around the notion that new executives must let go of previously successful tactics and pick up new ways of working at the higher level.  Simply doing more of the same is inadequate.  He quotes extensively from recognised high-performing executives.

The ideas and strategies suggested in ‘The Next Level’ are particularly pertinent for doctors in managerial/leadership positions, (or those who aspire to such positions).  For most of their careers, doctors have kept their ‘nose to the grindstone’ of clinical practice, studying for professional exams and perhaps engaging in some research of doubtful use.  They have not had to engage with non-clinical managers much, let alone executives or boards of organisations.  So when they achieve some sort of formal leadership role, say, Clinical Lead or Director, they usually don’t have the necessary skills to succeed.

Scott’s book has straightforward, practical advice drawn from real-life examples of success.  If you apply his advice you will astonish your colleagues and delight your board!

The Starbucks Experience: 5 principles for turning ordinary into extraordinary

Jospeh A Michelli, McGraw-Hill, New York

About 5:30 am in the waiting area of Liverpool airport, I was feeling dog-tired.  There was nearly an hour to kill before my flight and a Starbuck’s sign caught my eye.  I had never been to Starbucks before but I had in my mind an idea that that coffee was supposed to be good, certainly better than the usual airport fare.  I bought my espresso and was genuinely surprised by the local server asking if I wanted a glass of water with it.  I accepted, and sat down.  I was thinking, “Is that normal for Starbucks, or did this just happen to be an unusually friendly and insightful Scouser?”  Whatever, I was pleased; my expectations had been exceeded.

This really is the essence of the book.  Starbucks aims to turn an ordinary event (buying a cup of coffee) into an extraordinary experience for the customer.  This permits Starbucks to charge higher prices, and to ensure the customer comes back.  A ‘win-win’ situation.

This book was recommended to me by my old CEO at Nations Healthcare Ltd, a young, independent healthcare company trying to break into the NHS.  The idea was that what Starbucks could do for coffee-drinkers, we could do for patients.

It was a neat idea.  The NHS is ordinary, it’s OK, it’s mediocre1.  It could be great if the experience of the patient was taken seriously, i.e. enacted as opposed to espoused.  Starbucks takes the customer experience seriously, that is, it plans it, expends resources on it and ensures its implementation from the bottom of the organisation to the top.  Anyone who works in a service industry and genuinely wants to enhance the consumers’ experience should learn from this book.

Bear in mind the author and organisation are Americans, so for a British reader the style can be a bit cloying.  However, the central message is valid and certainly applicable to healthcare.

Here’s some brief thoughts I picked out from the 5 principles that can easily be applied to healthcare: 

Principle 1:  make it your own:

  • Be welcoming: hospitals are scary places, show hospitality!
  • Be genuine: connect, discover, respond
  • Be considerate:  mindful of the needs of others
  • Be knowledgeable:  love what you do and share that knowledge with others
  • Be involved: in your workplace, department, hospital, community 

Principle 2:  Everything matters:  small details can make all the difference, there really is no way to hide poor quality, ask patients what details they notice about us 

Principle 3:  Surprise and delight:  under-promise and over-deliver (how often the NHS gets it the opposite way round!  For example, think of how we send out appointments, then phone to say they’ve been cancelled).  Don’t be content with ‘satisfactory’ look for ‘delighted’.  Efforts to surprise and delight are contagious.  Patients can even be delighted by the way we make things right 

Principle 4:  Embrace resistance: don’t mind criticism.  If it is untrue, disregard it; if unfair, keep from irritation; if it is ignorant, smile; if it is justified, learn from it 

Principle 5:  Leave your mark:  “How wonderful it is that nobody need wait a single moment before starting to improve the world.” – Anne Frank

1          Health Consumer Powerhouse (2007).  Euro Health Consumer Index 2007, available at http://www.healthpowerhouse.com/media/Rapport_EHCI_2007.pdf [accessed 14/02/08].  (The UK NHS ranks 17th out of 29 countries in Europe).

The 7 habits of highly effective people: powerful lessons in personal change




Stephen Covey.  Simon & Schuster UK Ltd, London

It’s hard to know where to start with a book as famous as this.  I had to read this book; I mean, literally!  It was mandatory reading prior to starting my MBA course.  I would never have normally read such a book, but I’m very glad I did.

It is the personal development book par excellence.  It is very easy to read and verbalises a lot of intuitive common sense.  But remember, common sense is not common practice!

I think that Stephen’s central theme is that there are certain truthful, absolutes in life.  Adhering to these principles will always lead to satisfaction, whether at work or in ones private life.  For me, it revolutionised the way I interact at work and, for anyone contemplating how to be an effective leader, this book is indispensable.  I have also seen Stephen’s video of how children can utilise the ‘7 Habits’, which is quite astonishing.  However, like many good ideas the principles need to be put into practice (made into habits) in order to work and, of course, that’s the difficult bit!