The GA-NORA is inherently intertwined with the surgical activity [7], often sharing not only the same clinical objectives but also the organizational ones. Its recent growth has also led to an increased focus on efficiency indicators [8]. Efficiency indicates how well an organization uses its resources (inputs) to produce goods and services (outputs). Pandit created a formula to demonstrate that a surgical list is most efficient when all the scheduled time is utilized, without overrun and without cancellation [6]. We decided to apply Pandit’s formula to a GA-NORA setting to check its validity and applicability and to see if it would be useful in this context. This formula has been shown to be an interesting, feasible and a reproducible tool for the operating room. According to our vision, it is crucial to find a simple and easy-to-use tool that can assist the NORA team in maximizing the utilization of the NORA scheduled list while minimizing overruns and cancellations.
The results show that both efficiency and list utilization are very high, exceeding 90% and also productivity (136 patients). The goal of achieving 85% efficiency was easily accomplished and this is due to the fact that only one out of ten patients was cancelled, and this result tells us that patient cancellation is not a problem in the NORA setting (2.9%); on the contrary, OR cases should have a cancellation rate of less than 5% [9].
Time utilization and cancellation rates are less variable than their OR counterparts [5, 10]. There is indeed a delayed start time and a finish time that consistently remains within the set limits; this is slightly different from the operating room where there is usually a slight delay in the start time (equal to NORA), but often the end of the procedures exceeds the scheduled time. Turn-over times for NORA cases are about 50% shorter (16.21 vs. 37.18 mins) than OR times; meanwhile the first case start delay (first patient in) is twice as great in NORA as OR (11.97 vs. 5.9 mins) [5, 11].
This is probably due to the fact that GA-NORA has less equipment, faster procedure times, and faster discharge times [5, 11]; additionally, in the afternoon, there may be other procedures to be carried out in the same suite without the presence of an anesthesiologist, so it was no longer a NORA setting. All these reasons contribute to the necessity of ensuring that the utilization of the endoscopy room must end on time, by 02:00 pm. However, less importance is given to the start times [5, 12-14], as its fluctuation is regularly accepted as being within the norm. Seeing these results, we have verified how the programming of the first patient was done, and we have found that 90% of outpatients filled out paperwork (like informed consent) and had the anesthesiologist visit on the day of the procedure; the effect was a delay of the first case start time (first patient in) equal to 27 minutes.
On just four out of 31 days, the scheduled NORA list was not followed, resulting in the cancellation of four patients. In three out of those four days when patients were cancelled, the endoscopy procedures finished earlier than scheduled (by 70 mins, 19 mins and 30 mins). This is interesting, as it highlights the importance of avoiding overruns to the system, and also indicates the potential margin for time recovery; time that can be regained or made available for other procedures or activities. This margin can be used for various purposes, such as accommodating additional procedures, reducing waiting-times or optimizing the overall efficiency of the endoscopy department. By gaining 40 minutes you can improve your efficiency by treating one or two more patients.
By reducing the delay in the start time, and extending the end time of each session towards 2:00 pm, the NORA team could potentially increase the number of scheduled procedures to be performed. This adjustment can help improve the overall efficiency and utilization of the endoscopy room, allowing for more procedures within the allocated time.
Accurate scheduling could result in adding an extra patient each day, and it can also contribute to an increase in the number of procedures performed within the given time frame. By carefully planning and optimizing the scheduling process, the team can effectively utilize the available resources, and potentially accommodate additional patients, thereby improving efficiency (more than 95%) and productivity in the endoscopy room.
There are several limitations to this study. First, the formula used was originally created for the operating room and not specifically for NORA contexts. It thus tends to emphasize the importance of minimizing the cancellation of scheduled patients and ensuring that the entire scheduled list is completed. The formula minimizes the fact that, very frequently, the NORA session starts slightly after 08:00 am and always ends before 02:00 pm. This is because in operating rooms, gaining an extra 20 minutes may not necessarily result in increased productivity, whereas in a NORA context, it could lead to an increase in the number of scheduled cases treated. Second, the formula does not consider the case mix, since it focuses only on the overall number of cases; this is certainly a limitation but, in our opinion, it is also a significant strength. The formula does not analyze individual performance but rather the team’s performance. It is the Director of the Operating Unit who will have to decide which modifications and improvement actions to implement because he/she has a deep understanding of the case mix within the hospital. Third, the number of analyzed activity days is low, and they should be distributed over a year rather than during a limited period to provide a more accurate representation of NORA’s activity. In addition, in this case, the GA-NORA has started relatively recently (2021); the number of sessions (two per week) is not high, and the idea is to move towards a progressive increase. The use of the Pandit formula opens up another line of discussion: do we really need multiple efficiency measurement systems, or can we use a single one that can be implemented, based on the context? The authors believe that the best way to measure efficiency inside or outside operating rooms is to have a single, unique instrument or formula. This would allow for more direct comparisons, and reduce the influence of different instruments. In our opinion, the ideal approach would be to have a single instrument and then modify it, without altering its essence, based on specific needs.
Indeed, this formula represents a valuable and easy-to-use tool that provides a reference point for reasoning and analysis. It can assist in evaluating and optimizing efficiency in NORA settings and serve as a basis for further discussions and decision-making. The authors tend to emphasize that the limitations of use are not related to the formula itself, but rather to its application in the NORA context. Further, in our opinion, the formula represents a valuable efficiency analysis tool that can be applied not only in operating rooms but also in other contexts. Our advice is to use and apply it in this specific GA-NORA context as well.