Smooth Operators

By the standards of a major urban hospital, the events taking place inside Operating Room 30 at Massachusetts General Hospital do not constitute a crisis. It's just after 9 a.m. on a rainy spring day, and vital signs are not plunging. No alarms are sounding. In fact, more than an hour after the day's first operation was scheduled to begin, there's not a patient in sight, due to a last-minute cancellation. So a nurse and a scrub technician languidly go about their business.

Finally, by 9:30, a patient has been rolled into the room on a stretcher. For the next few minutes he lies there, talking with the anesthesiologist and nurses. By 9:40, the staff is ready to move the patient from his gurney to the OR table. A voice comes over the public address system: "Lifting help to Room 30, please. Lifting help to three-o, please." Inside the OR, the staff waits.

On a different floor of the hospital sit the accountants who will eventually send out a bill for this time. At Mass. General, patients are billed $3,600 for each hour they occupy an operating room. That's $1 per second, a tally that does not include fees for the surgeons or anesthesiologists. So for every second an operating room sits empty -- as OR 30 did for more than an hour on this morning -- Mass. General loses $1 in revenue. And for every second that a patient lies in a room awaiting the scalpel, someone -- the patient, his insurance company, Medicaid, or Medicare -- may be paying for services rendered inefficiently.

Five minutes pass, and the patient still hasn't moved. A voice returns over the PA system. "Lifting help to Room 30, please. Thank you." Inside the OR, the staff still stands idle.

Medically speaking, this is not a problem. Economically, it's a big one.

Only after several more minutes do six workers assemble to lift the patient onto the operating table. And as the clock ticks toward 10 a.m. -- two hours after the day's first operation should have begun -- the staff finally begins rendering this patient unconscious and ready for surgery.

Outside the room, anesthesiologist Warren Sandberg watches ruefully. Sandberg, 41, sports a closely trimmed beard and a multicolored surgical cap. On his heavy webbed belt he carries a cellphone, a pager, and a digital camera; in the breast pocket of his scrubs he keeps a personal digital assistant. Though Sandberg has both a medical degree and a doctorate in biochemistry, he often speaks like a management consultant, using terms such as "throughput" when discussing the surgery taking place in the 50 operating rooms on Mass. General's third floor.

While Sandberg's paramount concern is patients' well-being, he's also concerned with making surgery faster, better, and cheaper. While the hours wasted in OR 30 this morning aren't entirely typical, the average OR has plenty of downtime: Mass. General's overall operating room utilization rate is just 50 percent, meaning that half of each workday is spent cleaning, prepping, and waiting for doctors and patients to get ready for surgery.

To increase those efficiency measures, Sandberg and a team of doctors, nurses, and researchers have been working for the last two years in a specially designed space. The sign on the door identifies it as OR 49, but this suite of rooms is better known by another name: the Operating Room of the Future. Mass. General's project is the flagship in a nationwide network of pilot programs that receive $24 million in annual funding from the federal government. Says Gerald Moses, a federal official from the US Army's Telemedicine and Advanced Technology Research Center, who oversees this program: "What they're doing right now is going to define how surgery is going to be done in the future."

The project's guiding premise -- that a better-designed space can lead to better medicine -- is one that's catching on throughout US hospitals. A recent analysis by The Center for Health Design found "overwhelming evidence" that facility design can have "substantial effects on patient health and safety, care efficiency, and staff effectiveness." Researchers found that better-located sinks, for instance, increased hand washing and reduced infections. Putting nurses' stations closer to patients' rooms decreased the incidence of falls. Hospitals are focusing particular attention on their operating rooms, since insurance companies typically reimburse surgery costs at higher rates than they do for other medical treatments (such as taking X-rays or caring for a patient with pneumonia), making it an especially profitable piece of most hospitals' operations. Inside Mass. General's OR of the Future, a team of doctors and nurses is rethinking everything they do in an attempt to spend less time waiting around -- and more time actually helping patients.

FOR A FACILITY with such a grandiose name, the room itself -- 650 square feet previously used for storage -- doesn't look particularly space-age. It's only by comparison with the equipment and procedures used in traditional operating rooms that OR 49 seems advanced.

Consider the televisions. Although laparoscopic surgeries -- in which doctors use tiny cameras and long-handled surgical tools to operate through small incisions -- are among Mass. General's most frequent operations, traditional ORs aren't equipped with the television monitors necessary to view images from the laparoscopes. So when a doctor schedules a laparoscopic procedure, an employee pushes two unwieldy carts into an OR. Strapped atop each is a clunky TV that resembles the units wheeled around high schools so teachers can show videos to students. Many of the patients whose innards will be viewed on these screens have better-looking TVs in their living rooms.

In OR 49, by contrast, a 42-inch plasma monitor is mounted on one wall, while a half-dozen smaller touch-screens surround the operating table. The adjustable screens mean surgeons can work more comfortably. "You can do three or four hours of cases with much less fatigue and stress," says Dr. Keith Isaacson, who performed the first surgery in the room in August 2002. The multitude of screens also ensures that everyone in the room -- from nurses to med students -- has a great view of the action, allowing them to anticipate what they should be doing next. "When the lights go out in that room, you really feel immersed because of that big plasma screen," says Dr. David Rattner, the project's chief surgeon.

The TVs -- along with the lights, towers of medical equipment, and computers -- hang from ceiling-mounted booms. That apparatus eliminates the tangle of cords that surgeons and nurses must hopscotch in ordinary ORs. Permanently installing the equipment also minimizes wear and tear caused by moving gear from room to room.

In the center of the room, where the operating table should be, a thick steel column sprouts from the floor. Instead of rolling patients into the OR on a stretcher and then transferring them to a traditional operating table, OR 49 utilizes a rolling operating table that patients board outside the OR, before they're sedated. When the patient is ready for surgery, the staff rolls the table into the OR and positions it over the steel column, which rises up, latches on, and then mechanically lifts the table off its wheels; the process looks similar to how the lift in a mechanic's garage raises an automobile. Attached below the bed are vital-signs monitors, so there's no hooking or unhooking of patients as they are moved from room to room. That means patients spend less time unmonitored, enhancing safety. And thanks to the newfangled bed, staffers spend less time waiting for lifting help.

Beyond the sterile space are three adjoining rooms that are every bit as crucial as the operating space itself. Just outside one wall, behind windows, lies the control room, a narrow space with chairs and computers arrayed down a long counter. Here doctors hang out between operations, checking e-mail and medical records, making phone calls, or dictating notes. The space functions much like an airport's first-class lounge, helping the staff be more productive during downtime -- and reducing doctors' temptation to sneak back to the office between procedures and possibly create delays.

Just outside the OR's main doors are two roughly 10-foot-by-10-foot spaces. In one, called the "induction room," patients are anesthetized prior to entering the OR. In the other, an "early recovery" space, patients linger for a few minutes after surgery, being monitored while emerging from anesthesia before making the long trip to the hospital's general recovery rooms. While induction areas are common in Europe, "typically in America, most ORs don't have that room, so the patient ends up in the hallways," says architect Harvey Kirk of The Stubbins Associates, the Cambridge architectural firm that designed the Mass. General space.

Beyond giving patients more comfort and privacy, the adjoining rooms allow the staff to move patients through surgery more efficiently. In a traditional OR, patients arrive and depart the room awake; getting them anesthetized and revived consumes crucial minutes. The techniques employed in Room 49 -- moving anesthetized patients between rooms on rolling operating tables -- may sound like minor improvements, but in the tradition-bound world of surgery, "we're doing something really radical here," says Sandberg. "We're moving anesthetized patients around just for the purpose of improving our throughput."

THE RESULTS OF THIS redesign are in evidence just after 7 a.m. one day in June. Inside OR 49, two workers ready bundles of instruments wrapped in surgical-blue cloth; piled on a table, the instruments look like elaborate Christmas presents. By 7:22, a 25-year-old patient named Kellie lies on the rolling operating table in the induction room. She suffers from achalasia, a disorder of the esophagus that makes swallowing difficult. Rattner will perform a laparoscopic Heller's myotomy, a procedure to loosen her lower esophagus to let food pass to her stomach more easily.

The patient is visibly nervous, so anesthesiologist Julian Goldman mixes serious questions ("When was the last time you had anything to drink?") with jokes and banter. As he prepares to put Kellie to sleep, he gives her a serious look. "Don't worry -- I already went to the ATM on my way in, so I don't need to go out for any cash," he says, in a joking reference to an orthopedic surgeon who famously went AWOL mid-surgery to attend to his banking. A few moments later, Kellie is unconscious, her eyes taped shut, a ventilator supplying her breath. Only then is she wheeled into the operating room.

Soon the big plasma screen is awash in pinks and purples as Rattner and an assistant trace her esophagus with their tiny cameras. Manipulating instruments, Rattner snips and cauterizes tissue. Although 34,000 operations are performed annually at Mass. General, this operation is unusual, done perhaps once a month, so several students are there to observe. The procedure could take three hours, but after 50 minutes, Rattner asks whether the next patient will be ready to go. By 9:30, Rattner is nearly done closing the incisions. Says nurse Peg Caulfield: "Before this patient is even awake, the next one [will be ready] to go to sleep."

Indeed, by 10 a.m., that scenario -- and Room 49's vaunted "parallel processing" -- is playing out. Kellie, barely awake and groaning, has been rolled into the early recovery area, where the anesthesiologist administers morphine. Simultaneously, nurses scurry about the OR, emptying trash bags, reprogramming monitors, and laying out new instruments. In the induction room, meanwhile, another patient is being put to sleep. Ordinarily, these steps would happen one after another, each tying up the OR. Here they happen at once.

In the control room, Rattner telephones a patient and checks e-mail. A trio of younger surgeons discusses the ideal music for surgery. (One doc's recommendation: Make the first incision to Dido, play Celine Dion throughout mid-surgery, and close to the Spice Girls.) Today, Rattner's team will complete three operations in OR 49, but on days when it books shorter procedures, the room rocks. "We were flying" last Wednesday, Rattner says. "I won a bottle of wine from [the OR director]. He said, `You won't have five cases done by 5 o'clock.' I had five done by 3:45." (When asked later about the bet, the OR director insisted it was only in jest.)

Of course, among the least reassuring things a patient can hear about a surgeon is "He's really, really fast." So everyone involved in the project emphasizes that the teams are not trying to rush the surgery itself, just the pre- and postoperative rigamarole. In fact, surgery at Mass. General is sometimes intentionally slower than it need be: Because it's a teaching hospital, doctors work deliberately so they can instruct students and let newbies handle the scalpel. "I lose all track of time when I'm actually doing an operation," says Rattner, explaining that downtime is the real enemy of his profession. "All surgeons gripe about how long it takes to turn a room over." The good news is that while it takes 36 minutes to clean and retool the average Mass. General OR between cases, Room 49 completes that work in just 24 minutes. At $1 per second, that saves $720 in unbillable time every time OR 49 is turned over.

TO ADMINISTRATORS, those sorts of numbers are essential if the ORs of the present will ever resemble this OR of the Future. No one questions that the new space functions more efficiently: Administrators say OR 49 averages 3.2 operations per day, compared with 2.5 per day for ordinary rooms. But as the project's leaders look ahead, they're focusing on two questions: Does the extra output justify the extra costs, and can the lessons learned in OR 49 be applied to other operating rooms?

On count one, the project seems to be acquitting itself nicely. It cost approximately $2 million to design and build OR 49, perhaps $500,000 to $700,000 more than a typical operating room, says Ann Prestipino, Mass. General's senior vice president for surgical and anesthesia services. It's bigger than the average OR, meaning it carries more in overhead charges; it's also staffed with two extra nurses, which adds to expenses. But "our preliminary analysis," Prestipino says, "looks as if the additional cases you can drive through that environment should cover those costs."

To better understand the efficiencies, a team of researchers -- partly funded by government grants -- is doing studies and publishing papers on how the operating suite functions. To measure the flow of both patients and staff, everyone in the suite wears radio frequency identification tags, which allow computers to track their movements minute by minute. In one study, the group found that OR 49 patients spend 12.1 minutes in the OR waiting for surgery to begin (versus 29.9 minutes for a regular OR) and just 8.3 minutes in the OR after surgery is complete (versus 15.6 minutes in traditional rooms).

Enthusiasm for such glowing results, however, is tempered by several factors. For instance, doctors and nurses currently working in OR 49 are self-selected, so it's possible the room's apparent advantages stem as much from highly motivated employees as they do from better processes, design, and technology.

Nor is it clear just how scalable, in business terms, the room's innovations will prove to be. "The thing I worry most about is its applicability across more surgeons and more surgical disciplines," says Prestipino. "My biggest fear is it's going to work for a limited group -- mostly laparoscopic [surgery], and mostly for the three or four disciplines doing that kind of work." For orthopedic, cardiac, or neurosurgery cases -- lengthy procedures that together make up a big volume of Mass. General's cases -- OR 49 ultimately may yield few benefits. That's one reason the team describes its space as a "learning laboratory" rather than a template for new ORs.

Still, after two years of learning to make the most of the redesigned space, the OR 49 team is looking to expand its empire. At the end of a long hallway of operating rooms, Sandberg shows off an area the team hopes to take over next. The space currently houses four ORs, but the team would like to turn it into a "high-velocity pod" consisting of three ORs and a shared early-recovery era. "That's the next logical step," says Marie Egan, a nurse who helps manage the OR 49 research team. To bring it to fruition, the team members will have to convince administrators that the plan is economically viable and persuade a new crew of doctors and nurses to join them in their push toward tomorrow. For now, the clock is still ticking. And as health care costs spiral upward, the pressure to heal patients better, faster, and cheaper will only grow more acute.

Daniel McGinn is national correspondent for Newsweek, based in Boston. He lives in Westborough. He can be reached at mcginndan@aol.com.