Caroline Palmer, MD, named the first woman Anesthesiology Chair of Stanford Medical School in 1909, was a key contributor in the development of what we know today as operating room efficiency. “Her recommendations, published in 1923, were clearly ahead of their time and are nearly indistinguishable from those currently practiced by anesthesia departments in university hospitals.” 1  noted Dr. Jay Brodsky and Dr. Lawrence Saidman in a December 2015 Anesthesia and Analgesia article on Dr. Palmer.

While many of her innovations were centered around the safe care of patients undergoing anesthesia, she also had recommendations about operations themselves. “Palmer noted that the operating room schedule should be sufficiently flexible to provide for delays from surgeons arriving late and for operations that required more than the estimated time,” 2 and that time should be allocated to surgeons to do their cases. We can assume this is where the surgical block concept began.

The formation of three major organizations in the 20th century, the American Society of Anesthesiologists in 1905, the American College of Surgeons in 1913, and the Association of Operating Room Nurses in 1949, would contribute to and help evolve this concept through evidence-based research and external engineering. The addition of business concepts, such as Lean principles, further emphasized the importance of OR efficiency.

Around 30 years ago, when I started my perioperative career, the OR schedule was still on paper and whiteboards. In one of many roles that had me directly involved in perioperative suite management and operations, I saw firsthand the issues that rigid block allocation created for surgeons who wanted more OR time and perioperative leaders who wanted to improve utilization. Block utilization started becoming a factor in driving efficiency in the OR as revenue and throughput developed as concepts, and business performance began to have equal weight to quality patient care as a concern for hospital leaders. Back then, block calculations and efficiency metrics were done manually, either hand-counted or tabulated from paper records. Perioperative leaders would go into the schedule, figure out what happened, then calculate metrics.

We soon moved to EHRs, which captured the necessary data and eventually got us off of paper, but collating the data and analyzing it still needed to be done manually using Excel, and it was hardly actionable information. It was at least 30 days behind the actual events in the report, so the timeliness and accuracy of any conclusions drawn were likely to be questioned during reallocation discussions. This left organizations reluctant to reallocate the block schedule with any frequency and created inconsistencies in how hospitals created and enforced block policies and allocation.

Today, perioperative leaders are trying to drive throughput and utilization as far as they can go for a number of reasons. On the clinical side, the focus is now on safer, better, minimally-invasive surgeries that are less traumatizing to patients and generally quicker to perform. On the business side, a renewed emphasis on value-based care and CMS reimbursements moving away from a fee-for-service model makes volume and case mix important and inefficiency more damaging.

First and foremost, the emphasis should always be on what the patient needs, but organizations simply must be able to understand the health of their business in order to maintain revenues at a level that allow them to keep the lights on and the doors open, particularly in rural areas, in order to serve the mission.

But knowing the importance that block reallocation has in optimizing block utilization is one thing, knowing how to do it is another. It’s always a tough conversation for perioperative leaders because if one surgeon is gaining time another must be losing their time. At Hospital IQ, we introduced the metric of Block Fit, which looks beyond allocated time to examine all procedures performed, including those performed outside of block time, to create a holistic look at individual utilization. It helped us engage surgeons and show them that we understand their business imperatives and are looking at their performance as a whole to ensure they are allocated the time they need to complete their surgical volume.

Block Fit created the foundation for an entirely new capability within Hospital IQ that simplifies the process of understanding how blocks should be reallocated. By showing utilization metrics for each surgeon, service line, and practice, metrics that we define according to each customer’s unique policies, we deliver specific recommendations detailing exactly which surgeons need more time and when, and which existing blocks should be reallocated for improved utilization. We also simulate the impact of these potential changes, giving perioperative leaders the insight they need to manage their stakeholders during reallocation discussions to ensure they receive buy-in. Surgeons will be able to understand the motivation and reasoning behind changes while still benefiting from right-sizing block allocation.

Block allocation has long been a part of OR management despite its inherent inefficiencies. Hospital IQ can help perioperative leaders by simplifying the process by giving them the tools and insight needed to optimize the allocation of surgical blocks as in conjunction with their overall goal of optimizing OR utilization and performance.

For a deeper dive and demo on Hospital IQ’s block allocation tools including Block Fit, check out our on-demand webinar, Optimizing the Block Schedule.



  • Brodsky, Jay B. MD; Saidman, Lawrence J. MD, “Caroline B. Palmer: Pioneer Physician Anesthetist and First Chair of Anesthesia at Stanford” Anasthesia & Analgesia, December 2015,
  • Ibid





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