On behalf of my coauthors, I would like to thank Dr. Metz for his concern regarding the role of a surgeon in operating room efficiency. It is true that longer-than-average case times cause inefficiency and can lead to increased staffing costs as well as increased fixed costs.1,2 

Our study, however, was merely a process-oriented approach in which the focus was not the value-adding time, be it anesthesia time or surgery time. Instead, the goal was to decrease nonoperative time. In fact, before implementing the induction room model, the average nonoperative time in our orthopaedic case mix exceeded the average surgery time. Because the percentage seems to be substantial in many other surgical services as well,3decreasing nonoperative time seems like a logical starting point in improving operating room efficiency.

Fortunately, not all surgeons are slow. Lengthy nonoperative times, in turn, tend to be an everyday phenomenon, occurring between every case and easily adding up to at least one case length per day.4Surely, after the nonoperative time has been decreased to minimum, attention should be turned to value-adding time.

Helsinki University Central Hospital, Helsinki, Finland. riitta.marjamaa@hus.fi

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Abouleish AE, Dexter F, Whitten CW, Zavaleta JR, Prough DS: Quantifying net staffing costs due to longer-than-average surgical case durations. Anesthesiology 2004; 100:403–12
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