Surgery does not begin in the operating room

The visible procedure is not the complete process

Discussions about surgical capacity often focus first on the operating room: How many procedures are possible per hour, how quickly can the next patient be prepared and how many operating days are available?

These questions matter, but they capture only part of the process. Organizationally, a procedure begins long before the patient enters the operating room and does not end when the patient leaves it. The quality of an outpatient surgical service is created above all at the interfaces between indication, preparation, procedure and follow-up.

Patient selection is the first process step

Not every medically possible procedure can be performed on every patient under the same outpatient conditions. In addition to the indication, comorbidities, mobility, support at home, ability to communicate, anaesthesia and reliable follow-up all play a role.

Germany's 2026 AOP Contract uses contextual factors that can justify inpatient delivery of services that are generally suitable for outpatient provision. The contract and its annexes were updated with effect from 1 January 2026; an amended version of Annex 1 has applied since 1 July 2026. Suitability for outpatient care remains an individual clinical and organizational decision.

A process that identifies unsuitable patients only on the day of surgery does not have an operating-room problem. It has a preparation problem.

The preoperative assessment must produce a complete outcome

A preoperative assessment is not successful merely because every planned device was used. It is successful when all information needed for a safe decision and preparation is available.

In cataract surgery, depending on the individual case, this may include the indication, relevant comorbidities, biometry, lens selection, surgical planning and informed consent. Incomplete assessments create rework, delay orders and shift decisions to a point at which time pressure is already high.

For every type of surgery, the organization should therefore define the mandatory status that must be reached after the preoperative assessment.

The operating list is more than a sequence of names

A functioning operating list reflects clinical and organizational dependencies: materials, type of anaesthesia, special support, required qualifications, additional equipment and a sensible sequence.

Especially at high volumes, small planning errors can have substantial effects. If an implant is missing or a special requirement has not been marked, the team has to improvise at short notice. A good plan makes risks visible early and is not interpreted for the first time on the morning of the procedure.

Materials logistics are part of clinical safety

Medicines, implants, sterile materials and consumables need to be reliably available, stored correctly and assigned unambiguously to the patient and procedure. Traceability is not merely an administrative requirement.

Specific hygiene requirements apply to the reprocessing of medical devices. The joint KRINKO and BfArM recommendation sets out the fundamental requirements; an annex concerning requirements for reprocessing units was updated in 2024.

Materials management in an operating unit is therefore not ordinary inventory control. Errors can have direct clinical consequences.

Checklists are not a sign of insufficient competence

Experienced teams know their workflows. Routine, however, can make individual steps feel so self-evident that they are simply assumed to have been completed.

The WHO Surgical Safety Checklist contains 19 items at defined perioperative points. It is intended to reduce errors and adverse events and to improve communication and teamwork. Early international implementation data showed better clinical outcomes. What matters, however, is genuine use by the team; a form completed retrospectively as a routine exercise does not create safety.

The individual patient must remain unmistakably central

Before every procedure, the following must be clear: the right patient, the right side, the right procedure, valid consent, known risks and the correctly assigned implant.

The higher the volume, the more important consistent identification becomes at every step. Efficiency must not cause the individual patient to disappear within a standardized process chain.

Staffing needs to cover the entire process

An additional hour of operating time is usable only if reception, preparation, assistance, instrumentation, reprocessing, postoperative care, documentation and appointment planning are staffed adequately.

If only the physician's operating capacity is expanded, the bottleneck moves elsewhere. Patients then wait in preparation or the team falls behind with documentation and reprocessing. Utilization therefore needs to be assessed across the complete process chain.

Follow-up is part of the surgical service

An outpatient procedure does not end at discharge. Patients need understandable information about how to behave after the procedure, expected symptoms and warning signs. The next follow-up appointment and a clear route for problems outside regular opening hours need to be organized.

Unclear follow-up creates avoidable questions, uncertainty and potentially delayed responses to complications. It therefore needs to be defined before the procedure.

The right metrics for an operating unit

In addition to procedure volume, relevant metrics include short-notice cancellations caused by incomplete preparation, delays to the first procedure, turnover times, interruptions caused by missing materials, deviations from the operating list, completeness of documentation, unplanned postoperative contacts and overtime.

An operating unit can achieve a high procedure volume and still be unstable. If output is possible only through constant improvisation and overtime, the process is not efficient; it is overloaded.

Conclusion

Patient selection, preoperative assessment, materials, hygiene, staffing, checklists, documentation and follow-up jointly determine safety and performance.

More operating time does not automatically create more surgical capacity. Additional capacity emerges only when the entire process chain supports that time reliably. Surgery begins with the first decision to place a patient on a surgical care pathway.