Canadian healthcare confronts persistent surgical capacity constraints driven by demographic pressures, economic limitations and inefficient resource utilization. Despite substantial resource requirements, operating rooms frequently remain underutilized due to misaligned policies and incentives. Introducing “collectable time” provides a foundation for comprehensive policy reform to resolve these inefficiencies. Addressing these inefficiencies through detailed, multi-level policy changes is critical to sustainably improving healthcare system productivity. Embedding collectable time metrics within institutional, provincial, federal and regulatory frameworks could increase surgical capacity without requiring additional staff or infrastructure.

Introduction

Surgical services are among the most resource-intensive components of Canadian healthcare, yet they often operate below their full potential. Despite clinical advancements and growing demand, operating room (OR) capacity remains underutilized, partially contributing to persistent waitlists. The system is plagued with multiple inefficiencies that reduce utilization. Upstream improvements, including single-entry models, address variable waitlists among surgeons but do not address OR-use inefficiencies. These inefficiencies stem from a complex web of scheduling constraints, staffing shortages, bed unavailability and siloed financial incentives.

Traditional performance metrics, such as overall utilization rates, fail to identify unproductive but schedulable time. This paper introduces the concept of “collectable time” – the OR time during staffed hours that is left unused despite being schedulable – as a key lever for improving productivity. More specifically and practically, collectable time is the sum of unused time, over allowable turnover time, and late start times that, when added together, could have led to an additional completed case without going overtime. We argue that integrating this metric into policy frameworks at the institutional, provincial and federal levels can unlock significant latent capacity without increasing infrastructure or workforce (Eskander et al. 2022).

Why Now: A Convergence of Pressures and Capabilities

Canada's healthcare system ranks among the highest globally in per capita spending – over 12% of gross domestic product – yet lags in surgical throughput relative to other Organisation for Economic Co-operation and Development nations (CMA 2025). Fiscal pressure to “do more with less” is intensifying, but so too are the tools available to meet this challenge.

Hospitals are increasingly equipped with enterprise resource planning systems such as Epic, Cerner and Meditech that can capture near-real-time surgical data. With advances in computing power and data analytics, hospitals can now process detailed performance metrics such as collectable time. This information can then be used for quality improvement at the institution: two to three weeks prior to scheduled surgery to move cases around to maximize on OR time, a week prior to surgery to avoid cancellations and plan for in-patient beds, even on any given surgical date to consider where add-on/emergency cases can be added on the grid. The intersection of rising demand, strained budgets, operational complexity and technological readiness makes this the ideal moment to modernize surgical policy.

Highlighting Systemic Inefficiencies: Joanna's Story

Joanna, a patient in Ontario, prepared for months for a long-awaited hysterectomy – only to have it cancelled on the morning of surgery due to a lack of post-operative bed availability. Her surgeon, the OR team and Joanna herself were all ready, but the cascade of system bottlenecks made it impossible to proceed with the procedure. Situations such as Joanna's are not rare. Across Canada, one in seven surgeries is cancelled on the day of operation, compounding the backlog and eroding trust (Eskander et al. 2022).

For Priority 4 surgical patients – those with non-urgent but medically necessary conditions – delays can extend over many months. As of January 2025, Ontario patients face a median wait of 3.8 months for an obstetrician-gynecologist consultation, and an additional five months to receive the procedure (Ontario Health 2025). These inefficiencies are not solely a matter of inconvenience; they represent missed opportunities for care and, in some cases, lead to compromised patient outcomes.

The Policy Gap: Limitations of Current Approaches

Data from Toronto General Hospital show that its ORs operate at only 64% efficiency (Naderi et al. 2021), despite being fully staffed. Given that OR time costs approximately $46 per minute, this underuse represents both a clinical and financial loss. Research indicates that by optimizing surgical scheduling alone – without adding downstream resources such as intensive care unit beds – up to 24% of cases could be managed more efficiently, potentially raising overall utilization to 80% (Smith et al. 2022).

Ontario's current policy frameworks, such as the Surgical Efficiency Targets Program (SetP) and Quality-Based Procedures (QBPs), attempt to standardize performance monitoring and incentivize high-value care while paying for procedures by volume. However, they fall short. SetP provides delayed, aggregate metrics that obscure individual surgeon performance and offer limited day-to-day relevance for surgical teams and the hospital. QBPs only apply to select procedures, limiting their system-wide impact and do not pay for performance/value but rather for volume. SetP and QBPs are implemented in Ontario; however, the majority of remaining provinces' hospitals operate under a global budget and have few incentives to maximize OR use, and surgeons typically face no accountability linked to the efficiency of their block allocations.

The Case for Collectable Time as a Policy Anchor

Collectable time represents the schedulable but unused portion of staffed OR hours – an indicator of modifiable inefficiency. Unlike retrospective utilization measures, collectable time enables near-real-time analysis of where surgical capacity is lost, by whom and why.

Crucially, it democratizes data, making performance metrics available not only to administrators but also to front-line clinicians: surgeons, anesthetists, nurses and peri­operative managers. By layering on existing data infrastructure such as SetP, hospitals can implement collectable time without major information technology overhauls. The difference lies in granularity and accessibility. Where SetP ends, collectable time begins, with actionable, provider-specific insights.

Empowering Surgical Teams Through Real-Time Insight

OR efficiency is inherently a team sport. Each surgical day begins with assumptions: about how long cases will take, how quickly rooms can be turned over and whether staff and beds will be available. When these assumptions prove inaccurate – and they often do – delays snowball. Yet, most surgical teams operate in a data vacuum, with limited feedback on what caused delays or how to prevent them.

Collectable time bridges this feedback gap. It transforms opaque administrative metrics into a clinically relevant tool. By offering confidential, individualized insights, it fosters a learning culture rather than a punitive one. Surgeons and anesthetists can use these metrics to adjust sequencing, anticipate bottlenecks and collaborate more effectively.

From Reactive to Proactive: A Cultural Shift

By integrating collectable time into daily OR operations, hospital leaders (chief of surgery, chief of anesthesia and administrative surgical leadership) shift from a reactive mode, addressing problems after they occur, to a proactive culture of anticipatory scheduling. Surgeons and anesthetists are no longer left guessing why delays happen or how to prevent them. Instead, they gain visibility into performance patterns and the tools to act in real time. This leads to more stable surgical days, fewer cancellations, better staff coordination and more efficient use of expensive OR time.

Importantly, collectable time is not about increasing workload. It is about optimizing flow, making better use of existing resources by reducing idle periods and inefficiencies. As an example, with over 2.3 million surgeries performed annually in Canada, even an 8% gain in efficiency would create capacity for approximately 184,000 additional surgeries each year, without hiring more staff or building new ORs.

“Collectable time” offers a precise, scalable and transparent way to align team performance with system-wide goals while respecting the clinical complexity of surgical care. By embedding this metric into policy and operational practice, healthcare systems can unlock the full potential of existing surgical infrastructure and deliver better, faster care to the patients who need it. A shift in policy may be required at the institutional, provincial, regulatory and federal levels. This will require a multi-faceted approach, which should ultimately lead to clear incentives at the hospital and physician level to achieve success.

Policy Implementation at the Institutional Level

Hospitals are the linchpin of collectable time implementation. To maximize surgical productivity, hospitals must transition away from static scheduling practices toward dynamic, real-time management systems. OR administrators can actively monitor performance metrics to identify underused surgical blocks. These can then be dynamically reallocated or shared among surgeons, enhancing resource use without the need for additional staff or infrastructure (Naderi et al. 2021).

In addition, hospitals must provide clinicians and administrators with regular, near-real-time productivity reports. Delayed or inaccessible data limit its value. Real-time feedback allows providers to promptly recognize and correct scheduling inefficiencies. Hospitals must also foster collaborative scheduling models where surgeons coordinate block use and jointly address bottlenecks. Institutional policy should define data standards and privacy protocols to build trust and ensure sustained engagement.

Currently, surgeons in Canada act as independent contractors and, for the most part, can use their OR time as they see fit without explicit accountability to the hospital or healthcare system goals. This likely contributes to underutilization and could be modified through team-based models or shared-care models (Reid et al. 2020). The use of collectable time that could be used by a team could further improve utilization even with different models of care, particularly if there is a responsibility around OR time use given to surgeons, chiefs of departments and OR administrators. This is already being done in certain hospitals where services with underutilized time are warned of time claw-back in the future; however, this approach alone is not enough to modify booking behaviours systematically. A broader approach is required, and different models of care are more likely to succeed.

Aligning Provincial Policy: Incentives and Accountability

Provinces can scale these gains through payment reform. By incorporating collectable time into the Physician Schedule of Benefits, provinces can link clinician compensation to productive OR use. Efficient use of block time can be rewarded, while consistently underused blocks could prompt remediation, reallocation or professional development.

Such performance-linked funding models should be developed collaboratively with surgeons, hospital leaders and patient advocates. Existing initiatives such as Ontario's Pay-for-Results model for emergency care show that funding linked to measurable outcomes can drive improvements. Expanding this approach to surgical performance holds similar promise.

Role of Professional Regulators: Stewardship, Not Surveillance

Professional regulatory bodies, such as the College of Physicians and Surgeons of Ontario (CPSO) and equivalent nursing regulators, have an important role to play in advancing collectable time as a tool for clinical accountability and continuous improvement. Integrating this metric into existing performance and quality frameworks aligns with established ethical responsibilities for resource stewardship, as outlined in policies such as the CPSO's Essentials of Medical Professionalism. Currently, the CPSO is requiring physicians to engage in a quality improvement project within their own practice to maintain certification, and for surgeons/anesthetists, priority can be given to projects that assess collectable time to put it at the forefront.

Research underscores the effectiveness of individualized, evidence-based feedback in driving clinical and operational improvements. Study by Lingard et al. (2024) shows that timely, scientifically grounded performance data lead to measurable gains in both efficiency and patient outcomes. Collectable time provides this type of actionable insight, enabling clinicians to benchmark against peers, identify areas for improvement and pursue tailored development opportunities.

Crucially, the application of collectable time must remain transparent and supportive. When framed around quality enhancement and professional growth – not punitive oversight – it fosters trust, encourages engagement and reinforces shared accountability for system-wide efficiency.

Federal Leadership: Standardizing and Scaling

The federal government holds significant potential to catalyze nationwide surgical efficiency improvements by integrating collectable time metrics within existing national reporting systems, particularly those managed by CIHI (2024). Establishing collectable time as a standardized metric across provinces would facilitate consistent benchmarking, allowing precise comparison of surgical performance and fostering a national culture of continuous improvement.

Moreover, conditional health transfers from the federal government, tied explicitly to surgical productivity metrics such as reduced collectable time and shorter surgical waitlists, could provide provinces with powerful incentives for prioritizing efficiency enhancements. Such federal policy measures have successful precedents in healthcare systems internationally, where linking funding to measurable outcomes has significantly boosted provider accountability.

To effectively leverage collectable time data nationally, the federal government should invest in advanced data analytics infrastructure. Strengthening analytical capabilities at the federal and provincial levels enables effective capture, reporting and interpretation of peri­operative productivity metrics, supporting long-term efficiency improvements. Centralized analytics platforms could identify nationwide best practices, facilitate interprovincial knowledge exchange and inform ongoing refinement of policy interventions.

From Metric to Mandate

Collectable time is a transformative concept with system-wide relevance. It enables teams to identify hidden capacity, governments to design smarter incentives and regulators to support professionalism grounded in stewardship. Most importantly, it helps patients such as Joanna avoid delays.

Policy execution can begin at any level – from an individual department to a provincial health ministry. But to fully realize its promise, collectable time must move from being a metric to becoming a mandate. It is time to shift from measuring inefficiency to managing it – together.

Correspondence may be directed to Trevor Bardell by email at trevor.bardell@gmail.com.

Libérer la capacité chirurgicale grâce au temps non utilisé : un cadre stratégique à plusieurs niveaux pour les systèmes de santé canadiens

Résumé

Les soins de santé au Canada font face à des contraintes persistantes en matière de capacité chirurgicale, lesquelles découlent des pressions démographiques, des limites économiques et de l'utilisation inefficace des ressources. Malgré des besoins importants en ressources, les salles d'opération sont souvent sous-utilisées en raison de politiques et de mesures incitatives mal alignées. L'emploi du « temps non utilisé » jette les bases d'une réforme complète des politiques afin de résoudre ces inefficacités. Remédier aux inefficacités par des changements de politique détaillés et à plusieurs niveaux est essentiel pour améliorer durablement la productivité du système de santé. L'intégration des mesures du temps non utilisé dans les cadres institutionnels, provinciaux, fédéraux et réglementaires pourrait augmenter la capacité chirurgicale sans nécessiter un supplément de personnel ou d'infrastructure.

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