A theatre session belongs to the patients waiting for it

Walk into the theatre suite of almost any Australian private hospital at seven in the morning and you will see the same pattern on the whiteboard. Most theatres carry the name of a surgeon who has held that session on that weekday for years, sometimes for decades. The arrangement has history behind it. Private hospitals depend on specialists choosing to bring their patients, and a secure weekly session is one of the strongest reasons to choose. I understand why hospitals offer it. I have come to believe that, without rules, it quietly transfers time from patients who are waiting to surgeons who are not using it.

At Kelvarra Health in 2022, 66 per cent of booked theatre time was actually used. Seventeen per cent of sessions were released within forty-eight hours of the list, far too late for anyone else to fill them. At the same time, newly credentialed surgeons could not obtain regular time, our contracts with the state to treat public patients were limited by theatre availability, and same-day cancellations ran at 5.8 per cent because some lists were overbooked to compensate for others that sat empty. Each of these facts appeared in a different report owned by a different manager. Taken together, they described a scheduling system organised around tenure.

Utilisation measures the surgeon, not the theatre

The standard measure, utilisation of booked time, is usually presented as a property of the theatre suite. It is more accurately a property of each surgeon's practice. A theatre at 66 per cent is not two-thirds efficient; it is the sum of some surgeons who fill every minute, some who finish early by habit and some who rarely operate on their allotted day at all. Averaging those behaviours hides the very variation a manager can act on.

Utilisation also has a darker side when used alone. If managers chase it hard, surgeons respond by overbooking, lists run late, staff work unplanned overtime and patients at the end of the day are cancelled after fasting since midnight. A suite can report excellent utilisation while treating its last patient of the day badly. For that reason I never report utilisation without three companions: same-day cancellations, sessions released at least fourteen days ahead, and lists that finish more than thirty minutes beyond their planned time. Together, those four measures show whether time is being used well, not merely whether it is full.

Release rules surgeons can live with

Our rules, introduced across all sixteen sites, are simple. A session released at least fourteen days ahead carries no penalty, because that is enough notice to offer it to another surgeon or a public list. A session used below 75 per cent for two consecutive quarters is reviewed by the hospital's surgical services committee, with the surgeon present, and may be reallocated after a quarter's notice. Annual leave, illness and parental leave never count against anyone. New specialists receive a share of released time while they build a practice.

Two features made the rules workable. First, every surgeon received two quarters of private data about their own sessions before anything took effect. Many were surprised. Some changed their habits immediately, and several voluntarily gave up sessions they had stopped needing. Second, the review belongs to clinicians: a committee of surgeons and anaesthetists decides, on evidence, rather than a manager sending a letter. Doctors accept a decision from peers who can see their figures far more readily than one from administration.

I will not pretend the rules were free. An orthopaedic group of six surgeons, among our busiest, objected strongly and moved about a third of their joint replacements to another hospital in 2023–24. We lost about A$8.7 million of revenue that year. Some of that loss was caused less by the rule than by how I introduced it: the group learnt the details from a memorandum, not from me. Within a year the revenue had returned through other surgeons using the released time, and two of the six have since increased their work with us again.

The gains were real. By 2025 utilisation of booked time had reached 81 per cent, same-day cancellations had fallen to 2.7 per cent and forty-one sessions a week had moved, including eleven to newly credentialed specialists and six to public patients. The number that matters most is harder to measure: the weeks by which some patients' operations came sooner because a session that would have sat empty was filled.

What a board should ask to see

Directors of hospital companies rarely see theatre data beyond a single utilisation figure and the revenue it produces. I think they should ask for more, without becoming schedulers. Four questions cover most of what matters. What share of booked time is used, shown by specialty rather than as one average? How many sessions are released late, too late to fill? How many patients are cancelled on the day of surgery, and why? And how is new surgical time allocated, by tenure or by need?

The answers reveal whether a hospital's most valuable asset is managed for the patients who need it. They also show whether the hospital can welcome new specialists, which is a strategic question as much as an operating one. A suite in which every session is owned for life will age with its surgeons, and the hospital will discover too late that the next generation built their practices somewhere else.

There is also a quieter governance point. Theatre allocation is one of the few places where a private hospital's commercial interest and its patients' interests can be aligned by a rule rather than by hope. Empty theatre time earns nothing and helps no one. Releasing it fairly, under clinical review, is good for patients, good for younger surgeons and, over a few years, good for the hospital. It requires a willingness to lose some revenue and some goodwill while the change settles, and a board prepared to hold steady while it does.