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Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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Chief Surgical Officers Are Needed in Hospitals with Complex OR Environments

David A. Etzioni, MD, MSHS, FACS

May 8, 2024


Dr. David Etzion

The care of surgical patients constitutes a significant portion of the overall enterprise of healthcare delivery. Data from the Centers for Medicare & Medicaid Services suggest that payments for surgical care represent more than 50% of federal healthcare expenditures and these disbursements are growing rapidly.1 Within the US alone, there were 14.4 million OR procedures in 2018, incurring an overall cost of $210.3 billion.2 A recent analysis of California hospitals found an average cost of $36–$47 per minute of surgery performed.3

In order to achieve optimal function in the OR, this environment requires the seamless collaboration of a broad spectrum of healthcare providers, including surgeons, anesthesiologists, and nurses, as well as coordinated efforts within different areas of the hospital such as central sterile, preoperative/recovery spaces, radiology, and others.

Decision-making in each of these areas encompasses considerations related to quality of care, cost-effectiveness, diplomacy, and culture. Rapid evolution in the scope of technologies that are available within the OR (e.g., robotic platforms, integration, image guidance) requires a growing degree of strategic and operational oversight.

Strong leadership in the OR is necessary not only for efficient care but also to improve patient outcomes. The inherently multidisciplinary care within the OR depends on effective communication for high-quality care; attention to best practices has the potential to improve communication and reduce incidents of potential harm.

The culture within an OR environment has an important impact on patient outcomes as well, and effective leadership has a profound but inestimable impact on maintaining a culture that is appropriately patient-focused.4

With this concept in mind, I propose a chief surgical officer position or title within every hospital that has a multifaceted OR environment.

What Are the Responsibilities of a Chief Surgical Officer?

The OR is a limited resource with significant associated costs, and therefore, access (allocated starts) needs to be managed wisely, including setting block allocations and managing flexibility for emergent cases. Polarities arise and must be managed by a leader who listens and carries the respect of the OR community. Ensuring that the structure and processes within the OR support optimal practice and quality of care is clearly an important domain of leadership.

Acute shocks to normal operations will occur; for example, the COVID-19 pandemic had an impact on standard operating procedures specifically concerning issues related to capacity and safety. These situations need thoughtful leadership and clear communication.

Additional responsibilities may be less obvious, but also are within the scope of a chief surgical officer. Plans to grow OR capacity need to fit in with the overall strategic plan of a hospital campus. Growth in surgical capacity requires more than implementing adjustments in the OR, as accompanying increased capacity in preoperative/recovery spaces, central sterile processing, waiting areas, staff touchdown areas, and sterile cores also should be considered. The chief surgical officer is integral to representing all these concerns.

Who Is Qualified to Be a Chief Surgical Officer?

It should be noted that a chief surgical officer does not need to be a surgeon. The main requisite for the role is that the individual be a respected leader within the community of physicians and allied health staff who work within the OR. Other important attributes of a chief surgical officer include a passion for improving the function of the OR and a willingness to interface collaboratively with other disciplines to identify and achieve shared goals.

This new title is necessary because no other title fits this purpose. Many hospitals already have leaders in the surgical space—such as the surgeon-in-chief or chief medical officer—who have responsibilities along the lines described in this viewpoint article. However, as noted earlier, a chief surgical officer does not need to be a surgeon. Therefore, the title of surgeon-in-chief may not be appropriate. The title of chief medical officer also does not fit, as the experience/expertise, decision-making, and relationships that a leader needs to exert to be effective as a chief surgical officer are distinct from those of a chief medical officer. Other intra-institutional roles (e.g., chief operations officer) do not specifically pertain to the complex clinical considerations that are inherent to effective surgical care.

The chief surgical officer role also is important because it is essential to effectively defining and developing leaders who seek to elevate their profiles and have a lasting impact in this important sphere. Resources to support a chief surgical officer do exist, and I list several of them here. The ACS published a handbook—Optimal Resources for Surgical Quality and Safety—that focuses on quality with many practical and real-world concepts. The second edition of the textbook Operating Room Leadership and Perioperative Practice Management was published in 2019, and this is an excellent resource.5

In addition, academic programs focusing on surgical leadership are certainly useful for surgeons who seek to expand their leadership skills. Programs that are formally designed to train chief medical officers abound, but none that are specifically focused on the complex multidisciplinary leadership that is necessary for an effective chief surgical officer.

In each hospital with a busy OR, there currently is a person functioning (formally or informally) as a chief surgical officer, and this person may be struggling to define their role in the OR within a vacuum.

In addition to formally proposing and defending the title of chief surgical officer, the secondary goal of this viewpoint is to highlight the need for organized forums where the skills of a chief surgical officer can grow within a community of other leaders facing similar challenges. The conferences, educational programs, and other venues where surgical leaders convene need to formally include content that focuses on the needs of the chief surgical officer. Our leaders, hospitals, and patients will surely benefit.


The thoughts and opinions expressed in this viewpoint article are solely those of the author and do not necessarily reflect those of the ACS.

Dr. David Etzioni is chair of the Department of Surgery and chief surgical officer at the Mayo Clinic in Phoenix, Arizona. 

  1. Kaye DR, Luckenbaugh AN, Oerline M, Hollenbeck BK, et al. Understanding the costs associated with surgical care delivery in the Medicare population. Ann Surg. 2020;271(1):23-28.
  2. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. Available at: https://hcup-us.ahrq.gov/reports/statbriefs/sb281-Operating-Room-Procedures-During-Hospitalization-2018.jsp. Accessed March 14, 2024.
  3. Childers CP, Maggard-Gibbons M. Understanding costs of care in the operating room. JAMA Surgery. 2018;153(4):e176233-e176233.
  4. Nwosu ADG, Ossai E, Ahaotu F, Onwuasoigwe O, et al. Patient safety culture in the operating room: A cross-sectional study using the Hospital Survey on Patient Safety Culture (HSOPSC) Instrument. BMC Health Serv Res. 2022;22(1):1445.
  5. Kaye AD. Urman RD, Fox III CJ. Operating Room Leadership and Perioperative Practice Management 2nd Edition. New York: Cambridge University Press, 2019.