Navigating the red tape: A case for hybrid ORs in the VA

Courtney Morgan

The United States military has access to the most cutting-edge equipment to perform its duties, so we should expect nothing less for its veterans. As vascular surgeons, we all appreciate the importance of high-functioning, cutting-edge equipment. Over the past decade, hybrid operating rooms (ORs) have become more commonplace and are becoming the norm rather than the exception to be able to provide comprehensive vascular care in an efficient manner.1 

Any institution that has been involved in the acquisition of a hybrid OR system understands the complex process involved. Multiple stakeholders, including representatives from specialties expecting to utilize the equipment—OR leadership, hospital finance, acquisition committees and biomedical engineering—need to work together to determine the optimal operating system to best serve patients’ needs that will fit within the confines of the physical space and budget. 

This can be a particularly overwhelming challenge within the Department of Veterans Affairs (VA) system due to the increased level of bureaucracy involved. Like any institution, the utility of a hybrid OR must first be established locally. This often involves cooperation between services that will utilize the system besides vascular surgeons, such as neurosurgeons, interventional radiologists, cardiologists, pulmonologists and nephrologists, to name a few. 

In addition to vascular surgery, the progression of structural heart programs and transcatheter aortic valve procedures has largely driven this need and may create additional utilization when determining expected volume. Once the need for a hybrid OR system has been established within a specific VA medical center, approval through the Veterans Integrated Service Network (VISN) budget is required. 

Even with the support of the VISN, the high cost of hybrid room technology and intricate construction required for installation pushes this acquisition into the classification of High-Cost High-Technical (HCHT), and must go through the VA National Acquisition Center (NAC). The application considers all aspects of the project, including clinical justifications, finance, impact of veterans’ wait time, and how this all fits into strategic planning. 

Moreover, in selecting the specific hybrid system, because the purchaser is the federal government, additional layers of scrutiny are required to ensure open and fair competition among vendors. Once the system and construction budget is approved, additional time for construction and installation should be anticipated. Multidisciplinary collaboration for shared use of cardiac catheterization labs or interventional radiology suites may be required to continue to provide clinical services during a prolonged construction phase. 

Conquering the alphabet soup of government acquisition approval is well worth it in the end, and many high-complexity VA facilities already have hybrid ORs. Early adopters have been utilizing their hybrid ORs for nearly 20 years, providing equally complex endovascular aortic repairs to their partnering academic institutions.2 The direct impact on care of a hybrid OR for veterans is easily appreciated, but just as important is the impact on training the next generation of vascular surgeons, with more than half of VA vascular surgeons providing direct teaching to vascular surgery trainees.2,3 

Unfortunately, the lifetime of a hybrid OR is not indefinite, and several of the early hybrid ORs in the VA system are undergoing—or have already undergone—upgrades and replacement that are equally as involved as installing a new system. Just as the U.S. military is constantly evaluating its technology to ensure access to the optimal equipment, we as vascular surgeons should continue to advocate for the best equipment within our VAs to optimize care for veterans and enhance training. When undertaking such a planning project, start early and anticipate a lengthy, involved process. 


  1. Spenkelink IM, Heidkamp J, Fütterer JJ, Rovers MM (2022) Image-guided procedures in the hybrid operating room: A systematic scoping review. PLOS ONE 17(4): e0266341. 
  2. Flannagan CP, Gasper WJ, Caring for the veteran, training the surgeon: The role of the VA in vascular surgery training. Vascular Specialist. 2021 Aug 23 
  3. Longo WE, Cheadle W, Fink A, Kozol R, DePalma R, Rege R, Neumayer L, Tarpley J, Tarpley M, Joehl R, Miller TA, Rosendale D, Itani K. The role of the Veterans Affairs Medical Centers in patient care, surgical education, research and faculty development. Am J Surg. 2005 Nov;190(5):662-75. doi: 10.1016/j.amjsurg.2005.07.001. PMID: 16226937. 

Courtney Morgan, MD, is a member of the VA Vascular Surgeons Committee. 


Please enter your comment!
Please enter your name here